Local Data for Local Decision Making -- Selected Counties, Connecticut, Massachusetts, and New York, 1997

Although the delivery of clinical preventive services to adults, such as adult vaccinations and cancer and cardiovascular screening, reduces premature morbidity and mortality (1), such services are underused (1-3). Performance monitoring at the population level plays a critical role in supporting efforts to increase the use of clinical preventive services. However, many communities do not have the capacity to measure prevention activities. Without such information, efforts aimed at improving the county-wide or regional use of clinical preventive services must rely on state or national data. To examine the use of seven clinical preventive services among adults at the county level and to demonstrate how a population-based survey can be used to guide local prevention efforts, a community-based coalition (the Sickness Prevention Achieved through Regional Collaboration {SPARC}), in collaboration with state health departments, peer review organizations, and CDC, conducted a survey in the four-county SPARC region. This report summarizes the results of this analysis, which indicate that clinical preventive services in this region were underused despite high levels of access to medical care.

The SPARC initiative, established by the Berkshire Taconic Community Foundation in 1994, represents a collaboration of 75 organizations and businesses with an interest in disease prevention in a four-county region at the junction of Connecticut, Massachusetts, and New York (regional population: 636,000). SPARC's mission is to improve the health of residents by increasing their use of clinical preventive services.

Using methodology from the Behavioral Risk Factor Surveillance System (BRFSS), the SPARC Disease Prevention Survey was designed to establish county-level baseline estimates and identify barriers to increasing the use of preventive health services. The survey provides prevalence estimates for the use of screening measures, such as blood cholesterol level, blood stool test, sigmoidoscopy, Papanicolaou test, mammography, and influenza and pneumococcal vaccinations.

Data are presented for 2241 noninstitutionalized respondents selected by random-digit-dialed telephone survey methods. Only adults aged greater than or equal to 50 years were selected because many prevention services are not recommended until age 50 years (e.g., blood stool test and sigmoidoscopy) or age 65 years (e.g., influenza and pneumococcal vaccination). The overall response rate for the survey was 63%. Data were weighted to correct for disproportionate probabilities of selection and to post-stratify the data to census estimates of the population age and sex distributions for the four counties. SUDAAN was used to produce confidence intervals and to account for the complex survey design. Results are not stratified by race/ethnicity because the population was predominately white (95%) and non-Hispanic (98%).

Prevalence of health-care coverage was high among this age group, with approximately 42% of respondents on Medicare (Table_1). Most respondents had had a routine checkup during the preceding 2 years (Table_2). The prevalence of specific clinical preventive services varied by county. The least used services were blood stool test in Litchfield County, Connecticut (32.2%), sigmoidoscopy in Columbia County, New York (26.0%), and pneumococcal vaccination in Dutchess County, New York (36.9%). Physician recommendation for preventive services was strongly associated with the patient receiving the services. For example, the prevalence of persons who received a preventive service after a physician recommendation was higher than that of persons who received the service without a recommendation (e.g., blood stool test {57.0% versus 15.3%}, pneumococcal vaccination {92.0% versus 13.6%}, and influenza vaccination {80.4% versus 43.1%}). The prevalence of clinical preventive services use in surveyed counties was similar to the prevalences for Connecticut, Massachusetts, and New York collected through state BRFSS surveys.

Reported by: D Shenson, MD, D DiMartino, MSN, V Stucker, MBA, M Alderman, MD, Sickness Prevention Achieved through Regional Collaboration, Lakeville, Connecticut; M Metersky, MD, D Mathur, MPH, Connecticut Peer Review Organization, Middletown; M Adams, MPH, Connecticut Dept Public Health. J Quinley, MD, IPRO, Lake Success; M Caldwell, MD, Dutchess County Dept of Health, Poughkeepsie; C Maylahn, MPH, New York State Dept of Health. P O'Reilly, PhD, Massachusetts Peer Review Organization, Waltham; D Brooks, MPH, Massachusetts Dept of Public Health. R Dicker, MD, M Campbell, PhD, Health Care Financing Administration. Div of Epidemiology and Surveillance, and Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion; National Immunization Program, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that despite high levels of health-care coverage and access to physicians, adult clinical preventive services in the region are not fully used. These findings are consistent with studies in other populations that indicate patients are often not aware of the need for these services and that clinicians frequently do not recommend preventive services to their patients (4-6). As a result of the survey findings, SPARC plans to broaden its partnerships with medical specialists and generalists to improve the use of preventive services.

Acquiring information at the local level helps local institutions, organizations, and persons recognize the existence and magnitude of a public health challenge and creates new opportunities for community-wide interventions that can increase the use of preventive services. Performance monitoring is an important tool for establishing shared responsibility among community-level health-care providers (7). A major reason preventive services are not fully used in the United States may be that no defined public or private organization takes responsibility for assuring that all residents in a community are presented with an informed choice and reasonable access to these services.

SPARC is an example of a public/private partnership that fosters community-based activism for clinical preventive services. Although SPARC does not deliver these services, it has developed a local infrastructure that can use data from the survey as a basis for action. For example, SPARC has been working since 1995 to increase the use of influenza vaccination among persons aged greater than or equal to 65 years in each of the four counties through outreach and marketing campaigns. To promote pneumococcal vaccination, in 1997, SPARC's collaborators in two counties offered pneumococcal vaccination along with influenza vaccination, which more than doubled the prevalence of pneumococcal vaccination with only a modest increase in resources. From 1996 to 1997, the annual prevalence of pneumococcal vaccinations reimbursed by Medicare increased from 5.9% to 12.1% in Litchfield County and from 6.7% to 13.4% in Dutchess County (Health Care Financing Administration, unpublished data, 1998).

Based on these survey data, SPARC and its collaborators (i.e., preventive service providers, community associations, businesses, and county and municipal health departments) are designing and implementing additional ways of increasing the use of preventive services. Outreach strategies include community mailings, establishment of new sites for prevention activities, improved access to information hotlines, and radio and local cable television announcements.

The findings in this report are subject to at least three limitations. First, the survey excluded households without telephones; however, telephone coverage in all three states is very high (93%-96%) (8). Second, self-reported data are subject to recall bias, potentially resulting in overestimates or underestimates of use. Finally, the survey excludes nursing home residents who comprise approximately 5% of the population aged greater than or equal to 65 years in these four counties.

A second SPARC survey is planned for 2001 to measure anticipated progress in the county and regional delivery of clinical preventive services. Enlisting the support of health-care providers, community associations, and patients in increasing the use of clinical preventive services for adults can reduce health-care costs and morbidity and mortality and enhance the quality of life in the aging U.S. population.

References

1. US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore, Maryland: Williams & Wilkins, 1996.

2. Public Health Service. Healthy people 2000: midcourse review and 1995 revisions. Washington, DC: US Department of Health and Human Services, Public Health Service, 1995.

3. CDC. Use of clinical preventive services by Medicare beneficiaries aged greater than or equal to 65 years -- United States, 1995. MMWR 1997;46: 1138-43.

4. Lurie N, Manning WG, Peterson C, et al. Preventive care: do we practice what we preach? Am J Public Health 1987;77:801-4.

5. Lemley KB, O'Grady ET, Rauckhorst L, et al. Baseline data on the delivery of clinical preventive services provided by nurse practitioners. Nurs Pract 1994;19:57-63.

6. Rosenblatt RA, Hart LG, Baldwin L, et al. The generalist role of specialty physicians: is there a hidden system of primary care? JAMA 1998;279:1364-70.

7. Durch JS, Bailey LA, Stoto MA. Improving health in the community: a role for performance monitoring. Washington, DC: Institute of Medicine, National Academy Press, 1997.

8. Kulp DW. US Census Bureau and GENESYS sampling systems: estimating coverage bias in random-digit dialed samples with Current Population Survey data. Presented at the 1998 Behavioral Risk Factor Surveillance System Conference, Atlanta, Georgia. May 4-6, 1998.

TABLE 1. Number and percentage of persons aged >=50 years reporting selected demographic and health-care factors, by
county -- Sickness Prevention Achieved through Regional Collaboration survey, 1997
======================================================================================================================================================
                         Berkshire County, Mass.   Columbia County, N.Y.   Dutchess County, N.Y.   Litchfield County, Conn.
                         -----------------------   ---------------------   ---------------------   ------------------------
Characteristic                No.     (%)               No.     (%)             No.    (%)                No.    (%)
---------------------------------------------------------------------------------------------------------------------------
Sex
  Women                       278    (57.4)             315    (54.7)           392   (54.3)              328   (54.4)
  Men                         210    (42.6)             199    (45.3)           263   (45.7)              256   (45.6)

Age group (yrs)
  50-64                       231    (44.9)             285    (48.7)           364   (54.2)              317   (49.6)
   >=65                       257    (55.1)             229    (51.3)           291   (45.8)              267   (50.4)

Education level
  Less than high school        74    (15.2)              72    (15.6)            79   (11.4)               78   (14.0)
  Some college                184    (38.3)             209    (41.9)           232   (35.8)              214   (37.6)
  College graduate            228    (46.5)             230    (42.5)           341   (52.8)              288   (48.4)

Employment status
  Employed                    173    (33.0)             215    (36.9)           274   (42.0)              269   (41.5)
  Unemployed                   15    ( 2.9)              10    ( 1.4)            20   ( 2.8)               13   ( 2.2)
  Homemaker/Student            12    ( 2.8)              24    ( 4.4)            27   ( 4.1)               25   ( 4.1)
  Retired                     287    (61.4)             264    (57.3)           333   (51.1)              274   (52.2)

Health-care coverage*
  Yes                         461    (95.2)             485    (95.1)           623   (95.4)              554   (96.2)
  No                           26    ( 4.8)              29    ( 4.9)            32   ( 4.6)               25   ( 3.8)

Type of coverage
  Employer                    185    (38.8)             214    (40.0)           313   (51.1)              246   (42.9)
  Private pay                  32    ( 7.3)              46    ( 9.2)            28   ( 4.3)               39   ( 6.5)
  Medicare                    205    (47.5)             184    (43.6)           224   (36.6)              226   (44.0)
  Medicaid                     21    ( 3.6)              17    ( 3.2)            19   ( 2.5)                8   ( 2.0)
  Other                        15    ( 2.8)              21    ( 4.1)            36   ( 5.5)               30   ( 4.6)

Health status+
  Excellent/Very good/Good    403    (83.0)             412    (79.3)           531   (81.9)              488   (83.9)
  Fair/Poor                    84    (17.0)             102    (20.7)           120   (18.1)               92   (16.1)
---------------------------------------------------------------------------------------------------------------------------
* Respondents were asked, "Do you have any kind of health care coverage, including prepaid plans such as HMOs or government plans such as Medicare?"
+ Respondents who reported excellent, very good, or good health are compared with those reporting fair or poor health.
======================================================================================================================================================

TABLE 2. Prevalence of factors related to access to health care and prevalence of clinical preventive health behaviors among
adults aged >=50 years, by county -- Sickness Prevention Achieved through Regional Collaboration survey, 1997
============================================================================================================================================================
                                Berkshire Co., Mass.          Columbia Co., N.Y.           Dutchess Co., N.Y.         Litchfield Co., Conn.
                              -------------------------    -------------------------   -------------------------    -------------------------     BRFSS
Factor                        No.     %      (95% CI*)     No.    %       (95% CI*)    No.     %      (95% CI)      No.    %       (95% CI)    median+ (%)
----------------------------------------------------------------------------------------------------------------------------------------------------------
Last routine checkup
  <2 years ago                439    91.3   (88.6-93.9)    466   93.3    (91.0-95.6)   582    90.6   (88.1-93.1)    529   91.7    (89.3-94.1)      89.9

Regular care source           442    91.0   (88.3-93.7)    471   91.9    (89.4-94.5)   584    88.7   (85.8-91.5)    523   89.9    (87.3-92.6)      NA&

Cost is barrier@               27     5.5   ( 3.3- 7.7)     25    4.7    ( 2.8- 6.7)    32     3.9   ( 2.5- 5.3)     31    5.4    ( 3.4- 7.3)       6.6

Ever had cholesterol check    436    90.6   (87.9-93.3)    472   94.1    (92.0-96.3)   605    93.0   (90.8-95.1)    508   89.5    (86.9-92.1)      89.2

Blood stool test
  <1 year ago                 190    40.3   (35.6-45.0)    163   35.8    (31.1-40.5)   211    33.5   (29.5-37.5)    186   32.2    (28.1-36.3)       NA

Sigmoidoscopy examination
  <5 years ago                134    27.9   (23.6-32.2)    127   26.0    (21.7-30.2)   206    33.8   (29.8-37.9)    163   29.2    (25.2-33.3)      30.5

Last Papanicolaou smear**
  <2 years ago                135    76.4   (69.6-83.3)    164   72.3    (65.7-78.9)   211    73.9   (68.3-79.6)    161   72.0    (65.7-78.3)      74.4

Last mammogram
 <2 years ago                 220    80.0   (74.9-85.1)    232   72.8    (67.1-78.5)   278    71.6   (66.7-76.5)    249   78.3    (73.6-83.0)      73.4

Last influenza shot++
  <1 year ago                 183    73.7   (68.0-79.5)    147   65.6    (58.9-72.2)   178    62.0   (55.9-68.1)    177   67.1    (61.1-73.1)      65.5

Pneumococcal shot ever++      123    50.6   (44.0-57.2)     89   39.8    (32.8-46.8)   100    36.9   (30.8-43.0)    112   43.4    (36.9-49.9)      45.4
----------------------------------------------------------------------------------------------------------------------------------------------------------
 * Confidence interval.
 + From the 1997 U.S. Behavioral Risk Factor Surveillance System (BRFSS) survey.
 & Not available.
 @ Respondents were asked, "Was there a time in the last 12 months when you needed to see a doctor but could not because of the cost?"
** Percentage of female respondents, without hysterectomy, who report that they had had a Papanicolaou smear within the preceding 2 years.
++ Only reported for persons aged >= 65 years.
============================================================================================================================================================

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