- Email: [email protected]
Prevention Services Received by Veterans Visiting VHA Facilities
27, 604–610 (1998) PM980333
PREVENTIVE MEDICINE ARTICLE NO.
Prevention Services Received by Veterans Visiting VHA Facilities Laurence G. Branch, Ph.D.,*,†,1 Donna J. Rabiner, Ph.D.,*,† Patricia Patterson, R.N., Ph.D.,‡ and Robert J. Sullivan, Jr., M.D., M.P.H.*,† *National Center for Health Promotion, Veterans Administration Medical Center, 508 Fulton Street, Durham, North Carolina 27705; †Duke University Medical Center, Center for the Study of Aging and Human Development, Campus Box 3003, Durham, North Carolina 27710; and ‡Veterans Administration Medical Center, 3710 Southwest Veterans Hospital Road, Portland, Oregon 97207
Objectives. This paper presents rates with which veterans report receiving 13 recommended health promotion and disease prevention services. Results were compared with the U.S. Healthy People 2000 goals. Methods. Random samples of 300 men and 150 women visiting primary care clinics in six Veterans Health Affairs facilities were drawn. A 66% adjusted response rate was achieved after two mailings (n 5 1,703). Weighted averages for each prevention service were calculated. Results. For preventive services targeted to all age groups, both male and female veterans currently exceed the Year 2000 goal in hypertension detection and tobacco counseling. Female veterans also exceed the Year 2000 goal in “almost always” using seat belts. For prevention services targeted to specific age–gender subgroups, both male and female veterans currently exceed the Year 2000 goals for four of the six primary and secondary prevention services. Conclusions. Both male and female veterans exceed Year 2000 goals for the receipt of nearly half of the preventive services. Nevertheless, additional screening and counseling services should be made available to veterans of all age categories. q1998 American Health Foundation and Academic Press
Key Words: health promotion; disease prevention; veterans; Healthy People 2000.
INTRODUCTION
The Department of Veterans Affairs (VA) has fostered health promotion and disease prevention activities since 1979. In 1995, the VA established a National Center for Health Promotion and Disease Prevention (NCHP) to monitor and encourage the provision, evaluation, and improvement of preventive medicine services for veterans and the promotion of clinical, research, 1 To whom reprint requests should be addressed. Fax: (919) 4165879. E-mail: [email protected].
and educational activities. A list of 13 recommended health promotion and disease prevention services was developed by the NCHP to serve as a minimum for all asymptomatic and average-risk veterans receiving primary care in Veterans Health Administration (VHA) facilities. Each recommended service is based upon evidence of proven value according to the criteria and recommendations of the U.S. Preventive Services Task Force (USPSTF) [1]. Primary prevention services for VHA facilities include the following: (1) hypertension detection, (2) hyperlipidemia detection, (3) influenza immunization, (4) pneumococcal vaccination, and (5) tetanus and diphtheria immunization. Secondary prevention services within the VA include early detection and treatment of: (6) cervical cancer, (7) breast cancer, and (8) colorectal cancer. Assessment and counseling, if appropriate, are recommended with regard to: (9) tobacco use, (10) problem drinking, (11) weight control and nutrition, (12) fitness and exercise, and (13) seat belt use and accident avoidance. The VA’s health promotion and disease prevention guidelines are consistent with the USPSTF recommendations. While it would be ideal from the perspective of personal health if compliance with each goal were 100%, in most cases this is not practical. Accordingly, measurable goals are modeled after those described in Healthy People 2000 [2], a national initiative to improve the health of all Americans through prevention. Healthy People 2000, which is driven by 300 specific national health promotion and disease prevention objectives targeted for achievement by the Year 2000, defines three goals to help the United States reach its full potential: to increase the average span of healthy life, to reduce disparities in health among U.S. citizens, and to provide access to health maintenance activities for all Americans [3,4]. As one of the largest organized health care systems
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0091-7435/98 $25.00 Copyright q 1998 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
PREVENTION SERVICES RECEIVED BY VETERANS
in the United States, the Veterans Administration recognizes the importance of the Healthy People 2000 initiative and has adopted the goals set out by this document when setting specific and attainable goals for its veteran patient population. For purposes of determining compliance with national norms in this investigation, attention is restricted to veterans enrolled in the primary care clinics in which comprehensive medical care, including prevention services, is available. The purpose of the present analysis is to present information obtained by mail survey on the rates with which veterans report actually receiving the 13 recommended health promotion and disease prevention services at VHA facilities or from community providers. While others have investigated the rates with which veterans reported receiving 1 specific recommended health promotion/disease prevention activity or service (e.g., Nichol et al. [5] reported the rates with which veterans received influenza vaccinations and Shaffer and Wexler [6] reported on the impact of hyperlipidemia screening in a multidisciplinary VHA collaborative practice), this study is unique in providing information on the rates with which veterans reported receiving 13 different health promotion and disease prevention services recommended by the USPSTF either at VHA facilities or from community providers. For purposes of comparison, Belcher [7] reported that the 1980 rates of compliance with 5 prevention activities among male veterans attending any of Seattle’s VHA outpatient clinics were approximately 25% for annual smoking counseling, annual alcohol counseling, and fecal occult blood tests in the prior 3 years; 74% for blood pressure screening; and 15% for influenza vaccinations. The survey reported in this paper was done as a pilot study for a much larger effort being launched in the 1997 fiscal year. The results obtained from this initial study will help policy makers both within and outside of the VA to: (a) obtain important information from users of the largest health care delivery system in the country about the preventive medical services that currently exceed the U.S. Year 2000 goals and (b) determine which preventive medical services are still in need of additional attention. METHODS
Sample Six VHA facilities located in Durham, North Carolina; Fresno, Long Beach, and Loma Linda, California; Manhattan, New York; and Seattle, Washington, volunteered to test the first implementation of a new survey process and data collection procedure. These sites are located in large-, middle-, and small-sized communities and dispersed geographically in northeast, southeast, and west coast locations. Random samples of 300 men and 150 women were drawn from the list of individuals
605
receiving primary care in any of the following VHA outpatient facilities within the past year: general internal medicine clinics, women’s health clinics, geriatrics clinics, and primary medicine clinics. Each individual was sent a questionnaire accompanied by a letter explaining the survey process. A 66% adjusted response rate was achieved after two mailings (1,703 respondents in total of 2,700 initial subjects sampled minus 131 subjects deceased or unable to be located). Although the same number of men (300) and women (150) were sampled at each VHA facility, the total number of men and women actually receiving VHA services (and thus, eligible to be included in the initial sampling frame) varied by VHA setting. Therefore, the calculated probability of selection into the sample was different for men and women and different at each VHA facility. Consequently, weighting was necessary to obtain proper estimates of rates for the entire VA population. Questionnaire The NCHP questionnaire was designed to obtain information directly from the men and women who visit VHA primary care clinics about whether each of the 13 recommended services was received, when it was received, and where (within VHA facilities or from nonVHA sources). The survey approach avoids a potential undercounting bias that would result if VA medical records were used as the sole source of information because services received outside VHA facilities would be omitted. The survey was pilot-tested in Seattle and subsequently tested in the Minneapolis, Minnesota, VHA facility. The final version of the questionnaire modeled the structure of HHS National Health Interview and its other national surveys. The 52-item questionnaire, entitled the Veterans Health Survey, asked a series of questions about each recommended prevention measure. The first question in each series asked whether the veteran had ever received a specific procedure or test (yes/no). Those answering “yes” to this item were asked how long it had been since the specific procedure/test was last performed. Finally, the respondents who reported receiving the specific procedure/test were asked to indicate where the procedure had been performed (at a VHA facility or elsewhere). The estimated average time to complete the survey document was 10 min. Procedures The outpatient encounter file provided the sampling frame used for each VHA facility. This file captures all of the detail of each outpatient clinic visit and includes information on individual demographics, veteran eligibility for care, clinics visited, and all procedures [8]. A complete listing of veterans receiving primary care at each of the six VHA facilities between March 1, 1995,
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and February 29, 1996, was compiled. Random samples of 300 men and 150 women representing unique users (not weighted by the amount of use) were then drawn. Identification numbers were assigned to each person sampled and used in lieu of names to preserve the anonymity of potential study respondents. The initial mailing of the Veterans Health Survey was sent to the residential addresses of the selected veterans in the spring of 1996. Nonrespondents received a second mailing approximately 4 weeks later. The deadline for the receipt of completed questionnaires was mid-September 1996. Data Processing Data from the six sites were entered, verified, and cleaned. Test–retest k reliability statistics were calculated for the 52 items on the questionnaire using data from 32 veterans who happened to complete the survey twice, presumably because their first response crossed in the mail with a second request to which they also responded. Thirty-seven percent of the 52 survey questions had k scores greater than 0.80, another 33% were greater than 0.60, and another 19% were greater than 0.40, which exceeds the customary threshold for acceptable reliability [9]. Of the remaining 6 questions, 5 had dispersion characteristics that rendered the k statistic inadequate as an indicator of reliability. The blood pressure and breast cancer survey questions for women were among the items with the highest k values, while those inquiring about the location of care (i.e., inside the VHA, outside the VHA, or both) had relatively lower k values. Data Analysis Weighted averages for receipt of the 13 prevention services were calculated using the SAS program for microcomputers [10]. Weighted proportions were calculated for specific population subgroups (e.g., males and females ages 65 or older who received an influenza vaccine this year). Two-way cross-tabulations were produced using data stratified by age and gender to examine differences in the responses to specific study questions. x2 statistics and Cochran–Mantel–Haenszel statistics were used to assess the statistical significance of age–gender differences in the survey. Weighted proportions were used to examine the extent to which veterans were receiving specific prevention services. Unweighted proportions were used to obtain significance levels since the P values from weighted proportions would have been artificially inflated due to the size of the study sample. A significance level of P , 0.05 was selected for all x2 and Cochran–Mantel–Haenszel statistics. Missing values were retained in the denominators when calculating weighted proportions, but omitted
from unweighted proportions when generating P values. Characteristics of Respondents (Weighted) Among the male respondents, the modal age was 65–69 years, with 50% above age 65. Among the female respondents, the modal age was 40–44 years, with 50% under age 50. For both males and females, nearly a third reported traveling 30 to 59 min from their home to the VHA facility, and slightly more than a third travel an hour or more. More than half the males and females reported they received “almost all (90% or more)” of their health care at VHA facilities, but about one in five male and female users of VHA primary care clinics reported getting less than half of their health care from the VA. The VA health care system is by no means a closed-panel of providers for veterans, suggesting the lack of coordinated care could be problematic. RESULTS AND DISCUSSION
Preventive Services Not Targeted to Specific Age Subgroups Findings presented in Table 1 indicate that both male (95%) and female (93%) veterans currently exceed the U.S. Year 2000 goal of 90% in the area of hypertension detection (primary prevention), both male (78%) and female (88%) veterans exceed the adapted U.S. Year 2000 goal of 75% in the area of tobacco counseling, and female veterans (93%) also exceed the Year 2000 goal of 85% in “almost always” using seat belts. There were statistically significant gender differences after controlling for age for three of the nine primary prevention, and screening and counseling services listed in Table 1 as follows: (1) counseling for the proportion of current tobacco users, (2) the proportion receiving physical activity screening and counseling in the past year, and (3) the proportion reporting “almost always” using seat belts. However, in only one area, the use of seat belts, did gender differences exceed 5%. Female veterans were more likely than their male counterparts to indicate that they “almost always” used seat belts (93% versus 82%, respectively). There were no significant gender differences after controlling for age in the proportion of the veteran population receiving tetanus immunization, offered tobacco use counseling, being screened for problem drinking and offered alcohol moderation counseling, receiving weight control and nutrition screening and counseling, or receiving seat belt and accident avoidance counseling this year. It is worth noting that the magnitude of the weighted rates for males and females does not correlate well with the statistical significance based on unweighted rates in stratified Cochran– Mantel–Haenszel composite tests. This is attributed to an anomaly of the necessary weights and the large
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TABLE 1 Sex- and Age-Specific Self-Reported Rates of Use of Various Health Promotion and Disease Prevention Services Appropriate for All Age Groups among Veterans Receiving Primary Care from the VA Compared with the U.S. Goals for the Year 2000 Weighted 1996 VA rates U.S. goals for Year 2000 Primary prevention Hypertension detection % with blood pressure check in the past 2 years Tetanus immunization % receiving Td booster at least once in the past decade Screening and counseling Tobacco use counseling % who are current tobacco users % of tobacco users offered counseling Problem drinking and alcohol moderation counseling % asked/screened for problem drinking and alcohol use this year Weight control and nutrition counseling % receiving nutrition counseling this year Physical activity counseling % receiving activity counseling this year Seat belt and accident avoidance counseling % receiving seat belt use and accident avoidance counseling this year % reporting “almost always” using seat belts
All ages Male
Age
Female Probabilitya
Under 35
35–49
50–64
65–74
75 and over Probabilityb
90%
95%
93%
0.102
87%
94%
95%
97%
94%
0.001
62%
50%
60%
0.855
70%
67%
50%
48%
37%
0.001
15% 75%c
26% 78%
27% 88%
0.033 0.397
25% 69%
44% 75%
28% 83%
24% 82%
10% 72%
0.001 0.001
75%c
13%
11%
0.051
14%
20%
16%
11%
6%
0.001
75%c
34%
33%
0.348
16%
37%
42%
36%
22%
0.001
50%c
45%
49%
0.013
35%
41%
46%
49%
44%
0.001
50%c
5%
7%
0.155
1%
3%
3%
7%
7%
0.285
85%
82%
93%
0.006
88%
82%
81%
83%
87%
0.257
a Probabilities are based on results from unweighted cross-tabulations of each prevention measure by sex, controlling for age, omitting missing values, consistent with conventional practice. b Probabilities are based on results from unweighted cross-tabulations of each prevention measure by age, controlling for sex, omitting missing values, consistent with conventional practice. c Adapted from percent of physicians offering the service to the percent receiving the service.
numbers of younger women and older men in these populations. Consequently, we will focus our attention on differences that are both statistically significant at the traditional 0.05 level and practically important as indicated by mean differences of 5% or more. Once gender differences were taken into account, significant age differences remained in the proportion of veterans receiving each of the primary prevention and screening and counseling services listed in Table 1, except for seat belt and accident avoidance counseling. The VA rates for some age subgroups exceeded the overall U.S. goals for the Year 2000 in three preventive services: (1) blood pressure checks within the past 2 years among all subgroups ages 35 and older, (2) tetanus boosters in the past 10 years among the subgroups under age 50, and (3) the percentage reporting “almost always” wearing seat belts among the subgroups under age 35 and ages 75 or older. Veterans ages 75 or older
were the only subgroup to achieve the Year 2000 goal for current tobacco users (a reduction target). Only 10% of those ages 75 or older reported currently using tobacco, while the Year 2000 goal calls for less than 15% use. Across most prevention categories, age analysis revealed that veterans between the ages of 35 and 74 were the most likely to exceed the Year 2000 goals. Those under age 35 or over age 75 in general were substantially less likely to receive screening/counseling services than were those between ages 35 and 74 for each of the following services: (1) blood pressure checks, (2) tobacco counseling, (3) nutrition screening and counseling, as appropriate, and (4) physical activity screening and counseling in the past year. A somewhat less prevalent pattern was detected for the proportion of the subgroups receiving tetanus boosters and alcohol
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TABLE 2 Sex- and Age-Specific Self-Reported Rates of Use of Various Health Promotion and Disease Prevention Services Appropriate for Specific Age Subgroups among Veterans Receiving Primary Care from the VA Compared with the U.S. Goals for the Year 2000 Weighted 1996 VA rates
Primary prevention Hyperlipidemia detection % with cholesterol checked in the past 5 years (males ages 35 through 64; females ages 45 through 64) Influenza immunization % who received an influenza vaccine this year (age 65 plus) Pneumococcal vaccination % who received pneumococcal vaccine at least once (age 65 plus) Secondary prevention Cervical cancer detection % of females with Papanicolaou test in the past 3 years (under age 65) Breast cancer detection % of females who received a mammogram in the past 2 years (ages 50 through 69) Colorectal cancer detection % receiving a fecal occult blood test this year (age 50 plus)
U.S. goals for Year 2000
Male
75%
82%
85%
60%
76%
60%
Age subgroups
Age Under 35
35–49
50–64
65–74
0.088
54%
80%
82%
97%
81%
0.001
72%
0.084
28%
37%
52%
75%
77%
0.001
43%
51%
0.006
18%
14%
19%
43%
45%
0.001
85%
N/A
93%
N/A
100%
91%
92%
85%
76%
0.001
60%
N/A
91%
N/A
20%
65%
91%
92%
87%
0.001
50%
34%
30%
0.438
11%
14%
33%
34%
31%
0.001
Female Probabilitya
75 and over Probabilityb
a
Probabilities are based on results from unweighted cross-tabulations of each prevention measure by sex for the targeted age group, omitting missing values, consistent with conventional practice. b Probabilities are based on results from unweighted cross-tabulations of each prevention measure by age, controlling for sex, omitting missing values, consistent with conventional practice.
counseling, for problem drinking. The proportion of veterans ages 65 and over receiving these two prevention and screening/counseling services was notably lower compared with their younger age counterparts. These results suggest that additional primary prevention and screening/counseling efforts should be recommended for clinicians treating substantial numbers of male and female veterans over the age of 65 or under the age of 35. Overall, the results from Table 1 suggest that while there are few significant gender differences in the receipt of the listed primary prevention and screening/ counseling services for male and female veterans of all ages, significant age-related differences exist in the proportion of veterans receiving these services. Most importantly, veterans between ages 35 and 65 are generally more likely to receive these prevention services relative to their counterparts under age 35 or over age 65.
Preventive Services Targeted to Specific Age Subgroups Four of the six prevention services for targeted age subgroups exceeded the U.S. goals for the Year 2000: (1) hyperlipidemia detection, (2) influenza immunization, (3) cervical cancer detection, and (4) breast cancer detection. Preventive services provided in VHA facilities did not meet the Year 2000 recommendations for pneumococcal vaccination and colorectal cancer detection. Results presented in Table 2 indicate that there are few gender differences in the primary and secondary prevention measures that target particular age subgroups. The one instance in which the rates did vary significantly by gender was for the receipt of pneumococcal vaccination at least once in a lifetime for those age 65 or older. Females age 65 or older were substantially more likely than their male counterparts to have
PREVENTION SERVICES RECEIVED BY VETERANS
received a pneumococcal vaccination at least once (51% versus 43%). Age-specific effects were anticipated for the primary and secondary prevention measures presented in Table 2 that target specific age groups since, by definition, only certain age groups of average-risk, asymptomatic veterans were being addressed [1]. Nevertheless, it is interesting to compare the prevalence rates across age categories both to pinpoint specific ages at which additional services may be warranted (i.e., the underserved target age groups) and to identify groups for which preventive services have been provided to nontargeted veterans. We hasten to add that these data do not allow us to distinguish between the overserved average-risk veteran versus appropriately served veterans with chronic diseases. The analysis of age-specific rates reveals that some preventive medical services were commonly received at very high rates by age subgroups that were not the intended targets. For example, cholesterol checks are recommended every 5 years for males between the ages of 35 and 64 and for females ages 45 through 64. Table 2 indicates that a substantial number of veterans outside these age groups reported receiving this primary prevention measure within the past 5 years. For example, cervical cancer detection smears are recommended every 3 years only for women under age 65, yet 85% of female veterans ages 65–74 and 76% of female veterans ages 75 and older received this secondary prevention measure within the past 3 years. A similar pattern of service delivery to nontargeted veterans was revealed for the following areas: (1) influenza and pneumococcal immunizations for those under age 65, (2) breast cancer detection for those under age 50 or over age 69, and (3) colorectal cancer tests for those under age 50. CONCLUSIONS
These data indicate that preventive medical services received by both male and female veterans currently exceed the U.S. Year 2000 goals in the areas of hypertension detection, tobacco counseling, hyperlipidemia detection, and influenza immunization. Preventive medical services for female veterans exceed the goals in three additional areas including cervical cancer detection, breast cancer detection, and seat belt use. The preventive medical service most in need of attention is screening and counseling, as appropriate, for problem drinking and alcohol moderation. Although there were few gender differences after controlling for age in the receipt of preventive medical services by male and female veterans, females seemed to fare better when differences did exist. The women veterans’ health clinics deserve credit for successful
609
attention to the preventive medical care needs of female veterans. Age-specific differences in the rates of receipt of both age-targeted and non-age-targeted preventive medical services suggest that additional attention is needed for male and female veterans under age 35 and over age 65. In particular, screening and counseling for problem drinking, weight control, and physical activity need to be offered to greater numbers of veterans. Some preventive services targeted to particular age subgroups of average-risk veterans are beneficial to individuals suffering from chronic disease. Thus it is not surprising to find a substantial number outside the expected age brackets reporting service receipt. Furthermore, given the changing nature of preventive medicine recommendations over the past few years, prudent VHA physicians may choose to recommend preventive medical services to veterans falling outside targeted age groups. Subsequent research can clarify which portion of these rates is attributable to overuse by average-risk individuals and which portion is attributable to prudent use among individuals with chronic disease. The NCHP will implement the Veterans Health Survey in all VHA facilities in Fiscal Year 1997. The data obtained will serve as a baseline for assessing future improvements in the provision of health promotion and disease prevention services. The current study will add to our understanding of the rates of preventive medical services received by veterans and help to target efforts to those most likely to receive substantial benefits. ACKNOWLEDGMENTS The authors acknowledge with gratitude Donald Belcher, M.D., for sage advice on all phases of this effort; Kristin Nichol, M.D., for assisting in the conceptualization and development of the Veterans Health Survey; and Lori Bastian, M.D., for providing many insightful comments regarding the interpretation of these data. The views expressed are those of the authors and do not represent the Department of Veterans Affairs. REFERENCES 1. U.S. Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore: William & Wilkins, 1996. 2. U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000; national health promotion and disease prevention objectives. Washington: U.S. Govt. Printing Office, 1991. [DHHS Publication No. (PHS) 91-50212] 3. U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000 update: achieving the nation’s health objectives. Washington: Office of Disease Prevention and Health Promotion, 1993 Feb/Mar. 4. Sullivan LW. Sounding board: Healthy People 2000. N Engl J Med 1990;323:1065–7. 5. Nichol KL, Korn JE, Margolis KL, Poland GA, Petzel RA, Lofgren
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RD. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med 1990;89:156–60. 6. Shaffer J, Wexler LF. Reducing low-density lipoprotein cholesterol levels in an ambulatory care system. Results of a multidisciplinary collaborative practice lipid clinic compared with traditional physician-based care. Arch Intern Med 1995;155:2330–5. 7. Belcher DM. Implementing preventive services: success and failure in an outpatient trial. Arch Intern Med 1990;150:2533-41.
8. Lamoreaux J. The organizational structure for medical information management in the Department of Veterans Affairs: an overview of major healthcare databases. Med Care 1996;34(3): MS31–44. 9. Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York: Wiley, 1981. 10. SAS Institute. SAS/STAT user’s guide. Vol. 1 and 2. Version 6. Cary (NC): SAS Inst., 1990.
PREVENTIVE MEDICINE ARTICLE NO.
Prevention Services Received by Veterans Visiting VHA Facilities Laurence G. Branch, Ph.D.,*,†,1 Donna J. Rabiner, Ph.D.,*,† Patricia Patterson, R.N., Ph.D.,‡ and Robert J. Sullivan, Jr., M.D., M.P.H.*,† *National Center for Health Promotion, Veterans Administration Medical Center, 508 Fulton Street, Durham, North Carolina 27705; †Duke University Medical Center, Center for the Study of Aging and Human Development, Campus Box 3003, Durham, North Carolina 27710; and ‡Veterans Administration Medical Center, 3710 Southwest Veterans Hospital Road, Portland, Oregon 97207
Objectives. This paper presents rates with which veterans report receiving 13 recommended health promotion and disease prevention services. Results were compared with the U.S. Healthy People 2000 goals. Methods. Random samples of 300 men and 150 women visiting primary care clinics in six Veterans Health Affairs facilities were drawn. A 66% adjusted response rate was achieved after two mailings (n 5 1,703). Weighted averages for each prevention service were calculated. Results. For preventive services targeted to all age groups, both male and female veterans currently exceed the Year 2000 goal in hypertension detection and tobacco counseling. Female veterans also exceed the Year 2000 goal in “almost always” using seat belts. For prevention services targeted to specific age–gender subgroups, both male and female veterans currently exceed the Year 2000 goals for four of the six primary and secondary prevention services. Conclusions. Both male and female veterans exceed Year 2000 goals for the receipt of nearly half of the preventive services. Nevertheless, additional screening and counseling services should be made available to veterans of all age categories. q1998 American Health Foundation and Academic Press
Key Words: health promotion; disease prevention; veterans; Healthy People 2000.
INTRODUCTION
The Department of Veterans Affairs (VA) has fostered health promotion and disease prevention activities since 1979. In 1995, the VA established a National Center for Health Promotion and Disease Prevention (NCHP) to monitor and encourage the provision, evaluation, and improvement of preventive medicine services for veterans and the promotion of clinical, research, 1 To whom reprint requests should be addressed. Fax: (919) 4165879. E-mail: [email protected].
and educational activities. A list of 13 recommended health promotion and disease prevention services was developed by the NCHP to serve as a minimum for all asymptomatic and average-risk veterans receiving primary care in Veterans Health Administration (VHA) facilities. Each recommended service is based upon evidence of proven value according to the criteria and recommendations of the U.S. Preventive Services Task Force (USPSTF) [1]. Primary prevention services for VHA facilities include the following: (1) hypertension detection, (2) hyperlipidemia detection, (3) influenza immunization, (4) pneumococcal vaccination, and (5) tetanus and diphtheria immunization. Secondary prevention services within the VA include early detection and treatment of: (6) cervical cancer, (7) breast cancer, and (8) colorectal cancer. Assessment and counseling, if appropriate, are recommended with regard to: (9) tobacco use, (10) problem drinking, (11) weight control and nutrition, (12) fitness and exercise, and (13) seat belt use and accident avoidance. The VA’s health promotion and disease prevention guidelines are consistent with the USPSTF recommendations. While it would be ideal from the perspective of personal health if compliance with each goal were 100%, in most cases this is not practical. Accordingly, measurable goals are modeled after those described in Healthy People 2000 [2], a national initiative to improve the health of all Americans through prevention. Healthy People 2000, which is driven by 300 specific national health promotion and disease prevention objectives targeted for achievement by the Year 2000, defines three goals to help the United States reach its full potential: to increase the average span of healthy life, to reduce disparities in health among U.S. citizens, and to provide access to health maintenance activities for all Americans [3,4]. As one of the largest organized health care systems
604
0091-7435/98 $25.00 Copyright q 1998 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
PREVENTION SERVICES RECEIVED BY VETERANS
in the United States, the Veterans Administration recognizes the importance of the Healthy People 2000 initiative and has adopted the goals set out by this document when setting specific and attainable goals for its veteran patient population. For purposes of determining compliance with national norms in this investigation, attention is restricted to veterans enrolled in the primary care clinics in which comprehensive medical care, including prevention services, is available. The purpose of the present analysis is to present information obtained by mail survey on the rates with which veterans report actually receiving the 13 recommended health promotion and disease prevention services at VHA facilities or from community providers. While others have investigated the rates with which veterans reported receiving 1 specific recommended health promotion/disease prevention activity or service (e.g., Nichol et al. [5] reported the rates with which veterans received influenza vaccinations and Shaffer and Wexler [6] reported on the impact of hyperlipidemia screening in a multidisciplinary VHA collaborative practice), this study is unique in providing information on the rates with which veterans reported receiving 13 different health promotion and disease prevention services recommended by the USPSTF either at VHA facilities or from community providers. For purposes of comparison, Belcher [7] reported that the 1980 rates of compliance with 5 prevention activities among male veterans attending any of Seattle’s VHA outpatient clinics were approximately 25% for annual smoking counseling, annual alcohol counseling, and fecal occult blood tests in the prior 3 years; 74% for blood pressure screening; and 15% for influenza vaccinations. The survey reported in this paper was done as a pilot study for a much larger effort being launched in the 1997 fiscal year. The results obtained from this initial study will help policy makers both within and outside of the VA to: (a) obtain important information from users of the largest health care delivery system in the country about the preventive medical services that currently exceed the U.S. Year 2000 goals and (b) determine which preventive medical services are still in need of additional attention. METHODS
Sample Six VHA facilities located in Durham, North Carolina; Fresno, Long Beach, and Loma Linda, California; Manhattan, New York; and Seattle, Washington, volunteered to test the first implementation of a new survey process and data collection procedure. These sites are located in large-, middle-, and small-sized communities and dispersed geographically in northeast, southeast, and west coast locations. Random samples of 300 men and 150 women were drawn from the list of individuals
605
receiving primary care in any of the following VHA outpatient facilities within the past year: general internal medicine clinics, women’s health clinics, geriatrics clinics, and primary medicine clinics. Each individual was sent a questionnaire accompanied by a letter explaining the survey process. A 66% adjusted response rate was achieved after two mailings (1,703 respondents in total of 2,700 initial subjects sampled minus 131 subjects deceased or unable to be located). Although the same number of men (300) and women (150) were sampled at each VHA facility, the total number of men and women actually receiving VHA services (and thus, eligible to be included in the initial sampling frame) varied by VHA setting. Therefore, the calculated probability of selection into the sample was different for men and women and different at each VHA facility. Consequently, weighting was necessary to obtain proper estimates of rates for the entire VA population. Questionnaire The NCHP questionnaire was designed to obtain information directly from the men and women who visit VHA primary care clinics about whether each of the 13 recommended services was received, when it was received, and where (within VHA facilities or from nonVHA sources). The survey approach avoids a potential undercounting bias that would result if VA medical records were used as the sole source of information because services received outside VHA facilities would be omitted. The survey was pilot-tested in Seattle and subsequently tested in the Minneapolis, Minnesota, VHA facility. The final version of the questionnaire modeled the structure of HHS National Health Interview and its other national surveys. The 52-item questionnaire, entitled the Veterans Health Survey, asked a series of questions about each recommended prevention measure. The first question in each series asked whether the veteran had ever received a specific procedure or test (yes/no). Those answering “yes” to this item were asked how long it had been since the specific procedure/test was last performed. Finally, the respondents who reported receiving the specific procedure/test were asked to indicate where the procedure had been performed (at a VHA facility or elsewhere). The estimated average time to complete the survey document was 10 min. Procedures The outpatient encounter file provided the sampling frame used for each VHA facility. This file captures all of the detail of each outpatient clinic visit and includes information on individual demographics, veteran eligibility for care, clinics visited, and all procedures [8]. A complete listing of veterans receiving primary care at each of the six VHA facilities between March 1, 1995,
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and February 29, 1996, was compiled. Random samples of 300 men and 150 women representing unique users (not weighted by the amount of use) were then drawn. Identification numbers were assigned to each person sampled and used in lieu of names to preserve the anonymity of potential study respondents. The initial mailing of the Veterans Health Survey was sent to the residential addresses of the selected veterans in the spring of 1996. Nonrespondents received a second mailing approximately 4 weeks later. The deadline for the receipt of completed questionnaires was mid-September 1996. Data Processing Data from the six sites were entered, verified, and cleaned. Test–retest k reliability statistics were calculated for the 52 items on the questionnaire using data from 32 veterans who happened to complete the survey twice, presumably because their first response crossed in the mail with a second request to which they also responded. Thirty-seven percent of the 52 survey questions had k scores greater than 0.80, another 33% were greater than 0.60, and another 19% were greater than 0.40, which exceeds the customary threshold for acceptable reliability [9]. Of the remaining 6 questions, 5 had dispersion characteristics that rendered the k statistic inadequate as an indicator of reliability. The blood pressure and breast cancer survey questions for women were among the items with the highest k values, while those inquiring about the location of care (i.e., inside the VHA, outside the VHA, or both) had relatively lower k values. Data Analysis Weighted averages for receipt of the 13 prevention services were calculated using the SAS program for microcomputers [10]. Weighted proportions were calculated for specific population subgroups (e.g., males and females ages 65 or older who received an influenza vaccine this year). Two-way cross-tabulations were produced using data stratified by age and gender to examine differences in the responses to specific study questions. x2 statistics and Cochran–Mantel–Haenszel statistics were used to assess the statistical significance of age–gender differences in the survey. Weighted proportions were used to examine the extent to which veterans were receiving specific prevention services. Unweighted proportions were used to obtain significance levels since the P values from weighted proportions would have been artificially inflated due to the size of the study sample. A significance level of P , 0.05 was selected for all x2 and Cochran–Mantel–Haenszel statistics. Missing values were retained in the denominators when calculating weighted proportions, but omitted
from unweighted proportions when generating P values. Characteristics of Respondents (Weighted) Among the male respondents, the modal age was 65–69 years, with 50% above age 65. Among the female respondents, the modal age was 40–44 years, with 50% under age 50. For both males and females, nearly a third reported traveling 30 to 59 min from their home to the VHA facility, and slightly more than a third travel an hour or more. More than half the males and females reported they received “almost all (90% or more)” of their health care at VHA facilities, but about one in five male and female users of VHA primary care clinics reported getting less than half of their health care from the VA. The VA health care system is by no means a closed-panel of providers for veterans, suggesting the lack of coordinated care could be problematic. RESULTS AND DISCUSSION
Preventive Services Not Targeted to Specific Age Subgroups Findings presented in Table 1 indicate that both male (95%) and female (93%) veterans currently exceed the U.S. Year 2000 goal of 90% in the area of hypertension detection (primary prevention), both male (78%) and female (88%) veterans exceed the adapted U.S. Year 2000 goal of 75% in the area of tobacco counseling, and female veterans (93%) also exceed the Year 2000 goal of 85% in “almost always” using seat belts. There were statistically significant gender differences after controlling for age for three of the nine primary prevention, and screening and counseling services listed in Table 1 as follows: (1) counseling for the proportion of current tobacco users, (2) the proportion receiving physical activity screening and counseling in the past year, and (3) the proportion reporting “almost always” using seat belts. However, in only one area, the use of seat belts, did gender differences exceed 5%. Female veterans were more likely than their male counterparts to indicate that they “almost always” used seat belts (93% versus 82%, respectively). There were no significant gender differences after controlling for age in the proportion of the veteran population receiving tetanus immunization, offered tobacco use counseling, being screened for problem drinking and offered alcohol moderation counseling, receiving weight control and nutrition screening and counseling, or receiving seat belt and accident avoidance counseling this year. It is worth noting that the magnitude of the weighted rates for males and females does not correlate well with the statistical significance based on unweighted rates in stratified Cochran– Mantel–Haenszel composite tests. This is attributed to an anomaly of the necessary weights and the large
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PREVENTION SERVICES RECEIVED BY VETERANS
TABLE 1 Sex- and Age-Specific Self-Reported Rates of Use of Various Health Promotion and Disease Prevention Services Appropriate for All Age Groups among Veterans Receiving Primary Care from the VA Compared with the U.S. Goals for the Year 2000 Weighted 1996 VA rates U.S. goals for Year 2000 Primary prevention Hypertension detection % with blood pressure check in the past 2 years Tetanus immunization % receiving Td booster at least once in the past decade Screening and counseling Tobacco use counseling % who are current tobacco users % of tobacco users offered counseling Problem drinking and alcohol moderation counseling % asked/screened for problem drinking and alcohol use this year Weight control and nutrition counseling % receiving nutrition counseling this year Physical activity counseling % receiving activity counseling this year Seat belt and accident avoidance counseling % receiving seat belt use and accident avoidance counseling this year % reporting “almost always” using seat belts
All ages Male
Age
Female Probabilitya
Under 35
35–49
50–64
65–74
75 and over Probabilityb
90%
95%
93%
0.102
87%
94%
95%
97%
94%
0.001
62%
50%
60%
0.855
70%
67%
50%
48%
37%
0.001
15% 75%c
26% 78%
27% 88%
0.033 0.397
25% 69%
44% 75%
28% 83%
24% 82%
10% 72%
0.001 0.001
75%c
13%
11%
0.051
14%
20%
16%
11%
6%
0.001
75%c
34%
33%
0.348
16%
37%
42%
36%
22%
0.001
50%c
45%
49%
0.013
35%
41%
46%
49%
44%
0.001
50%c
5%
7%
0.155
1%
3%
3%
7%
7%
0.285
85%
82%
93%
0.006
88%
82%
81%
83%
87%
0.257
a Probabilities are based on results from unweighted cross-tabulations of each prevention measure by sex, controlling for age, omitting missing values, consistent with conventional practice. b Probabilities are based on results from unweighted cross-tabulations of each prevention measure by age, controlling for sex, omitting missing values, consistent with conventional practice. c Adapted from percent of physicians offering the service to the percent receiving the service.
numbers of younger women and older men in these populations. Consequently, we will focus our attention on differences that are both statistically significant at the traditional 0.05 level and practically important as indicated by mean differences of 5% or more. Once gender differences were taken into account, significant age differences remained in the proportion of veterans receiving each of the primary prevention and screening and counseling services listed in Table 1, except for seat belt and accident avoidance counseling. The VA rates for some age subgroups exceeded the overall U.S. goals for the Year 2000 in three preventive services: (1) blood pressure checks within the past 2 years among all subgroups ages 35 and older, (2) tetanus boosters in the past 10 years among the subgroups under age 50, and (3) the percentage reporting “almost always” wearing seat belts among the subgroups under age 35 and ages 75 or older. Veterans ages 75 or older
were the only subgroup to achieve the Year 2000 goal for current tobacco users (a reduction target). Only 10% of those ages 75 or older reported currently using tobacco, while the Year 2000 goal calls for less than 15% use. Across most prevention categories, age analysis revealed that veterans between the ages of 35 and 74 were the most likely to exceed the Year 2000 goals. Those under age 35 or over age 75 in general were substantially less likely to receive screening/counseling services than were those between ages 35 and 74 for each of the following services: (1) blood pressure checks, (2) tobacco counseling, (3) nutrition screening and counseling, as appropriate, and (4) physical activity screening and counseling in the past year. A somewhat less prevalent pattern was detected for the proportion of the subgroups receiving tetanus boosters and alcohol
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TABLE 2 Sex- and Age-Specific Self-Reported Rates of Use of Various Health Promotion and Disease Prevention Services Appropriate for Specific Age Subgroups among Veterans Receiving Primary Care from the VA Compared with the U.S. Goals for the Year 2000 Weighted 1996 VA rates
Primary prevention Hyperlipidemia detection % with cholesterol checked in the past 5 years (males ages 35 through 64; females ages 45 through 64) Influenza immunization % who received an influenza vaccine this year (age 65 plus) Pneumococcal vaccination % who received pneumococcal vaccine at least once (age 65 plus) Secondary prevention Cervical cancer detection % of females with Papanicolaou test in the past 3 years (under age 65) Breast cancer detection % of females who received a mammogram in the past 2 years (ages 50 through 69) Colorectal cancer detection % receiving a fecal occult blood test this year (age 50 plus)
U.S. goals for Year 2000
Male
75%
82%
85%
60%
76%
60%
Age subgroups
Age Under 35
35–49
50–64
65–74
0.088
54%
80%
82%
97%
81%
0.001
72%
0.084
28%
37%
52%
75%
77%
0.001
43%
51%
0.006
18%
14%
19%
43%
45%
0.001
85%
N/A
93%
N/A
100%
91%
92%
85%
76%
0.001
60%
N/A
91%
N/A
20%
65%
91%
92%
87%
0.001
50%
34%
30%
0.438
11%
14%
33%
34%
31%
0.001
Female Probabilitya
75 and over Probabilityb
a
Probabilities are based on results from unweighted cross-tabulations of each prevention measure by sex for the targeted age group, omitting missing values, consistent with conventional practice. b Probabilities are based on results from unweighted cross-tabulations of each prevention measure by age, controlling for sex, omitting missing values, consistent with conventional practice.
counseling, for problem drinking. The proportion of veterans ages 65 and over receiving these two prevention and screening/counseling services was notably lower compared with their younger age counterparts. These results suggest that additional primary prevention and screening/counseling efforts should be recommended for clinicians treating substantial numbers of male and female veterans over the age of 65 or under the age of 35. Overall, the results from Table 1 suggest that while there are few significant gender differences in the receipt of the listed primary prevention and screening/ counseling services for male and female veterans of all ages, significant age-related differences exist in the proportion of veterans receiving these services. Most importantly, veterans between ages 35 and 65 are generally more likely to receive these prevention services relative to their counterparts under age 35 or over age 65.
Preventive Services Targeted to Specific Age Subgroups Four of the six prevention services for targeted age subgroups exceeded the U.S. goals for the Year 2000: (1) hyperlipidemia detection, (2) influenza immunization, (3) cervical cancer detection, and (4) breast cancer detection. Preventive services provided in VHA facilities did not meet the Year 2000 recommendations for pneumococcal vaccination and colorectal cancer detection. Results presented in Table 2 indicate that there are few gender differences in the primary and secondary prevention measures that target particular age subgroups. The one instance in which the rates did vary significantly by gender was for the receipt of pneumococcal vaccination at least once in a lifetime for those age 65 or older. Females age 65 or older were substantially more likely than their male counterparts to have
PREVENTION SERVICES RECEIVED BY VETERANS
received a pneumococcal vaccination at least once (51% versus 43%). Age-specific effects were anticipated for the primary and secondary prevention measures presented in Table 2 that target specific age groups since, by definition, only certain age groups of average-risk, asymptomatic veterans were being addressed [1]. Nevertheless, it is interesting to compare the prevalence rates across age categories both to pinpoint specific ages at which additional services may be warranted (i.e., the underserved target age groups) and to identify groups for which preventive services have been provided to nontargeted veterans. We hasten to add that these data do not allow us to distinguish between the overserved average-risk veteran versus appropriately served veterans with chronic diseases. The analysis of age-specific rates reveals that some preventive medical services were commonly received at very high rates by age subgroups that were not the intended targets. For example, cholesterol checks are recommended every 5 years for males between the ages of 35 and 64 and for females ages 45 through 64. Table 2 indicates that a substantial number of veterans outside these age groups reported receiving this primary prevention measure within the past 5 years. For example, cervical cancer detection smears are recommended every 3 years only for women under age 65, yet 85% of female veterans ages 65–74 and 76% of female veterans ages 75 and older received this secondary prevention measure within the past 3 years. A similar pattern of service delivery to nontargeted veterans was revealed for the following areas: (1) influenza and pneumococcal immunizations for those under age 65, (2) breast cancer detection for those under age 50 or over age 69, and (3) colorectal cancer tests for those under age 50. CONCLUSIONS
These data indicate that preventive medical services received by both male and female veterans currently exceed the U.S. Year 2000 goals in the areas of hypertension detection, tobacco counseling, hyperlipidemia detection, and influenza immunization. Preventive medical services for female veterans exceed the goals in three additional areas including cervical cancer detection, breast cancer detection, and seat belt use. The preventive medical service most in need of attention is screening and counseling, as appropriate, for problem drinking and alcohol moderation. Although there were few gender differences after controlling for age in the receipt of preventive medical services by male and female veterans, females seemed to fare better when differences did exist. The women veterans’ health clinics deserve credit for successful
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attention to the preventive medical care needs of female veterans. Age-specific differences in the rates of receipt of both age-targeted and non-age-targeted preventive medical services suggest that additional attention is needed for male and female veterans under age 35 and over age 65. In particular, screening and counseling for problem drinking, weight control, and physical activity need to be offered to greater numbers of veterans. Some preventive services targeted to particular age subgroups of average-risk veterans are beneficial to individuals suffering from chronic disease. Thus it is not surprising to find a substantial number outside the expected age brackets reporting service receipt. Furthermore, given the changing nature of preventive medicine recommendations over the past few years, prudent VHA physicians may choose to recommend preventive medical services to veterans falling outside targeted age groups. Subsequent research can clarify which portion of these rates is attributable to overuse by average-risk individuals and which portion is attributable to prudent use among individuals with chronic disease. The NCHP will implement the Veterans Health Survey in all VHA facilities in Fiscal Year 1997. The data obtained will serve as a baseline for assessing future improvements in the provision of health promotion and disease prevention services. The current study will add to our understanding of the rates of preventive medical services received by veterans and help to target efforts to those most likely to receive substantial benefits. ACKNOWLEDGMENTS The authors acknowledge with gratitude Donald Belcher, M.D., for sage advice on all phases of this effort; Kristin Nichol, M.D., for assisting in the conceptualization and development of the Veterans Health Survey; and Lori Bastian, M.D., for providing many insightful comments regarding the interpretation of these data. The views expressed are those of the authors and do not represent the Department of Veterans Affairs. REFERENCES 1. U.S. Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore: William & Wilkins, 1996. 2. U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000; national health promotion and disease prevention objectives. Washington: U.S. Govt. Printing Office, 1991. [DHHS Publication No. (PHS) 91-50212] 3. U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000 update: achieving the nation’s health objectives. Washington: Office of Disease Prevention and Health Promotion, 1993 Feb/Mar. 4. Sullivan LW. Sounding board: Healthy People 2000. N Engl J Med 1990;323:1065–7. 5. Nichol KL, Korn JE, Margolis KL, Poland GA, Petzel RA, Lofgren
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RD. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med 1990;89:156–60. 6. Shaffer J, Wexler LF. Reducing low-density lipoprotein cholesterol levels in an ambulatory care system. Results of a multidisciplinary collaborative practice lipid clinic compared with traditional physician-based care. Arch Intern Med 1995;155:2330–5. 7. Belcher DM. Implementing preventive services: success and failure in an outpatient trial. Arch Intern Med 1990;150:2533-41.
8. Lamoreaux J. The organizational structure for medical information management in the Department of Veterans Affairs: an overview of major healthcare databases. Med Care 1996;34(3): MS31–44. 9. Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York: Wiley, 1981. 10. SAS Institute. SAS/STAT user’s guide. Vol. 1 and 2. Version 6. Cary (NC): SAS Inst., 1990.