Saag K G, Doebbeling B N, Rohrer J E, Kolluri S, Peterson R, Hermann M E, Wallace R B
Department of Internal Medicine, The University of Iowa College of Medicine, Iowa City, USA.
Med Care. 1998 Jul;36(7):965-76. doi: 10.1097/00005650-199807000-00004.
Tertiary prevention seeks to reduce chronic disease progression and illness-related dysfunction. Using the Aday-Andersen model, we evaluated the impact of predisposing, need, and enabling factors on tertiary prevention, hypothesizing that urban-rural geographic differences in delivery would be detected.
A population-based telephone survey was conducted evaluating six common chronic indicator conditions: arthritis (n = 488), hypertension (n = 414), cardiac disease (n = 185), diabetes mellitus (n = 125), peptic ulcer disease (n = 125), and chronic obstructive pulmonary disease (n = 103). Subjects were 787 (70% women) home-dwelling elderly (age > 65 years) who had one or more of the indicator conditions and who resided in Iowa's 12 most rural and 10 most urban counties. Tertiary prevention measures included counseling for and/or treatment with: influenza and pneumococcal vaccination, smoking cessation, dietary modifications, exercise, drug side effects, chronic disease rehabilitation, aspirin/estrogen for cardiac disease, and foot/eye care for diabetes. Tertiary prevention scores were calculated to compare preventive services across disease categories and to examine relations, in particular, with enabling factors.
Education beyond high school, alcohol use, cigarette smoking, and medical specialist use were all significantly greater among urban residents, whereas home services use was greater among rural residents. Respondents with either health maintenance organization or fee-for-service supplemental coverage had higher tertiary prevention scores than respondents without supplemental coverage. After adjustment for the significant effects of the number of diseases, higher income, and place of residence, rural respondents having health maintenance organization supplemental coverage had higher (better) tertiary prevention scores than other respondents.
In this community-based study of elderly, enrollment in an health maintenance organization plan, as opposed to a fee-for-service supplement to Medicare, increased tertiary prevention quality for rural but not for urban residents. This study emphasizes that additional research is needed to evaluate the importance of specific types of insurance coverage for preventive services among the elderly.
三级预防旨在减少慢性病进展及与疾病相关的功能障碍。我们运用阿代 - 安德森模型，评估了易患因素、需求因素及促成因素对三级预防的影响，并假设在服务提供方面会发现城乡地理差异。
开展了一项基于人群的电话调查，评估六种常见慢性指标疾病：关节炎（n = 488）、高血压（n = 414）、心脏病（n = 185）、糖尿病（n = 125）、消化性溃疡病（n = 125）和慢性阻塞性肺疾病（n = 103）。研究对象为787名（70%为女性）居家的老年人（年龄>65岁），他们患有一种或多种指标疾病，居住在爱荷华州12个最偏远的农村县和10个最城市化的县。三级预防措施包括咨询和/或治疗：流感和肺炎球菌疫苗接种、戒烟、饮食调整、运动、药物副作用、慢性病康复、心脏病的阿司匹林/雌激素治疗以及糖尿病的足部/眼部护理。计算三级预防得分，以比较不同疾病类别的预防服务，并特别考察与促成因素的关系。
城市居民中高中以上学历、饮酒、吸烟及看专科医生的比例均显著高于农村居民，而农村居民使用家庭服务的比例更高。拥有健康维护组织或按服务收费补充保险的受访者的三级预防得分高于没有补充保险的受访者。在对疾病数量、较高收入和居住地点的显著影响进行调整后，拥有健康维护组织补充保险的农村受访者的三级预防得分高于其他受访者（得分更高，即预防效果更好）。
在这项针对老年人的社区研究中，与医疗保险的按服务收费补充保险相比，加入健康维护组织计划提高了农村居民而非城市居民的三级预防质量。本研究强调，需要进一步研究以评估特定类型保险覆盖对老年人预防服务的重要性。
