摘要：Objectives. To determine the optimum strategy for increasing up-to-date (UTD) levels in older Americans, while reducing disparities between White, Black, and Hispanic adults, aged 65 years and older. Methods. Data were analyzed from the 2008 Behavioral Risk Factor Surveillance System, quantifying the proportion of older Americans UTD with influenza and pneumococcal vaccinations, mammograms, Papanicolaou tests, and colorectal cancer screening. A comparison of projected changes in UTD levels and disparities was ascertained by numerically accounting for UTD adults lacking 1 or more clinical preventive services (CPS). Analyses were performed by gender and race/ethnicity. Results. Expanded provision of specific vaccinations and screenings each increased UTD levels. When those needing only vaccinations were immunized, there was a projected decrease in racial/ethnic disparities in UTD levels (2.3%–12.2%). When those needing only colorectal cancer screening, mammography, or Papanicolaou test were screened, there was an increase in UTD disparities (1.6%–4.5%). Conclusions. A primary care and public health focus on adult immunizations, in addition to other CPS, offers an effective strategy to reduce disparities while improving UTD levels. Clinical preventive services (CPS), such as screening tests and vaccinations, are important interventions for identifying, forestalling, and preventing disease across the life span. They are typically delivered in primary care practices and, increasingly, in community settings. 1 The Advisory Committee on Immunization Practices (ACIP) 2 and the US Preventive Services Task Force (USPSTF) 3 have established guidelines for the delivery of these services for adults aged 65 years and older. Recommendations for persons aged 65 years and older include the following core CPS: influenza and pneumococcal vaccinations (PPV), cardiovascular screenings, and colorectal cancer screening. Additional recommendations for women in this age range include mammography and, in certain circumstances, Papanicolaou (Pap) tests. These core CPS are distinct in that they are ranked highly by the ACIP or USPSTF (grades A or B), and recommended based on demographic characteristics (age and gender) rather than on health condition, making them appropriate interventions for both primary care and public health. In 2010, a Healthy People 2020 objective was established to increase by 10% the proportion of older adults “up-to-date” (UTD) with core preventive services, from a 2008 baseline of 46.3% in men and 47.9% in women. 4 Several studies confirmed that racial and ethnic minorities were less likely to receive each of these measures compared with their non-Hispanic White peers. 5–7 Given a growing and increasingly diverse older US population, 8 expanding access to and delivery of core CPS, while reducing racial and ethnic disparities in the receipt of these measures, is a priority. 4 Developing an approach that integrates the work of the clinical and public health communities to accomplish this objective is likely to be the most effective strategy for achieving this goal. This integrated approach is supported by the recommendations of The Community Guide to Preventive Services 9 and the Guide to Clinical Preventive Services, 3 which together provide evidence-based recommendations across the prevention spectrum. 10 With the goal of enhancing the linkages between community and primary care to facilitate the uptake of preventive services, we examine the question of which preventive service(s) are needed to maximally improve UTD levels while decreasing racial/ethnic disparities in UTD levels among adults aged 65 years and older. Health disparities refer to “differences in health outcomes between groups that reflect social inequalities,” and their elimination requires an enhanced understanding of which groups are most vulnerable, how the disparities can be corrected through available interventions, and monitoring over time. 11 As part of this assessment, projected changes in UTD levels and disparities were calculated, based on comparing the impact of providing different core preventive services to persons in each racial/ethnic group who were missing a single service, using 2008 data as a baseline. Projected UTD changes for Blacks and Hispanics were compared with those for Whites. Because we analyzed an all-or-none measure, it was only when projecting increases in the delivery of preventive services for persons missing a single service that levels of being UTD and associated racial and ethnic disparities would change. From a programmatic standpoint, every person should receive every CPS recommended for him or her.
