1 Introduction

Health disparities span the continuum of health and healthcare –from prevention, diagnosis, to treatment and ongoing management [1,2,3]. Prior research demonstrated that receipt of recommended clinical preventive services is suboptimal and varies by preventive service [4,5,6]. Previously, we examined a composite of receipt of high-priority clinical preventive services by adults age ≥ 35 years and older, a measure of person-centered prevention. A prior study using this measure found that in 2015, only 8 percent of US adults ages 35 and older received all of their high-priority recommended clinical preventive services [5]. Sample size precluded assessment of disparities in receipt of these services associated with race/ethnicity and other sociodemographic characteristics.

In 2018, the Agency for Healthcare Research and Quality (AHRQ) began incorporating biannually the prevention questions that comprised the composite into the Medical Expenditure Panel Survey (MEPS), allowing production of national estimates of disparities in the use of high-priority, recommended clinical preventive services. The preventive services included measures of screening (e.g., blood pressure and colon cancer), screening and counseling (e.g., tobacco use), vaccinations (e.g., flu), and preventive medications (e.g., aspirin use) [5, 6]. More specifically they include: alcohol use screening & counseling, aspirin use discussion, blood pressure screening, breast cancer screening, cervical cancer screening, cholesterol screening, colon cancer screening, depression screening, flu vaccination, obesity screening & counseling, osteoporosis screening, pneumococcal vaccination, PSA screening, tobacco use screening & counseling, and Zoster vaccination.

The purpose of this paper is to examine potential disparities in the receipt of high-priority, clinical preventive services among adults.

2 Methods

Data from the AHRQ MEPS, Self-Administered Questionnaire (SAQ), Panel 23, Round 2 and Panel 22, Round 4 from the 2018 Full Year Consolidated public use file were used, including adults age ≥ 35 (n = 14,615). See Table 1.

Table 1 Civilian non-institutionalized population characteristics of survey respondents, 2018 (n = 14,615)
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The SAQ, response rate 87%, includes questions about the receipt of fifteen high-priority clinical preventive services identified and prioritized with input from an expert National Steering Committee [6]. The number of recommended preventive services varied based on age, sex, and medical history (min: 7; max: 13). Some medical histories affect eligibility for screening (e.g., an individual does not have the organ to be screened or previously was diagnosed with cancer affecting that part of the body). The composite measure accounts for both receipt of the service and clinical reasons for not receiving. The composite measure was designed to capture whether a person received all high-priority, appropriate clinical preventive services for his or her age group [5, 6].

More details about the survey questions, measures and eligibility are available in prior publications and available at: https://meps.ahrq.gov/data_files/publications/rf41/rf41.shtml [5, 6].

We examined differences in receipt of all recommended high-priority services associated with sex; race/ethnicity; education; region; insurance; income level; language spoken; help with activities of daily living (ADL) (e.g., bathing, dressing), instrumental activities of daily living (IADL) (e.g., using the telephone, paying bills), and use of assistive devices (AID) (e.g., walker); and having 3 or more chronic conditions.

Analyses were conducted using both SAS and Stata statistical software packages. Survey design variables and appropriate sample weights were utilized to account for the complex sample design of MEPS. Bivariable analyses were performed using the Rao-Scott chi-square test adjustment to test for statistical differences. Multivariable analyses were conducted using logistic regression and the evaluation of resulting odds ratios. Study limitations were described previously and include limitations of self-reported measures and potential for recall bias [5].

This study was conducted as an AHRQ intramural research project (IM21688) and deemed exempt from IRB review. MEPS data is publicly available.

3 Results

Overall receipt of all recommended preventive services among adults age ≥ 35 was low (6%). There were significant differences based on age, race/ethnicity, language spoken, chronic conditions, insurance status, education, and income (See Table 2). In bivariable analyses, receipt varied by age—4.5% of adults 50–64 received all of their recommended high-priority preventive services, compared to 7% of adults 35–49 and 65–74. Less than 4% of Black non-Hispanic adults and Hispanic adults received their recommended services, compared to nearly 7% of White non-Hispanic adults. Half the proportion of adults who spoke a language other than English compared to adults who spoke English received their recommended services (3.6% vs. 6.7%). One-third the proportion of adults who did not graduate high school compared to adults with a college degree or higher received their recommended preventive services (3.0% vs 9.0%). Only 3.6% of adults classified as poor received all services but 7.7% of adults with high income did.

Table 2 Bivariable: percent of civilian non-institutionalized population screened for all high-priority recommended preventive services by selected sociodemographic characteristics, 2018
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Less than 0.5% of uninsured adults received all recommended preventive services, compared with 6.4% of adults under 65 with any private health insurance and slightly more than 5% of adults with public only insurance. For adults over 65 years, 5.3% of adults 65 + with Medicare only and 4.3% of adults with Medicare and other public only received all services, compared with approximately 8.5% with Medicare and private insurance. Approximately half of adults with fewer than three chronic conditions compared to adults with three or more chronic conditions received these services as (4.9% vs. 8.7%). There were no statistically significant differences based on sex, region, or having any AID/ADL/IADLs.

Table 3 shows the results from the multivariable analysis. In multivariable models, the following adults were less likely to receive all recommended high-priority preventive services: black adults (compared to white adults); adults who are not a high school graduate, high school graduate or GED, or some college but no degree (compared to college or higher); uninsured (compared to any private); adults who are experiencing poverty, low income, or middle income (compared to high income); speak languages other than English (compared to no languages other than English); and adults with less than 3 chronic conditions (compared to those with 3 + chronic conditions).

Table 3 Logistic regression of receipt of all high-priority recommended services for adults 35 +, 2018 (n = 14,467)
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Black adults had 37% lower odds than white adults of receiving all recommended services (OR: 0.63, CI 0.46–0.86). Adults who were uninsured had 89% lower odds than those with private insurance of receiving all services (OR: 0.11, CI 0.04–0.27). Adults who spoke a language other than English compared to those who didn't had 35% lower odds of receiving all services (OR: 0.65, CI 0.45–0.95).

While only 6 percent of all adults 35 + are receiving all of their recommended preventive services, there is variation, and some adults are getting close to receiving all services. Nearly 30% of adults are receiving 76–100% of their recommended preventive services and more than 60% are receiving at least half. On the other side of the distribution, more than 14% received between 0 and 25% of their recommended preventive services (see Fig. 1).

Fig. 1
figure 1

Distribution of receipt of recommended preventive services, 2018 (n = 14,615)

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When looking at the individual preventive services that comprise the composite, some were more likely to be received than others and many of these differences varied by sex, race/ethnicity, and income level. While many adults received blood pressure screening (86.7%), other preventive services such as alcohol use screening and counseling (38.4%), depression screening (40.3%), tobacco use screening and counseling (57.5%), zoster vaccination (43.7%), and flu vaccination (46.6%), and were less frequently received (See Table 4).

Table 4 Receipt of individual reccommended preventive services in the US, 2018 (n = 14,615)
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4 Discussion and conclusions

This study provides the first national estimates of disparities in receipt of all recommended high-priority preventive services, a measure of person-centered prevention. Receipt of all recommended preventive services among adults age ≥ 35 was low (6%). Multivariable regression analysis found sizable disparities associated with all sociodemographic characteristics examined. We found that Black adults, adults with less education, adults who are uninsured, adults with lower income, and adults who spoke a language other than English were less likely to receive their recommended preventive services. While the passage of the Affordable Care Act increased access to care and coverage of preventive services without cost sharing [7], these results show a continuing need to identify and implement effective ways to equitably increase uptake of preventive services. These results also highlight the need to dig deeper into the reasons for the low overall receipt of preventive services (e.g., transportation, time, childcare barriers) as well as the root cause of the disparities (e.g., structural barriers), which will be important for the development of interventions to address them.

COVID-19 has negatively affected access to care and preventive services, necessitating a concerted focus on prevention [8,9,10]. Improving receipt of preventive care is the priority of Federal agencies, including the Department of Veterans Affairs and the Agency for Healthcare Research and Quality (AHRQ) [11, 12].

Improving population health depends upon effective strategies to increase uptake of high-priority preventive services while reducing disparities in receipt of these services. These findings can guide the implementation, evaluation, and scaling of interventions to achieve equity in the delivery of preventive services including enhanced models of primary care, use of digital health solutions, linkages between clinical care and public health and community-based organizations [13, 14].