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Use of Clinical Preventive Services by Adults Aged <65 Years Enrolled in Health-Maintenance Organizations United States, 1996Health-maintenance organizations (HMOs) are accountable for the preventive care of approximately one quarter of the U.S. population (1), and public health agencies have an increasing role in assessing the quality of care for populations enrolled in HMOs (2-4). The Health Plan Employer Data and Information Set (HEDIS 3.0) (5) reports on the performance of HMOs and is sponsored and maintained by the not-for-profit National Committee for Quality Assurance (NCQA). * This report summarizes state-specific HEDIS estimates for the delivery of four clinical preventive services: screening mammography and Papanicolaou (Pap) tests for women, screening retinal examinations for persons with diabetes, and advising smokers to quit. The advice-to-quit-smoking data from 12 states represented by HEDIS is then compared with data on insured respondents from the corresponding 12 states surveyed by the Behavioral Risk Factor Surveillance System (BRFSS). ** These findings underscore the potential public health importance of HEDIS data (e.g., creating the capacity to assess statewide prevention interventions) and highlights some of the methodologic issues of comparing performance measures from HEDIS to the BRFSS. The HEDIS data used in this report are for commercial HMO enrollees only (i.e., persons who joined the HMO through an employer group policy or an individual or family policy {excluding Medicaid and Medicare beneficiaries}). The 1996 HEDIS data used in this analysis were reported by 320 HMOs in 42 states and the District of Columbia; these HMOs are comparable to the 660 HMOs nationwide by HMO type, regional location, and tax status (5). Data for the measures on mammography, Pap tests, and retinal examinations for persons with diabetes were obtained from administrative data with optional medical record supplementation using standard HEDIS 3.0 methodology (5). *** To obtain data about the advice-to-quit-smoking measure, NCQA required HMOs to use independent contractors to administer and analyze a standardized mailed survey. **** The median response rate was 41%. A "national" HEDIS prevalence rate for each measure was calculated by first adjusting for HMO plan size and then for state population size. The BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized persons aged greater than or equal to 18 years in the 50 states and the District of Columbia. All persons responding to the BRFSS questionnaire were asked 1) whether they had health insurance, 2) what specific preventive health services they had received, and 3) the duration since they had received the service(s). BRFSS respondents reporting Medicare or Medicaid coverage or no insurance at all were excluded from the analysis. In 1996, a total of 12 states used the optional BRFSS module that contained the advice-to-quit-smoking question. Estimates were weighted to the states' age, sex, and race distribution of adults. Statistical Analysis System (SAS) software (6) was used to calculate point estimates, and SUDAAN (7) software was used to calculate 95% confidence intervals. The response rate for the BRFSS was estimated by the CASRO method as 63.8% (8). Standardization of HEDIS and BRFSS data to the same population was not possible because HEDIS provided only aggregated data. Among women aged 52-64 years, a median of 71.9% (range: 61.9%-83.2%) of HEDIS HMO records showed receipt of a mammogram during the preceding 2 years (Table_1). The prevalence of mammography was highest in New England states and lowest in the east south central states (Table_2). Among women aged 21-64 years, a median of 72.7% (range: 51.5%-85.6%) of HMO records showed receipt of a Pap test during the preceding 3 years. The prevalences of Pap test receipt for the HEDIS population were highest in the New England states and lowest in the east south central states. Among persons with diabetes aged 31-64 years in the HEDIS population, a median of 39.5% (range 19.2%-67.7%) had had a retinal examination during the previous year. Among smokers aged 18-64 years who were examined by a health-care provider during the previous year, a median of 63.0% (range: 32.3%-71.8%) reported receiving advice to quit. HEDIS data were compared with BRFSS data for the advice-to-quit measure for 12 states and the District of Columbia. Among HEDIS smokers aged 18-64 years who had been examined by a health-care provider during the previous year, a median of 63.2% (range: 56.2%-71.8%) reported receiving advice to quit; in comparison, among the insured BRFSS smokers who had been examined by a physician for a routine check-up during the previous year, a median of 62.4% (range: 49.9%-70.8%) reported receiving advice to quit (Table_3). Reported by: F Ahmed, J Thompson, National Committee for Quality Assurance, Washington, DC. The following BRFSS coordinators: B Bender, Arizona; J Senner, PhD, Arkansas; M Leff, MSPH, Colorado; F Breukelman, Delaware; C Mitchell, District of Columbia; M Perry, Kansas; K Asher, Kentucky; R Meriwether, MD, Louisiana; D Maines, Maine; P Arbuthnot, Mississippi; T Murayi, PhD, Missouri; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; N Hann, MPH, Oklahoma; L Redman, Virginia; F King, West Virginia. Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion; Office of Program Planning and Evaluation; Div of Prevention Research and Analytic Methods, Epidemiology Program Office; and an EIS Officer, CDC. Editorial NoteEditorial Note: The findings in this report indicate that the prevalences of preventive-care practices of HMOs in the United States varied among the states and regions. HEDIS data represent a large-scale private-sector effort to provide data that could have valuable public health applications. HEDIS measures are potentially useful for public-sector assessment of the quality of care provided by HMOs, especially because HMOs are increasingly contracted by the states and the Health Care Financing Administration to care for Medicaid and Medicare populations. This report provides the first published state-specific estimates of HEDIS performance and comparison of private-sector HEDIS data to the BRFSS, a public-sector data set. The findings in this report are subject to at least four limitations. First, it is unclear whether HEDIS is representative of a state's HMO population because the penetration of HMOs in each state's health-care system varies widely (1). Because there is no government or purchaser mandate to report data to HEDIS, HMOs can voluntarily choose to submit HEDIS performance data (5). HEDIS data for 1996 were not audited uniformly and may overrepresent HMOs in urban areas (5). Second, HEDIS and BRFSS populations could not be standardized to the same population. A county-by-county comparison of a large, multistate HMO population with the insured BRFSS population showed that HMO enrollees represented fewer minorities and were younger, were more likely to be married, and had higher income and education levels (9). Third, although the advice-to-quit-smoking measure in both populations was assessed by self-report, there were differences in both the mode of administration and wording of questions. BRFSS advice-to-quit rates may be overestimated because during routine checkups patients may be more likely to receive preventive advice than during other outpatient encounters. Finally, the low response rate for HEDIS may reflect nonresponse bias. HEDIS is a potentially valuable means of tracking the use of clinical preventive services for a large proportion of the U.S. population. Of the four measures studied, the national health objective for 2000 has been met only for mammography for women aged 52-64 years. To track prevention interventions provided by various health-delivery systems, more comparable population-based performance measures need to be developed. Such measures would benefit both health departments and HMO managers by identifying areas for improvement for clinical preventive service delivery (2-4) and enable states to monitor the effectiveness of communitywide health programs. References
* The source for data contained in this article is Quality Compass(TM) and is used with the permission of the NCQA. ** The estimates for mammography, Pap tests, and retinal examination rates from HEDIS were not compared with BRFSS because of the differences between records-based and self-reported measurement systems. *** The HEDIS data on advice to smokers, Pap tests, and retinal examinations were derived from members who were enrolled continuously in an HMO for at least 1 year. Calculation of HEDIS mammography coverage rates required at least 2 years of continuous enrollment. HEDIS does not permit more than one 45-day break in enrollment during the reporting year. **** Within each HMO, the survey was mailed to 1860 randomly chosen commercial enrollees aged greater than or equal to 18 years. Response rate was calculated as the number of completed surveys divided by the number of persons in the sample minus (the number of ineligible persons surveyed plus the number of persons who could not be contacted). Table_1 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
TABLE 1. Estimated prevalence of use of selected clinical preventive services by adults aged <65 years enrolled in
health-maintenance organizations (HMOs), by service and state -- United States, Health Plan Employer Data and Information
Set (HEDIS), 1996
============================================================================================================================================================
Papanicolaou Retinal examinations for Receipt of advice
Mammography * smear + persons with diabetes & to quit smoking @
----------------------------------- ----------------------------- ----------------------------- ------------------------------
No. HMOs No. HMOs No. HMOs No. HMOs
State reporting ** % (95% CI ++) reporting % (95% CI) reporting % (95% CI) reporting % (95% CI)
----------------------------------------------------------------------------------------------------------------------------------------------------------
Arkansas 2 71.7 (+/-5.0) 2 69.6 (+/- 4.8) 2 23.2 (+/- 6.0) NA &&
Arizona 8 75.1 (+/-1.3) 8 80.8 (+/- 2.8) 7 40.7 (+/- 2.8) 5 63.7 (+/- 3.3)
California 6 74.7 (+/-3.5) 6 73.1 (+/- 4.5) 6 51.6 (+/- 9.5) 6 61.4 (+/- 6.3)
Colorado 8 74.2 (+/-3.2) 8 73.8 (+/- 2.9) 8 46.9 (+/- 6.7) 6 61.9 (+/- 8.2)
Connecticut ** 7 69.7 (+/-3.9) 7 70.7 (+/- 4.3) 7 42.5 (+/- 5.0) 6 61.7 (+/- 9.7)
Delaware ** 7 70.3 (+/-0.5) 6 71.2 (+/- 0.2) 7 37.7 (+/- 0.7) 3 61.9 (+/- 4.7)
District of 4 66.5 (+/- 3.3)
Columbia ** 3 76.5 (+/-0.4) 3 82.9 (+/- 0.1) 3 56.5 (+/- 0.6)
Florida 30 70.8 (+/-0.8) 23 67.4 (+/- 3.0) 26 37.9 (+/- 2.9) 8 64.4 (+/- 3.2)
Georgia 4 69.2 (+/-6.3) 6 65.5 (+/- 7.1) 6 30.5 (+/- 5.0) 2 61.1 (+/-21.9)
Hawaii 1 77.7 (+/-0.3) 1 76.3 (+/- 0.2) 1 67.7 (+/- 0.5) 1 65.9 (+/- 3.2)
Illinois ** 7 66.6 (+/-4.9) 8 67.9 (+/- 6.6) 7 29.1 (+/- 7.8) 5 64.0 (+/- 5.1)
Indiana ** 5 75.6 (+/-6.0) 6 76.4 (+/- 8.8) 5 39.1 (+/- 9.7) 4 64.2 (+/- 6.0)
Iowa 1 78.2 (+/-3.3) 1 72.7 (+/- 0.5) 1 47.0 (+/- 3.9) 1 54.8 (+/- 6.2)
Kansas 6 72.0 (+/-3.2) 6 71.3 (+/- 5.4) 5 48.0 (+/-14.4) 3 63.2 (+/-11.5)
Kentucky 3 64.3 (+/-2.5) 3 69.3 (+/- 5.2) 3 43.3 (+/- 4.5) NA
Louisiana 4 66.6 (+/-3.0) 4 51.5 (+/-17.0) 4 26.9 (+/- 6.2) 3 56.2 (+/- 5.1)
Maine 3 83.2 (+/-0.9) 3 83.7 (+/- 0.3) 3 56.0 (+/- 1.8) 3 71.8 (+/- 4.2)
Maryland ** 15 68.3 (+/-0.3) 15 70.0 (+/- 0.1) 13 42.8 (+/- 2.2) 11 67.9 (+/- 2.4)
Massachusetts ** 12 80.2 (+/-0.2) 10 82.0 (+/- 0.9) 10 56.7 (+/- 2.1) 10 71.1 (+/- 3.0)
Michigan 12 75.3 (+/-2.3) 12 76.8 (+/- 3.2) 12 39.5 (+/- 5.8) 10 67.9 (+/- 2.6)
Minnesota 2 77.9 (+/-9.2) 2 85.6 (+/- 1.8) 2 51.3 (+/-22.4) 2 65.6 (+/- 5.1)
Missouri ** 9 69.4 (+/-4.7) 9 68.5 (+/- 3.2) 12 32.3 (+/- 4.7) 5 62.8 (+/- 2.7)
Nebraska 3 72.5 (+/-2.5) 3 76.6 (+/- 4.7) 3 19.2 (+/- 4.1) 3 62.5 (+/- 4.9)
Nevada 1 61.9 (+/-1.3) 1 69.3 (+/- 0.4) NA NA
New Hampshire 3 77.9 (+/-0.8) 3 81.5 (+/- 0.3) 3 60.9 (+/- 1.5) 2 69.6 (+/- 4.6)
New Jersey ** 9 65.8 (+/-4.8) 8 64.4 (+/- 3.9) 9 36.3 (+/- 6.1) 5 53.9 (+/- 7.8)
New Mexico 5 67.9 (+/-3.6) 4 65.1 (+/- 7.7) 4 42.7 (+/- 6.6) 1 32.3 (+/- 2.2)
New York ** 26 70.8 (+/-1.7) 27 74.2 (+/- 2.2) 27 50.2 (+/- 2.4) 14 62.1 (+/- 2.5)
North Carolina 6 70.8 (+/-5.2) 8 74.1 (+/- 3.4) 8 36.9 (+/- 5.3) 4 63.3 (+/- 2.9)
Ohio 16 70.6 (+/-2.9) 16 69.9 (+/- 2.8) 16 35.4 (+/- 4.7) 5 67.3 (+/- 5.2)
Oklahoma 6 74.1 (+/-2.5) 6 73.5 (+/- 1.6) 6 34.9 (+/- 4.9) 3 56.4 (+/- 3.2)
Oregon 7 74.2 (+/-1.0) 7 74.9 (+/- 1.9) 7 44.1 (+/- 2.9) 3 61.4 (+/-18.1)
Pennsylvania ** 23 73.4 (+/-0.2) 21 72.7 (+/- 0.1) 23 35.4 (+/- 0.1) 10 66.5 (+/- 2.7)
South Carolina ** 5 74.7 (+/-1.4) 5 66.3 (+/- 2.9) 5 25.7 (+/- 3.3) 3 58.5 (+/- 7.6)
South Dakota NA 1 66.2 (+/- 2.2) NA NA
Tennessee 8 64.3 (+/-3.3) 8 67.5 (+/- 2.5) 8 25.4 (+/- 6.2) 4 52.4 (+/- 6.2)
Texas 21 68.9 (+/-2.5) 22 73.4 (+/- 2.4) 20 35.1 (+/- 2.6) 6 59.7 (+/- 4.6)
Utah 3 68.2 (+/-4.4) 3 62.7 (+/- 2.5) 3 25.2 (+/- 4.3) 1 51.6 (+/- 3.6)
Vermont 1 81.0 (+/-2.6) 1 84.4 (+/- 2.4) 1 59.4 (+/- 3.2) NA
Virginia ** 5 63.5 (+/-4.2) 7 66.9 (+/- 3.5) 5 27.7 (+/- 3.7) 5 64.6 (+/- 3.5)
Washington 10 76.4 (+/-0.4) 10 77.5 (+/- 0.2) 10 56.6 (+/- 1.0) 7 60.8 (+/- 6.1)
West Virginia 1 69.2 (+/-0.2) 1 71.4 (+/- 0.1) 1 32.4 (+/- 0.3) 1 69.1 (+/- 2.5)
Wisconsin ** 6 75.2 (+/-4.1) 6 78.1 (+/- 3.1) 6 59.7 (+/- 8.7) 4 64.5 (+/- 5.6)
----------------------------------------------------------------------------------------------------------------------------------------------------------
* Women aged 52-64 years who had documented receipt of the service during the 2 years preceding the inquiry.
+ Women aged 21-64 years who had documented receipt of the service during the 3 years preceding the inquiry. Denominator may exclude women who
had had a hysterectomy.
& Adults aged 31-64 years who had diabetes diagnosed and who had documented receipt of a retinal examination during the previous year.
@ Adults aged 18-64 years who reported having seen a health-care provider during the year preceding the inquiry; data are from the HEDIS membership
satisfaction survey.
** HMOs for which the primary service area could not be determined had their preventive service coverage rates reported for each of the multiple states
served.
++ Confidence interval.
&& Not available.
============================================================================================================================================================
Return to top. Table_2 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
TABLE 2. Estimated prevalence of use of selected clinical preventive services, by region and service -- United States, Health
Plan Employer Data and Information Set (HEDIS), 1996
==========================================================================================================================================
Papanicolaou Retinal examinations Receipt of advice
Mammography * smear + for persons with diabetes & to quit smoking @
------------------- ---------------- --------------------------- -----------------
Region % (95% CI **) % (95% CI) % (95% CI) % (95% CI)
-------------------------------------------------------------------------------------------------------------
New England 77.5 (+/-1.3) 79.2 (+/-1.6) 53.4 (+/-2.3) 68.4 (+/-3.5)
Middle Atlantic 70.6 (+/-1.2) 71.7 (+/-1.3) 42.6 (+/-1.7) 61.8 (+/-2.2)
East North Central 71.8 (+/-2.0) 72.7 (+/-2.3) 37.9 (+/-3.5) 65.8 (+/-2.0)
West North Central 73.9 (+/-3.9) 74.7 (+/-3.2) 41.0 (+/-7.1) 62.2 (+/-2.8)
South Atlantic 70.0 (+/-0.8) 69.1 (+/-1.4) 34.8 (+/-1.7) 63.8 (+/-1.5)
East South Central 64.3 (+/-2.9) 68.3 (+/-2.6) 33.0 (+/-6.7) 52.4 (+/-6.5)
West South Central 69.4 (+/-1.8) 69.8 (+/-2.6) 32.8 (+/-2.2) 58.7 (+/-2.8)
Mountain 71.4 (+/-2.0) 72.7 (+/-3.3) 40.4 (+/-3.6) 56.5 (+/-5.7)
Pacific 74.9 (+/-2.0) 73.9 (+/-2.7) 52.1 (+/-4.4) 61.4 (+/-5.5)
National ++ 71.6 (+/-0.7) 72.1 (+/-0.9) 40.8 (+/-1.0) 62.3 (+/-0.7)
-------------------------------------------------------------------------------------------------------------
* Women aged 52-64 years with documented receipt of service during the preceding 2 years.
+ Women aged 21-64 years with documented receipt of service during the preceding 3 years. Denominator may exclude women who had had a
hysterectomy.
& Adults aged 31-64 years who had diabetes diagnosed and who had documented receipt of a retinal examination during the preceding year.
@ Smokers aged 18-54 years who had seen a health-care provider during the previous year and reported receipt of service.
** Confidence interval.
++ National rate adjusted for participating states' population.
==========================================================================================================================================
Return to top. Table_3 Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
TABLE 3. Estimated prevalence of receipt of advice to quit smoking for adults aged
<65 years, by selected states -- United States, Health Plan Employer Data and
Information Set (HEDIS) and Behavioral Risk Factor Surveillance System (BRFSS) *,
1996
===============================================================================================
Reported receipt of advice to quit smoking +
--------------------------------------------
HEDIS BRFSS
--------------------- -------------------
State % (95% CI &) % (95% CI)
-----------------------------------------------------------------
Arizona 63.7 (+/- 3.3) 51.6 (+/- 9.8)
Colorado 61.9 (+/- 7.0) 68.1 (+/- 8.5)
Delaware@ 61.9 (+/- 4.7) 66.2 (+/- 3.6)
District of Columbia@ 66.5 (+/- 3.9) 62.4 (+/-11.4)
Kansas 63.2 (+/-11.5) 49.9 (+/- 8.4)
Louisiana 56.2 (+/- 5.1) 51.5 (+/- 9.1)
Maine 71.8 (+/- 4.2) 66.9 (+/- 9.4)
Missouri 62.8 (+/- 2.5) 59.5 (+/- 9.1)
New York@ 62.1 (+/- 2.8) 69.5 (+/- 6.7)
North Carolina 63.3 (+/- 2.9) 64.5 (+/- 6.5)
Oklahoma 56.4 (+/- 3.2) 59.2 (+/- 8.7)
Virginia@ 64.6 (+/- 4.2) 70.8 (+/- 6.8)
West Virginia@ 69.1 (+/- 2.5) 62.0 (+/- 7.4)
Median 63.2 62.4
-----------------------------------------------------------------
* Persons responding to the BRFSS questionnaire were asked, "Do you have any kind of
health-care coverage, including health insurance, prepaid plans such as health-maintenance
organizations (HMOs), or government plans such as Medicare?" Those responding "yes" were
asked, "What type of health-care coverage do you use to pay for most of your medical care?"
Those reporting Medicare, Medicaid, or no insurance coverage were excluded from this analy-
sis.
+ Smokers aged 18-64 years who reported visiting a provider (HEDIS) or physician (BRFSS)
during the preceding year and received advice to quit. The BRFSS asked the advice-to-quit
smoking question in 12 states and the District of Columbia; the HEDIS data on this measure
is from the same 12 states and the District of Columbia.
& Confidence interval.
@ HMOs whose primary service area could not be determined had their preventive service
coverage rates reported for each of the multiple states served.
===============================================================================================
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