Dr. David Satcher,
Assistant Secretary for Health and Surgeon General will be joined by a
panel of experts representing purchasers of preventive services, health
plans, consumers, national provider organizations, local health
departments, quality measurement organizations, Federal agencies funding
health care services, State Medicaid agencies, health professions schools,
and other stakeholders. Participants will review the progress made on
meeting the goals and targets for the Clinical Preventive Services
priority area of Healthy People 2000, and to enable the policy planners,
educators, and providers of health care services to set priorities for the
delivery, quality, measurement, and coverage of clinical preventive
services.
Presentation
made by:
Edward J. Sondik, Ph.D.
Director
National Center for Health Statistics
January 20, 1998
Wilson Auditorium
National Institutes of Health
Thank you. This
afternoon, we’re focusing on the Nation's use of clinical preventive
services. As in past Healthy People reviews, we’ll examine where
progress has been made, where progress has lagged, and where disparities
still remain. The investment in preventive services has truly paid off, so
we'll also highlight a few examples of the impact of these services over
the past decade.
The data we are using
come from several key data sets. National data are primarily from the
National Health Interview Survey which gathers data on health promotion
and disease prevention, through a household interview survey. We just
completed the 1998 survey which will provide data for the final assessment
on Healthy People 2000. While these estimates for the nation as a whole
tell us a great deal, they can’t illustrate and highlight critical
differences which emerge as we examine the data state-by-state. So we use
complementary data on states from the Behavioral Risk Factor Surveillance
System, a collection of state surveys based on telephone interviews,
coordinated by our CDC colleagues.
Now let’s take a look
at some of the specific objectives. First, those where we're making
progress.
SLIDE
1 (Progress) - We have done well in raising levels of childhood
immunization and seeing that the elderly receive flu shots. And more
Americans than ever before are being screened for high cholesterol and
breast and cervical cancer. The next series of slides focus on these
objectives.
SLIDE
2 (Child Immunization) - For the year 2000, we set a target that at least
90 percent of our children, ages 19-35 months old, receive a recommended
set of childhood immunizations. I am pleased to report that progress in
this area has been impressive, with all of the recommended immunizations
nearing or exceeding the target.
SLIDE
2A. Even the newly recommended vaccination for hepatitis B has increased
four-fold, going from 16 percent of children immunized in 1993 to 82
percent by 1996.
Now for the elderly. .
. .
SLIDE
3 (Flu shots) - A vaccination can prevent what often could be a fatal bout
of the flu or lessen its severity. In 1997, vaccination rates among the
elderly had reached or exceeded the goal of 60 percent in all but the six
states and the District of Columbia, shown in red. States that have met
the target are in gray and blue; those in blue have achieved a 70 percent
vaccination rate. Turning now to cholesterol screening . . .
SLIDE
4 (Chol screen) - High cholesterol is an important risk factor for
cardiovascular disease. Cholesterol can be lowered through diet and, if
necessary, medication, but first individuals and their health care
providers need to screen and take appropriate action. These data show an
improvement in the percent of adults who have been screened in the past
two years.
SLIDE
4A. Looking at the two top groups shown on this chart, note that from 1991
to 1993, 19 percent more black Americans and 30 percent more American
Indian and Alaska Natives reported being screened for cholesterol--a very
significant improvement.
SLIDE
5. (Chol prev) - In fact that increase in screening has paid off. As shown
here, by the mid-1990s, fewer than 20 percent of the population had
elevated cholesterol levels, surpassing the Year 2000 target.
SLIDE
6. (Chol screen - map) - Using 1997 data from the Behavioral Risk Factor
Surveillance System, we see that screening varies across the country. In
that year, only five states and DC--shown in dark blue--had reached the
target of 75 percent of the population screened in the past 5 years, and
10 states, in red, are still below 65 percent. So we can and need to do
more.
SLIDE
7. (Pap test) Two of the objectives in this chapter address cancer.
Let’s look first at pap smears which are the principal reason that
cervical cancer death rates have fallen 75 percent in the past 40 years.
The data show that screening rates vary considerably by race.
SLIDE
7A. African American women 18 and over had a screening rate of 84 percent
in 1994, compared to 73 percent for American Indian and Alaska Native, and
a low of 66 percent for Asian and Pacific Islander women. These
disparities are cause for concern, and, in fact, cervical cancer screening
has been made a component of the Secretary's Initiative to Eliminate
Health Disparities.
SLIDE
8. (Pap test - map) When we look at screening by state, a majority of
states -- shown here in blue -- have reached the target of 85 percent of
adult women having had a pap test in the past 3 years. That's good news,
but still four states, the ones you see in red, are under 80 percent.
SLIDE
9. (Mam - map) Another service which can reduce cancer deaths is
mammography coupled with breast exams. In 1987, only 25 percent of women
aged 50 and older were regularly screened. These data from 1997 show that
all but five states--those in red--met the Year 2000 target of 60 percent
of women ages 50 and over having had a mammogram and clinical breast exam
in the past two years. This progress in screening and advances in
treatment have paid off. In fact, after remaining constant for almost 40
years, death rates for breast cancer have fallen 17 percent over the past
decade.
SLIDE
10 (Mam - race/eth) - When we look at mammography by race and ethnicity,
there is very little difference among white, black and Hispanic women.
SLIDE
10A. However, the differences by income and education in breast cancer
screening are quite dramatic. Women at the highest education or income
levels are twice as likely to have had a mammogram than women at the lower
end of the socioeconomic scale.
Now, I’d like to turn
now to some objectives where our progress has fallen far short of the
Healthy People targets:
SLIDE
11. (Pneumo elderly) - For pneumonococcal vaccinations, the goal of 60
percent of persons 65 and over ever having received a vaccination is far
from a reality. Although there is some modest progress for all of the
groups shown in this chart, we need to substantially increase the rate in
all race and ethnic groups in order to reach the goal.
SLIDE
12. (Pneumo Map) And, not a single state has met the 60 percent
vaccination target. The western and northeastern states rank higher on
this measure, but if we are to reach this target it is going to require a
concerted effort across the country.
SLIDE
13. (Reg care) - To receive preventive services, it's important to have a
regular source of health care. A regular source of care means doctors,
nurses and other health professionals who know their patients. They inform
their patients about testing, they schedule them for regular screening,
and they assist them in obtaining preventive services. While there was
some improvement in this measure, most recently there’s been very little
change and no group has reached the target of 95 percent.
SLIDE
14. (Blank) Progress is also weak for other recommended preventive service
objectives related directly to having a regular source of care. By the
way, we have included data for those objectives as well as the rest of the
objectives in this area in your briefing book. And for all of you the data
are available over the Internet. Let me just mention a couple of these
services now. For example, there has been little improvement in the
percentage of adult Americans who’ve had a routine checkup in the past
three years. And we've also seen no increase in the percent who report
that their doctor has asked them about health habits, such as diet and
exercise at their last visit.
SLIDE
15. (No coverage) - Having regular health care is strongly associated with
having health care coverage. An ambitious goal for the nation is for no
one to be without health care coverage, but as this chart shows, we are a
long way from achieving that goal. Overall some 16 percent of the
population under 65 years of age--that’s one in every 6--had no health
care coverage in 1996.
SLIDE
15A. And for Mexican Americans, more than one in three is without private
health insurance or coverage under public programs.
SLIDE
15B. The income gradient--certainly not unexpected--shows that those in
the lower income groups are far less likely to have health care coverage.
In fact, 33 percent of the lowest income group lacks health care coverage
compared to only 8 percent of those with the highest income.
SLIDE
16. (Minorities) - Objective 21.8 looks not at specific clinical services
but at the health care system itself. Healthy People 2000 calls for an
increase in minority participation in the health professions, targeted to
more closely reflect the diversity of our society. There has been some
improvement as measured by an increase in the proportion of degrees
awarded to black health professionals. However, African Americans received
only 6 percent of the health professional degrees in 1996, although they
comprise about 12 percent of the population. For Hispanics, the gap is
even greater, with only about 4 percent of degrees awarded to a group
which makes up about 11 percent of our population today. Clearly,
there’s a need to change this pattern in order to improve the diversity
of our health care.
SLIDE
17. (Conclusions) - To conclude: We certainly have made progress. More
Americans now receive preventive clinical services than a decade ago. And
disparities--by race, ethnicity, income and education--have surely been
reduced for some objectives. For other objectives, challenges persist.
Many of you have been involved in the process of setting the goals and
objectives for Healthy People 2010. One of these goals will be the
elimination of all health disparities--clearly a major challenge.
Our future progress
will also be challenged by changes in our health care system. The various
health care plans, which include or exclude certain preventive services,
and barriers based on level or type of coverage may create new disparities
in our health and health care. To meet those challenges we need new data
sources -- sources to provide data on service coverage and to monitor the
quality as well as the receipt of such services. The Medical Expenditures
Panel Survey, conducted by AHCPR, is one of those new data systems which
surely will be important for Healthy People 2010.
SLIDE
18. BLANK Indeed, data are at the core of Healthy People, and adequate
data to evaluate progress and identify problems will also be a challenge
for the entire Healthy People effort. With your help, we are working to
find the ways to meet those challenges — not only for the Clinical
Preventive Services we’ve talked about today — but for all of the
Healthy People objectives, now and in the future.