chen2005

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<p>R</p><p>S</p><p>J</p><p>O</p><p>M</p><p>R</p><p>C</p><p>I</p><p>R</p><p>e</p><p>S</p><p>t</p><p>a</p><p>c</p><p>s</p><p>b</p><p>e</p><p>n</p><p>m</p><p>s</p><p>p</p><p>F</p><p>P</p><p>U</p><p>M</p><p>A</p><p>3</p><p>acial/Ethnic Disparities in the Use of Preventive</p><p>ervices Among the Elderly</p><p>udy Y. Chen, MD, Allison Diamant, MD, MSHS, Nadereh Pourat, PhD, Marjorie Kagawa-Singer, PhD, RN</p><p>bjectives: Minorities have worse health outcomes compared to whites, which are partially explained</p><p>by racial/ethnic disparities in use of health services. Less well known, however, are whether</p><p>these disparities persist among the elderly, the only group that possesses near universal</p><p>health insurance coverage by Medicare, and how variation in Medicare coverage affects the</p><p>receipt of preventive services. The scope of racial/ethnic disparities in the use of preventive</p><p>services in the elderly was assessed, and the impact of the type of health insurance coverage</p><p>on the use of preventive services was measured.</p><p>ethods: Data were derived from the 2001 California Health Interview Survey, a random-digit-dial</p><p>population-based survey, collected between November 2000 and October 2001. Analysis for</p><p>this project was conducted in 2004. The association of race/ethnicity and type of health</p><p>insurance with receipt of preventive services was assessed using bivariate and multivariate</p><p>logistic regression models.</p><p>esults: African Americans and Latinos were significantly less likely to be vaccinated for influenza,</p><p>and Asian Americans were significantly less likely to obtain a mammogram compared to</p><p>whites, while controlling for other explanatory factors. Moreover, those with Medicare plus</p><p>Medicaid coverage were significantly less likely to use all four preventive services compared</p><p>to those with Medicare plus private supplemental insurance.</p><p>onclusions: Despite near-universal coverage by Medicare, racial/ethnic disparities in the use of some</p><p>preventive services among the elderly persist. Further research should focus on identifying</p><p>potential cultural and structural barriers to receipt of preventive services aimed at</p><p>designing effective intervention among high-risk groups.</p><p>(Am J Prev Med 2005;29(5):388–395) © 2005 American Journal of Preventive Medicine</p><p>s</p><p>u</p><p>t</p><p>a</p><p>w</p><p>i</p><p>h</p><p>t</p><p>t</p><p>u</p><p>c</p><p>r</p><p>n</p><p>N</p><p>o</p><p>s</p><p>M</p><p>D</p><p>S</p><p>h</p><p>ntroduction</p><p>esearch from the past decade indicates that</p><p>significant disparities in receipt of health ser-</p><p>vices exist primarily due to the effects of race/</p><p>thnicity, income,1–3 and health insurance coverage.4</p><p>ince 1965, most adults aged �65 years were guaran-</p><p>eed health insurance under Medicare. However, vari-</p><p>tions in types of Medicare supplemental insurance</p><p>overage exist.5</p><p>The effectiveness of age-appropriate and gender-</p><p>pecific preventive services in optimizing health has</p><p>een clearly demonstrated. Vaccination of persons at</p><p>levated risk from contracting influenza and pneumo-</p><p>ia has been cost-effective in reducing morbidity and</p><p>ortality.6–10 Similarly, breast and colorectal cancer</p><p>creening have been documented to be effective in</p><p>roviding early detection, reduction in mortality, and</p><p>rom the Department of Medicine (Chen, Diamant), School of</p><p>ublic Policy (Pourat), and School of Public Health (Kagawa-Singer),</p><p>niversity of California-Los Angeles, Los Angeles, California</p><p>Address correspondence and reprint requests to: Judy Y. Chen,</p><p>C</p><p>D, UCLA Department of Medicine, 911 Broxton Ave, 3rd Floor, Los</p><p>ngeles CA 90024. E-mail: jychen@mednet.ucla.edu.</p><p>88 Am J Prev Med 2005;29(5)</p><p>© 2005 American Journal of Preventive Medicine • Publish</p><p>ignificant improvement in quality of life.11–14 Yet doc-</p><p>mented disparities in preventive health service utiliza-</p><p>ion exist by race/ethnicity. Less well known, however,</p><p>re whether these disparities persist among the elderly</p><p>ho have access to health insurance coverage. Even less</p><p>s known about the effect of differences in the types of</p><p>ealth insurance for the elderly on receipt of preven-</p><p>ive services.15</p><p>To more closely investigate these gaps in the litera-</p><p>ure, (1) the scope of racial/ethnic disparities in the</p><p>se of three preventive services (influenza vaccine,</p><p>olorectal and breast cancer screening) among five</p><p>acial/ethnic groups (whites, African Americans, Lati-</p><p>os, Asian Americans, and American Indians/Alaskan</p><p>atives) were assessed; and (2) the impact of the type</p><p>f health insurance coverage on use of preventive</p><p>ervices was measured.</p><p>ethods</p><p>ata were used from the 2001 California Health Interview</p><p>urvey (CHIS 2001), a random-digit-dial (RDD) telephone</p><p>ealth survey of California households. Data collection for</p><p>HIS 2001 began in November 2000 and was completed in</p><p>0749-3797/05/$–see front matter</p><p>ed by Elsevier Inc. doi:10.1016/j.amepre.2005.08.006</p><p>O</p><p>C</p><p>n</p><p>C</p><p>K</p><p>a</p><p>5</p><p>s</p><p>i</p><p>a</p><p>y</p><p>w</p><p>A</p><p>(</p><p>(</p><p>s</p><p>D</p><p>O</p><p>r</p><p>U</p><p>C</p><p>w</p><p>r</p><p>w</p><p>c</p><p>U</p><p>(</p><p>F</p><p>e</p><p>s</p><p>t</p><p>s</p><p>t</p><p>u</p><p>p</p><p>t</p><p>i</p><p>p</p><p>I</p><p>O</p><p>h</p><p>A</p><p>i</p><p>c</p><p>p</p><p>s</p><p>h</p><p>S</p><p>y</p><p>w</p><p>e</p><p>a</p><p>o</p><p>i</p><p>(</p><p>t</p><p>w</p><p>A</p><p>c</p><p>n</p><p>v</p><p>M</p><p>h</p><p>a</p><p>a</p><p>S</p><p>B</p><p>i</p><p>W</p><p>s</p><p>g</p><p>t</p><p>i</p><p>c</p><p>i</p><p>r</p><p>c</p><p>a</p><p>d</p><p>s</p><p>o</p><p>1</p><p>t</p><p>a</p><p>2</p><p>M</p><p>A</p><p>a</p><p>i</p><p>y</p><p>v</p><p>m</p><p>w</p><p>R</p><p>S</p><p>T</p><p>m</p><p>p</p><p>g</p><p>(</p><p>h</p><p>p</p><p>w</p><p>v</p><p>i</p><p>w</p><p>p</p><p>ctober 2001. Analysis for this project was conducted in 2004.</p><p>omputer-assisted telephone interviews for the adult compo-</p><p>ent were conducted in six languages: English, Spanish,</p><p>hinese (Mandarin and Cantonese dialects), Vietnamese,</p><p>orean, and Khmer (Cambodian).16 Proxy interviews were</p><p>llowed for frail and ill persons aged �65 (n �316). Over</p><p>7,000 adults completed the interviews, with an overall re-</p><p>ponse rate based on completion of the screener and the</p><p>nterviews of 37.7%.16</p><p>To address the issue of preventive services utilization</p><p>mong the elderly, the study focused on people aged �65</p><p>ears who had completed the survey and self-identified as</p><p>hite (9064), African American (485), Latino (560), Asian</p><p>merican (489), and Native American and Alaskan Native</p><p>126). Pacific Islanders (41) and others of mixed descent</p><p>396) were excluded from the analysis because of insufficient</p><p>ample sizes and heterogeneity of these populations.</p><p>ependent Variables</p><p>utcomes of interest were receipt of preventive services</p><p>ecommended for people aged �65 years as of 2001 by the</p><p>.S. Preventive Services Task Force (USPSTF) and American</p><p>ancer Society (ACS).17,18 The specific preventive services</p><p>ere receipt of influenza vaccine within the preceding year,</p><p>eceipt of mammogram within the preceding 2 years for</p><p>omen, and receipt of colorectal cancer screening. Four</p><p>olorectal cancer screening modalities are recommended by</p><p>SPSTF and ACS: (1) annual fecal occult blood test (FOBT),</p><p>2) sigmoidoscopy every 5 years, (3) combination of annual</p><p>OBT and sigmoidoscopy every 5 years, and (4) colonoscopy</p><p>very 10 years. Because CHIS did not differentiate use of</p><p>igmoidoscopy versus colonoscopy, receipt of lower gastroin-</p><p>estinal (GI) endoscopy was defined as receipt of either</p><p>igmoidsocopy or colonoscopy. Based on these recommenda-</p><p>ions, receipt of colorectal cancer screening was assessed</p><p>sing three modalities: (1) receipt of FOBT within the</p><p>receding 2 years, (2) receipt of lower GI endoscopy within</p><p>he past 5 years, and (3) receipt of FOBT within the preced-</p><p>ng 2 years and receipt of lower GI endoscopy within the</p><p>receding 5 years.</p><p>ndependent Variables</p><p>ur main independent variables were race/ethnicity and</p><p>ealth insurance. Race/ethnicity was categorized as white,</p><p>frican American, Latino, Asian American, and Native Amer-</p><p>can and Alaskan Native. Health insurance coverage was</p><p>ategorized into five types: Medicare plus Medicaid, Medicare</p><p>lus other private source, Medicare only, other insurance</p><p>ource only, and no insurance.</p><p>Other covariates included sociodemographic variables,</p><p>ealthcare access, health status, and health risk behavior.</p><p>ociodemographic variables in this analysis are age (65 to 74</p><p>ears, and �74 years), gender, marital status (married versus</p><p>idowed, separated, divorced, cohabiting, or never married),</p><p>ducation (less than high school, high school graduate, and</p><p>ny college education), annual household income, and place</p><p>f birth (U.S. born vs foreign born). Annual household</p><p>ncome was classified according to federal poverty level</p><p>FPL): �100%, 100% to 199%, 200% to 299%, and �300% of</p><p>he FPL. l</p><p>For example, an annual household income of $10,715</p><p>ould correspond to 100% FPL for a two-person household.</p><p>ccess to care measures included having a usual source of</p><p>are and number of visits to a physician in the past year. The</p><p>umber of physician visits was dichotomized into one or no</p><p>isit versus two or more.</p><p>Health risk behavior included current smoking status.19</p><p>easures of health status included self-reported general</p><p>ealth status (excellent/very good, good, and fair/poor),20</p><p>nd the presence of diagnosed comorbidities: diabetes,</p><p>sthma, heart disease, hypertension, and arthritis.</p><p>tatistical Analysis</p><p>ivariate analyses were performed to examine the character-</p><p>stics of the population by race/ethnicity. Using the pairwise</p><p>ald chi-square test, the insurance types, use of preventive</p><p>ervices, and other covariates between white and nonwhite</p><p>roups were compared. The use of preventive services be-</p><p>ween individuals with Medicare plus private supplemental</p><p>nsurance and those with other insurance types were also</p><p>ompared. Using multivariate logistic regression models, the</p><p>ndependent effect of race/ethnicity was evaluated on the</p><p>eceipt of influenza vaccine, mammography, and colorectal</p><p>ancer screening, while controlling for type of health insur-</p><p>nce and other covariates. In the same model, the indepen-</p><p>ent effect of health insurance type on receipt of preventive</p><p>ervices was assessed while controlling for race/ethnicity and</p><p>ther covariates. SAS, version 8.2 (SAS Institute Inc., Cary NC,</p><p>999), and SUDAAN, version 8.0 (Research Triangle Insti-</p><p>ute, Research Triangle Park NC, 2001), were used for all</p><p>nalyses to adjust for the complex survey design of CHIS</p><p>001.</p><p>issing Data</p><p>ge, race/ethnicity, FPL, and insurance type were imputed</p><p>ccording to geographic, statistical distribution, and match-</p><p>ng methods.21 The number of visits to a physician in the past</p><p>ear had �4% missing values. All other variables had missing</p><p>alues of �2%, and there was no variation in distribution of</p><p>issing values stratified by race/ethnicity; these actual values</p><p>ere used for the analyses.</p><p>esults</p><p>ample Characteristics</p><p>here was significant variation by race/ethnicity for</p><p>ost covariates except gender and number of visits to a</p><p>hysician in the past year (Table 1). A significantly</p><p>reater proportion of Latinos (31%), Asian Americans</p><p>27%), and African Americans (22%) than whites (9%)</p><p>ad annual household incomes �100% FPL. Larger</p><p>roportions of Latino and Asian American elderly than</p><p>hites were foreign born (46% and 76%, respectively,</p><p>ersus 10%).</p><p>Overall, 99% of adults aged �65 years had health</p><p>nsurance. A significantly larger proportion of non-</p><p>hites (28% to 44%) than whites (13%) had Medicare</p><p>lus Medicaid coverage (p �0.05). Whites had the</p><p>argest proportion of those covered by Medicare plus</p><p>Am J Prev Med 2005;29(5) 389</p><p>p</p><p>o</p><p>S</p><p>A</p><p>i</p><p>(</p><p>L</p><p>t</p><p>A</p><p>N</p><p>N</p><p>r</p><p>8</p><p>p</p><p>e</p><p>a</p><p>a</p><p>o</p><p>2</p><p>t</p><p>I</p><p>T</p><p>A</p><p>h</p><p>w</p><p>L</p><p>m</p><p>m</p><p>T</p><p>F</p><p>A</p><p>M</p><p>%</p><p>E</p><p>F</p><p>T</p><p>U</p><p>N</p><p>D</p><p>A</p><p>H</p><p>H</p><p>A</p><p>G</p><p>C</p><p>a</p><p>* -squar</p><p>A</p><p>3</p><p>rivate supplemental insurance (78%) compared to</p><p>ther racial/ethnic groups (36% to 54%) (p �0.001).</p><p>ignificantly more African Americans, Latinos, and</p><p>sian Americans (6% to 8%) than whites (4%) had</p><p>nsurance coverage from other sources than Medicare</p><p>p �0.05). While elderly Asian Americans (3%) and</p><p>atinos (2%) had significantly higher uninsured rates</p><p>han whites (�1%) (p �0.001), uninsured rates of</p><p>frican Americans and American Indian and Alaskan</p><p>ative did not significantly differ from that of whites.</p><p>Significantly fewer American Indians and Alaskan</p><p>atives (91%) and Latinos (94%) than whites (97%)</p><p>eported having a usual source of care (p �0.01). Over</p><p>6% of the elderly had made two or more visits to a</p><p>hysician in the past year with no significant racial/</p><p>able 1. Descriptive statistics of variables by race/ethnicity</p><p>Whites</p><p>(n�9064) %</p><p>Black</p><p>(n�4</p><p>emale 58 60</p><p>ge (years)</p><p>65 to 74 50 55</p><p>�75 50 45</p><p>arital status</p><p>Married 56 43��</p><p>Othera 45 57��</p><p>Federal poverty level</p><p>0–99 9 22��</p><p>100–199 26 32*</p><p>200–299 20 16*</p><p>�300 45 30��</p><p>ducation</p><p>Less than high school 12 29��</p><p>High school graduate 30 28</p><p>Some college education 58 43��</p><p>oreign born 10 3</p><p>ype of health insurance</p><p>Medicare plus Medicaid 13 42��</p><p>Medicare plus private</p><p>supplemental</p><p>insurance</p><p>78 46��</p><p>Medicare only 6 6</p><p>Other insurance only 4 6*</p><p>No insurance �1 �1</p><p>sual source of care 97 99��</p><p>umber of visits to</p><p>physician in past year</p><p>One visit or no visit 14 14</p><p>Two or more visits 86 86</p><p>iabetes 13 25��</p><p>sthma 10 12</p><p>eart disease 25 19��</p><p>ypertension 53 70��</p><p>rthritis 51 56</p><p>eneral health</p><p>Excellent or very good 44 31��</p><p>Good 30 30</p><p>Fair or poor 26 39��</p><p>urrent smoker 8 13*</p><p>Widowed/separated/divorced/cohabitant/never married.</p><p>p�0.05; **p�0.01; ***p�0.001 compared to whites using Wald chi</p><p>IAN, American Indian and Alaskan Native.</p><p>thnic variation. Significant differences were also found i</p><p>90 American Journal of Preventive Medicine, Volume 29, Num</p><p>mong the groups for general health with whites having</p><p>significantly larger percentage of reporting excellent</p><p>r very good (44% compared to 26% to 35%) and only</p><p>6% of whites reporting fair or poor health compared</p><p>o 32% to 44% for the other ethnic groups.</p><p>nfluenza Vaccination</p><p>he majority of whites (69%), American Indians, and</p><p>laskan Natives (65%), and Asian Americans (71%)</p><p>ad received an influenza vaccination in the past year,</p><p>hile only 53% of African Americans and 54% of</p><p>atinos (p �0.01) had done so (Table 2). Significantly</p><p>ore individuals with Medicare plus private supple-</p><p>ental health insurance (71%) had received an</p><p>Latinos</p><p>(n�560) %</p><p>AIAN</p><p>(n�126) %</p><p>Asians</p><p>(n�489) %</p><p>58 55 53</p><p>72��� 70��� 53���</p><p>28��� 31��� 47���</p><p>53 50 67���</p><p>47 49 33���</p><p>31��� 13 27���</p><p>35��� 43�� 31*</p><p>13��� 17 13���</p><p>21��� 27�� 29���</p><p>52��� 21�� 25���</p><p>25��� 31 28</p><p>24��� 48* 47���</p><p>46��� <1��� 76���</p><p>44��� 28* 39���</p><p>36��� 54��� 45���</p><p>10 11 7</p><p>8�� 7 7*</p><p>2* �1 3*</p><p>94 91 98</p><p>12 11 18</p><p>89 89 82</p><p>24��� 17 15</p><p>10 20* 14*</p><p>18�� 35 19��</p><p>53 65* 57</p><p>49 67* 33���</p><p>26��� 35 27���</p><p>30 33 36*</p><p>44��� 32 37���</p><p>6 12 5*</p><p>e test (all bolded).</p><p>s</p><p>85) %</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>�</p><p>nfluenza vaccination in the past year compared to</p><p>ber 5</p><p>i</p><p>(</p><p>s</p><p>m</p><p>9</p><p>L</p><p>p</p><p>9</p><p>t</p><p>t</p><p>M</p><p>t</p><p>i</p><p>(</p><p>C</p><p>L</p><p>i</p><p>r</p><p>t</p><p>N</p><p>s</p><p>e</p><p>i</p><p>e</p><p>a</p><p>l</p><p>t</p><p>d</p><p>T</p><p>I</p><p>C</p><p>M</p><p>a</p><p>b</p><p>c</p><p>d</p><p>e</p><p>f</p><p>g</p><p>* (all bo</p><p>A d test</p><p>T</p><p>o</p><p>I</p><p>C</p><p>M</p><p>a</p><p>b</p><p>c</p><p>d</p><p>e</p><p>f</p><p>g</p><p>*</p><p>F</p><p>ndividuals with other insurance types (40% to 62%)</p><p>Table 3).</p><p>Controlling for other determinants of preventive</p><p>ervice use, significant racial/ethnic disparities re-</p><p>ained for African Americans (odds ratio [OR]�0.5,</p><p>5% confidence interval [CI]�0.4–0.6, p �0.001) and</p><p>atinos (OR�0.6, 95% CI�0.5–0.8, p �0.001) com-</p><p>ared to whites (Table 4). In contrast, Asians (OR�1.4,</p><p>5% CI�1.0–1.8, p �0.05) were more likely than whites</p><p>o have received an influenza vaccination. While con-</p><p>rolling for race/ethnicity and covariates, elderly with</p><p>edicare plus Medicaid were significantly less likely</p><p>han those with Medicare plus private supplemental</p><p>nsurance to have received an influenza vaccination</p><p>OR�0.8, 95% CI�0.7–1.0, p �0.05).</p><p>able 2. Comparison of preventive services utilization amon</p><p>Whites</p><p>(n�9064) %</p><p>B</p><p>(</p><p>nfluenza immunizationb 69 5</p><p>olorectal cancer screeningc 66 6</p><p>FOBT onlyd 14 1</p><p>Lower GI endoscopy onlye 29 2</p><p>FOBT and lower GI endoscopyf 24 2</p><p>ammogramg n�5220 n</p><p>% %</p><p>80 7</p><p>Probability values represent comparison of minority groups with wh</p><p>Receipt of influenza vaccine in past year.</p><p>Receipt of FOBT in preceding 2 years or receipt of lower endoscop</p><p>Receipt of FOBT in past 2 years only.</p><p>Receipt of lower endoscopy (flexible sigmodiscopy or colonoscopy)</p><p>Receipt of FOBT in past 2 years and receipt of lower endoscopy (fle</p><p>Receipt of mammogram in past 2 years for women.</p><p>p�0.01, **p�0.001 compared to whites using Wald chi-square test</p><p>IAN, American Indian and Alaskan Native; FOBT, fecal occult bloo</p><p>able 3. Comparison of preventive services utilization amon</p><p>ther insurance typesa</p><p>Medicare</p><p>plus private</p><p>(n�7627) %</p><p>Me</p><p>Me</p><p>(n�</p><p>nfluenza immunizationb 71 62�</p><p>olorectal cancer screeningc 69 55�</p><p>FOBT onlyd 14 12</p><p>Lower GI endoscopy onlye 30 27</p><p>FOBT and lower GI endoscopyf 25 16�</p><p>ammogramg n�4767 n�</p><p>% %</p><p>83 71�</p><p>Probability values represent comparison of other insurance groups</p><p>Receipt of influenza vaccine in past year.</p><p>Receipt of FOBT in past 2 years or receipt of lower endoscopy (flex</p><p>Receipt of FOBT in past 2 years</p><p>only.</p><p>Receipt of lower endoscopy (flexible sigmodiscopy or colonoscopy)</p><p>Receipt of FOBT in past 2 years and receipt of lower endoscopy (fle</p><p>Receipt of mammogram in past 2 years for women.</p><p>p�0.05; **p�0.01; ***p�0.001 compared to Medicare plus private using</p><p>OBT, fecal occult blood test; GI, gastrointestinal.</p><p>olorectal Cancer Screening</p><p>atinos (52%) and Asian Americans (57%) had signif-</p><p>cantly lower unadjusted colorectal cancer screening</p><p>ates than whites (66%) (Table 2). Unadjusted colorec-</p><p>al cancer screening rates for African Americans and</p><p>ative Americans and Alaskan Natives did not differ</p><p>ignificantly from those of whites. On more detailed</p><p>xamination of the different colorectal cancer screen-</p><p>ng modalities, the receipt of FOBT only or lower GI</p><p>ndoscopy only did not differ by race/ethnicity. Latinos</p><p>nd Asian Americans (14%) were significantly less</p><p>ikely to obtain both FOBT and lower GI endoscopy</p><p>han whites (24%) (Table 2).</p><p>Individuals with Medicare plus Medicaid (55%), in-</p><p>ividuals with Medicare only (53%), and the uninsured</p><p>tes versus four ethnic groupsa</p><p>s</p><p>5) %</p><p>Latinos</p><p>(n�560) %</p><p>AIAN</p><p>(n�126) %</p><p>Asians</p><p>(n�489) %</p><p>54�� 65 71</p><p>52�� 65 57*</p><p>11 12 14</p><p>27 32 29</p><p>14�� 20 14��</p><p>1 n�323 n�70 n�227</p><p>% % %</p><p>74 70 67��</p><p>ible sigmoidoscopy or colonoscopy) in past 5 years.</p><p>st 5 years only.</p><p>sigmodiscopy or colonoscopy) in past 5 years.</p><p>lded).</p><p>; GI, gastrointestinal.</p><p>se with Medicare plus private supplemental insurance with</p><p>plus</p><p>%</p><p>Medicare</p><p>only</p><p>(n�767) %</p><p>Other insurance</p><p>only</p><p>(n�397) %</p><p>Uninsured</p><p>(n�42) %</p><p>56��� 59��� 40��</p><p>53��� 63 25���</p><p>14 18 17</p><p>22�� 26 4���</p><p>18��� 19 4���</p><p>n�470 n�209 n�25</p><p>% % %</p><p>62��� 75 28*</p><p>edicare plus private.</p><p>igmoidoscopy or colonoscopy) in past 5 years.</p><p>st 5 years only.</p><p>sigmodiscopy or colonoscopy) in past 5 years.</p><p>g whi</p><p>lack</p><p>n�48</p><p>3��</p><p>4</p><p>3</p><p>5</p><p>7</p><p>�29</p><p>9</p><p>ites.</p><p>y (flex</p><p>in pa</p><p>xible</p><p>g tho</p><p>dicare</p><p>dicaid</p><p>485)</p><p>��</p><p>��</p><p>��</p><p>1203</p><p>��</p><p>with M</p><p>ible s</p><p>in pa</p><p>xible</p><p>Wald chi-square test (all bolded).</p><p>Am J Prev Med 2005;29(5) 391</p><p>(</p><p>c</p><p>p</p><p>E</p><p>m</p><p>d</p><p>M</p><p>v</p><p>a</p><p>c</p><p>r</p><p>i</p><p>c</p><p>(</p><p>(</p><p>(</p><p>o</p><p>u</p><p>l</p><p>t</p><p>i</p><p>B</p><p>A</p><p>u</p><p>w</p><p>(</p><p>(</p><p>(</p><p>m</p><p>u</p><p>c</p><p>u</p><p>t</p><p>l</p><p>(</p><p>p</p><p>s</p><p>m</p><p>D</p><p>F</p><p>p</p><p>t</p><p>p</p><p>p</p><p>a</p><p>A</p><p>b</p><p>a</p><p>a</p><p>c</p><p>a</p><p>a</p><p>t</p><p>n</p><p>e</p><p>s</p><p>l</p><p>p</p><p>n</p><p>t</p><p>t</p><p>l</p><p>T</p><p>R</p><p>M</p><p>a</p><p>p</p><p>b</p><p>c</p><p>d</p><p>e</p><p>*</p><p>A OR, o</p><p>3</p><p>25%) had significantly lower unadjusted colorectal</p><p>ancer screening rates than individuals with Medicare</p><p>lus private supplemental insurance (69%) (Table 3).</p><p>xamination of specific colorectal cancer screening</p><p>odalities revealed that receipt of FOBT only did not</p><p>iffer by insurance type. Individuals with Medicare plus</p><p>edicaid (16%) were significantly less likely than indi-</p><p>iduals with Medicare plus private supplemental insur-</p><p>nce (25%) to receive both FOBT and lower GI endos-</p><p>opy (Table 3).</p><p>In the adjusted multivariate analyses, there were no</p><p>acial/ethnic difference for colorectal cancer screen-</p><p>ng, but Medicare plus private supplemental insurance</p><p>overage was a significant positive determinant</p><p>p �0.01) for receipt of colorectal cancer screening</p><p>Table 4). Individuals with Medicare plus Medicaid</p><p>OR�0.7, 95% CI�0.7–0.9, p �0.001), with Medicare</p><p>nly (OR�0.7, 95% CI�0.7–0.9, p �0.01), and the</p><p>ninsured (OR�0.3, 95% CI�0.1–0.6, p �0.01) were</p><p>ess likely to have received colorectal cancer screening</p><p>han those with Medicare plus private supplemental</p><p>nsurance (Table 4).</p><p>reast Cancer Screening</p><p>sian American women (67%) had a significantly lower</p><p>nadjusted mammography rate than whites (79%),</p><p>hile rates for African Americans (80%), Latinos</p><p>74%), and Native Americans and Alaskan Natives</p><p>70%) did not differ significantly from those of whites</p><p>Table 2). Those with Medicare plus private supple-</p><p>ental insurance (83%) had a significantly higher</p><p>nadjusted mammography rate than those with Medi-</p><p>are plus Medicaid (71%), Medicare only (62%), or the</p><p>able 4. Odds ratios of preventive service use by elderly (age</p><p>Influenza</p><p>immunizationb</p><p>(n�10,724) OR</p><p>(95% CI)</p><p>ace (whites)e</p><p>African Americans 0.5 (0.4–0.6)���</p><p>Latinos 0.6 (0.5–0.8)���</p><p>AIAN 0.9 (0.5–1.6)</p><p>Asians 1.4 (1.0–1.8)*</p><p>edical insurance (Medicare</p><p>plus private insurance)</p><p>Medicare and Medicaid 0.8 (0.7–1.0)*</p><p>Medicare only 0.7 (0.5–0.8)��</p><p>Other insurance only 0.7 (0.5–0.9)*</p><p>Uninsured 0.5 (0.2–1.0)</p><p>These multivariate logistic regression models also controlled for a</p><p>resence of diabetes, asthma, heart disease, arthritis, and hypertensi</p><p>Receipt of influenza vaccine in the past year.</p><p>Receipt of fecal occult blood test in past 2 years or receipt of lower</p><p>Analysis of receipt of mammogram was restricted to women.</p><p>Control group for the multivariate logistic analysis is in parentheses</p><p>p�0.05; **p�0.01; ***p�0.001 (all bolded).</p><p>IAN, American Indian and Alaskan Native; CI, confidence interval;</p><p>ninsured (28%) (Table 3). s</p><p>92 American Journal of Preventive Medicine, Volume 29, Num</p><p>When controlling for other determinants of preven-</p><p>ive services utilization, Asian Americans were still less</p><p>ikely to utilize mammograms in comparison to whites</p><p>OR�0.6, 95% CI�0.4–1.0, p �0.05). Medicare plus</p><p>rivate supplemental insurance coverage was a highly</p><p>ignificant positive determinant for receipt of mam-</p><p>ography in all women aged �65 years.</p><p>iscussion</p><p>indings from this study reveal that racial/ethnic dis-</p><p>arities in preventive services use among the elderly in</p><p>he United States persist. Consistent with previously</p><p>ublished literature, we found that racial/ethnic dis-</p><p>arities for receipt of influenza vaccine22–25 persisted</p><p>fter controlling for other explanatory factors. African</p><p>mericans and Latinos were significantly less likely to</p><p>e vaccinated for influenza while Asian Americans had</p><p>higher likelihood than whites. The resistant attitudes</p><p>nd beliefs toward vaccination among African Ameri-</p><p>ans may be part of the explanation for the low rates</p><p>mong this group,26 and difficulty accessing health care</p><p>mong the Latinos may partly explain the low rates for</p><p>he latter.27 The higher likelihood of influenza vacci-</p><p>ation among Asian Americans is particularly of inter-</p><p>st since they have a lower rate of mammograms in this</p><p>tudy and in previously published literature.28,29 One</p><p>ikely explanation for this difference may be due to</p><p>ositive health beliefs among Asians concerning vacci-</p><p>ation.30 Asians may be more likely than other groups</p><p>o believe that they are susceptible to influenza and that</p><p>he vaccine would protect them from influenza. The</p><p>iterature includes studies that have demonstrated the</p><p>5 years)a</p><p>lorectal cancer screeningc</p><p>�10,724) OR (95% CI)</p><p>Mammogramd</p><p>(n�6131) OR (95% CI)</p><p>1 (0.8–1.4) 1.1 (0.7–1.6)</p><p>8 (0.6–1.0) 1.0 (0.7–1.6)</p><p>9 (0.5–1.4) 0.5 (0.2–1.0)</p><p>8 (0.6–1.0) 0.6 (0.4–1.0)*</p><p>7 (0.7–0.9)��� 0.7 (0.6–0.9)��</p><p>7 (0.5–0.9)�� 0.5 (0.4–0.6)���</p><p>8 (0.6–1.0) 0.7 (0.4–1.0)</p><p>3 (0.1–0.6)�� 0.2 (0.1–0.5)���</p><p>nder; marital status; income; education; foreign versus U.S. born;</p><p>alth status; and current tobacco use.</p><p>scopy (flexible sigmoidoscopy or colonoscopy) in past 5 years.</p><p>dds ratio.</p><p>d �6</p><p>Co</p><p>(n</p><p>1.</p><p>0.</p><p>0.</p><p>0.</p><p>0.</p><p>0.</p><p>0.</p><p>0.</p><p>ge; ge</p><p>on; he</p><p>endo</p><p>.</p><p>ignificant association of positive health beliefs regard-</p><p>ber 5</p><p>i</p><p>A</p><p>t</p><p>i</p><p>I</p><p>i</p><p>p</p><p>o</p><p>(</p><p>h</p><p>c</p><p>a</p><p>t</p><p>s</p><p>w</p><p>w</p><p>e</p><p>c</p><p>i</p><p>m</p><p>c</p><p>c</p><p>t</p><p>r</p><p>n</p><p>l</p><p>o</p><p>a</p><p>f</p><p>i</p><p>m</p><p>L</p><p>H</p><p>c</p><p>w</p><p>r</p><p>f</p><p>i</p><p>i</p><p>i</p><p>c</p><p>i</p><p>p</p><p>a</p><p>p</p><p>c</p><p>s</p><p>t</p><p>h</p><p>r</p><p>a</p><p>d</p><p>s</p><p>u</p><p>2</p><p>r</p><p>l</p><p>a</p><p>m</p><p>2</p><p>s</p><p>A</p><p>d</p><p>o</p><p>h</p><p>R</p><p>S</p><p>d</p><p>a</p><p>c</p><p>i</p><p>p</p><p>n</p><p>t</p><p>t</p><p>a</p><p>g</p><p>c</p><p>c</p><p>c</p><p>o</p><p>f</p><p>t</p><p>c</p><p>b</p><p>a</p><p>w</p><p>a</p><p>w</p><p>w</p><p>M</p><p>B</p><p>d</p><p>b</p><p>t</p><p>v</p><p>i</p><p>D</p><p>M</p><p>p</p><p>S</p><p>a</p><p>t</p><p>A</p><p>i</p><p>A</p><p>ng receipt of influenza vaccination.31–34 In addition,</p><p>sian American immigrants may be more familiar with</p><p>he benefits of vaccination as a consequence of massive</p><p>mmunization efforts in their country of origin.35–37</p><p>dentifying the reasons for the higher likelihood of</p><p>nfluenza vaccination among Asian Americans may</p><p>rovide insights into strategies to improve their use of</p><p>ther preventive services.</p><p>The low overall rates of colorectal cancer screening</p><p>�66%) for all ethnic/racial groups is a major public</p><p>ealth concern in diagnosing and treating colorectal</p><p>ancer in the U.S. population. These screening rates</p><p>re also lower on average than receipt of other preven-</p><p>ive services in this study and other previously published</p><p>tudies.38,39 Latinos and Asians were less likely than</p><p>hites to receive colorectal cancer screening, especially</p><p>ith regard to combined annual FOBT and lower GI</p><p>ndoscopy every 5 years.</p><p>Although this difference in</p><p>olorectal cancer screening between white and minor-</p><p>ty groups was absent in the adjusted multivariate</p><p>odel, racial/ethnic disparities in receipt of colorectal</p><p>ancer screening still persist. Other demographic, so-</p><p>ioeconomic, healthcare access, and health status fac-</p><p>ors account for the disparities.</p><p>Our findings reveal that ethnic/racial disparities in</p><p>eceipt of mammograms among elderly women are</p><p>arrowing. In the late 1980s and early 1990s, the</p><p>iterature documented significant disparities in receipt</p><p>f mammography among elderly African Americans</p><p>nd Latinos compared to whites even when controlling</p><p>or demographic and socioeconomic factors.1–3 Find-</p><p>ngs from this study reveal no differences in unadjusted</p><p>ammography rates among whites, African Americans,</p><p>atinos, and American Indians and Alaskan Natives.</p><p>owever, in unadjusted and adjusted analyses, Asians</p><p>ontinue to be less likely to receive mammograms than</p><p>hites. It appears that the increase in mammography</p><p>ates among other groups may be reflective of funding</p><p>or aggressive breast cancer screening promotion and</p><p>ntervention programs in recent years.40–42 Little fund-</p><p>ng has targeted Asian Americans, and the low rates</p><p>ndicate that the need still exists for focused breast</p><p>ancer screening intervention among Asian Americans.</p><p>Findings from this study indicate that type of health</p><p>nsurance is significantly associated with receipt of</p><p>reventive tests. Individuals with Medicare plus Medic-</p><p>id coverage were significantly less likely to use all four</p><p>reventive services compared to those possessing Medi-</p><p>are plus private supplemental insurance. This is con-</p><p>istent with previously published studies, which showed</p><p>hat dually eligible Medicare plus Medicaid individuals</p><p>ave high health service utilization rates but more</p><p>eports of difficulties in obtaining health care.5,43 They</p><p>re less likely to maintain a usual relationship with a</p><p>octor and more likely to seek health care in acute care</p><p>ettings such as emergency departments, hospitals, or</p><p>rgent care facilities.5 g</p><p>This survey has a number of strengths. First, CHIS</p><p>001 is a population-based study. Second, it includes</p><p>acial/ethnic groups that are often missing in other</p><p>arge population-based surveys such as Asian Americans</p><p>nd American Indians and Alaskan Natives, thus illu-</p><p>inating higher-risk elderly populations. Third, CHIS</p><p>001 was conducted in six languages, and therefore this</p><p>tudy includes monolingual and Latinos and Asian</p><p>mericans of limited English proficiency who are un-</p><p>er-represented in the literature.</p><p>There are also some limitations to address. First, the</p><p>verall 37% response rate is a potential source of bias;</p><p>owever, this response rate is similar to that of other</p><p>DD surveys like the California Behavioral Risk Factor</p><p>urveillance Survey.44 Moreover, race/ethnic and age</p><p>istribution of CHIS 2001 respondents matched that of</p><p>djusted 2000 Census data.45 The CHIS sample in-</p><p>luded a higher than expected proportion of low-</p><p>ncome persons and was very close to the expected</p><p>roportion for higher-income persons.45 Unfortu-</p><p>ately, comparison with Census data was available for</p><p>he whole CHIS sample only, and not available for just</p><p>he elderly.</p><p>Second, the smaller sample size of American Indians</p><p>nd Alaskan Natives in comparison to other ethnic</p><p>roups may have limited our ability to draw firm</p><p>onclusions about this diverse population. Third, re-</p><p>eipt of colorectal cancer screening may be under-</p><p>ounted because CHIS does not distinguish the receipt</p><p>f colonoscopy from sigmoidoscopy, and assessed both</p><p>or the preceding 5 years. Fourth, the age to discon-</p><p>inue breast and colorectal cancer screening is not</p><p>ertain, although most cancer screening studies have</p><p>een restricted to patients aged �80 years. Both ACS</p><p>nd USPSTF do not recommend screening in patients</p><p>hose age or comorbid conditions limit life expect-</p><p>ncy. Individuals may have been included in the study</p><p>ho might not benefit from cancer screening. Fifth, it</p><p>as not possible to differentiate between elderly with</p><p>edicare part A versus those with Medicare part A and</p><p>coverage. Finally, this study did not include other</p><p>eterminants of preventive services use such as health</p><p>eliefs, perceived need, and process of medical care</p><p>hat could possibly explain some of the remaining</p><p>ariation among racial/ethnic groups.</p><p>In conclusion, these data identify population groups</p><p>n immediate need of public health–targeted outreach.</p><p>espite the near universal health insurance coverage by</p><p>edicare, racial/ethnic disparities in the use of some</p><p>reventive services among the elderly in the United</p><p>tates persist. The receipt of influenza vaccine, a simple</p><p>nd cost-effective measure to prevent mortality among</p><p>he elderly,6,46 is disproportionately low among African</p><p>mericans and Latinos. Colorectal cancer screening is</p><p>nadequately low among all races/ethnicities. Asian</p><p>merican women lag behind in receipt of mammo-</p><p>rams. In addition, the receipt of preventive services</p><p>Am J Prev Med 2005;29(5) 393</p><p>v</p><p>t</p><p>c</p><p>s</p><p>a</p><p>g</p><p>g</p><p>W</p><p>f</p><p>G</p><p>o</p><p>R</p><p>1</p><p>1</p><p>1</p><p>1</p><p>1</p><p>1</p><p>1</p><p>1</p><p>1</p><p>1</p><p>2</p><p>2</p><p>2</p><p>2</p><p>2</p><p>2</p><p>2</p><p>2</p><p>2</p><p>2</p><p>3</p><p>3</p><p>3</p><p>3</p><p>3</p><p>aries significantly by type of insurance coverage. Fur-</p><p>her research should focus on identifying potential</p><p>ultural and structural barriers to receipt of preventive</p><p>ervices use to design effective intervention programs</p><p>mong high-risk ethnic minority groups to address the</p><p>rowing disparities in health outcomes among all</p><p>roups of color compared to whites.</p><p>e are grateful to the Robert Wood Johnson Foundation for</p><p>unding this project; Timothy Pan, MD, for his editing, and</p><p>race Park, MPH, for her statistical assistance.</p><p>No financial conflict of interest was reported by the authors</p><p>f this paper.</p><p>eferences</p><p>1. Gornick ME, Eggers PW, Reilly TW, et al. Effects of race and income on</p><p>mortality and use of services among Medicare beneficiaries. N Engl J Med</p><p>1996;335:791–9.</p><p>2. Gornick ME. A decade of research on disparities in Medicare utilization:</p><p>lessons for the health and health care of vulnerable men. 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Wang CS, Wang ST, Chou P. Efficacy and cost-effectiveness of influenza</p><p>vaccination of the elderly in a densely populated and unvaccinated</p><p>community. Vaccine 2002;20:2494–9.</p><p>9. De GD, Beutels P. Economic aspects of pneumococcal pneumonia: a review</p><p>of the literature. Pharmacoeconomics 2004;22:719–40.</p><p>0. Conaty S, Watson L, Dinnes J, Waugh N. The effectiveness of pneumococ-</p><p>What This Study Adds . . .</p><p>Documented disparities in preventive health ser-</p><p>vices utilization exist by race/ethnicity.</p><p>Whether these disparities persist among the</p><p>elderly who have access to health insurance is less</p><p>well known.</p><p>This study found that racial/ethnic disparities</p><p>in the use of some preventive services among the</p><p>elderly in the United States remain. Receipt of</p><p>influenza vaccine is disproportionately low among</p><p>African Americans and Latinos. 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Center for Health Policy Research. California Health Interview Survey.</p><p>The CHIS 2001 sample: response rate and representativeness. Technical</p><p>paper 1. Los Angeles: Center for Health Policy Research, University of</p><p>California-Los Angeles, December 2003.</p><p>6. Vu T, Farish S, Jenkins M, Kelly H. A meta-analysis of effectiveness of</p><p>influenza vaccine in persons aged 65 years and over living in the commu-</p><p>nity. Vaccine 2002;20:1831–6.</p><p>Am J Prev Med 2005;29(5) 395</p><p>Racial/Ethnic Disparities in the Use of Preventive Services Among the Elderly</p><p>Introduction</p><p>Methods</p><p>Dependent Variables</p><p>Independent Variables</p><p>Statistical Analysis</p><p>Missing Data</p><p>Results</p><p>Sample Characteristics</p><p>Influenza Vaccination</p><p>Colorectal Cancer Screening</p><p>Breast Cancer Screening</p><p>Discussion</p><p>Acknowledgements</p><p>References</p>