0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Influenza and Pneumococcal Vaccination Among Native American Elders in a Primary Care Practice FREE

Dedra Buchwald, MD; John Sheffield, MD; Richard Furman, MA; Suzanne Hartman; Matt Dudden, MS; Spero Manson, PhD
[+] Author Affiliations

From the Departments of Medicine, University of Washington, Seattle, (Drs Buchwald and Sheffield, Mr Furman, and Ms Hartman); and the Department of Psychiatry, University of Colorado Health Sciences Center, Denver (Mr Dudden and Dr Manson).


Arch Intern Med. 2000;160(10):1443-1448. doi:10.1001/archinte.160.10.1443.
Text Size: A A A
Published online

Background  More than 2 million Native Americans (ie, Native Americans and Native Alaskans) live in the United States; 60% reside in cities. This population, especially its elders, is especially susceptible to respiratory diseases; yet, adherence to guidelines for influenza and pneunococcal immunizations is unknown.

Objectives  To evaluate how frequently older and high-risk adults received vaccinations for influenza and pneumoncoccal infection and to identify patient characteristics associated with adherence to published recommendations.

Methods  Retrospective medical record review of 550 Native American elders seen in an urban primary care practice defined using a culturally appropriate age threshold (≥50 years) and standard criteria (≥65 years). Univariate analyses examined demographic and clinical information by vaccination status. Logistic regressions identified factors associated with adherence to immunization guidelines.

Results  Among patients aged 50 years and older with any indication according to published recommendations, rates were low for influenza (31%) and pneumococcal (21%) immunizations. Likewise, few subjects at least 65 years of age had been immunized appropriately against influenza (38%) or pneumococcus (32%). Younger age and alcohol use were significantly associated with less frequent immunization; Medicare insurance, depression, and more health problems and taking more medications predicted significantly higher immunization rates. Aged 65 years or older and having cardiovascular disease or diabetes mellitus were specific indications significantly correlated with receipt of influenza and pneumococcal vaccine.

Conclusions  Regardless of age or risk, inadequate vaccination rates were observed in elderly Native Americans. Our findings suggest the need to identify obstacles to immunization and to conduct prospective and elderly intervention studies in Native American populations.

MORE THAN 2 million Native Americans (hereafter referred to American Indians [AIs]) and Alaska Natives (ANs) live in the United States.1 The number of urban dwellers has increased dramatically since World War II; only 25% of AIs/ANs reside on reservations and trust lands and 60% reside in cities.1 Although vast strides have been made in recent years, AIs/ANs still lag behind the general population for major health status indicators.2 Infectious diseases such as tuberculosis and gastroenteritis have been replaced as the leading causes of death by diabetes mellitus, cardiovascular disease, and hypertension.3 It is not surprising, then, that AI/AN life expectancy is 8 years less than nonnative peoples and is accompanied by higher age-specific mortality rates than the population at large.4,5 Yet, despite the emergence of chronic health conditions and increased mortality rates, virtually no information exists on the implementation of preventive measures among AIs/ANs.

American Indians/Alaskan Natives are especially susceptible to respiratory tract diseases, including pneumococcal infections.6,7 According to Indian Health Service statistics, influenza and pneumonia constitute the sixth leading cause of death among AIs of all ages and the fourth leading cause of death among American Native elders.8 Moreover, the mortality rate increases markedly with age: for persons 65 years or older, mortality due to influenza and pneumonia is greater for AIs/ANs than the general US population.8,9 However, although data specific to AIs/ANs are unavailable, national sources indicate that minority populations receive influenza and pneumococcal vaccines at substantially lower rates than white persons.9 Since minority adults use preventive services less, are initially seen for care at more advanced stages of disease, and have greater morbidity and mortality than higher-income individuals,10,11 AI/AN elders may be at great risk for not obtaining recommended interventions such as influenza and pneumococcal vaccinations.

In this retrospective study, we reviewed the medical records of 550 AIs/ANs who were at least 50 years of age seen in a primary care practice during a 1-year period. Our objectives were to evaluate how frequently influenza and pneumococcal vaccinations were given according to 2 age thresholds as well as published guidelines applicable to persons with chronic medical conditions. A secondary goal was to identify factors associated with nonadherence to immunization recommendations. In contrast with studies relying strictly on self-report, review of medical records allowed us to document compliance with vaccination guidelines.

CLINICAL SETTING

According to the 1990 census, almost 17,800 AIs/ANs live in King County, Washington, with 7325 residing in Seattle. The Seattle Indian Health Board (SIHB), a multidisciplinary, community-based organization, is the major source of health care for the urban King County Native American population. It is considered one of the most comprehensive, off-reservation, primary care programs for AIs/ANs in the nation, providing diverse medical, mental health, dental, preventive, and educational services. The SIHB serves more than 6000 individuals who make more than 40,000 visits per year. Over half of the clinic clientele are at least 45 years old, almost half are unemployed, 58% have no form of health insurance, and 80% have incomes under the federally determined "poverty line." Owing to its urban location, SIHB patients are affiliated with approximately 250 tribes.

PATIENT POPULATION

Because of increased morbidity and mortality, impairments associated with aging may occur 20 years earlier among AIs/ANs than in the general population.12 Thus, AIs/ANs often require, at a younger age, services typically deemed the province of "the elderly." In addition, owing to the shorter life expectancy and high birth rate of AIs/ANs, elders also constitute a much smaller percentage of the total Native American population compared with other ethnic or racial minorities. This situation has led to lower age eligibility criteria for federally and state funded programs. For example, Title VI of the Older Americans Act has recognized the need to provide services to AIs living on reservations who are younger than 60 years by allowing each tribe to set its own age eligibility requirements. Finally, among AIs/ANs, "elder" status is not solely a function of chronological age, and may be conferred much earlier than in the majority culture. For these reasons, then, data were examined for 2 different definitions of elder. In one instance, elder was defined as a person at least 50 years of age, consistent with the foregoing observations, which relate as well to broader national concerns regarding race and health disparities. In the other instance, elder was defined in the more conventional fashion as a person aged 65 years or older.

A list was generated from the computerized visit records of SIHB with the names of all AIs/ANs aged 50 years or older who had been seen on at least 1 occasion between June 1, 1994, and June 30, 1995. A total of 550 patients were identified and their medical records retrieved. Of the 550 medical records eligible for review, all (100%) were located and abstracted, representing the entire eligible population.

RETROSPECTIVE MEDICAL RECORDS REVIEW

The medical records were reviewed by a single chart abstractor who was trained in data collection. To confirm the accuracy and reliability of the medical record abstraction, a sample of medical records was independently reviewed by a general internist. The abstracting process focused on determining the frequency of administration of influenza and pneumococcal immunizations, as well as demographic information including date of birth, sex, tribal affiliation, blood quantum series, educational level, employment status, marital status, number of household members, and type of insurance. Other data included whether patients smoked, used alcohol or other substances, and a listing all health problems (as documented in the medical record by a clinic provider, typically in notes or problem lists), and current medications.

IMMUNIZATION RECOMMENDATIONS

Several sources were reviewed regarding the appropriate preventive guidelines for immunization in this population. Influenza and pneumococcal vaccinations are recommended by the US Preventive Services Task Force, the American College of Physicians, American Academy of Family Physicians, and the Centers for Disease Control and Prevention. Influenza vaccination is also recommended by the Canadian Task Force on the Periodic Health Examination, American Cancer Society, and the American College of Obstetrics and Gynecology (reviewed in reference 13). The US Preventive Services Task Force states that individuals aged 65 years or older should be vaccinated once against pneumococcus and annually against influenza.14 For persons at high risk, the task force also recommends annual influenza vaccination and a single administration of pneumococcal vaccine. High-risk populations should receive a second dose of pneumococcal vaccine 5 years after the first administration or when they reach the age of 65 years if 5 or more years have passed since the first dose. High-risk individuals are those who are alcoholics; who are in renal failure; or those who have cardiovascular, pulmonary, and immunocompromising diseases; diabetes mellitus; human immunodeficiency virus infection; and cancer.

STATISTICAL ANALYSES

Performance was examined for each measure using 2 age thresholds. The conventionally defined sample of older adults (those aged ≥65 years) was, thus, a subset of the more culturally appropriate one (those aged at least 50 years). We assessed adherence for influenza immunizations using 2 time frames: ever having received a vaccination and having received a vaccination in the year prior to the last primary care visit. For pneumococcal vaccination, we determined only if it had ever been administered. Group differences on discrete variables were examined with χ2 analyses. Continuous variables were compared with t test. Univariate logistic models, controlled for age and sex, were also calculated for each potential predictor. Because the 2 univariate techniques yielded similar results, we only list the latter in Table 1. Owing to the number of statistical tests performed and to minimize the type 1 error rate, only differences of P≤.01 were considered statistically significant. Trend level differences (P≤.05) were noted for descriptive purposes only.

Table Graphic Jump LocationTable 1. Demographic and Clinical Characteristics of 550 Native American Elders by Vaccination Status

Three logistic regression analyses were performed to determine the best predictors of receiving pneumococcal vaccine at least once, influenza vaccine at least once, and influenza vaccine within the last year (dependent variables). To assess factors associated with administration, only baseline variables that were related to immunization at P≤.10 significance levels in relevant univariate logistic analyses were used in the models (independent variables included the following: age; aged ≥65 years; sex; marital status; insurance status; current alcohol use; other substance abuse; and smoking; purified protein derivative placement; depression; number of health problems; having cardiovascular disease, pulmonary disease, or diabetes mellitus; and the mean number of medications taken). For all regressions, educational level and the number of household members were excluded owing to missing data. All models were assessed for statistical outliers; these were removed and the models were refit. For regression analyses, P≤.05 were considered statistically significant.

The mean age of the 550 older urban Native American patients was 60.6 years; females composed 61%, and 28% were married. Overall, 45% had at least a high school education; 43% were employed; 49% were receiving Medicare or Medicaid insurance coverage. A total of 492 (89%) of the 550 patients had documented medical problems (mean=2.95) and 299 (54%) of the 550 patients had documented psychological problems (mean=0.7). Influenza vaccine had been administered to 270 patients ever (49%), and 163 patients (30%) in the last year. For pneumococcal immunization, 118 (21%) had been previously vaccinated. Characteristics of the study sample by vaccination status are given in Table 1. In general, patients who were younger (P≤.01-P≤.001) or current users of alcohol (P≤.05-P≤.001) were immunized less often while those with Medicare insurance (P≤.05), depression (P≤.01-P≤.001), a greater number of health problems (P≤.01), and taking more medications were vaccinated more frequently (P≤.001).

In terms of strict adherence to published guidelines, the data in Table 2 demonstrate that being 65 years or older (P≤.01), having cardiovascular disease (P≤.01), pulmonary disease (P≤.05), or diabetes mellitus (P≤.001) were correlated with receipt of influenza vaccine in the last year. Similarly, age (P≤.001) and having cardiovascular disease (P≤.01), pulmonary disease (P≤.01), or diabetes mellitus (P≤.01) were associated with ever receiving a pneumococcal vaccination. Overall, among Native American elders with any indication, only 31% had received influenza in the previous year and 21% pneumococcal immunizations in accord with widely accepted recommendations. Among patients not considered at high risk, 16% of all patients and 40% of those at least 65 years old had been vaccinated against influenza in the last year. All patients who received a pneumococcal immunization had a medical indication.

Table Graphic Jump LocationTable 2. Indications for Vaccination Among 550 Native American Elders

Odds ratios and 95% confidence intervals for receipt of immunizations are given in Table 3. The logistic regression revealed that the only factor significantly associated with receiving an influenza vaccine in the last year was the presence of diabetes mellitus. The factors associated with ever receiving an influenza vaccination included greater mean numbers of health problems and current medications, having had a purified protein derivative placed, and type of insurance, particularly Medicare (P≤.01). Similarly, predictive factors for lifetime receipt of pneumococcal vaccine were greater number of health problems, the presence of diabetes mellitus, and type of insurance, again most importantly Medicare (P≤.01).

Table Graphic Jump LocationTable 3. Odds Ratios and 95% Confidence Intervals for Receipt of Immunizations

Physicians agree that prevention and early disease detection are crucial. Furthermore, increasing public awareness, decreasing costs of screening, and the demonstrated cost-effectiveness of preventive services have encouraged their implementation.15 Yet, despite the proven benefit of many preventive measures, recent studies in clinical practices have shown that use of preventive services is low and only a minority of eligible patients actually receive them. Furthermore, little is known about the use of most preventive and screening measures among older adults. At least for some screening procedures, the elderly, as well as those who are poor, less educated, and nonwhite, are the least likely to receive them.10,16,17 This is unfortunate since screening and preventative guidelines, typically implemented in the general medical setting, may have the greatest benefit among older persons.18 These observations suggest that elderly AIs/ANs may be an especially neglected population.

Among the elderly, influenza and invasive pneumococcal infections may be the most vaccine-preventable infectious diseases.14 In the United States, approximately 120,000 older adults are hospitalized for influenza and 200,000 for pneumococcal pneumonia annually.19 Together, these 2 infections account for 50,000 to 80,000 deaths per year—almost 85% in the elderly.19 Yet, despite this substantial morbidity and mortality, adherence to immunization guidelines has varied widely. For example, statistics compiled using the 1997 Behavioral Risk Factor Surveillance System revealed that among persons at least 65 years of age, 66% reported receipt of influenza vaccine in the past year while 45% reported ever receiving pneumococcal vaccine.20 In contrast, some authorities have estimated that only 10% to 20% of target populations have been vaccinated against influenza or pneumococcus despite adequate Medicare reimbursement.19,21 Similarly, in a recent primary care study, influenza and pneumococcal vaccines were administered to just 5% and 21% of the eligible adults, respectively.22 Other investigators have observed higher, though still inadequate, rates of pneumococcal (32%) and influenza (57%) immunization among patients 70 years or older.23 Thus, the rates of immunization at SIHB, although inadequate particularly for the high-risk groups, are similar to those published for other populations.

Respiratory diseases, most prominently pneumonia, are an important cause of disability and death among Native American peoples. For example, pneumonia accounts for 5% of hospitalizations among AIs/ANs.7 By the age of 75 years, the cumulative incidence (7%) and mortality (1%) of pneumococcal infections among ANs is 4 times higher than the rates observed in nonnatives.6 American Indians/Alaskan Natives also seem to have more recurrent disease than nonnatives. In this regard, an older study reporting the Navajo experience observed recurrences of pneumonia in 7.6% of adults.24 Yet, despite their vulnerability, even those AIs/ANs at high risk are infrequently immunized—in another investigation only 17% of AN adults with predisposing conditions and invasive pneumococcal infections had previously received pneumococcal vaccine.6 Moreover, national statistics have consistently documented that older minority individuals (there are no data specific to AIs/ANs) are less likely than whites to receive influenza and pneumococcal vaccine.20,25 The public health implications of these missed opportunities for immunization are obvious.

Although this study does not directly address barriers to care, many patient- and physician-based factors have been associated with poor implementation of screening guidelines, including lack of health insurance, culturally influenced beliefs, the type of clinical setting in which medical care is provided, and physician factors.10,2630 For example, the Survey of American Indians and Alaska Natives, a 1987 study by the Agency for Health Care Policy and Research,31 revealed that AIs were much less likely to have private insurance coverage than any other segment of the US population (28% vs 81% whites, 53% blacks, 50% Hispanics). Even excluding Indian Health Service coverage, AI households had significantly higher rates of public coverage than the total US population (17% vs 10%). Both findings relate directly, albeit in inverse ways, to employment and job opportunities. However, these data also indicate that AI people who work and have health coverage as an option are less likely to enjoy private coverage than their nonnative counterparts (eg, 36% vs 75%). Overall, 55% of AI families are either uninsured or entirely reliant on the Indian Health Service for health care. This set of circumstances is especially disheartening given the association between adherence to immunization guidelines and type of insurance observed in the present study.

Provider- and facility-based factors for low immunization rates may be of equal importance to economic ones. In this regard, physicians whose practices consisted primarily of minorities saw more patients, spent less time with each patient, and incorporated fewer preventive practices into their encounters than did providers who had more affluent, predominantly white patients.27 Another study of primary care providers found that although 88% agreed that guidelines improved care for the elderly, physicians' attitudes often did not correlate with their use of preventive care recommendations.28 These studies are consistent with others that have found lack of time was the reason for failure to comply with guidelines reported most often by physicians.29,30 Together, the issues cited above are important to the health of elderly AIs/ANs, as well as the attainment of the Healthy People 2000 objective to increase to 40% the proportion of older adults who receive all screening and immunization services and at least 1 age-and sex-appropriate counseling service as recommended by the US Preventive Services Task Force.32

This study has several limitations. First, complicating studies of vaccination is the absence of universally accepted recommendations. Second, owing to the nature of the sample, our findings cannot be generalized to other, particularly nonurban, clinics serving AIs/ANs. This drawback is somewhat attenuated by the fact that most Native American people now live significant portions of their lives in cities. Third, because the SIHB is a model program for the health care of urban AIs/ANs, the proportion of patients receiving preventive procedures might exceed that in other metropolitan settings. Even so, since this investigation was retrospective and based exclusively on medical record reviews, it precluded the consideration of outside sources of care. Thus, it is likely that we underestimated the frequency of immunization since some patients may have been vaccinated in other settings (eg, Public Health Clinics, seniors centers) without this information being recorded in their SIHB medical record. Finally, studies such as the present one can not directly ascertain the barriers to care experienced by specific individuals or even the group as a whole.

If validated by further research, these data have important clinical implications and suggest strategies for optimizing immunization by improving physician performance and increasing patient awareness. For example, a nurse-initiated prompting system, flow sheets, and computerized reminders have all been shown to increase the delivery of preventive services3336 and may be well advised here. Among urban minorities, compliance with preventive measures has been enhanced by an intense, personal intervention designed to remove barriers to care,37 and by computerized patient reminders.38 Other interventions such as mobile units, videotapes, culturally relevant educational material,39 or site of service modification34 also may be useful in caring for AI/AN populations. Tribal health care centers and organizations interacting with older AIs/ANs will need to develop effective means of educating both providers and patients about the importance of respiratory disease prevention. We believe our findings underscore the need to identify patient-based and primary care physician-based obstacles to immunization, and to conduct evidence-based prospective and intervention studies in clinic- and community-based Native populations.

Accepted for publication October 20, 1999.

This investigation was supported in part by grants 1P30AG/NE15292 from the National Institute of Aging and the National Institute of Nursing Research (Drs Buchwald and Manson), and 90-AM-0757 from the Administration on Aging (Dr Manson) Rockville, Md.

We thank the Seattle Indian Health Board and Executive Director Ralph Forquera, MPH, for facilitating the conduct of this work.

Corresponding author: Dedra Buchwald, MD, Harborview Medical Center, 325 Ninth Ave, Box 359780, Seattle, WA 98104 (e-mail: dedra@u.washinton.edu).

Paisano  EUS Bureau of the Census, The American Indian, Eskimo, and Aleut Population. Available at: http://www.census.gov/population/www/pop-profile/amerind.html. Accessed January 1, 1999
US Department of Health and Human Services,Public Health Service, Office of Minority Affairs., Report of the Public Health Service Task Force on Minority Health Data.  Washington, DC US Government Printing Office1992;
Nutting  PAHelgersen  SDWelty  TK  et al.  A research agenda for Indian health, part 5: researchable questions in chronic disease. Indian Health Service Primary Care Provider. 1990;1537- 48
Kramer  BJ Urban American Indian aging. J Cross-Cultural Gerontol. 1991;6205- 217
Link to Article
Indian Health Service, Trends in Indian Health 1996. Indian Health Service, Office of Planning, Evaluation, and Legislation, Division of Program Statistics. Rockville, Md US Dept of Health and Human Services1996;
Davidson  MParkinson  AJBulkow  LRFitzgerald  MAPeters  HVParks  DJ The epidemiology of invasive pneumococcal disease in Alaska, 1986-1990: ethnic differences and opportunities for prevention. J Infect Dis. 1994;170368- 376
Link to Article
Rhoades  ER The major respiratory diseases of American Indians. Am Rev Respir Dis. 1990;141595- 600
Link to Article
John  R American Indian and Alaska Native Elders: An Assessment of This Current Status and Provision of Services.  Washington, DC US Dept of Health and Human Services, Indian Health Service, Office of Health Programs1994;
US Department of Health and Human Services, Closing the gap. Newslett of Office Minority Health. November1998;
Moormeier  J Breast cancer in black women. Ann Intern Med. 1996;124897- 905
Link to Article
Burns  RBMcCarthy  EPFreund  KM  et al.  Black women receive less mammography even with similar use of primary care. Ann Intern Med. 1996;125173- 182
Link to Article
National Indian Council on Aging, Annual Report.  Albuquerque, NM National Indian Council on Aging1981;
Hayward  SASteinberg  EPFord  DERoizen  MFRoach  KW Preventive care guidelines: 1991. Ann Intern Med. 1991;114758- 783
Link to Article
US Preventive Services Task Force, Guide to Clinical Preventive Services.  Baltimore, Md Williams & Wilkins1996;
Buchwald  DFurman  RAshton  SDudden  MManson  S Adherence to preventive care guidelines in older Native American primary care patients. J Gen Med. In press
Hayward  RShapiro  MFreeman  A  et al.  Who gets screened for cervical and breast cancer? results from a new national survey. Arch Intern Med. 1988;1481177- 1181
Link to Article
Woolhandler  SHimmelstein  DU Reverse targeting of preventive care due to lack of health insurance. JAMA. 1988;2592872- 2874
Link to Article
Nystrom  LRutqvist  LEWall  S  et al.  Breast cancer screening with mammography: overview of Swedish randomized trials. Lancet. 1993;3421973- 978
Link to Article
Fedson  DS Clinical practice and public policy for influenza and pneumococcal vaccination of the elderly. Clin Geriat Med. 1992;8183- 199
Williams  WWHickson  MAKane  MA  et al.  Immunization policies and vaccine coverage among adults. The risk for missed opportunities. Ann Intern Med. 1988;108616- 625
Link to Article
Not Available, US Department of Health and Human Services.Influenza and pneumococcal vaccination levels among adults aged greater than or equal to 65 years—United States. MMWR Morb Mortal Wkly Rep. 1998;47797- 802
Tape  TGCampbell  JR Computerized medical records and preventive health care: Success depends on many factors. Am J Med. 1993;94619- 625
Link to Article
Anderson  PAFortinsky  RBowman  KMiller  DGLandefeld  CS Do older patients remember preventive care [abstract]? J Gen Intern Med. 1995; Aprilsuppl97
Oseasohn  RSkipper  BETempest  B Pneumonia in a Navajo community: a two-year experience. Am Rev Respir Dis. 1978;1171003- 1009
US Department of Health and Human Services, Health Status of Minorities and Low-Income Groups.  Washington, DC US Government Printing Office1991;Publication 271-848-40085
Davis  TArnold  CJackson  RGlass  JSentell  TStewart  A Knowledge and attitudes about screening mammography [abstract]. J Gen Intern Med. 1995; Aprilsuppl99
Gemson  DHElinson  JMesseri  P Differences in physician prevention practice patterns for white and minority patients. J Community Health. 1988;1353- 64
Link to Article
Litzelman  DKDittus  RSMiller  METierney  WM Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols. J Gen Intern Med. 1993;8311- 317
Link to Article
Gemson  DHElinson  J Prevention in primary care: variability in physician practice patterns in New York City. Am J Prev Med. 1986;2226- 234
Weingarten  SStone  EHayward  R  et al.  The adoption of preventive care practice guidelines by primary care physicians: do actions match intentions? J Gen Intern Med. 1995;10138- 144
Link to Article
Cunningham  PSchur  C Health Care Coverage: Findings From the Survey of American Indians and Alaska Natives. National Expediture Survey Research Findings Volume 8 Rockville, Md Agency for Health Care Policy and Research, US Dept of Health and Human Services1991;1- 13AHCPR publication 91-00271
American Association of Retired People, Healthy People 2000. Healthy Older Adults. Washington, DC American Association of Retired People Health Advocacy Services1991;
Harris  RPO'Malley  MSFletcher  SWKnight  BP Prompting physicians for preventive procedures: a five-year study of manual and computer reminders. Am J Prev Med. 1990;6145- 152
Gann  PMelville  SKLuckmann  R Characteristics of primary care office systems as predictors of mammography utilization. Ann Intern Med. 1993;118893- 898
Link to Article
Tape  TGCampbell  JR Computerized medical records and preventive health care: success depends on many factors. Am J Med. 1993;94619- 625
Link to Article
Litzelman  DKDittus  RSMiller  METierney  WM Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols. J Gen Intern Med. 1993;8311- 317
Link to Article
Weber  BEReilly  BM Enhancing compliance with mammography in the inner city [abstract]. J Gen Intern Med. 1995; Aprilsuppl126
Burack  RCGimotty  PAGeorge  JStengle  WWarbasse  LMoncrease  A Promoting screening mammography in inner-city sittings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography. Med Care. 1994;32609- 624
Link to Article
US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, Cancer Statistics Review, 1973-1986.  Bethesda, Md US Government Printing Office1989;NIH publication 89-2789

Figures

Tables

Table Graphic Jump LocationTable 1. Demographic and Clinical Characteristics of 550 Native American Elders by Vaccination Status
Table Graphic Jump LocationTable 2. Indications for Vaccination Among 550 Native American Elders
Table Graphic Jump LocationTable 3. Odds Ratios and 95% Confidence Intervals for Receipt of Immunizations

References

Paisano  EUS Bureau of the Census, The American Indian, Eskimo, and Aleut Population. Available at: http://www.census.gov/population/www/pop-profile/amerind.html. Accessed January 1, 1999
US Department of Health and Human Services,Public Health Service, Office of Minority Affairs., Report of the Public Health Service Task Force on Minority Health Data.  Washington, DC US Government Printing Office1992;
Nutting  PAHelgersen  SDWelty  TK  et al.  A research agenda for Indian health, part 5: researchable questions in chronic disease. Indian Health Service Primary Care Provider. 1990;1537- 48
Kramer  BJ Urban American Indian aging. J Cross-Cultural Gerontol. 1991;6205- 217
Link to Article
Indian Health Service, Trends in Indian Health 1996. Indian Health Service, Office of Planning, Evaluation, and Legislation, Division of Program Statistics. Rockville, Md US Dept of Health and Human Services1996;
Davidson  MParkinson  AJBulkow  LRFitzgerald  MAPeters  HVParks  DJ The epidemiology of invasive pneumococcal disease in Alaska, 1986-1990: ethnic differences and opportunities for prevention. J Infect Dis. 1994;170368- 376
Link to Article
Rhoades  ER The major respiratory diseases of American Indians. Am Rev Respir Dis. 1990;141595- 600
Link to Article
John  R American Indian and Alaska Native Elders: An Assessment of This Current Status and Provision of Services.  Washington, DC US Dept of Health and Human Services, Indian Health Service, Office of Health Programs1994;
US Department of Health and Human Services, Closing the gap. Newslett of Office Minority Health. November1998;
Moormeier  J Breast cancer in black women. Ann Intern Med. 1996;124897- 905
Link to Article
Burns  RBMcCarthy  EPFreund  KM  et al.  Black women receive less mammography even with similar use of primary care. Ann Intern Med. 1996;125173- 182
Link to Article
National Indian Council on Aging, Annual Report.  Albuquerque, NM National Indian Council on Aging1981;
Hayward  SASteinberg  EPFord  DERoizen  MFRoach  KW Preventive care guidelines: 1991. Ann Intern Med. 1991;114758- 783
Link to Article
US Preventive Services Task Force, Guide to Clinical Preventive Services.  Baltimore, Md Williams & Wilkins1996;
Buchwald  DFurman  RAshton  SDudden  MManson  S Adherence to preventive care guidelines in older Native American primary care patients. J Gen Med. In press
Hayward  RShapiro  MFreeman  A  et al.  Who gets screened for cervical and breast cancer? results from a new national survey. Arch Intern Med. 1988;1481177- 1181
Link to Article
Woolhandler  SHimmelstein  DU Reverse targeting of preventive care due to lack of health insurance. JAMA. 1988;2592872- 2874
Link to Article
Nystrom  LRutqvist  LEWall  S  et al.  Breast cancer screening with mammography: overview of Swedish randomized trials. Lancet. 1993;3421973- 978
Link to Article
Fedson  DS Clinical practice and public policy for influenza and pneumococcal vaccination of the elderly. Clin Geriat Med. 1992;8183- 199
Williams  WWHickson  MAKane  MA  et al.  Immunization policies and vaccine coverage among adults. The risk for missed opportunities. Ann Intern Med. 1988;108616- 625
Link to Article
Not Available, US Department of Health and Human Services.Influenza and pneumococcal vaccination levels among adults aged greater than or equal to 65 years—United States. MMWR Morb Mortal Wkly Rep. 1998;47797- 802
Tape  TGCampbell  JR Computerized medical records and preventive health care: Success depends on many factors. Am J Med. 1993;94619- 625
Link to Article
Anderson  PAFortinsky  RBowman  KMiller  DGLandefeld  CS Do older patients remember preventive care [abstract]? J Gen Intern Med. 1995; Aprilsuppl97
Oseasohn  RSkipper  BETempest  B Pneumonia in a Navajo community: a two-year experience. Am Rev Respir Dis. 1978;1171003- 1009
US Department of Health and Human Services, Health Status of Minorities and Low-Income Groups.  Washington, DC US Government Printing Office1991;Publication 271-848-40085
Davis  TArnold  CJackson  RGlass  JSentell  TStewart  A Knowledge and attitudes about screening mammography [abstract]. J Gen Intern Med. 1995; Aprilsuppl99
Gemson  DHElinson  JMesseri  P Differences in physician prevention practice patterns for white and minority patients. J Community Health. 1988;1353- 64
Link to Article
Litzelman  DKDittus  RSMiller  METierney  WM Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols. J Gen Intern Med. 1993;8311- 317
Link to Article
Gemson  DHElinson  J Prevention in primary care: variability in physician practice patterns in New York City. Am J Prev Med. 1986;2226- 234
Weingarten  SStone  EHayward  R  et al.  The adoption of preventive care practice guidelines by primary care physicians: do actions match intentions? J Gen Intern Med. 1995;10138- 144
Link to Article
Cunningham  PSchur  C Health Care Coverage: Findings From the Survey of American Indians and Alaska Natives. National Expediture Survey Research Findings Volume 8 Rockville, Md Agency for Health Care Policy and Research, US Dept of Health and Human Services1991;1- 13AHCPR publication 91-00271
American Association of Retired People, Healthy People 2000. Healthy Older Adults. Washington, DC American Association of Retired People Health Advocacy Services1991;
Harris  RPO'Malley  MSFletcher  SWKnight  BP Prompting physicians for preventive procedures: a five-year study of manual and computer reminders. Am J Prev Med. 1990;6145- 152
Gann  PMelville  SKLuckmann  R Characteristics of primary care office systems as predictors of mammography utilization. Ann Intern Med. 1993;118893- 898
Link to Article
Tape  TGCampbell  JR Computerized medical records and preventive health care: success depends on many factors. Am J Med. 1993;94619- 625
Link to Article
Litzelman  DKDittus  RSMiller  METierney  WM Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols. J Gen Intern Med. 1993;8311- 317
Link to Article
Weber  BEReilly  BM Enhancing compliance with mammography in the inner city [abstract]. J Gen Intern Med. 1995; Aprilsuppl126
Burack  RCGimotty  PAGeorge  JStengle  WWarbasse  LMoncrease  A Promoting screening mammography in inner-city sittings: a randomized controlled trial of computerized reminders as a component of a program to facilitate mammography. Med Care. 1994;32609- 624
Link to Article
US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, Cancer Statistics Review, 1973-1986.  Bethesda, Md US Government Printing Office1989;NIH publication 89-2789

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 18

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
JAMAevidence.com

Users' Guides to the Medical Literature
Influenza

The Rational Clinical Examination
Make the Diagnosis: Influenza