Important Health Care Lacking for Older People

Older Americans are not getting six key preventive services or appropriate treatment for hypertension that clinical practice guidelines indicate they generally should receive, according to two studies recently published in the Journal of the American Medical Association.  The preventive services study raises questions about disparities in health care based on economic status, and about the factors used in pay-for-performance programs.  The hypertension study suggests the importance of changing clinical practice to treat hypertension more aggressively in older patients.

Preventive Services

Reviewing Medicare claims data for 2001, researchers found that Medicare beneficiaries ages 65 and older receive the following preventive services at rates far below recommended levels.

Preventive service

Expected proportion receiving service in a year

Observed proportion of beneficiaries receiving service in 2001

Diabetic eye examination            100%       47.9%
Hemoglobin A monitoring            100%       55.9%
Mammography            100%       46.7%
Coloncancer screening              30%         9.04%
Influenza vaccination            100%       46.5%
Pneumococcal vaccination              10%         8.0%

Medicare beneficiaries are more likely to receive preventive care if:

  • They have higher median incomes;
  • Their physicians are board-certified;
  • Their physicians graduated from US or Canadian medical schools;
  • Their physicians practice in group practices of three or more physicians;
  • Their physicians’ practice derives less than 5% of its income from Medicaid; and
  • Their physicians are general internists, rather than family/general practitioners (only for diabetic eye examinations, mammograms, colon cancer screening, and pneumococcal vaccination); no difference found for services typically provided in the physician’s office.

Medicare beneficiaries’ receipt of preventive services is not affected by:

  • Physician gender (except that patients of female physicians are more likely to receive more mammograms and less likely to receive influenza vaccinations than patients of male physicians);
  • Availability of information technology (except for diabetic eye examinations and pneumococcal vaccinations);
  • Urban or rural physician practice;
  • Number of years physician was in practice; and
  • Percentage of physician’s revenue derived from managed care or Medicare.

Hoangmai H. Pham, et al, “Deliver of Preventive Services to Older Adults by Primary Care Physicians,” JAMA. 2005; 294:473-481.

Hypertension (high blood pressure)

People over age 80 in general, and women over age 80 in particular, do not receive antihypertensive therapies that are recommended by current clinical practice guidelines.  While more than 70% of people over age 80 have hypertension, researchers found that only 38% of men and 23% of women had their high blood pressure appropriately controlled.   The prevalence of hypertension increases with advanced age.  The same treatment principles, however, are recommended without regard to age by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).

Poor control of older people’s high blood pressure was due to “lack of use of combination therapy” and, possibly, “poor selection of drug classes.”  Researchers found under-use of thiazides, which have been found to be the most cost-effective agents for blood pressure reduction, and greater use of newer antihypertensive agents, whose effectiveness in older patients has not been proven.

The study concluded that “urgent public health efforts are needed for patients and physicians to improve awareness of risks of hypertension at older ages, strategies and benefits of therapy, and importance of achieving blood pressure reduction, if possible to goal blood pressure levels.”

Donald M. Lloyd-Jones, et al., “Hypertension in Adults Across the Age Spectrum; Current Outcomes and Control in the Community.”  JAMA.  2005; 294:466-472.