Surveillance for Use of Preventive Health-Care Services by Older Adults, 1995-1997

Gail R. Janes, Ph.D., M.S.¹
Donald K. Blackman, Ph.D.²
Julie C. Bolen, Ph.D, M.P.H.¹
Laurie A. Kamimoto, M.D., M.P.H.^1,3
Luann Rhodes, M.P.A., M.P.H.¹
Lee S. Caplan, M.D, M.P.H., Ph.D.²
Marion R. Nadel, Ph.D., M.P.H.²
Scott L. Tomar, D.M.D., Dr.P.H.⁴
James F. Lando, M.D., M.P.H.⁵
Stacie M. Greby, D.V.M., M.P.H.⁶
James A. Singleton, M.S.⁶
Raymond A. Strikas, M.D.⁶
Karen G. Wooten, M.A.⁷

Problem/Condition: In 1995, a total of 55 million persons aged greater than or equal to 55 years lived in the United States. The members of this large and growing segment of the population are major consumers of health care. Their access to medical and dental preventive services contributes to their likelihood of healthy later years and influences their long-term impact on the health-care delivery system.

Reporting Period: 1995-1997.

Description of Systems: This report summarizes data from the National Health Interview Survey (NHIS), the state-based Behavioral Risk Factor Surveillance System (BRFSS), and the Medicare Current Beneficiary Study (MCBS) to describe national, regional, and state-specific patterns of access to and use of preventive services among persons aged greater than or equal to 55 years.

Results: During 1995-1997, approximately 90% of persons aged greater than or equal to 55 years living in the United States reported having a regular source of health-care services. However, only 75%-80% reported receiving a routine checkup during the preceding 2 years. The estimated percentage of persons who reported not being able to receive medical care because of cost was highest for those aged 55-64 years. Within this age group, the percentage was highest among Hispanics (4%) and persons without a high school diploma. Approximately 11% of Medicare beneficiaries reported delaying care because of cost or because they had no particular source of care. Percentage estimates varied according to age, race/ethnicity, and sociodemographic status. Approximately 95% of persons aged greater than or equal to 55 years reported having their blood pressure checked during the preceding 2 years, but only 85%-88% had received a cholesterol evaluation during the preceding 5 years. The percentage of women receiving breast and cervical cancer screening decreased with increasing age, and the percentage of persons aged greater than or equal to 55 years who had received some form of screening for colorectal cancer was low -- approximately 25% for fecal occult blood testing (FOBT) and 45% for endoscopy. State-specific rates of compliance with vaccination recommendations among persons aged greater than or equal to 65 years were higher for influenza vaccine (range: 54%-74%) than for pneumococcal vaccine (range: 32%-59%), and compliance increased with advancing age. State-specific estimates of the percentage of annual dental visits varied 40%-75%, and 41%-88% of persons aged greater than or equal to 65 years reported not having dental insurance.

Interpretation: Access to medical services among adults living in the United States is greater for persons aged greater than or equal to 65 years, compared with those aged less than 65 years, presumably because of Medicare coverage. In contrast, use of dental services decreased, despite increased need for preventive and restorative dental care. Although Medicare covers many medical services for older adults, financial, personal, and physical barriers to both medical and dental care create racial, regional, and sociodemographic disparities in health status and use of health services in the United States.

Public Health Action: Continued surveillance of access to and use of health services among older adults (i.e., persons aged greater than or equal to 65 years), as well as among persons aged 55-64 years, will help health-care providers target underserved groups, make Medicare coverage decisions, and develop public health programs to ensure equitable access to services and improve the health of older adults.

Life expectancy has increased substantially during this century, and persons living in the United States who reach age 65 years have a high probability of living to age 80 years. Numerous health problems often accompany the last decades of life. However, adequate access to medical and dental care, including preventive services, can reduce premature morbidity and mortality, as well as preserve function and enhance overall quality of life (1-3). This report examines determinants of access to and use of health-care services among persons aged greater than or equal to 55 years living in the United States.

The Institute of Medicine (IOM) defines appropriate health-care access as "the timely use of personal health services to achieve the best possible health outcomes" (4). Access is influenced by many factors, including facilitators of and barriers to care. Having a regular source of care -- defined as a doctor or other health-care provider, or a specific site where care is provided -- is one of the strongest determinants of access to health care, independent of a person's age (5), potentially influencing both the likelihood of receiving care and the quality of that care.

IOM describes several types of barriers that can block access to health care, including financial and structural (i.e., physical) barriers. Lack of insurance is often a major financial barrier for persons aged less than 65 years. For persons aged greater than or equal to 65 years, access to care improves when they become eligible for Medicare, which now covers many clinical preventive services (6). However, out-of-pocket health-care costs for Medicare beneficiaries lacking supplemental insurance can still pose a major barrier, causing some beneficiaries to delay or avoid services viewed as discretionary (e.g., filling prescriptions) (7). Medicare beneficiaries who opt to join a Medicare managed-care plan can avoid some of these expenses and also receive coverage for some preventive services not covered by traditional Medicare. However, at the end of each calendar year, managed-care plan administrators can renegotiate their charges and covered benefits or leave the Medicare program. Difficulties getting to a health-care provider or long waiting times for an appointment can be major structural obstacles for older adults. This report presents age-specific national and state estimates of the percentage of these factors, based on the 1995 National Health Interview Study (NHIS), the 1995-1997 Behavioral Risk Factor Surveillance System (BRFSS), and the 1996 Medicare Current Beneficiary Survey (MCBS).

Timely and appropriate access to preventive services is important with increasing age. The Guide to Clinical Preventive Services of the U.S. Preventive Services Task Force (USPSTF) recommends screening older adults for treatable chronic conditions that are the major causes of death for this population (e.g., cardiovascular disease and cancer) (8). Screening for hypertension is recommended for both children and adults. Healthy People 2000 recommends increasing to greater than or equal to 90% the proportion of adults who have had their blood pressure measured during the preceding 2 years and who can state whether their blood pressure was normal or high (objective 15.13) (1). Hypertension is most prevalent among older adults and is a leading risk factor for both heart disease and cerebrovascular disease. Data from multiple trials suggest that antihypertensive treatment of persons aged greater than or equal to 60 years reduces mortality from all causes and reduces morbidity and mortality from stroke and coronary heart disease (CHD) (9).

Elevated serum cholesterol is also a major risk factor for CHD among men and women, but USPSTF deemed the epidemiologic evidence linking cholesterol and all-cause mortality among persons aged greater than 65 years insufficient to indicate the need for cholesterol screening for all persons in this age group (8). Thus, USPSTF recommends screening only for persons aged greater than 65 years with CHD risk factors. No direct evidence indicates that lowering cholesterol levels is beneficial for this population, but clinical trials are under way. Evidence indicates that cholesterol levels in older adults can be lowered by behavioral and pharmacologic interventions (8). The National Cholesterol Education Program Adult Treatment Panel II (NCEP II) revisited its guidelines in 1994 and now recommends routine measurement of nonfasting total cholesterol and high-density lipoprotein cholesterol (HDL-C) in all adults aged greater than or equal to 20 years at least once every 5 years (10). A Healthy People 2000 objective is to increase to greater than or equal to 75% the proportion of adults who have had their blood cholesterol checked during the preceding 5 years (objective 15.14) (1). Age-specific state estimates of the percentage of screening for hypertension and elevated serum cholesterol were calculated from the 1997 BRFSS for this report.

Morbidity and mortality associated with many types of cancers also increase with age. The significance of cancer prevention efforts have increased in recent years. For many cancers, risk factors are not amenable to change, so secondary prevention through screening and early detection is the main form of intervention. This report examines three cancers for which effective screening has been demonstrated to reduce mortality -- breast, cervical, and colorectal cancers.

In 1999, breast cancer will be diagnosed in an estimated 175,000 women, and 43,300 will die from the disease (11). An estimated 12,800 women will be diagnosed with invasive cervical cancer, and 4,800 will die (11). Approximately 129,400 persons will be diagnosed with colorectal cancer, and 56,600 will die from the disease (11). Early detection and timely treatment of these diseases can alter their progression and reduce mortality. USPSTF recommends regular breast cancer screening for women aged 50-69 years, although many groups recommend initiating screening at age 40 years. Breast cancer screening guidelines do not extend to women aged greater than or equal to 70 years because of the lack of clinical data on the effectiveness of screening this population. The American College of Physicians (ACP) recommends mammograms every 2 years for women aged 50-74 years. Healthy People 2000 set a national objective of increasing to greater than or equal to 60% the proportion of women aged greater than or equal to 50 years who have received a clinical breast examination and a mammogram during the preceding 1-2 years (objective 16.11) (1). USPSTF recommends routine cervical cancer screening with Papanicolaou (Pap) testing for all women who are sexually active and have a cervix. There is insufficent clinical data to support recommending Pap tests for women aged greater than 65 years whose previous screenings have been negative (8). This is supported by the Healthy People 2000 objective to increase to greater than or equal to 95% the proportion of women aged greater than or equal to 18 years with a cervix who have ever received a Pap test and to greater than or equal to 85% those who have received a Pap test during the preceding 1-3 years (objective 16.12) (1).

To reduce mortality from colorectal cancer, one or more of the following tests are recommended for persons aged greater than or equal to 50 years: a) annual fecal occult blood testing (FOBT), b) flexible sigmoidoscopy, or c) double-contrast barium enema (8,12,13). A Healthy People 2000 objective recommends increasing to greater than or equal to 50% the proportion of persons aged greater than or equal to 50 years who have received FOBT during the preceding 1-2 years and to greater than or equal to 40% those who have ever received proctosigmoidoscopy (objective 16.13) (1). This report presents 1997 state-specific BRFSS data on self-reported breast and cervical cancer screening among women aged greater than or equal to 55 years and colorectal cancer screening among men and women aged greater than or equal to 55 years.

As noted, Medicare covers several clinical preventive services, including influenza and pneumococcal vaccination, mammography, pap tests and pelvic exams, and colorectal cancer screening (including screening FOBT, flexible sigmoidoscopy, and colonoscopy). However, Medicare coverage for most preventive services was increased or initiated on January 1, 1998, by the Medicare provisions of the Balanced Budget Act of 1997. The data in this report were collected during 1997 (except 1995 NHIS data and 1995-1997 dental services data). In 1997, Medicare covered biennial screening mammography for women aged greater than or equal to 65 years and screening pap tests every 3 years, subject to the deductible for Medicare Part B (which covers physician services); influenza and pneumoccal vaccinations were covered with no deductible. Screening for colorectal cancer and elevated serum cholesterol were not covered benefits in 1997.

Appropriate and timely vaccination can substantially reduce the impact of vaccine-preventable infectious disease. In 1997, a total of 90% of U.S. deaths attributed to pneumonia and influenza occurred among persons aged greater than or equal to 65 years, making these illnesses the fifth leading cause of death for this age group (14). During influenza epidemics, persons aged greater than or equal to 65 years face increased risk for influenza-associated hospitalizations (range: from 200 to greater than 1,000/100,000 population during epidemics from 1972 through 1981) and deaths (range: from 25 to greater than 150/100,000 during 19 epidemics from 1972 through 1995) (15). Persons aged greater than or equal to 65 years are also at increased risk for invasive pneumococcal disease, including bacteremia and meningitis, with an estimated annual incidence of 50-83 cases/100,000 population compared with 15-30 cases/100,000 among persons of all ages (16).

To decrease morbidity and mortality from influenza and pneumococcal disease, annual influenza vaccinations and one dose of pneumococcal polysaccharide vaccine are recommended for persons aged greater than or equal to 65 years (8,15,16). Medicare has reimbursed one lifetime pneumococcal vaccination, including the cost of the vaccine since 1981 and the cost of administration since 1992. Since May 1, 1993, Medicare has reimbursed health-care providers for the cost of influenza vaccine and its administration. Both pneumococcal and influenza vaccination are covered under Medicare Part B, with no deductible. A Healthy People 2000 objective is to increase influenza and pneumococcal vaccination levels to greater than or equal to 60% among persons at high risk for complications, including those aged greater than or equal to 65 years (objective 20.11) (1). This report analyzes influenza and pneumococcal vaccination rates from the 1997 BRFSS by age and state.

Regular dental care is also important for older adults, who are at higher risk for numerous oral conditions and diseases because of age-related physiologic changes, use of various medications, and underlying chronic diseases (17). Oral diseases and conditions can impact quality of life among older adults (18-20). Regular dental visits allow dental health professionals to provide preventive services, early diagnosis, and treatment. Although limited empirical evidence supports the universal need for annual dental examinations, and because the appropriate frequency of dental visits is usually left to clinicians' judgment (8), older adults who do not receive regular care can be at increased risk for serious oral diseases. Thus, annual oral examinations are recommended for all adults, including those aged greater than or equal to 55 years (21). The American Cancer Society (ACS) recommends annual oral examinations for persons aged greater than or equal to 40 years (22), and USPSTF recommends regular dental visits for persons aged greater than or equal to 65 years (8).

Recognizing the importance of periodic dental visits, Healthy People 2000 established a national objective of increasing to approximately 70% the proportion of persons aged greater than or equal to 35 years who receive oral health care each year (objective 13.14) (1). Target levels for population subgroups with historically low rates of dental service use are slightly lower -- 50% for edentate persons (i.e., those with no natural teeth) and 60% for persons aged greater than or equal to 65 years.

Dental insurance coverage is a strong correlate of dental care use, particularly among older adults (23). Because dental insurance typically is provided as an employee benefit, retired persons are less likely to have dental insurance. With few exceptions, Medicare does not cover dental care services (24), and few states provide adult dental coverage under their Medicaid programs (25). This report analyzes the percentage of persons aged greater than or equal to 55 years who reported a dental visit and dental insurance coverage during the 12 months preceding participation in the 1995-1997 BRFSS, by age and state.

All tables in this report were created using data from the 1995 NHIS, the 1995-1997 BRFSS, or the 1996 MCBS. All three data systems rely on self-reports, which can over- or underestimate the percentage of certain behaviors. The NHIS is an ongoing, annual, cross-sectional household survey of the U.S. resident civilian, noninstitutionalized population. NHIS data are obtained through personal interviews with household members. Information on all members of the household is collected, and proxy responses are allowed. The 1995 NHIS consisted of two parts: a set of basic health and demographic items and questions concerning current health topics. The 1995 sample design included the oversampling of both black and Hispanic persons to improve the stability of estimates for these groups (26). For this report, percentage estimates were stratified by age (55-64 years, 65-74 years, and greater than or equal to 75 years), race/ethnicity,* sex, education (less than 12 years of school, 12 years, or greater than 12 years), and region.**

SAS software (i.e., an integrated system for data access, management, analysis, and presentation) was used to calculate percentage estimates. Software for Survey Data Analysis (SUDAAN) (Version 7.0; Research Triangle Institute, Research Triangle Park, North Carolina) was used to calculate 95% confidence intervals (CIs).

The BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of U.S. resident civilian, noninstitutionalized persons aged greater than or equal to 18 years. This survey collects self-reported information regarding behaviors related to health status (27). The BRFSS excludes households without telephones, but only approximately 2.5% of older adults do not have a phone. Institutionalized persons, who are also excluded, likely account for approximately 5% of persons aged greater than or equal to 65 years (28). In 1997, a total of 25,000 persons aged greater than or equal to 65 years from 52 reporting areas (i.e., the 50 states, the District of Columbia, and Puerto Rico) participated in the BRFSS. Data from Puerto Rico were not included in these analyses. An Oral Health Module was added in 1995, and 46 states administered this module at least once during 1995-1997.

For this report, BRFSS data were aggregated to create a yearly sample for each state and stratified by age group (55-64 years, 65-74 years, greater than or equal to 65 years, and greater than or equal to 75 years). Missing data or data coded as "don't know" or "refused" were excluded from analyses. The data were then weighted to both the respondent's probability of selection and the distribution of each state's population by age, sex, and race/ethnicity, according to current census or intercensal estimates (29,30). SUDAAN statistical software was used to calculate state-specific percentages and 95% CIs. Median percentage estimates were based on combined state-specific percentage estimates from the 50 states and the District of Columbia. To increase the precision of estimates from the BRFSS Oral Health Module, data from multiple years (1995-1997) were merged for states that had administered the module at least once during this period.

The MCBS is a continuous, multipurpose, complex survey of noninstitutionalized and institutionalized Medicare beneficiaries, including disabled persons. It is designed to determine expenditures and sources of payment for all services used by Medicare beneficiaries, as well as the beneficiaries' health status and functioning, income, assets, living arrangements, family support, and access to medical care. For this report, MCBS data were summarized from the 1996 Access to Care File, a public-use data set of annual use and expenditure summaries from Medicare files, along with survey data about insurance coverage, health status and functioning, access to care, information needs, satisfaction with care, and income (31). The sampling frame comes from Medicare enrollment files of the Health Care Financing Administration (HCFA), with oversampling of disabled persons aged less than 65 years and all persons aged greater than or equal to 85 years. A new sample is added each year to include new Medicare beneficiaries and to replenish sample groups depleted by refusals and death. Personal interviews are conducted with beneficiaries or their proxies three times a year where the respondents reside. Sample members are followed for 4 years. This report analyzes only noninstitutionalized respondents aged greater than or equal to 65 years.

Two MCBS questions were designed to assess respondents' access to health care: "Have you had any trouble getting health care that you wanted or needed?" and "Were any medicines prescribed for you that you did not get [during the current year]?" Respondents who answered yes to the first question were classified as having trouble getting health care. Those who answered yes to the second question were classified as not getting prescribed medications. The following queries examined potential barriers to receipt of health care:

• "Have you delayed seeking medical care because you were worried about the cost?" Respondents answering yes were classified as having delayed care because of cost.
• "Please indicate how satisfied you have been with the ease and convenience in getting to a doctor from where you live." Respondents who indicated that they were either dissatisfied or very dissatisfied were classified as not satisfied with how easily they could get to a doctor.
• "Is there a particular medical person or clinic you usually go to when you are sick or for advice about your health?" Respondents who answered no were classified as having no particular source of health care.
• "Is there a particular doctor you usually see at this place?" Respondents who answered yes to the previous question were asked this follow-up question. Those who answered no to this question were classified as having no particular doctor at their usual health-care site.

SUDAAN statistical software was used to calculate percentage estimates and standard errors, adjusting for the complex structure of the survey. The estimates were stratified by combinations of race (black or white) and sex, by age groups (65-74 years, 75-84 years, and greater than or equal to 85 years), and by income levels (greater than $25,000, less than or equal to $25,000, less than or equal to $15,000, and less than or equal to $10,000), which are cumulative rather than mutually exclusive. The estimates were age-adjusted within the race/sex strata, sex-adjusted within the age strata, and age- and sex-adjusted within the income strata to the 1970 U.S. standard population.

Most adults aged greater than or equal to 55 years reported having a regular source of medical care during the preceding year (Table 1). However, when the responses were stratified by age, persons aged less than 65 years were consistently less likely to have a regular source of care than persons aged greater than or equal to 65 years. The proportion of respondents who had a regular source of care also increased with education level. Hispanics aged less than 65 years were less likely to have a regular source of care, but data from respondents aged greater than or equal to 65 years demonstrated no consistent differences across racial and ethnic groups. Men were slightly but consistently less likely to report a regular source of care than women.

Persons with a regular source of medical care are more likely to receive basic medical services (e.g., a routine checkup), which presents the opportunity for delivery of preventive services (5). Most persons aged greater than or equal to 55 years reported having a routine checkup during the preceding 2 years, and use of this preventive service increased with increasing age (Table 2). The median value was 77.3% for persons aged 55-64 years, 84.6% for persons aged 65-74 years, and 87.8% for those aged greater than or equal to 75 years. The median of all responses was 86.1%. Across all age groups, the lowest percentage was among persons aged 55-64 years in California (66.2%), and the highest was among persons aged greater than or equal to 75 years in Louisiana (94.7%).

The NHIS asked respondents whether they had delayed seeking medical care during the preceding 12 months because of concern regarding the cost. In general, few respondents said yes (Table 3). Among persons aged less than 65 years, greater than or equal to 10% of Hispanics,*** non-Hispanic blacks, and persons with less than a high school education indicated that they had delayed care because of cost during the preceding year. The rate decreased for respondents aged greater than or equal to 65 years; for those aged 65-74 years, the rate was greater than 5% for Hispanics and persons with less than a high school education. Persons aged greater than or equal to 75 years reported that they rarely encountered this problem. Respondents to the BRFSS were also asked whether they had failed to receive medical care during the preceding year because of cost (Table 4). The percentage of persons who reported that cost was not a barrier increased with advancing age: the median value was 92.3% for persons aged 55-64 years, 96.2% for persons aged 65-74 years, and 97.0% for those aged greater than or equal to 75 years. The highest percentage of respondents who reported that cost was not a barrier was among persons aged greater than or equal to 75 years in Nevada (99.8.%), and the lowest was among persons aged greater than or equal to 75 years in Arizona (71.3%).

The MCBS also includes data on noninstitutionalized Medicare beneficiaries aged greater than or equal to 65 years who reported difficulties in accessing medical care (Table 5). Fewer than 5% of MCBS respondents reported problems receiving care or prescribed medications. When stratified by sex and race, the percentage of persons who reported difficulties receiving care ranged from 2.1% (white males) to 4.1% (black females). The percentage of persons who did not receive prescribed medications ranged from 2% (white males) to 4.7% (black females). When stratified by income, the proportion of persons who reported difficulties receiving care ranged from 2% for those in the highest income group (greater than $25,000) to 4% for those with incomes less than or equal to $10,000. In the high-income category, 1.7% did not receive prescribed medications, compared with 3.3% in the low-income group. Overall, respondents were more likely to report specific barriers to care (e.g., lack of ease getting to the doctor, cost, or no specific source of care). Among sex and race groups, 8.3% of black females reported dissatisfaction with the ease of getting to the doctor, compared with 3.7% of black males. Of the three age groups (i.e., 65-74 years, 75-84 years, and greater than or equal to 85 years), persons aged greater than or equal to 85 years were the most likely to report difficulties getting to the doctor (6.8%) as were those in the lowest income group (7.3%).

Despite the minimal percentage of respondents who reported difficulties receiving care or who did not fill prescriptions, a larger percentage reported delaying care because of cost, although percentages varied across groups. Approximately twice as many black males reported delaying care because of cost than did white males (9.3% versus 4.7%), and the same was true when black females were compared with white females (11.1% versus 6.5%). Persons aged 65-74 years were approximately twice as likely as persons aged greater than or equal to 85 years to have delayed care (6.8% versus 3.7%), and those in the lowest income stratum were approximately five times as likely as those in the highest income stratum to report delaying care (11.2% versus 2.3%). Black males and females also were more likely than white males and females to report not having a regular source of medical care (11.1% and 8.7% versus 7.4% and 6.0%). Persons with incomes less than or equal to $10,000 were approximately twice as likely as persons earning greater than $25,000 to have no regular source of care (11.0% versus 5.2%). Respondents who reported having a regular site of care were asked whether they saw a particular doctor at that site; 23.6% of black males and 15.6% of black females reported that they did not, compared with 11.3% of white males and 8% of white females. A higher percentage of persons aged 65-74 years reported not seeing a particular doctor (11.6%), compared with persons aged greater than or equal to 85 years (7.7%). Of persons earning greater than $25,000, a total of 7.5% reported having no regular doctor, compared with 18.9% of those with an income less than or equal to $10,000.

Data from the BRFSS were used to analyze how many adults aged greater than or equal to 55 years received blood pressure checks during the preceding 2 years. The median estimates were 95.1% among persons aged 55-64 years, 96.7% among persons aged 65-74 years, and 97.7% among persons aged greater than or equal to 75 years (Table 6). Values ranged from 89% for persons aged 55-64 years in Wisconsin to 100% for persons aged greater than or equal to 75 years in Georgia and the District of Columbia. The median estimates of the percentage of blood cholesterol checks during the preceding 5 years (Table 7) ranged from 84.9% among persons aged 55-64 years to 88.3% among persons aged 65-74 years. Values ranged from 68.3% among persons aged greater than or equal to 75 years in Kansas to 94.9% among persons aged 55-64 years in Michigan.

For breast cancer screening, the median percentages of women who reported having a mammogram during the preceding 2 years were 77.0% among those aged 55-64 years, 75.4% among those aged 65-74 years, and 61.4% among those aged greater than or equal to 75 years (Table 8). State-specific percentages ranged from 57.3% (Arkansas) to 90.7% (Alaska) among women aged 55-64 years; from 55.7% (Arkansas) to 87.4% (Rhode Island) among women aged 65-74 years; and from 37.9% (Indiana) to 75.3% (District of Columbia) among women aged greater than or equal to 75 years. For most states, the lowest percentage was among women aged greater than or equal to 75 years.

The BRFSS also collects data on eligible women (i.e., those with an intact uterus) who reported having a Pap test during the preceding 3 years (Table 9). The median percentages were 83.4% among women aged 55-64 years, 77.4% among women aged 65-74 years, and 58.2% among women aged greater than or equal to 75 years. State-specific percentages ranged from 66.8% (Arizona) to 92% (District of Columbia) among women aged 55-64 years; from 65.7% (Nevada) to 89.1% (South Carolina) among women aged 65-74 years; and from 40.7% (Mississippi) to 81.8% (District of Columbia) among women aged greater than or equal to 75 years. For all states except Arizona, the lowest percentage was among women aged greater than or equal to 75 years.

The median percentages of persons who reported having FOBT during the preceding 2 years were 25.8% among persons aged 55-64 years, 31.7% among persons aged 65-74 years, and 27.2% among persons aged greater than or equal to 75 years (Table 10). The percentages ranged from 12.9% (Mississippi) to 40.0% (North Carolina) among persons aged 55-64 years; from 13.6% (Oklahoma) to 46.8% (Oregon) among persons aged 65-74 years; and from 13.9% (Oklahoma) to 43.0% (Maine) among persons aged greater than or equal to 75 years. When the values were stratified according to sex and age, more women reported having FOBT than did men in both age groups (55-64 years and greater than or equal to 65 years). Among both men and women, the median percentages were higher among persons aged greater than or equal to 65 years than among those aged 55-64 years.

The median percentages of persons who reported ever having sigmoidoscopy or proctoscopy were 40.3% among persons aged 55-64 years, 48.3% among persons aged 65-74 years, and 46.3% among persons aged greater than or equal to 75 years (Table 11). State-specific percentages ranged from 26.8% (Oklahoma) to 54.0% (Minnesota) among persons aged 55-64 years; from 17.4% (Oklahoma) to 61.9% (Wisconsin) among persons aged 65-74 years; and from 30.6% (Oklahoma) to 63.5% (Virginia) among persons aged greater than or equal to 75 years. Among men, the median percentages were 44.3% among those aged 55-64 years and 53.3% among those aged greater than or equal to 65 years. Among women, the corresponding median values were 37.2% and 43.3%. Median percentages were consistently higher among men, as well as among men and women aged greater than or equal to 65 years.

In 1997, the percentage of persons aged 55-64 years who reported receiving influenza vaccination during the preceding 12 months ranged from 28.5% in Georgia to 54.7% in Colorado (median: 38.2%) (Table 12). Among persons aged 65-74 years, percentages ranged from 48.7% in Nevada to 72.4% in Colorado (median: 63.6%). Among persons aged greater than or equal to 75 years, percentages ranged from 51.7% in the District of Columbia to 82.0% in Arizona (median: 71.4%).

The percentage of persons aged 55-64 years who reported in 1997 that they had ever received a pneumococcal vaccination ranged from 9.5% in New York to 30.7% in Alaska (median: 17.1%) (Table 13). Among persons aged 65-74 years, percentages ranged from 30.1% in New Jersey to 56.9% in Arizona (median: 42.6%). Among persons aged greater than or equal to 75 years, percentages ranged from 31.4% in Louisiana to 79.0% in Nevada (median: 53.3%).

According to the BRFSS data, the percentage of persons aged greater than or equal to 65 years who had visited a dentist during the preceding 12 months ranged from 39.7% in Oklahoma to 75.4% in Hawaii (median: 59.1%) (Table 14). Overall, use of dental services decreased with advancing age, from a median of 67.5% among persons aged 55-64 years to 63.0% among persons aged 65-74 years and to 56.1% among persons aged greater than or equal to 75 years. Of the 46 states with data on adult dental visits, 22 (48%) reported that<F128M> "60% of persons aged greater than or equal to 65 years had obtained dental services during the preceding 12 months, which is the Healthy People 2000 objective (objective 13.14). In seven states (15%), fewer than 50% of persons aged greater than or equal to 65 years visited a dentist during the preceding 12 months. Five of these states were located in the South. In 15 states (33%), fewer than 50% of persons aged greater than or equal to 75 years visited a dentist during the preceding 12 months.

Lack of dental insurance coverage was more common among persons aged greater than or equal to 65 years (median: 73.8%) than among those aged 55-64 years (median: 48.1%) (Table 15). In every state except Hawaii, greater than 50% of persons aged greater than or equal to 65 years reported not having dental insurance. In all 46 states included in this analysis, most persons aged greater than or equal to 75 years reported not having dental insurance coverage (median: 79.8%). In 31 states (67%), greater than or equal to 75% of persons in this age group reported not having dental care coverage.

Ensuring access to the full range of medical and dental services is critical to both the duration and quality of life for older adults living in the United States. This report examines barriers to health care (e.g., cost and the lack of a regular source of care). Overall, cost is not a major barrier to care for most older adults, although certain factors (e.g., race/ethnicity, educational attainment, and income) can increase a person's chances of deferring care because of cost. Although out-of-pocket expenses (i.e., copayments and deductibles) can be a burden for some Medicare beneficiaries who cannot afford supplemental or Medi-gap insurance (7), MCBS data indicate that few Medicare beneficiaries have problems receiving care or prescribed medications for any reason. A slightly higher percentage of persons reported not being satisfied with the ease of getting to a doctor, which might reflect age-related transportation difficulties (e.g., persons who no longer drive and are dependent on friends and relatives or on public transportation).

Most persons aged greater than or equal to 55 years also reported having a regular source of care. Research has demonstrated that persons with any type of regular source of health care have better access to care than those without a regular source, as measured by a set of preventive and primary-care use indicators (5). Because persons with a regular source of care are more likely to access primary-care services, the rates of persons receiving routine checkups and the rates of persons who have a regular source of care should be similar. However, state- and age-specific estimates of the percentage of persons aged greater than or equal to 55 years reporting a routine check-up during the preceding 2 years is lower than the national estimates of persons with a regular source of care. One reason could be that respondents who receive care of some chronic condition(s) might have underreported this factor, although they receive regular preventive care as part of their routine visits.

Numerous health reports have emphasized the importance of primary, secondary, and tertiary screening of older adults to prevent, delay, or minimize disease, risk factors, preexisting conditions, and disability and to enhance both health status and quality of life (2,32). Thus, USPSTF and other organizations (e.g., ACP and ACS) have published age-specific guidelines for delivery of preventive services to persons aged greater than or equal to 65 years (8). Screening for cardiovascular disease (CVD) and its risk factors is particularly important among older adults. The percentage of hypertension, an important risk factor for CVD, increases with age, and treatment has been demonstrated to be effective for all adults, including persons aged greater than or equal to 55 years (2). Regular screening for hypertension is recommended for all adults aged greater than or equal to 21 years (8). The relation between cholesterol and CVD is supported by clinical and epidemiologic studies (33), and regular screening is recommended for persons who are middle-aged or at high risk for disease (8,10). Although the relation between lipid-lowering therapies and morbidity and mortality among older adults is less conclusive than for younger adults, evidence indicates that cholesterol reduction could be effective for older adults (34). Both USPSTF and ACP suggest that individualized screening and treatment is appropriate for persons aged 65-75 years who are healthy but at high risk for disease (8,2,35). NCEP II recommends routine measurement of nonfasting total cholesterol and HDL-C levels in adults aged greater than or equal to 20 years every 5 years (10). Consistent with these recommendations, the state- and age-specific percentage estimates for blood pressure screening are high (median: greater than 95% for adults aged greater than or equal to 55 years). However, rates are lower for blood cholesterol checks, which vary from 85% to 90% for adults aged greater than or equal to 55 years.

In 1991, Healthy People 2000 set objectives for increasing the use and timeliness of cancer screening procedures (1). Several federal initiatives have been developed in recent years for breast and cervical cancer screening. Breast cancer is the most common malignancy among women and is second only to lung cancer as the leading cause of cancer deaths (11). In the United States, the incidence of breast cancer increased rapidly during 1973-1990 but remained stable during 1991-1995 (36). The death rate from breast cancer, which had been on the rise, has decreased 5.3% among white women but increased 0.6% among black women during 1991-1995 (36,37). Breast cancer screening has been demonstrated to reduce mortality in women aged 50-69 years (8,38,39). Most recommendations suggest screening women in this age group with a mammogram and a clinical breast examination every 1-2 years. Less consensus exists regarding continued screening among women aged greater than or equal to 70 years because of the lack of data on screening effectiveness for this age group. However, both breast cancer incidence and mortality increase substantially with advancing age (37,40). Despite this, the results reported in this publication indicate that breast cancer screening is less common among women aged greater than or equal to 65 years, compared with women aged 55-64 years.

During 1973-1995, the incidence of cervical cancer declined 43.3% overall and 52.0% among women aged greater than or equal to 65 years, whereas the mortality rate declined 45.9% overall and 50.0% among women aged greater than or equal to 65 years (37). Much of this reduction has been associated with increased use of Pap tests, although the effectiveness of this test for reducing cervical cancer mortality has only been evaluated in observational studies, not in randomized clinical trials (41). Pap tests can detect asymptomatic precancerous lesions (i.e., dysplasia), as well as preinvasive lesions that can progress to invasive cervical cancer if untreated (41). Detection and treatment of precancerous and preinvasive lesions can reduce the risk for developing invasive cervical cancer (42) and thereby improve the prognosis for women diagnosed with these conditions. An estimated 37%-60% reduction in cervical cancer mortality could be achieved with regular screening for all women (43). Thus, USPSTF, ACS, ACP, and other health organizations recommend Pap tests for all sexually active women aged less than or equal to 65 years who have a cervix. USPSTF states that testing can be discontinued after age 65 years if previous screenings have been negative. However, older women are more often diagnosed at later stages of disease and are more likely to die from the disease than younger women (1). They also are less likely than younger women to have ever received screening. Furthermore, the 5-year survival rate is 57.0% among women aged 65-74 years and 45.7% among women aged greater than or equal to 75 years, compared with 61.4% among women aged 55-64 years (11). For these reasons, older women could benefit from timely cervical cancer screening (11).

Comparing this report's findings on Pap tests with reports during 1988-1989 indicates that the proportion of women who reported ever receiving a Pap test and the proportion who reported receiving a test during the preceding 3 years have not changed substantially in the past decade (1,44,45). In this report, approximately 83% of women aged 55-64 years reported receiving a Pap test during the preceding 3 years, which suggests that more progress has been made toward achieving the Healthy People 2000 objective (objective 16.12) among this age group (95%) than among women aged greater than or equal to 75 years (median: 58%).

Colorectal cancer is the second leading cause of cancer-related death and the third most commonly diagnosed cancer for both men and women in the United States (11). The risk for developing colorectal cancer increases with advancing age, and the risk is higher among men than women (37,12). Overall, colorectal cancer incidence decreased 7.4% during 1973-1995. During the same period, incidence decreased 5.3% among males and 10.4% among females, 9.6% among persons aged less than 65 years, and 6.1% among persons aged greater than or equal to 65 years (37). However, the incidence among blacks of both sexes, especially males, has increased and exceeds the rate among whites. Although the colorectal cancer mortality rate decreased 20.8% among the general population during 1973-1995, mortality increased 26.1% among black males aged greater than or equal to 65 years and 15.6% among black males aged less than 65 years (37). Overall mortality is considerably higher among blacks than whites.

Recent research has demonstrated that screening to detect colorectal cancer early reduces mortality (13). Current technology also allows curative excision of early-stage colorectal cancers during the screening procedure. The 5-year survival rate for persons with localized disease is approximately 91%. However, only 37% of colorectal cancers are diagnosed at a localized stage. The 5-year survival rate is reduced to 34% for persons with regional-stage disease and to 8% for those with advanced-stage disease.

ACS recommends screening all persons aged greater than or equal to 50 years who are at average risk for disease, using one of the following methods: a) annual FOBT plus flexible sigmoidoscopy every 5 years, b) total colon exam by either colonoscopy every 10 years, or c) double-contrast barium enema every 5-10 years (12). ACS also recommends a digital rectal exam with sigmoidoscopy or colonoscopy. An interdisciplinary task force supported by five major gastroenterological professional societies has released similar guidelines (13). In 1996, USPSTF revised its clinical preventive services guidelines (8,12) following the results of a randomized clinical trial that demonstrated a 33% reduction in colorectal cancer mortality among persons advised to have annual FOBT, compared with controls. USPSTF now recommends annual FOBT beginning at age 50 years and recommends sigmoidoscopic screening but does not specify how often.

The 1997 BRFSS data demonstrate that screening rates for colorectal cancer among older adults are lower than those for breast and cervical cancers, a finding that is consistent with earlier reports (13,46,47). Trends for FOBT are difficult to estimate because the 1997 BRFSS question was changed to apply to home test kits only. Approximately 28% of persons aged greater than or equal to 55 years reported having FOBT using a home kit during the preceding 2 years, which is less than the Healthy People 2000 objective of 50% (objective 16.13). Approximately 40% of persons aged greater than or equal to 55 years reported ever having proctoscopy or sigmoidoscopy, which is consistent with the Healthy People 2000 objective (objective 16.13). However, the BRFSS questionnaire does not distinguish between tests conducted for diagnosis and those conducted for screening, resulting in a likely overestimate of the actual percentage of screening (47). This might explain why persons aged 65-74 years have the highest screening rates, followed by persons aged greater than or equal to 75 years.

These results reflect varying degrees of progress toward achieving national objectives for cancer screening. Data suggest major strides in increasing the proportion of women who receive timely breast and cervical cancer screening, although the numbers are still lower for older women, despite Medicare coverage for these services since 1991. Ongoing programs (e.g., CDC's National Breast and Cervical Cancer Early Detection Program) designed to promote screening, follow-up, and referral for medically underserved women should be broadened to include older women. Colorectal cancer screening has been slow to gain acceptance among both patients and health-care providers, and similar efforts might be required to support and encourage delivery and use of this clinical preventive service.

This report indicates that in 1997, influenza vaccination coverage exceeded the Healthy People 2000 objective of 60% (objective 20.11) in 38 states among persons aged 65-74 years and in all states except Alaska among persons aged greater than or equal to 75 years. Among persons aged greater than or equal to 65 years, only five states and the District of Columbia had coverage levels less than 60%.

Among persons aged 65-74 years and greater than or equal to 65 years, no state met or exceeded the Healthy People 2000 objective of 60% pneumococcal vaccination coverage (objective 20.11). Among persons aged greater than or equal to 75 years, pneumococcal vaccination coverage exceeded the 60% objective in nine states.

Persons aged greater than or equal to 75 years were more likely than persons aged 65-74 years to report receiving influenza and pneumococcal vaccinations or better health care that impacts survival. Increased age might represent increased opportunity for patient encounters with the health-care system, increased offers for vaccination by providers, and increased perception of need for vaccination by both patients and providers. Awareness of the need for routine vaccination should be increased among health-care providers and all persons aged greater than or equal to 65 years.

Low vaccination rates among persons aged 55-64 years could reflect the lack of routine vaccination recommendations for this population in 1997 and the lack of Medicare coverage, which does not begin until age 65 years. Among persons aged 55-64 years, influenza vaccination is particularly recommended for the following groups: a) residents of nursing homes or other chronic care facilities that house persons of any age with chronic medical conditions; b) persons with chronic disorders of the pulmonary or cardiovascular system; c) persons who required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, or hemoglobinopathies; d) persons with immunosuppression, including those infected with the human immunodeficiency virus (HIV); and e) persons who care for or live with persons at high risk for complications of influenza (15).

Pneumococcal vaccination is recommended for the following groups of persons aged 2-64 years: a) those with chronic cardiovascular disease, chronic pulmonary disease (i.e., chronic obstructive pulmonary disease and emphysema, but not asthma), diabetes mellitus, alcoholism, chronic liver disease, cerebrospinal fluid (CSF) leaks, or functional or anatomic asplenia; b) persons in certain environments or social settings (e.g., Alaskan Natives and some American Indian populations living on reservations with high disease incidence); and c) immunocompromised persons, including persons infected with HIV (16). Most subgroups recommended for influenza and pneumococcal vaccination could not be identified with BRFSS, and institutionalized populations are not included in BRFSS.

Vaccination rates varied substantially by state. Multiple factors are likely to account for state differences, including patterns of physician practice, existence of public health adult vaccination programs, and patients' attitudes and access to care. Public and private providers of adult immunization services at the state level need to be more aware of the factors known to affect vaccination services (e.g., a doctor's recommendation for vaccination, locations of vaccination services, and a patient's reasons for accepting or declining vaccination services). Increased awareness will aid the development and implementation of effective public health policies and practices to increase adult vaccination rates.

This study has at least two limitations. First, self-reports regarding vaccination were not validated. However, in previous studies, the sensitivity of self-report of influenza vaccination during the preceding influenza season ranged from 92% to 100% when vaccination status was validated by record review; specificity ranged from 71% to 98% (48,49). Using an interpretation of the kappa scale (50), the agreement between self-report and medical records ranged from substantial to almost perfect (kappa range: 0.74-0.92). The sensitivity of self-report of ever receiving pneumococcal vaccination ranged from 87% to 97% when vaccination status was validated by record review. Specificity ranged from 53% to 76%, and agreement with record review was moderate to substantial (kappa range: 0.42-0.64) (49,50). The second limitation of this study is that samples of persons in racial and ethnic minority groups were not large enough to accurately estimate vaccination coverage for these populations in most states. Analysis of the 1997 BRFSS aggregated data across states for persons aged greater than or equal to 65 years indicated lower levels of influenza and pneumococcal vaccination among non-Hispanic blacks and Hispanics compared with whites (51).

During 1995-1997, influenza and pneumococcal vaccination coverage among persons aged greater than or equal to 65 years increased in most states (51). However, use of both vaccines among persons aged 65-74 years and use of pneumococcal vaccine among all persons aged greater than or equal to 65 years must increase to reach the Healthy People 2000 objectives. An objective of greater than or equal to 90% coverage for influenza and pneumococcal vaccinations among persons aged greater than or equal to 65 years has been developed for the Healthy People 2010 objectives planned for release in January 2000 (52).

Since 1981, pneumococcal vaccinations have been covered for persons enrolled in Medicare Part B; influenza vaccinations have been covered since 1993 (6). Continued education of health-care providers and the community is needed to increase awareness of and demand for adult vaccination services. Interventions (e.g., standing orders for vaccination, provider reminders and feedback, and patient reminders) have been effective in increasing adult vaccination levels (53,54). Guidelines and tools for implementing these interventions are available through Put Prevention into Practice, a national campaign to improve delivery of clinical preventive services (55). In addition, opportunities for vaccination outside traditional health-care settings could be increased to reach older adults who do not routinely access traditional health-care settings.

Based on BRFSS data, fewer than one-half of states have achieved the Healthy People 2000 objective for increased use of dental care services among persons aged greater than or equal to 65 years (objective 13.14). This suggests a need for improvement in appropriate use of care. For example, edentate persons (i.e., those who have lost all of their natural teeth) are substantially less likely than dentate persons (i.e., those with natural teeth) to seek dental care (17). Older adults are more likely than younger adults to be edentate, and this factor could account for some differences in the use of dental services among age groups. A strong correlation exists between the proportion of older adults in a state who visited a dentist and the proportion of this population who are edendate (CDC, unpublished data, 1999). Because edentate persons are less likely to visit a dentist, their likelihood of early detection of oral pathology as part of a periodic dental exam is lower. However, tooth loss is not an inevitable characteristic of aging and probably reflects past dental treatment practices and societal attitudes toward tooth loss, as well as dental disease experience (56). Both life expectancy and the proportion of persons retaining their natural teeth into advanced age are increasing in the United States, and the need for preventive and restorative oral health services also will increase (57).

Ensuring oral health function and quality of life among older adults living in the United States will require sustained efforts to promote proven methods of preventing and controlling oral disease. These measures include community water fluoridation, clinical preventive services, and early detection and treatment of oral and dental conditions. To help ensure appropriate and equitable access to and use of oral health services among older adults, health-care delivery systems might need to be modified to include coverage for these services.

References

1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.
2. Goldberg TH, Chavin SI. Preventive medicine and screening in older adults. J Am Geriatr Soc 1997;45:344-54.
3. CDC. Pneumococcal and influenza vaccination levels among adults aged greater than or equal to 65 years--United States, 1995. MMWR 1997;46:913-9.
4. Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Millman M, ed. Washington, DC: National Academy Press, 1993.
5. Lambrew JM, DeFriese GH, Carey TS, Ricketts TC, Biddle AK. The effects of having a regular doctor on access to primary care. Med Care 1996;34:138-51.
6. 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.
7. Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med 1995;332:1138-43.
8. U.S. Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore, MD: Williams & Wilkins, 1996.
9. Insua JT, Sacks HS, Lau T-S, et al. Drug treatment of hypertension in the elderly: a meta-analysis. Ann Intern Med 1994;121:355-62.
10. Grundy SM. National cholesterol education program: second report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Circulation 1994;89:1331-63.
11. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1998 [published errata appear in CA Cancer J Clin 1998;48:192 and 1998;48:329]. CA Cancer J Clin 1998;48:6-29.
12. Byers T, Levin B, Rothenberger D, Dodd GD, Smith RA. American Cancer Society guidelines for screening and surveillance for early detection of colorectal polyps and cancer: update 1997. CA Can J Clin 1997;47:154-60.
13. Winawer SJ, Fletcher RH, Miller R, et al. Colorectal cancer screening: clinical guidelines and rationale. Gastroenterology 1997;112:594-642.
14. Hoyert DL, Kochanek KD, Murphy SL. Deaths: Final data for 1997. Natl Vital Stat Rep 1999;47.
15. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1999;48(No. RR-4).
16. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(No. RR-8).
17. Dolan TA, Atchison KA. Implications of access, utilization, and need for oral health care by the non-institutionalized and institutionalized elderly on the dental delivery system. J Dent Educ 1993;57:876-87.
18. Smith JM, Sheiham A. How dental conditions handicap the elderly. Community Dent Oral Epidemiol 1979;7:305-10.
19. Reisine ST. The impact of dental conditions on social functioning and the quality of life. Annu Rev Public Health 1988;9:1-19.
20. Locker D, Slade GD. Oral health and the quality of life among older adults: the oral health impact profile. J Can Dent Assoc 1993;59:830-44.
21. Public Health Service. Clinician's handbook of preventive services: putting prevention into practice. Washington, DC: US Department of Health and Human Services, Public Health Service, 1994.
22. American Cancer Society. Cancer facts & figures--1998. Atlanta, GA: American Cancer Society, 1998.
23. Manski RJ, Goldfarb MM. Dental utilisation for older Americans aged 55-75. Gerodontology 1996;13:49-55.
24. Meskin LH, Mason LD. Problems in oral health care financing for the elderly. Clin Geriatr Med 1992;8:685-92.
25. American Dental Association. 1998 survey of state dental programs in Medicaid. Chicago, IL: American Dental Association, Council on Dental Benefits Programs, 1998.
26. Benson V, Marano MA. Current estimates from the National Health Interview Survey, 1995. Vital and Health Stat 10 1998;199.
27. Powell-Griner E, Anderson JE, Murphy W. State- and sex-specific prevalence of selected characteristics--Behavioral Risk Factor Surveillance System, 1994 and 1995. In: CDC surveillance summaries (August 1). MMWR 1997;46(No. SS-3):1-31.
28. US Bureau of the Census. National population estimates. Available on the Internet at http://www.census.gov/population/www/estimates/uspop.html#monthly. Accessed July 12, 1999.
29. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In: Using chronic disease data: a handbook for public health practitioners. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC;1992:4-1-4-17.
30. Gentry EM, Kalsbeek WD, Hogelin GC, et al. The behavioral risk factor surveys II: Design, methods, and estimates from combined state data. Am J Prev Med 1985;1:9-14.
31. Adler G. A profile of the Medicare Current Beneficiary Survey. Health Care Financing Review. Summer 1994:153-63.
32. German PS, Burton LC, Shapiro S, et al. Extended coverage for preventive services for the elderly: response and results in a demonstration population. Am J Public Health 1995;85:379-86.
33. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4,444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383-9.
34. Gordon DJ, Rifkind BM. Treating high blood cholesterol in the older patient. Am J Cardiol 1989;63:48H-52H.
35. Anonymous. Guidelines for using serum cholesterol, high-density lipoprotein cholesterol, and triglyceride levels as screening tests for preventing coronary heart disease in adults. American College of Physicians. Part 1 [see comments]. Ann Intern Med 1996;124:515-7.
36. CDC. Breast cancer incidence and mortality--United States, 1992. MMWR 1996;45:833-7.
37. Ries LAG, Kosary CL, Hankey BF, Miller BA, Edwards BK, eds. SEER cancer statistics review, 1973-1995. Bethesda, MD: National Cancer Institute, 1998.
38. Kerlikowske K, Grady D, Rubin SM, Sandrock C, Ernster VL. Efficacy of screening mammography: a meta-analysis. JAMA 1995;273:149-54.
39. Tabar l, Fagerberg G, Chen H-H, et al. Efficacy of breast cancer screening by age: new results from the Swedish Two-County Trial. Cancer 1995;75:2507-17.
40. Faulk RM, Sickles EA, Sollitto RA, Ominsky SH, Galvin HB, Frankel SD. Clinical efficacy of mammographic screening in the elderly. Radiology 1995;194:193-7.
41. Schiffman MH, Brinton LA, Devesa SS, Fraumeni JF, Jr. Cervical cancer. In: Schottenfeld D, Fraumeni JF, Jr., eds. Cancer epidemiology and prevention. 2nd ed. Oxford: Oxford University Press, 1996.
42. Kiviat N. Natural history of cervical neoplasia: overview and update. Am J Obstet Gynecol 1996;175:1099-104.
43. Brownson RC, Reif JS, Alavanja MCR, Bal DG. Cancer. In: Brownson RC, Remington PL, Davis JR, eds. Chronic disease epidemiology and control. Washington, DC: American Public Health Association, 1993:137-67.
44. National Center for Health Statistics. Healthy people 2000 review, 1993. Hyattsville, MD: US Department of Health and Human Services, Public Health Service, 1994.
45. Ackermann SP, Brackbill RM, Bewerse BA, Sanderson LM. Cancer screening behaviors among U.S. women: breast cancer, 1987-1989, and cervical cancer, 1988-1989. In: CDC surveillance summaries (April 24). MMWR 1992;41(No. SS-2):17-34.
46. CDC. Trends in cancer screening--United States, 1987 and 1992. MMWR 1996;45:57-61.
47. CDC. Screening for colorectal cancer--United States, 1992-93, and new guidelines. MMWR 1996;45:107-10.
48. Hutchison BG. Measurement of influenza vaccination status of the elderly by mailed questionnaire: response rate, validity and cost. Can J Public Health 1989;80:271-5.
49. Mac Donald R, Baken L, Nelson A, Nichol KL. Validation of self-report of influenza and pneumoccocal vaccination status in elderly outpatients. Am J Prev Med 1999;16:173-7.
50. Landis JR, Koch GC. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-74.
51. CDC. Influenza and pneumococcal vaccination levels among adults aged greater than or equal to 65 years--United States, 1997. MMWR 1998;47:797-802.
52. Office of Disease Prevention and Health Promotion. Healthy people 2010 objectives: draft for public comment. Washington, DC: US Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion, 1998.
53. Shefer A, Briss P, Rodewald L, et al. Improving immunization coverage rates: an evidence-based review of the literature. Epidemiol Rev 1999;21:96-142.
54. Gyorkos TW, Tannenbaum TN, Abrahamowicz M, et al. Evaluation of the effectiveness of immunization delivery methods. Can J Public Health 1994;85(suppl 1):S14-S30.
55. Agency for Health Care Policy and Research. The clinician's handbook of preventive services. 2nd ed. Rockville, MD: US Department of Health and Human Services, Agency for Health Care Policy and Research, 1998. Publication no. APPIP98-0025. Also available on the Internet at http://www.ahcpr.gov/ppip/handbkiv.htm. Accessed July 12, 1999.
56. Burt BA. Epidemiology of dental diseases in the elderly. Clin Geriatr Med 1992;8:447-59.
57. Gift HC, Newman JF. How older adults use oral health care services: results of a national health interview survey. J Am Dent Assoc 1993;124:89-93.

* Race/ethnicity data are presented only for non-Hispanic whites, non-Hispanic blacks, and Hispanics because sample sizes for other racial/ethnic groups were too small for meaningful analysis.

** Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; and West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

*** Persons of Hispanic origin can be of any race.