VARIATION IN TERTIARY PREVENTION AND HEALTH-SERVICE UTILIZATION AMONGTHE ELDERLY - THE ROLE OF URBAN-RURAL RESIDENCE AND SUPPLEMENTAL INSURANCE

OBJECTIVES. Tertiary prevention seeks to reduce chronic disease progre ssion 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 differ ences in delivery would be detected. METHODS. A population-based telep hone survey was conducted evaluating six common chronic indicator cond itions: 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 78 7 (70% women) home-dwelling elderly (age > 65 years) who had one or mo re of the indicator conditions and who resided in Iowa's 12 most rural and 10 most urban counties. Tertiary prevention measures included cou nseling for and/or treatment with: influenza and pneumococcal vaccinat ion, smoking cessation, dietary modifications, exercise, drug side eff ects, chronic disease rehabilitation, aspirin/estrogen for cardiac dis ease, and foot/eye care for diabetes. Tertiary prevention scores were calculated to compare preventive services across disease categories an d to examine relations, in particular, with enabling factors. RESULTS. Education beyond high school, alcohol use, cigarette smoking, and med ical specialist use were all significantly greater among urban residen ts, whereas home services use was greater among rural residents. Respo ndents with either health maintenance organization or fee-for-service supplemental coverage had higher tertiary prevention scores than respo ndents without supplemental coverage. After adjustment for the signifi cant effects of the number of diseases, higher income, and place of re sidence, rural respondents having health maintenance organization supp lemental coverage had higher (better) tertiary prevention scores than other respondents. CONCLUSIONs. In this community-based study of elder ly, enrollment in an health maintenance organization plan, as opposed to a fee-for-service supplement to Medicare, increased tertiary preven tion quality for rural but not for urban residents. This study emphasi zes that additional research is needed to evaluate the importance of s pecific types of insurance coverage for preventive services among the elderly.