Use of preventive health services is affected by factors such as patient demographics, clinical characteristics, type of provider, and type of healthcare system.1 Although people with multiple sclerosis may have impaired mobility, their lifespans are similar to age matched population controls. They therefore need standard preventive services to prevent early mortality. We evaluated the relation between mobility and use of preventive services in women with multiple sclerosis.
Participants, methods, and results
In 1996, we sent questionnaires to 1164 adults with multiple sclerosis who had received outpatient care in 1993 or 1994 from one of three systems of health care (two forms of managed care and fee for service insurance) in two regions of the United States.2 The overall response rate was 80% (930/1164). We report here survey analyses from the 713 women respondents.
We collected self reported rates of cervical smear testing, mammography, and breast examination (if over age 50), blood pressure checks, cholesterol screening, and physician assessment of health habits. We assessed these rates according to the patient's mobility level (fully ambulatory, ambulatory with help, and not ambulatory) and compared them with Healthy People 2000 recommendations.3 For each preventive service, we used logistic regression to model the relation between that service, mobility, patient demographics, comorbidity,2 system of health care, indicators for having a primary care physician and a multiple sclerosis physician, and specialty of these physicians.
The mean age of the women was 47 years; 86% were white and 40% had a four year college degree. Overall rates for cervical smear tests, breast examinations, and mammography exceeded Healthy People 2000 recommendations, but rates were highest for the ambulatory group and lowest for the non-ambulatory group (P⩽0.05, table). Cervical smear testing was below Healthy People 2000 goals for the ambulatory with help and non-ambulatory groups. In contrast, rates for general preventive services did not differ by mobility.
In the multivariable models, ambulatory patients had 5.32 times the odds of having a cervical smear test, 3.62 times the odds of having a breast examination, and 3.24 times the odds of having mammography relative to non-ambulatory patients (all P<0.05). Older age was associated with a lower rate of cervical smear tests; however, no other variables were related to receipt of women's preventive services. Except for an increased odds of assessing eating habits in the non-ambulatory group, mobility status did not affect the odds of receiving general preventive services.
Comment
Use of women's preventive health services was lower in non-ambulatory women than in fully or partially ambulatory women with multiple sclerosis. These results are the same as those in a previous population based US study of women with and without mobility impairments due to various conditions,4 even though women in our study had a single chronic condition, were younger, were more educated, and all had health insurance and a regular source of care in health systems that met broad national screening goals.
There are several possible explanations for these findings. Doctors may believe that such patients do not have an adequate life expectancy to warrant women's preventive screening. However, such attitudes would be incompatible with the high rates of blood pressure and cholesterol checks. Alternatively, patients may be reluctant to undergo screening services that are potentially uncomfortable or embarrassing.5 A third possibility is that the medical systems cannot easily accommodate patients with mobility impairments, who may require access to specialised equipment and extra time.
Women with impaired mobility should be considered a vulnerable population for receipt of breast examinations, mammography, and cervical smear tests. Studies are needed to identify factors causing this and to evaluate interventions to reduce the variation across mobility levels.
Table.
Use of preventive services among women with multiple sclerosis by degree of mobility
| Healthy People 2000 target rates (%) | No (%) reporting use of preventive services (unadjusted)*
|
P value | Validation (c) statistic for logistic regression | Adjusted odds ratios (95% CI)¶
|
|||||
|---|---|---|---|---|---|---|---|---|---|
| Overall (n=713) | Fully ambulatory† (n=363) | Ambulatory with help‡ (n=239) | Not ambulatory§ (n=111) | Fully ambulatory | Ambulatory with help | ||||
| Women's preventive health services | |||||||||
| Cervical smear test in past 3 years | 85 | 585/692 (85) | 334/361 (93) | 181/228 (79) | 70/103 (68) | 0.001 | 0.73 | 5.32 (2.74 to 10.3)†† | 2.11 (1.15 to 3.85)†† |
| Breast examination in past year** | 60 | 196/245 (80) | 83/96 (86) | 82/104 (79) | 31/45 (69) | 0.05 | 0.67 | 3.62 (1.39 to 9.42) | 1.83 (0.75 to 4.48) |
| Mammography in past 2 years** | 60 | 211/245 (86) | 85/95 (89) | 94/105 (90) | 32/45 (71) | 0.006 | 0.71 | 3.24 (1.13 to 9.29) | 3.37 (1.17 to 9.65) |
| General preventive health services | |||||||||
| Blood pressure checked in past year | 90‡‡ | 532/678 (78) | 268/351 (76) | 179/223 (80) | 85/104 (82) | 0.37 | 0.70 | 0.83 (0.43 to 1.59) | 0.78 (0.39 to 1.53) |
| Cholesterol checked in past 5 years | 75 | 494/626 (79) | 258/326 (79) | 164/205 (80) | 72/95 (76) | 0.70 | 0.72 | 1.31 (0.69 to 2.49) | 1.17 (0.61 to 2.26) |
| In past year, a doctor asked about: | |||||||||
| Eating habits | 207/631 (33) | 100/329 (30) | 66/206 (32) | 41/96 (43) | 0.08 | 0.63 | 0.44 (0.25 to 0.76) | 0.53 (0.30 to 0.93) | |
| Exercise habits | 327/639 (51) | 172/336 (51) | 111/209 (53) | 44/94 (47) | 0.60 | 0.61 | 0.86 (0.51 to 1.47) | 1.00 (0.58 to 1.73) | |
| Alcohol or drug use | 148/616 (24) | 84/326 (26) | 44/197 (22) | 20/93 (22) | 0.56 | 0.60 | 1.04 (0.56 to 1.91) | 1.03 (0.54 to 1.94) | |
Response rates exclude women who answered “not sure.” When women who responded not sure were combined with those who responded no, the results were similar.
Can walk at least 1 block or 90 m without ambulation aid.
Can walk at least 4.5 m with the aid of a cane, crutch, brace, or walker.
Unable to walk 4.5 m with the aid of a cane, crutch, brace, or walker.
Compared with not ambulatory group. Covariates include mobility, age, race, education, comorbidity, system of health care, indicators for having a primary care physician and multiple sclerosis physician, and specialty of these physicians. Interaction terms of mobility and health system, and mobility and education were included in models but were not significant.
For respondents aged ⩾50 years.
Healthy People 2000 goal is for 90% of adults to have had blood pressure checked in past 2 years.
The fully ambulatory group also had significantly higher odds of smear testing relative to the “ambulatory with help” group.
Acknowledgments
We thank Robert Brook for advice in designing the protocol and contributing to the interpretation of results, Martin Shapiro for help in designing the survey, and Rebecca Hanson for help in designing the survey protocol and collecting data.
Footnotes
Editorial by Wagner
Funding: This work was supported by the Veteran's Administration, the Robert Wood Johnson Foundation, the health care delivery and policy research program of the National Multiple Sclerosis Society (contract HC 0003), and the National Institute for Neurological Disorders and Stroke (K08 NS01669).
Competing interests: None declared.
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