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UI study: Access, insurance affect treatment for rural elderly with chronic illness

IOWA CITY, Iowa -- The frequency with which elderly people with chronic illness receive recommended preventive medical treatment depends upon their insurance coverage, and that differs among rural and urban residents, according to findings by University of Iowa researchers.

A survey of people over age 65 with chronic medical conditions from 10 urban counties and 12 rural counties in Iowa found that, though the elderly do not get all the recommended preventive care for chronic conditions, those who had only Medicare received the lowest amount of preventive treatment.

The frequency of preventive treatment for chronic conditions was highest among the elderly who had either a health maintenance organization (HMO) or fee-for-service supplemental insurance plan. Those living in rural areas who supplemented their Medicare coverage with an HMO received more frequent preventive treatment than those with other types of coverage.

The researchers interviewed 787 elderly people who lived at home and had at least one of six common chronic conditions: arthritis, hypertension, heart disease, diabetes, peptic ulcer, and emphysema or chronic bronchitis.

Preventive medical treatment for chronic conditions is somewhat different from other types of preventive medicine. It is designed to prevent further complications from the condition rather than to prevent the condition. An example of preventive treatment would be periodic foot and eye examinations and testing blood glucose control for a diabetic, Doebbeling said.

It is a combination of treatment and prevention, said Dr. Bradley Doebbeling, UI professor of internal medicine, one of the authors of the study. The research team was led by Dr. Kenneth Saag, former UI professor of internal medicine and currently at the University of Alabama in Birmingham.

These findings, published in the July issue of the journal Medical Care, may be more a reflection of access to care than of a specific type of insurance plan, Doebbeling said.

"Physician resources are more limited in rural areas," he said. "Those doctors are very busy and may be more likely to focus on acute medical problems and their management than preventive treatment for the elderly. In urban areas there are more physicians, they may not be quite as busy and they have the time to focus on preventive treatment for elderly people with chronic conditions."

Doebbeling speculated that if there were adequate availability of physicians in both rural and urban communities, there would be no difference between groups in the amount of preventive treatment received.

When the number of physicians in an area is limited and elderly patients don't have a specific complaint, busy physicians without a preventive treatment system -- some sort of check list of tests to do -- may not consider preventions such as an eye test or foot exam for a diabetic. HMOs and group practices more often have that sort of system, Doebbeling said.

9"It is becoming increasingly apparent that the best way to deliver preventive services is to have a good system in place and an information system to track the services provided," he said.

"This study is one of the first to show that there is a gap in preventive medical services recommended for elderly with chronic illness and what they receive. It argues that there should be a system in place to track the services provided to the elderly with chronic conditions," Doebbeling said.

The rural Iowa counties included in the study were Adams, Calhoun, Decatur, Fremont, Keokuk, Pocahontas, Ringgold, Sac, Taylor, Van Buren, Wayne and Worth. The urban counties were Black Hawk, Dallas, Dubuque, Johnson, Linn, Polk, Pottawattamie, Scott, Warren and Woodbury.