Quality of health care for older women: What do we know?

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

OBJECTIVES

To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as specified by Cochrane.

MAIN RESULTS

We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

AUTHORS' CONCLUSIONS

We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.

Germain A, Egede LE. Trends in sex differences in the receipt of quality of care indicators among adults with diabetes: United States 2002-2011

BACKGROUND

Evidence suggests disparities in quality of care (QoC) indicators based on sex exist in adults diagnosed with diabetes; however, this research is limited. Therefore, the objective of this research study was to assess differences in QOC indicators in a nationally representative sample of men and women with diabetes.

METHODS

Cross-sectional study of 17,702 men and women (≥18 years of age) with diabetes from the 2002-2011 Medical Expenditure Panel Survey Household Component. Sex was the main predictor variable, and the dependent variables were five binary indicators to measure QOC, which included testing of hemoglobin A1c, examining feet annually, getting eyes dilated, checking blood pressure, and visiting the doctor annually. Sample demographics by sex were assessed. Unadjusted analyses were computed for descriptive statistics by sex and proportions of QOC indicators over time. Logistic regression evaluated associations between QOC indicators and sex, while controlling for sociodemographic characteristics, time, and comorbid conditions.

RESULTS

Approximately 44% and 56% of the sample was comprised of men and women, respectively. Unadjusted analyses showed significant differences in A1c testing (p < 0.001) and foot examinations (p = 0.002) for the entire sample, and significant differences in A1c testing (p = 0.027), foot examinations (p = 0.01), and dilated eye exams (p = 0.026) among men and A1c testing (p < 0.001) among women overtime. Adjusted analyses found women to be significantly more likely to have dilated eye examinations during a given year (OR = 1.14; 95% CI 1.04, 1.24), to get their blood pressure checked by a doctor in a given year (OR = 1.44; 95% CI 1.13, 1.84), and to visit a doctor annually (OR = 1.39; 95% CI 1.22, 1.58) compared to men.

CONCLUSIONS

In this sample of adults with diabetes, women had significantly higher odds of receiving quality of care compared to men. These findings suggest the importance of educating patients about appropriate metrics of diabetes management, especially men, and the need for continuous empowerment of women to receive proper and optimal care. Additional research is needed to identify causes and reduce sex and gender disparities associated with diabetes quality of care.

The Treatment of Primary Breast Cancer in Older Women With Adjuvant Therapy: A Retrospective Analysis of Data From Over 3000 Patients From the PATH Biobank, With Two-Year Follow-up

BACKGROUND

Breast cancer is the most common cancer in women in Germany. Mortality from breast cancer has declined over the past 15 years, but less so in women aged 70 or older than in younger women. The discrepancy might be explained by age-related differences in treatment.

METHODS

Data from the Patients' Tumor Bank of Hope (PATH) database of women who underwent adjuvant treatment for the treatment of an invasive primary tumor without distant metastases (year of diagnosis, 2006-2011) were retrospectively analyzed. The clinical and tumor-biological findings and treatment data over two years of follow-up were compared across three age groups (under age 50, ages 50 to 69, and ages 70 and up). Chi-square tests were carried out to reveal significant differences, and post-hoc multiple comparisons were performed with and without Bonferroni correction. Treatment data were adjusted for staging and grading and tested for age-dependence with logistic regression.

RESULTS

Follow-up data were available for 3257 (65% ) of 4981 women, of whom 61% were in the middle age group and 22% in the oldest. Compared to women aged 50 to 69, those aged 70 and up less commonly received breast-conserving treatment (68.8% vs. 86.4% ), chemotherapy (27.5% vs. 44.1% ), radiotherapy (81.8% vs. 92.4% ), and trastuzumab (52.9% vs. 79.3% ; p<0.001 for all differences). All differences remained significant after stastistical adjustment.

CONCLUSION

The cause of these age-related differences is unclear. It cannot be determined from these data whether concomitant disease, the older patients' individual decisions, or other factors were responsible for their not receiving treatment as often as the younger patients did.

State of Health and Quality of Life of Women at Advanced Age

Background

Evaluation of the state of health, quality of life, and the relationship between the level of the quality of life and health status in a group of women at an advanced age (90 years of age and older) in Poland.

Material/Methods

The study was conducted in 2014 in an all-Polish sample of 870 women aged 90 years and older. The research instruments were: the authors’ questionnaire and several standardized tests: Katz Index of Independence in Activities of Daily Living (Katz ADL), Abbreviated Mental Test Score (AMTS), and the World Health Organization Quality of Life (WHOQOL)-BREF. The results of the study were statistically analyzed using significant t-test for mean and regression analysis.

Results

The majority of women at an advanced age suffered from chronic pain (76%) and major geriatric problems such as hypoacusis (81%), visual disturbances (69%) and urinary incontinence (60%); the minority of women at an advanced age suffered from falls and fainting (39%), stool incontinence (17%), severe functional impairment (24%), and cognitive impairment (10%).

On a scale of 1 to 5, women at an advanced age assessed positively for overall quality of life (mean 3.3), social relationships (3.5), and environment (3.2), but negatively for general health, physical health, and psychological health (2.7, 2.7, and 2.8, respectively).

The presence of chronic pain and geriatric problems, including urinary and stool incontinences, falls and faint ing, visual disturbances and hypoacusis, significantly decreased overall quality of life; general health, physical health, psychological health, social relationships, and environment.

Overall quality of life, general health, physical health, psychological health, social relationships, and environment was correlated with functional and cognitive impairments.

Conclusions

Quality of life of women at an advanced age decreased if chronic pain, major geriatric problems, or functional or cognitive impairments occurred.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain.

OBJECTIVES

To assess access, provider, system and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted influenza vaccine uptake data.

MAIN RESULTS

This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%). Increasing community demand (32 trials, 10 strategies)The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective. Enhancing vaccination access (10 trials, six strategies)The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250). Provider- or system-based interventions (17 trials, 11 strategies)The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective. Interventions at the societal level We identified no RCTs of interventions at the societal level.

AUTHORS' CONCLUSIONS

There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.

Are there changes in characteristics and therapy of young patients with early-onset breast cancer in Germany over the last decade?

PURPOSE

The objective of the study is to investigate recent changes in patient characteristics and treatment procedures of young breast cancer patients over the last 10 years in Germany.

METHODS

The study describes the data of 518 patients who were treated adjuvantly between 2008 and 2011 and participated in a resident mother-child program for rehabilitation (cohort II). The data includes TNM-categories, biology of tumor and therapies. This population is compared to a cohort of 535 patients, who were treated between 2002 and 2006 (cohort I). Characteristics and treatment of cohort II are compared with a normally age distributed cohort.

RESULTS

51.5 % of the patients in cohort II were diagnosed with tumor category pT1, 36.9 % pT2, 4.4 % pT3 and 1.2 % pT4. 3.3 % had merely DCIS. 58.1 % of the patients were pN0, 28.4 % pN1 and 13.5 % had a more intense manifestation of lymph nodes. 45.8 % of the tumors showed a grading classified as G3, 69.3 % were estrogen and progesterone hormone receptor positive and 21.8 % Her2 positive. 24.5 % of the examined patients showed a triple negative carcinoma. 66.2 % of the patients with pT1 or pT2 underwent breast-conserving surgery. Overall 19.2 % of the women received mastectomy only and 17.4 % received mastectomy with subsequent reconstruction. 98.6 % of the patients received axillary surgery, 87.6 % chemotherapy. Overall, 21.0 % of the patients received their chemotherapy in connection with clinical studies. 88.0 % of the patients with hormone receptor positive tumors received endocrine therapy, 25.5 % of them with GnRH-analogs. In comparison with cohort I the tumors in cohort II were detected with a higher proportion of negative lymph nodes (48.8 %/58.1 %, p = 0.008) and G1 grading (4.9/5.6 %, p = 0.001). On the other hand the percentage of triple negative tumors increased from 21.0 % to 24.5 % (p = 0.018). Operative therapy has adjusted to a more moderate way. Breast-conserving therapy with pT1 and pT2 increases from 57.3 % to 66.2 % (p = 0.006), sentinel lymph node biopsy only from 24.5 % to 47.5 % (p[Symbol: see text]0.001) over the years. The percentages of chemotherapy, radiation, endocrine therapy and antibody therapy with positive receptor have stayed stable over the last decade. Comparing cohort II with a normally age distributed group (DMP II 2007-2009) the young patients have still a much lower portion of negative lymph nodes (58.1 %/67.9 %) and positive hormone receptor status (69.3 %/85.1 %). The percentage of a high grading G3 is 45.8 % in cohort II versus 24.7 % in DMP II. The portion of breast-conserving therapy with pT1 is with 68.9 versus 82.2 % still comparatively low. Young patients received more axillary surgery (98.6 %/81.5 %) but less endocrine therapy with hormone receptor positive tumors (93.3 %/94.7 %).

CONCLUSION

Young breast cancer patients in Germany can still be regarded as a special group. Although tumors are now more often detected before reaching the lymph nodes than 10 years ago, an even bigger percentage is triple negative. Operative treatment has improved to a less aggressive way. Still operative and medical treatments have to be chosen after very careful evaluation.

Appraising hospital performance by using the JCHAO/CMS quality measures in Southern Italy

Objectives

The main objective of the present study was to estimate the uptake to quality indicators that reflect the current evidence-based recommendations and guidelines.

Methods

A retrospective review of medical records of patients admitted to two hospitals in the South of Italy was conducted. For the purposes of the analysis, a sets of quality indicators has been used from the Joint Commission on Accreditation of Hospital Organizations and Centers for Medicare & Medicaid Services. Four areas of care were selected: acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), and surgical care improvement project (SCIP). Frequency or median was calculated, as appropriate, for each indicator. A composite score was calculated to estimate the overall performance for each area of care.

Results

A total of 1772 medical records were reviewed. The adherence rates showed a wide-ranging variability among the selected indicators. The use of aspirin and angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for AMI, the use of ACEI or ARB for HF, the use of appropriate thromboembolism prophylaxis and appropriate hair removal for surgical patients almost approached optimal adherence. At the other extreme, rates regarding adherence to smoking-cessation counseling in AMI and HF patients, discharge instructions in HF patients, and influenza and pneumococcal vaccination in pneumonia patients were noticeably intangible. Overall, the recommended processes of care among eligible patients were provided in 70% for AMI, in 32.4% for HF, in 46.4% for PN, and in 46% for SCIP.

Conclusions

The results show that there is still substantial work that lies ahead on the way to improve the uptake to evidence-based processes of care. Improvement initiatives should be focused more on domains of healthcare than on specific conditions, especially on the area of preventive care.

Gender disparities in the pharmacological treatment of cardiovascular disease and diabetes mellitus in the very old: an epidemiological, cross-sectional survey

BACKGROUND

There are many reports of disparities in health and medical care both between women and men and between various age groups. In most cases, men receive better treatment than women and young and middle-aged people are privileged compared with the old and the very old. Cardiovascular morbidity and diabetes mellitus are common, increase with age and are often treated extensively with drugs, many of which are known to have significant adverse effects.

OBJECTIVE

The aim of the study was to analyse gender differences in the pharmacological treatment of cardiovascular disease and diabetes among very old people.

METHODS

The study took the form of an epidemiological, cross-sectional survey. A structured interview was administered during one or more home visits, and data were further retrieved from medical charts and interviews with relatives, healthcare staff and other carers. Home-dwelling people as well as people living in institutional care in six municipalities in the county of Västerbotten, Sweden, in 2005-7 were included in the study. Half of all people aged 85 years, all of those aged 90 years and all of those aged ≥95 years living in the selected municipalities were selected for inclusion in the study. In total, 467 people were included in the present analysis. The main study outcome measures were medical diagnoses and drug use.

RESULTS

In total, women were prescribed a larger number of drugs than men (mean 7.2 vs 5.4, p < 0.001). Multiple logistic regression models adjusted for age and other background variables as well as relevant medical diagnoses (hypertension, heart failure) showed strong associations between female sex and prescriptions of thiazide diuretics (odds ratio [OR] 4.4; 95% CI 1.8, 10.8; p = 0.001), potassium-sparing diuretics (OR 3.5; 95% CI 1.4, 8.7; p = 0.006) and diuretics as a whole (OR 1.8; 95% CI 1.1, 2.9; p = 0.021). A similar model, adjusted for angina pectoris, showed that female sex was associated with prescription of short-acting nitroglycerin (OR 3.7; 95% CI 1.6, 8.9; p = 0.003). However, more men had been offered coronary artery surgery (p = 0.001). Of the participants diagnosed with diabetes, 55% of the women and 85% of the men used oral antihyperglycaemic drugs (p = 0.020), whereas no gender difference was seen in prescriptions of insulin.

CONCLUSIONS

Significant gender disparities in the prescription of several drugs, such as diuretics, nitroglycerin and oral antihyperglycaemic drugs, were observed in this study of very old people. In most cases, women were prescribed more drugs than men. Men more often had undergone coronary artery surgery. These disparities could only in part be explained by differences in diagnoses and symptoms.

Gender differences in hospitalization after emergency room visits for depressive symptoms

BACKGROUND

Depressed women have greater than three times the odds of hospitalization as clinically comparable men. The objective of this study is to understand if these gender differences emerge in admissions decisions after depressed individuals' arrival at the emergency room (ER).

METHODS

We used multivariate logistic regression to examine gender differences in hospitalization after 6266 ER visits for depressive symptoms in the nationally representative 1998-2007 National Hospital Ambulatory Care Medical Survey.

RESULTS

ER visits by depressed women have only 0.82 the odds of hospitalization (95% confidence interval [CI] 0.70-0.96, p=0.02) in models adjusted for sociodemographic, clinical, and system covariates. Sensitivity analyses demonstrate gender differences in visits by patients with no injury but not in visits by patients with self-inflicted injury.

CONCLUSIONS

These findings suggest that admission decisions after ER visits are not responsible for the increased risk of hospitalization previously reported in depressed women, as ER visits by women with depressive symptoms actually have lower odds of hospitalization than visits by men. We encourage further research to explore the causes and consequences of this practice pattern to move toward rational delivery systems committed to providing comparable treatment to clinically comparable individuals regardless of gender.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

Although the evidence to support influenza vaccination is poor, it is promoted by many health authorities. There is uncertainty about the effectiveness of interventions to increase influenza vaccination rates in those 60 years or older.

OBJECTIVES

To assess effects of interventions to increase influenza vaccination rates in those 60 or older.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1950 to July 2010), PubMed (January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and CINAHL (1982 to July 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) to increase influenza vaccination rates in those aged 60 years and older, recording influenza vaccination status either through clinic records, billing data or local/national vaccination registers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Forty-four RCTs were included. All included RCTs studied seniors in the community and in high-income countries. No RCTs of society-level interventions were included. Heterogeneity was marked and meta-analysis was limited. Only five RCTs were graded at low and six at moderate risk of bias. They included three of 13 personalized postcard interventions (all three with the 95% confidence interval (CI) above unity), two of the four home visit interventions (both with 95% CI above unity, but one a small study), three of the four reminder to physicians interventions (none with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity, and one P < 0.01). The other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn.

AUTHORS' CONCLUSIONS

Personalized postcards or phone calls are effective, and home visits, and facilitators, may be effective. Reminders to physicians are not. There is insufficient good evidence for other interventions.

Women with diagnosed diabetes across the life stages: underuse of recommended preventive care services

Diabetes is a common and costly disease. In 2007, an estimated 24 million people in the United States had diabetes, with almost half of these being women. Diabetes increases the risk of morbidity and mortality from several conditions, including cardiovascular disease, several types of cancers, influenza and pneumococcal infection, and kidney, eye, and periodontal diseases. The aim of this study was to examine the quality of care that women with diabetes receive and to assess how receipt of some clinical preventive services and screening for common conditions associated with diabetes vary according to socioeconomic factors. Our findings indicate that use of diabetes-specific preventive care among women is low, with the youngest women (< or =45 years) and those with low educational levels being the least likely to receive the recommended services. Women with diabetes were less likely than women without diabetes to receive a Pap smear, with the oldest women (> or =65 years) being the most vulnerable. Women with diabetes who were poor and nonwhite were less likely than more affluent and white women to receive a pneumococcal vaccination. This study's findings suggest that having a chronic disease may serve as a barrier to the receipt of recommended preventive care among women. Effective interventions should be designed to meet the needs of the most vulnerable women with diabetes, in particular, those who are at the extremes of the life cycle, are poor, and have low levels of education. Programs should use a life stage approach to address the unique needs of women with diabetes.

Unhealthy drinking patterns and receipt of preventive medical services by older adults

BACKGROUND

Preventive service use among older adults is suboptimal. Unhealthy drinking may constitute a risk factor for failure to receive these services.

OBJECTIVES

To determine the relationship between unhealthy drinking and receipt of recommended preventive services among elderly Medicare beneficiaries, applying the framework of current alcohol consumption guidelines.

DESIGN/METHODS

The data source is the nationally representative 2003 Medicare Current Beneficiary Survey. The sample included community-dwelling, fee-for-service Medicare beneficiaries 65 years and older (N = 10,523). Based on self-reported drinking, respondents were categorized as nondrinkers, within-guidelines drinkers, exceeding monthly but not daily limits, or heavy episodic drinkers. Using survey and claims data, influenza vaccination, pneumonia vaccination, glaucoma screening, and mammogram receipt were determined. Bivariate and logistic regression analyses were conducted.

RESULTS

Overall, 70.3% received flu vaccination and 49% received glaucoma screening during the year, 66.8% received pneumonia vaccination, and 56.2% of women received a mammogram over 2 years. In logistic regression, heavy episodic drinking was associated with lower likelihood of service receipt compared to drinking within guidelines: flu vaccination (OR 0.75, CI 0.59-0.96), glaucoma screening (OR 0.74, CI 0.58-0.95), and pneumonia vaccination (OR 0.75, CI 0.59-0.96). Nondrinkers when compared with those reporting drinking within guidelines were less likely to receive a mammogram (OR 0.83, CI 0.69-1.00).

CONCLUSIONS

Heavy episodic drinking is associated with lower likelihood of receiving several preventive services. Practitioners should be encouraged to screen all elders regarding alcohol intake and in addition to appropriate intervention, consider elders reporting heavy episodic drinking at higher risk for non-receipt of preventive services.

Routine preventive services for older women: a composite measure highlights gaps in delivery

BACKGROUND

We used a composite measure to examine the delivery of routine clinical preventive services to U.S. women aged 50-64 years and > or =65 years in 2004.

METHODS

We analyzed state data from the 2004 Behavioral Risk Factor Surveillance System (BRFSS) and created a composite measure that included screening of women > or =50 years for colorectal cancer, cervical cancer, breast cancer, vaccination against influenza, and, for women aged > or =65 years only, pneumococcal vaccination. The composite measure quantified the percentage of women who were up-to-date (UTD) according to recommended schedules for these services.

RESULTS

Approximately 23% of women aged 50-64 years and 32.5% of women aged > or =65 years were UTD in 2004. Results varied by education, race/ethnicity, marriage status, insurance status, and health status. There was also considerable geographic variation in state-specific UTD estimates, ranging from 16.7% (California) to 38.4% (Minnesota) for women aged 50-64 years and from 25.7% (Indiana) to 48.5% (Minnesota) for women aged > or =65 years.

CONCLUSIONS

Although rates for some individual services were > or =75%, the percentage of women aged 50-64 years and > or =65 years UTD on all routinely recommended cancer screenings and vaccinations was low, with <1 in 3 being UTD.

The impact of a change in Medicare reimbursement policy and HEDIS measures on stage at diagnosis among Medicare HMO and fee-for-service female breast cancer patients

OBJECTIVE

To examine the effects of health plan enrollment [health maintenance organizations (HMO) or fee-for-service (FFS)], a change in Medicare reimbursement policy which allowed for annual rather than biennial mammograms, and Health Plan Employer Data Information Set (HEDIS) measures on stage at diagnosis among older women with breast cancer.

METHODS

We used the population-based Surveillance Epidemiology and End Results (SEER)-Medicare database to identify all elderly women age 65-74 who were diagnosed with breast cancer from 1994 to 2002. We compared stage at diagnosis, demographic characteristics, and tumor characteristics for FFS or HMO enrollment in the periods before and after the 1998 policy change. We compared the effect of women age 65-69 whose mammography use in the HMO system is measured by HEDIS and those who are older (age 70-74).

RESULTS

We identified 20,106 women enrolled in FFS Medicare, and 10,751 women enrolled in an HMO. Women ages 65-74 who were enrolled in a Medicare HMO were more likely to be diagnosed at an early stage both before and after the policy change, but the disparity decreased from 4.7% to 2.3%, a relative change of 51.1%. The disparity was not specific to the ages included in the HEDIS measure.

CONCLUSIONS

A decrease of 51.1% in the HMO-FFS disparity in breast cancer stage at diagnosis coincided with the 1998 change in Medicare mammography reimbursement policy. The existence of HEDIS measures for HMOs does not create a disparity in stage at diagnosis between those whose mammograms are measured by HEDIS (younger women) and those whose are not (older women).