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Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the report in the subject line of e-mail. Local Data for Local Decision Making -- Selected Counties, Connecticut, Massachusetts, and New York, 1997Although 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 NoteEditorial 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
Table_1 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size. 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. ====================================================================================================================================================== Return to top. Table_2 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size. 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. ============================================================================================================================================================ Return to top. 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