Were scheduled intervals for services met? Adults could meet the recommendation for colorectal cancer screening by either having a fecal occult blood test (FOBT) within 1 year or colonoscopy or sigmoidoscopy within 10 years. The USPSTF and other national guidelines recommend a 5-year interval for sigmoidoscopy and a 10-year interval for colonoscopy.6,7 However, no direct evidence has determined the optimal interval for either test,8 and the BRFSS question did not distinguish between the 2 interventions. Because either FOBT or endoscopy satisfies screening recommendations, we did not exclude respondents with missing values for 1 test if they had the other test within the recommended interval.
Other services and recommended intervals were pneumococcal vaccination (ever), influenza vaccination (in past year), and, for women, mammogram (within 2 years) and Pap test (within 3 years).
Assigning Yes or No to responses. If respondents had never received a particular preventive service or had received it outside the interval recommended by the USPSTF,4 we included them in the group answering No. We eliminated 3324 men and 6295 women with missing values for 1 or more measures.
Final determination of being “up to date.” After noting how many of the recommended services each individual had received according to age and sex, we dichotomized the sample according to whether all recommendations had been met—3 clinical preventive services for men 65 years and older (colorectal cancer screening, influenza, and pneumonia vaccination) and 5 for women (adding mammography and Pap test), with a single exception. Because Pap testing is often reported only for women with an intact cervix,9 we excused the lack of a Pap test for women who had undergone hysterectomy (47% of all women ages 65+, or 27,243). We required only that they meet 4 clinical preventive services to be considered up to date. A prior study revealed that excluding the Pap test entirely from the up-to-date measure for women 65 years and older had a minimal effect on up-to-date rates (34.2% when excluding the Pap test vs 32.5% including the Pap test).10
One of the strengths of the up-to-date measure is that it assesses the proportion of those fully up to date and thus allows for variability within subgroups, such as women who have had hysterectomies, without eliminating them arbitrarily from the sample.
Additional participant characteristics. We divided respondents into 4 racial/ethnic categories based on responses to BRFSS questions: White (non-Hispanic); Black (non-Hispanic); Hispanic of any race; or “Other” (American Indians, Asians, Pacific Islanders, and individuals of other or multiple race categories). Age categories were 65 to 69 years, 70 to 74 years, 75 to 79 years, or >80 years. Education categories: less than high school, high school graduate or general equivalency diploma recipient, some college, or college graduate. We further dichotomized the sample according to marital status, having 1 or more personal health care providers (vs none), and health status (fair/poor or good/very good/excellent). Given the amount of missing data (20%), household income was not included in the analysis.
Quantifying health care access. We created a measure of health care access using 3 factors:
- health insurance (“Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?”)
- one or more personal health care providers (see above)
- no cost barrier to seeing a doctor (“Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?”).
To measure relative health care access, we scored each of the above items 1 for affirmative or 0 for negative. The sum (0, 1, 2, or 3) represented level of access. Lower numbers indicated more barriers and higher numbers represented greater access. Because only 48 older men and 59 older women had total scores of 0, the lower 2 levels were combined and the resulting 3 levels were termed “low” (0 & 1), “medium” (2) and “high” (3) access. Two of the measures used for health care access were also used to define 3 mutually exclusive health insurance categories: uninsured, fully insured, and underinsured (insured but reporting a cost barrier).2
We determined whether a routine checkup had occurred in the past 2 years by asking, “About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.”