Paul Shekelle, MD, PhD, a researcher at West Los Angeles Veterans Administration Medical Center, directed an exhaustive review by The Rand Corporation for the Healthy Aging project of the Health Care Financing Administration (HCFA). The review examined studies that focus on how to deliver Medicare-funded vaccines and cancer screens to the elderly more effectively. The report was delivered to HCFA in September 1999. [7]

Q. Why focus on preventive services for seniors?

A. Older people are particularly susceptible to disease. Typical ailments, such as influenza and pneumonia, become devastating to the elderly. Cancers of the breast, cervix, and colon are among the leading causes of cancer and cancer deaths in older persons. That’s why disease prevention, or at least early detection, is a matter of life and death for people 65 and older.

Q. Science has produced excellent screenings and prevention methods for each of those diseases, and Medicare covers them. What more can be done?

A. Plenty. A huge gap exists between the available services and the people who would benefit from them. Right now, no more than 70 percent of eligible seniors have their influenza shots. Maybe 45 percent get the pneumonia vaccine. Perhaps the same percentage undergoes colorectal cancer screenings. And at most two-thirds of older women have had even one mammogram, much less regularly scheduled ones. The numbers aren’t in for pelvic exams (cervical cancer tests), but I imagine they are similar. And minorities and poor people are the ones least likely to take advantage of these procedures.

For example, low-income people are only about 80 percent as likely to receive mammograms as are others. These odds are significant.

Q. Why aren’t people getting the services that are available?

A. There are many reasons. Access barriers exist despite Medicare coverage. Seniors still have to get to the doctor or clinic, which may require a car, bus or taxi. Because of people’s schedules, they can’t always reach the clinic during regular hours. Some people are still unaware of the importance of these services or that they are covered. Minorities especially might be affected by all these barriers.

We shouldn’t always expect patients to keep track of whether they’ve had their shots and tests. Patients will sometimes forget. It’s not only patients; their physicians and nurses forget to remind them, too.

Q. What can be done about it?

A. Behavioral change must occur along with biomedical advances. We’ve made great progress developing highly sophisticated tools to detect diseases and the medications and treatments to prevent or reverse them, but the medical professions need to pay more attention to the behavioral questions these technologies raise. The technology can do no good unless both the providers of care and the people who would benefit most from that technology change their pattern of behavior to assure the widespread use of the tools we have at hand. And this suggests seriously rethinking the very structures and processes we use in connecting people with the health care they need.

Q. You have analyzed the results of nearly 200 studies on this issue. What solutions work best?

A. Health-care organizations that change the way they operate turn in the best results, especially those that issue "standing orders" for preventive care, making vaccinations and screens basic, routine procedures. For example, doctors and nurses can be trained to ask about – and if appropriate, administer – the vaccines or cancer screens, whenever older patients come in for appointments. This makes prevention as automatic in the doctor’s office as blood pressure checks are now. Unfortunately, the way it often works today, even when providers discover that patients need vaccines or tests, they must schedule them to get them at some other time or at a different location.

Q. What other interventions are effective?

A. Reminders work well, both for patients and providers. If Mrs. Jones receives a letter that reminds her it’s time for a mammogram, she often will follow up. She’s even more likely to follow up if her doctor signs the letter and includes statistics on breast cancer within her age group, along with a date and time for her to come in.

Reminders for physicians, in the form of automatic entries in computerized patient records, or hand-written notes in patient files, also improve the likelihood that the vaccines and cancer screens will be administered.

Q. You said low-income people and some minorities have even lower odds of getting the services. What would raise their odds?

A. We don’t yet know the answer to that one. Unfortunately, the results from interventions that have been tried aren’t consistent. Hence, we don’t believe firm conclusions can be drawn about which interventions are most effective for special populations, geographic settings, or delivery systems.

Q. How can we best implement your findings?

A. There is no "magic bullet" solution. The most effective intervention will always depend on what local barriers need to be surmounted. My guess is that we need to spend money and energy on finding out what local barriers are, and that means communicating with and among providers and patients. Then we can design interventions, whether that means organizational change such as standing orders, reminders, disseminating educational and promotional materials about the services, or making certain that physicians get feedback on how their patients perform in clinical evaluations.

Q. Do your findings have implications for others besides the elderly?

A. Absolutely. They apply to many situations besides Medicare-funded services – whether it’s infant and child care; routine adult health care; or targeted care for those with a history of heart disease or who have had heart attacks and require rehabilitation services. Wherever we look in health care delivery, we see mismatches between the services that are known to be effective and the people who would benefit from them. Our results for increasing immunizations and cancer screening in the elderly apply equally to all adults.

Interview #2: 'Standing Orders: Vaccinate'

David Rhew, MD, is an infectious disease staff physician at West Los Angeles Veteran’s Administration Medical Center. A leading researcher in the field of preventive vaccines, he is also assistant professor of medicine at the University of California, Los Angeles.

Q. Is pneumonia still a major health problem, now that we have vaccines to prevent it?

A. Yes it is. Streptococcus pneumoniae, the most common cause of community-acquired pneumonia, is responsible for up to 20,000 deaths a year. In the United States, it is the number one cause of death due to infection, and the elderly are particularly susceptible to it. That’s because they often have a diminished ability to fight disease. Many contend with other ailments simultaneously, such as cardio-pulmonary problems, diabetes, and renal failure.

Q. How long have we had a vaccine to prevent pneumonia?

A. Pneumonia vaccines go back many years. The current 23-valent vaccine was licensed in the United States in 1983. It replaced the older, 14-valent vaccine, which was licensed in 1977. The larger that number, the more protective it is against infection because it covers more strains of pneumonia.

Q. How effective is the latest version?

A. For every 1,000 eligible persons over the age of 65 who receive it, four pneumonias could be prevented.

Q. That doesn’t sound very effective.

A. But it is disease prevention, and this vaccine is benign. With pneumonia becoming more resistant to treatment, it’s important to promote whatever prevention we can.

The vaccine has not become a standard protocol of care because of controversy surrounding some randomized trials. A recent meta-analysis showed it was effective in preventing pneumonia in patients who were fairly healthy persons, but the research wasn’t able to find it beneficial in all cases. We do know that just within the elderly population, 80 percent of those who have the vaccine develop antibodies to help protect against the infection, but the remaining 20 percent do not mount that response.

Q. How successful are our efforts?

A. Only about 45 percent of people over 65 report ever having had the vaccine. Minorities are even less likely than that. The vaccination rate in elderly blacks is around 30 percent, and among Hispanics, 35 percent.

Q. What has limited this measure’s use?

A. The current method of providing pneumonia vaccines in many institutions is this: patients are seen by physicians who evaluate them for eligibility. They discuss it, and the patients agree. Doctors write prescriptions which patients take to nurses who in turn administer the vaccine. But often the patients are at their doctors’ offices for a variety of reasons and ailments. It is difficult for doctors to remember to bring up the pneumonia vaccine subject.

Q. How can we do better?

This is one of the situations that could probably be handled with protocols. That is, just by following a standardized series of orders. Nurses could do it all without doctors’ involvement, just as is done with influenza vaccinations.

In 1997, we gave two teams of nurses at our Veteran’s Administration clinic in Los Angeles standing orders to administer pneumonia vaccines to eligible patients. We had been at 2 percent of all our eligible patients getting these shots, those who were 65 or older and had other conditions, such as chronic cardiopulmonary disease and diabetes. After three months, that rose to between 36 percent and 41 percent within the two teams.

In a third team, physicians still had to issue specific orders for each patient, but they and the other health care providers received computerized reminders about vaccines. Seven percent of their eligible patients were vaccinated, so it did improve results, but not nearly as much as the nurse standing orders.

We also put posters in the waiting rooms and assessment areas to remind all patients to inquire about their eligibility. Something as simple as this makes a difference. It empowers patients to help themselves. If you are a busy doctor, and your patient comes in and says, "I am eligible and old enough for the pneumonia vaccine, and I would like to have it," you’ll be glad to see that the patient gets it. Doctors in general feel that anything that improves vaccination rates is worth doing.

The Healthy Aging "Revolution":

When the Health Care Financing Administration (HCFA), the federal agency that administers Medicare, launched its Healthy Aging project, it was in recognition that a revolution had taken place in how scientists think of the aging process: that behaviors and psychosocial factors play important roles in whether or not aging leads to debility and illness.

"We’d been thinking about healthy aging for a couple of years," says Catherine Gordon, who directs health promotion and disease prevention within HCFA’s Office of Clinical Standards and Quality. "There had been a revolution in the way we looked at it. We had learned, for example, that there’s a lot people can do to influence the course of their own aging experience. It involves taking advantage of preventive health services, as well as making good choices in relation to diet, exercise, and stress.

"Psychosocial factors matter, too. Older people must feel they have meaning, purpose, and support. When all these things work in tandem, your chances of having a healthy aging experience improve. So we began to think more broadly about how Medicare might push this along."

One of the first things HCFA decided to do was take a science-based look at what works. "There is a whole range of interventions one could chose to promote healthy aging," Gordon notes. "Some work much better than others. The first thing we’re looking at is what the evidence shows and experts say about the best ways to promote Medicare clinical preventive and screening services. That’s a logical place to start because Medicare already pays for influenza and pneumonia vaccines, and screening tests for breast, cervical, and colon cancer."

HCFA contracted with The Rand Corporation to do the study, and its initial report was received in September. HCFA intends to use its findings to step up efforts to promote use of Medicare-covered preventive and screening services.

The Five Avoidable Killers:

Influenza: The flu and consequent respiratory diseases are common causes of morbidity and mortality, with 20,000-40,000 deaths reported for each influenza epidemic, over 90 percent of them among those 65 or older. Vaccination decreases hospitalizations by 27 to 57 percent, and deaths by 27 to 30 percent. [7]

Pneumonia: Invasive pneumoccocal infection has a mortality rate of over 30 percent among seniors. Studies have shown that vaccination has an aggregate efficacy of about 55 to 70 percent for preventing infection in elderly persons. The newer, 23-valent vaccine may prove even more effective. [7]

Breast Cancer: Just under half of all new breast cancer cases, but slightly more than half of breast cancer deaths, occur among women 65 or older. Although routine mammography decreases breast cancer mortality among women over age 50 by 20 to 30 percent, only 58 percent of women age 55 or older have ever received one. [7]

Cervical Cancer: Pap smears are associated with a 20 to 60 percent decrease in cervical cancer mortality, yet there were still 16,000 new cervical cancer cases and 4,800 deaths attributable to cervical cancer in 1995 [10], and 17 percent of women over age 65 and 32 percent of poor women in that age group have never received a Pap test. [3] The U.S. Preventive Services Task Force recommends that all women over 65 receive at least one if they have not had them regularly in the past.

Colorectal Cancer: With 140,000 new cases and 55,000 deaths a year, colorectal cancer is the second most common cause of cancer death in the U.S., [10] and the risk of getting the cancer increases with age. The risk of death decreases by about one-third with early detection and treatment, yet the Federal Centers for Disease Control and Prevention reported in 1997 that among persons 65 and older, 56 percent said they had never had a fecal occult blood test, and 53 percent said they had never had either a sigmoidoscopy or proctoscopic exam. [1] The U.S. Preventive Services Task Force recommends everyone over age 65 have one of these tests at least once.

What Medicare Covers:

Medicare covers the following preventive and screening services for persons over age 65:

• Influenza vaccine: Annual
• Pneumococcal vaccine: As needed (once, except for persons at high risk who need revaccination)
• Mammogram: Annual (20% co-payment)
• Pap smear/Pelvic exam: Every 3 years; annual for women at highest risk (20% co-payment)
• Colorectal screening: Fecal blood test: Annual ; Sigmoidoscopy: Every two years (20% co-payment; Part B deductible)

WHAT: A Health Care Financing Administration (HCFA) initiative to identify evidence-based approaches to promote health among the nation’s senior population. The five-year project’s first report, completed in September 1999, explores how best to increase use of Medicare-covered vaccinations and cancer screenings. A second report, due next spring, will focus on reducing behavioral risk factors among seniors and will address smoking cessation, health risk appraisals with targeted follow-up, self-management of chronic illness, physical activity, and preventing falls. HCFA also plans to pilot test interventions to reduce behavioral risk factors among Medicare beneficiaries.

WHY: America’s senior population, now 34 million, will be 76 million in 30 years. The nation has an imperative to improve this population’s overall health and a financial imperative to lower the projected growth in Medicare costs. This requires tested and proven cost-effective interventions that address the behavioral and psychosocial aspects of aging.

Copies of the initial report are available from the Health Care Financing Administration.

The Research:

1. 1997. "Behavior Risk Factor Surveillance System" of the Federal Centers for Disease Control and Prevention.
2. Beck A, et al. (1997). "A Randomized Trial of Group Outpatient Visits for Chronically Ill Older HMO Members: The Cooperative Health Clinic." Journal of the American Geriatrics Society, 45: 543-549.
3. Calle EE, Flanders WD, Thun MJ, and Martin LM. (1993) "Demographic Predictors of Mammography and Pap Smear Screening in US Women." American Journal of Public Health, 83: 53-60.
4. Nichol K, et al. (September 14, 1998). "Benefits of Influenza Vaccination for Low-, Intermediate-, and High-Risk Senior Citizens." Archives of Internal Medicine, 158: 1769-1776.
5. Preston J, et al. (December 1998). "The Impact of a Physician Intervention Program on Older Women’s Mammography Use." Evaluation & the Health Professions, 21(4): 502-513.
6. "Quality Care Alert." (February 1999). American Medical Association. 2(1).
7. The Rand Corporation, "Interventions that Increase the Utilization of Medicare-Funded Preventive Services for Persons Age 65 and Older."
8. Rhew D, et al. (1999). "Improving Pneumococcal Vaccine Rates." Journal of General Internal Medicine, 14: 351-356.
9. Ruchlin H. (July 1997). "Prevalence and Correlates of Breast and Cervical Cancer Screening among Older Women." Obstetrics & Gynecology, 90(1): 16-21.
10. Wingo P, et al. (1995). "Cancer Statistics." CA-A Cancer Journal for Clinicians, 45(2): 8-30.

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
College on Problems of Drug Dependence
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, , a nonprofit institute, promotes the science that explores health as a complex and dynamic system of relationships among biology, behavior, psychology, and social context and works to integrate this knowledge into public awareness, health care policy, and health care practice. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding.

For more information contact:
Petrina Chong Director of Communications
phone: 202.387.2829
To e-mail Petrina Chong