Use of Clinical Preventive Services by Medicare Beneficiaries Aged greater than or equal to 65 Years -- United States, 1995

Delivery of clinical preventive services to older adults can reduce premature morbidity and mortality while preserving function and enhancing overall quality of life (1,2). Until recently, the use of such services has been low among older adults because Medicare coverage has not been extended to many preventive services (3). Medicare coverage now includes four clinical preventive services: a single lifetime pneumococcal polysaccharide vaccination (vaccine plus any required revaccination and administration) (since 1981); annual influenza vaccination (vaccine and administration) (since 1993); and for women, biennial mammography screening (since 1991) and Papanicolaou smear screening every 36 months (since 1990) (4,5). To assess current state-specific levels of use of these services among Medicare beneficiaries, CDC and the Health Care Financing Administration (HCFA) analyzed data from the 1995 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the findings of this analysis, which indicate that, despite Medicare coverage of these preventive services, many U.S. adults aged greater than or equal to 65 years did not receive such services in 1995, and state-specific use of these services varied substantially.

The BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of U.S. civilian, noninstitutionalized adults aged greater than or equal to 18 years. In 1995, all 50 states participated in the survey (6). All persons responding to the BRFSS questionnaire were asked 1) "Do you have any kind of health-care coverage, including health insurance, prepaid plans such as HMOs {health-maintenance organizations}, or government plans such as Medicare?" and 2) what specific preventive health services they had received and the duration since they had received the service(s). Of the 113,934 survey participants, 22,849 were aged greater than or equal to 65 years. Because the 1995 survey did not ask specifically whether the respondent had Medicare insurance, a "yes" response to the health insurance status question was used as a proxy for Medicare coverage. A total of 22,500 (98.5%) respondents aged greater than or equal to 65 years indicated having such coverage. Male survey respondents were excluded from estimates of prevalences of mammography and Pap smear screenings. Female respondents from California also were excluded from these estimates because of the different wording of the survey questions in that state. Statistical Analysis Software (SAS) was used to calculate the prevalence estimates, and Software for Survey Data Analysis (SUDAAN) was used to calculate 95% confidence intervals (CIs). Although differences in state-specific prevalence estimates may reflect, in part, disparate age distributions, the sizes of the samples did not permit age adjustment of prevalence rates.

In 1995, state-specific estimates of the percentage of persons aged greater than or equal to 65 years who had received influenza vaccinations during the 12 months preceding the survey ranged from 46.2% (95% CI=40.3%-52.1%) (Alabama) to 70.3% (95% CI=65.4%-75.2%) (Utah) (median: 60.6%) (Table_1). The prevalences for most southeastern states were in the lowest quartile (46.2%-56.1%) and for most western states were in the highest quartile (64.1%-70.3%) (Figure_1).

Estimates of the percentage of persons aged greater than or equal to 65 years who had ever received a pneumococcal vaccination ranged from 13.1% (95% CI=8.0%-18.2%) (New Jersey) to 49.3% (95% CI=43.0%-55.6%) (Arizona) (median: 38.5%). Prevalences were higher in western states.

The percentage of women aged greater than or equal to 65 years who had received a mammogram during the 2 years preceding the survey ranged from 52.7% (95% CI=44.3%-61.1%) (New Jersey) to 80.4% (95% CI=68.8%-92.0%) (Alaska) (median: 65.0%), and prevalences did not vary by region. Percentages of women aged greater than or equal to 65 years who had obtained Pap smears during the 3 years preceding the survey ranged from 52.2% (95% CI=44.9%-59.5%) (Kentucky) to 88.5% (95% CI=83.4%-93.6%) (Arizona) (median: 70.0%); a substantial number of states in the Midwest ranked in the second lowest quartile (range: 63.7%-67.3%) (Figure_2).

Reported by: Behavioral Risk Factor Surveillance System coordinators. L Rhodes, MPH, Klemm Analysis Group; D Arday, MD, S Arday, MHS, Office of Clinical Standards and Quality, Health Care Financing Administration. Health Care and Aging Studies Br and Behavioral Surveillance Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: This report documents substantial variation in the state-specific prevalences of four preventive services (pneumococcal polysaccharide vaccination, influenza vaccination, mammography screening, and Pap smear screening) used recently by Medicare-eligible adults. Although all four services are covered by Medicare and endorsed by many organizations and agencies (7), many states have not met the national health objectives for 2000 for use of these services (60% coverage with influenza and pneumonia vaccines {objective 20.1} and use of Pap smears by 70% of women aged greater than or equal to 70 years with an intact cervix {objective 16.12} *) (3). These findings also indicate that health-care coverage alone does not ensure use of preventive services, even though previous national studies have documented that uninsured persons were less likely to receive preventive health services (8). The use of a state-specific survey such as BRFSS enables individual states and HCFA's peer review organizations to estimate prevalences and tailor intervention strategies.

The findings in this report are subject to at least four limitations. First, because BRFSS includes only households with a telephone, the findings may underestimate prevalences among groups with lower socioeconomic status, resulting in overestimation of the prevalences of use of preventive services. Second, because limitations in the sample sizes precluded age-adjustment by state, disparities in state-specific age distributions may account for some of the variation in rates of service delivery. Third, self-reported data are subject to recall bias, especially telescoping (i.e., the tendency to recall an event as having occurred later or earlier than it actually did). Women often report having had a mammogram or Pap smear in the recommended time frame when the actual interim since their last screening has been longer, resulting in overestimates of state-based prevalences. Finally, although age and health insurance status were used as a proxy for Medicare coverage of preventive services, other factors that may have affected out-of-pocket costs (e.g., "medi-gap" programs that supplement Medicare, Medicaid, and employer health insurance programs) were unaccounted for in the analysis (9). For example, although the Supplementary Medical Insurance Program (i.e., Medicare Part B) reimburses all the services included in this report, enrollment is voluntary and requires payment of a monthly premium; persons not enrolled could incur substantial out-of-pocket expenses after receipt of services. In 1995, 5%-6% of the population aged greater than or equal to 65 years was not covered by Medicare Part B.

The likelihood of use of clinical preventive services is decreased among persons without a usual source of care and among those in lower income and education groups (7,8). Other barriers to receipt of such services include 1) provider knowledge and attitudes (lack of training or disagreement with guidelines); 2) patient knowledge and attitudes (anxiety, discomfort, or apathy); and 3) system factors (lack of provider staff or reminder systems). Elimination of barriers will require changes in policy, legislation, and the development of outreach programs of clinical preventive services targeted to older adults. Although provider-directed strategies emphasizing continuing medical education has had limited success in changing professional practice patterns, some office-based interventions (e.g., prompting, monitoring, and providing performance feedback) have modestly increased delivery of preventive services (10). Additional efforts should assess the effectiveness of patient-directed interventions that specifically address the needs and attitudes of older adults. The delivery of preventive services to older adults also will require broad-based interventions implemented simultaneously at several levels. These interventions should include changes in the structure of the delivery of preventive services in health care and increased consensus regarding prevention guidelines.

References

1. Goldberg TH, Chavin SI. Preventive medicine and screening in older adults. J Am Geriatr Soc 1997;45:344-54.

2. CDC. Pneumococcal and influenza vaccination levels among adults aged greater than or equal to 65 years -- United States, 1995. MMWR 1997;46:913-9.

3. Public Health Service. Healthy people 2000: midcourse review and 1995 revisions. Washington, DC: US Department of Health and Human Services, Public Health Service, 1995.

4. Chin JS, Ellerbeck EE, Jencks SF. Improving preventive health care in Medicare's health care quality improvement program. Am J Prev Med 1995;11:397-401.

5. Fahs MC, Mandelblatt J, Schechter C, Muller C. Cost effectiveness of cervical cancer screening for the elderly. Ann Intern Med 1992;117:520-7.

6. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In: CDC. Using chronic disease data: a handbook for public health practitioners. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1992:4-17.

7. US Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Baltimore, Maryland: Williams & Wilkins, 1996.

8. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Health Statistics, 1994. (Advance data no. 254).

9. Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med 1995;332:1138-43.

10. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5.

* The national health objective for use of mammography is combined with clinical breast examination (CBE). Medicare does not pay specifically for CBE.

+------------------------------------------------------------------- ------+ | Erratum: Vol. 46, No. 48 | | ======================== | | SOURCE:47(14);287-289 DATE:April 17, 1998 | |             | | In the report, "Use of Clinical Preventive Services by | | Medicare Beneficiaries Aged greater than or equal to 65 Years -- | | United States, 1995," on page 1139, the percentages in the first | | sentence of the first paragraph were incorrect. The sentence should | | read: "The percentage of women aged greater than or equal to 65 | | years who had received a mammogram during the 2 years preceding the | | survey ranged from 52.8% (95% CI=44.2%-61.3%) (New Jersey) to 80.8% | | (95% CI=69.4%-92.2%) (Alaska) (median: 65.5%), and prevalences did | | not vary by region." | | In the same report, in Table 1 on pages 1140-1, the | | mammography prevalence estimates and confidence intervals were | | incorrect. Following is the corrected table (Table_1e). | |             | +------------------------------------------------------------------- ------+
Table_1
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TABLE 1. Estimated prevalence of use of four clinical preventive services by Medicare beneficiaries* aged >=65 years, by service and state -- United
States, Behavioral Risk Factor Surveillance System (BRFSS), 1995
==================================================================================================================================================================
                             Influenza                           Pneumococcal                       Mammography@                       Papanicolaou
                            vaccination+                         vaccination&                                                             smear**
------------------------------------------------------------------------------------------------------------------------------------------------------------------
State                    %             (95% CI++)             %              (95% CI)             %               (95% CI)           %              (95% CI)
------------------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama                 46.2          (40.3%-52.1%)          33.4          (27.9%-38.9%)        65.0         (57.9%-72.1%)          64.3          (55.1%-73.5%)
Alaska                  49.8          (33.9%-65.7%)          46.3          (29.8%-62.8%)        80.4         (68.8%-92.0%)          86.5          (74.3%-98.7%)
Arizona                 65.0          (59.1%-70.9%)          49.3          (43.0%-55.6%)        78.0         (70.9%-85.1%)          88.5          (83.4%-93.6%)
Arkansas                62.1          (57.0%-67.2%)          37.6          (32.1%-43.1%)        62.4         (56.1%-68.7%)          68.7          (59.9%-77.5%)
California              60.9          (56.0%-65.8%)          44.8          (39.9%-49.7%)         NA&&                                NA
Colorado                66.9          (61.4%-72.4%)          46.7          (40.6%-52.8%)        65.0         (58.5%-71.5%)          70.2          (61.6%-78.8%)
Connecticut             63.2          (57.5%-68.9%)          38.3          (32.6%-44.0%)        77.2         (71.3%-83.1%)          70.0          (61.8%-78.2%)
Delaware                57.3          (52.2%-62.4%)          41.7          (36.8%-46.6%)        69.6         (63.5%-75.7%)          69.1          (61.1%-77.1%)
Florida                 62.4          (58.7%-66.1%)          39.9          (36.2%-43.6%)        78.5         (74.6%-82.4%)          82.3          (77.2%-87.4%)
Georgia                 47.6          (42.7%-52.5%)          40.5          (35.6%-45.4%)        75.2         (69.3%-81.1%)          73.9          (65.7%-82.1%)
Hawaii                  62.4          (56.9%-67.9%)          42.9          (37.2%-48.6%)        74.1         (68.0%-80.2%)          78.7          (70.7%-86.7%)
Idaho                   64.4          (59.9%-68.9%)          40.1          (35.4%-44.8%)        64.1         (58.6%-69.6%)          67.3          (59.7%-74.9%)
Illinois                57.7          (51.4%-64.0%)          29.0          (23.3%-34.7%)        70.2         (65.3%-75.1%)          71.7          (65.6%-77.8%)
Indiana                 59.7          (55.0%-64.4%)          34.5          (30.0%-39.0%)        64.3         (58.6%-70.0%)          68.3          (61.6%-75.0%)
Iowa                    63.7          (60.2%-67.2%)          44.8          (40.9%-48.7%)        63.0         (58.5%-67.5%)          67.9          (62.4%-73.4%)
Kansas                  62.3          (57.0%-67.6%)          45.1          (39.8%-50.4%)        69.2         (63.1%-75.3%)          71.6          (63.8%-79.4%)
Kentucky                53.6          (49.1%-58.1%)          25.6          (21.7%-29.5%)        58.1         (52.8%-63.4%)          52.2          (44.9%-59.5%)
Louisiana               52.8          (46.5%-59.1%)          25.7          (20.6%-30.8%)        60.8         (53.7%-67.9%)          54.6          (43.6%-65.6%)
Maine                   65.9          (59.6%-72.2%)          36.5          (29.8%-43.2%)        68.9         (61.3%-76.5%)          74.3          (65.7%-82.9%)
Maryland                58.4          (54.7%-62.1%)          33.6          (30.1%-37.1%)        75.5         (71.6%-79.4%)          69.1          (63.6%-74.6%)
Massachusetts           60.3          (54.4%-66.2%)          33.1          (27.2%-39.0%)        77.6         (71.3%-83.9%)          75.2          (67.2%-83.2%)
Michigan                57.2          (52.3%-62.1%)          40.0          (35.1%-44.9%)        76.5         (71.4%-81.6%)          71.4          (64.3%-78.5%)
Minnesota               63.6          (59.9%-67.3%)          40.5          (36.8%-44.2%)        68.3         (63.8%-72.8%)          73.2          (68.1%-78.3%)
Mississippi             57.1          (51.2%-63.0%)          40.0          (34.1%-45.9%)        53.1         (46.2%-60.0%)          63.9          (54.9%-72.9%)
Missouri                66.7          (60.6%-72.8%)          32.9          (26.6%-39.2%)        69.3         (62.4%-76.2%)          66.4          (56.2%-76.6%)
Montana                 64.9          (58.6%-71.2%)          35.6          (29.1%-42.1%)        61.7         (53.7%-69.7%)          69.4          (58.6%-80.2%)
Nebraska                64.1          (59.4%-68.8%)          36.3          (31.6%-41.0%)        60.3         (54.4%-66.2%)          66.0          (58.4%-73.6%)
Nevada                  52.4          (46.5%-58.3%)          40.4          (34.5%-46.3%)        63.6         (56.3%-70.9%)          70.4          (60.2%-80.6%)
New Hampshire           56.1          (49.4%-62.8%)          40.6          (33.7%-47.5%)        74.8         (67.0%-82.6%)          74.0          (63.2%-84.8%)
New Jersey              48.4          (40.8%-56.0%)          13.1          ( 8.0%-18.2%)        52.7         (44.3%-61.1%)          63.2          (52.2%-74.2%)
New Mexico              69.4          (62.3%-76.5%)          40.3          (32.9%-47.7%)        67.6         (58.6%-76.6%)          80.1          (69.9%-90.3%)
New York                56.6          (51.3%-61.9%)          26.9          (22.0%-31.8%)        64.3         (57.8%-70.8%)          64.2          (56.8%-71.6%)
North Carolina          52.9          (49.0%-56.8%)          31.7          (28.2%-35.2%)        64.2         (59.7%-68.7%)          73.2          (67.7%-78.7%)
North Dakota            57.4          (52.5%-62.3%)          33.3          (28.4%-38.2%)        62.2         (56.3%-68.1%)          66.2          (58.6%-73.8%)
Ohio                    62.7          (56.0%-69.4%)          40.4          (33.3%-47.5%)        64.4         (56.8%-72.0%)          66.4          (56.2%-76.6%)
Oklahoma                61.0          (56.3%-65.7%)          36.9          (32.2%-41.6%)        58.3         (52.2%-64.4%)          71.4          (62.0%-80.8%)
Oregon                  67.3          (63.2%-71.4%)          46.1          (41.6%-50.6%)        76.8         (72.1%-81.5%)          80.7          (74.4%-87.0%)
Pennsylvania            58.7          (54.2%-63.2%)          38.7          (33.8%-43.6%)        59.3         (54.2%-64.4%)          61.7          (55.0%-68.4%)
Rhode Island            66.8          (61.3%-72.3%)          31.0          (25.5%-36.5%)        69.8         (63.1%-76.5%)          59.3          (50.3%-68.3%)
South Carolina          51.7          (46.0%-57.4%)          26.8          (21.9%-31.7%)        70.1         (63.2%-77.0%)          77.6          (68.6%-86.6%)
South Dakota            60.1          (55.2%-65.0%)          31.2          (26.3%-36.1%)        59.7         (53.2%-66.2%)          69.1          (61.3%-76.9%)
Tennessee               63.6          (58.1%-69.1%)          29.5          (24.6%-34.4%)        64.7         (58.4%-71.0%)          66.9          (58.7%-75.1%)
Texas                   57.3          (50.4%-64.2%)          45.6          (38.3%-52.9%)        62.9         (55.3%-70.5%)          64.9          (54.1%-75.7%)
Utah                    70.3          (65.4%-75.2%)          42.9          (37.4%-48.4%)        66.6         (60.7%-72.5%)          72.0          (64.2%-79.8%)
Vermont                 64.0          (59.1%-68.9%)          36.0          (31.1%-40.9%)        65.7         (59.6%-71.8%)          77.5          (70.8%-84.2%)
Virginia                53.2          (46.3%-60.1%)          40.2          (32.9%-47.5%)        70.4         (62.2%-78.6%)          79.5          (70.5%-88.5%)
Washington              67.5          (63.0%-72.0%)          46.7          (41.8%-51.6%)        74.2         (69.1%-79.3%)          77.0          (69.6%-84.4%)
West Virginia           53.6          (49.3%-57.9%)          37.1          (32.6%-41.6%)        61.0         (55.9%-66.1%)          65.7          (59.2%-72.2%)
Wisconsin               56.7          (50.8%-62.6%)          35.8          (30.1%-41.5%)        59.2         (51.8%-66.6%)          71.7          (63.1%-80.3%)
Wyoming                 66.5          (61.4%-71.6%)          44.4          (39.1%-49.7%)        59.6         (52.9%-66.3%)          63.5          (54.7%-72.3%)
------------------------------------------------------------------------------------------------------------------------------------------------------------------
*  All persons responding to the BRFSS questionnaire were asked "Do you have any kind of health-care coverage, including health insurance, prepaid
   plans such as HMOs (health-maintenance organizations), or government plans such as Medicare?" A "yes" response was used as a proxy for Medicare coverage.
+  Vaccination received during the 12 months preceding the survey.
&  Vaccination received during their lifetime.
@  Service received during the previous 2 years.
** Service received during the previous 3 years. Excludes women with no uterine cervix.
++ Confidence interval.
&& Female respondents from California were excluded from these estimates because of the different wording of the survey questions in that state.
=================================================================================================================================================================

TABLE 1. Estimated prevalence of use of four clinical preventive services by Medicare beneficiaries* aged >= 65 years, by service
and state -- United States, Behavioral Risk Factor Surveillance System (BRFSS), 1995
===================================================================================================================================
                                              Pneumococcal                                     Papanicolaou
                 Influenza vaccination +      vaccination &          Mammography @               smear **
                 -----------------------  ---------------------    --------------------    ---------------------
State              %       (95% CI ++)     %        (95% CI)        %       (95% CI)        %       (95% CI)
----------------------------------------------------------------------------------------------------------------
Alabama           46.2    (40.3%-52.1%)   33.4    (27.9%-38.9%)    66.3   (59.2%-73.4%)    64.3    (55.1%-73.5%)
Alaska            49.8    (33.9%-65.7%)   46.3    (29.8%-62.8%)    80.8   (69.4%-92.2%)    86.5    (74.3%-98.7%)
Arizona           65.0    (59.1%-70.9%)   49.3    (43.0%-55.6%)    80.5   (73.9%-87.1%)    88.5    (83.4%-93.6%)
Arkansas          62.1    (57.0%-67.2%)   37.6    (32.1%-43.1%)    63.7   (57.3%-70.0%)    68.7    (59.9%-77.5%)
California        60.9    (56.0%-65.8%)   44.8    (39.9%-49.7%)    NA &&                   NA
Colorado          66.9    (61.4%-72.4%)   46.7    (40.6%-52.8%)    65.5   (58.9%-72.0%)    70.2    (61.6%-78.8%)
Connecticut       63.2    (57.5%-68.9%)   38.3    (32.6%-44.0%)    79.0   (73.2%-84.8%)    70.0    (61.8%-78.2%)
Delaware          57.3    (52.2%-62.4%)   41.7    (36.8%-46.6%)    70.2   (64.2%-76.2%)    69.1    (61.1%-77.1%)
Florida           62.4    (58.7%-66.1%)   39.9    (36.2%-43.6%)    78.5   (74.6%-82.4%)    82.3    (77.2%-87.4%)
Georgia           47.6    (42.7%-52.5%)   40.5    (35.6%-45.4%)    75.4   (69.6%-81.3%)    73.9    (65.7%-82.1%)
Hawaii            62.4    (56.9%-67.9%)   42.9    (37.2%-48.6%)    74.4   (68.3%-80.4%)    78.7    (70.7%-86.7%)
Idaho             64.4    (59.9%-68.9%)   40.1    (35.4%-44.8%)    64.4   (58.9%-69.8%)    67.3    (59.7%-74.9%)
Illinois          57.7    (51.4%-64.0%)   29.0    (23.3%-34.7%)    70.4   (65.5%-75.2%)    71.7    (65.6%-77.8%)
Indiana           59.7    (55.0%-64.4%)   34.5    (30.0%-39.0%)    65.5   (59.9%-71.1%)    68.3    (61.6%-75.0%)
Iowa              63.7    (60.2%-67.2%)   44.8    (40.9%-48.7%)    63.6   (59.1%-68.0%)    67.9    (62.4%-73.4%)
Kansas            62.3    (57.0%-67.6%)   45.1    (39.8%-50.4%)    69.4   (63.4%-75.5%)    71.6    (63.8%-79.4%)
Kentucky          53.6    (49.1%-58.1%)   25.6    (21.7%-29.5%)    59.4   (54.2%-64.7%)    52.2    (44.9%-59.5%)
Louisiana         52.8    (46.5%-59.1%)   25.7    (20.6%-30.8%)    61.0   (53.9%-68.1%)    54.6    (43.6%-65.6%)
Maine             65.9    (59.6%-72.2%)   36.5    (29.8%-43.2%)    69.7   (61.9%-77.5%)    74.3    (65.7%-82.9%)
Maryland          58.4    (54.7%-62.1%)   33.6    (30.1%-37.1%)    76.9   (73.0%-80.8%)    69.1    (63.6%-74.6%)
Massachusetts     60.3    (54.4%-66.2%)   33.1    (27.2%-39.0%)    77.6   (71.3%-83.9%)    75.2    (67.2%-83.2%)
Michigan          57.2    (52.3%-62.1%)   40.0    (35.1%-44.9%)    77.4   (72.5%-82.4%)    71.4    (64.3%-78.5%)
Minnesota         63.6    (59.9%-67.3%)   40.5    (36.8%-44.2%)    69.7   (65.2%-74.1%)    73.2    (68.1%-78.3%)
Mississippi       57.1    (51.2%-63.0%)   40.0    (34.1%-45.9%)    54.0   (47.0%-61.0%)    63.9    (54.9%-72.9%)
Missouri          66.7    (60.6%-72.8%)   32.9    (26.6%-39.2%)    69.7   (62.9%-76.6%)    66.4    (56.2%-76.6%)
Montana           64.9    (58.6%-71.2%)   35.6    (29.1%-42.1%)    62.0   (53.9%-70.1%)    69.4    (58.6%-80.2%)
Nebraska          64.1    (59.4%-68.8%)   36.3    (31.6%-41.0%)    60.7   (54.7%-66.6%)    66.0    (58.4%-73.6%)
Nevada            52.4    (46.5%-58.3%)   40.4    (34.5%-46.3%)    63.6   (56.2%-70.9%)    70.4    (60.2%-80.6%)
New Hampshire     56.1    (49.4%-62.8%)   40.6    (33.7%-47.5%)    75.8   (68.0%-83.6%)    74.0    (63.2%-84.8%)
New Jersey        48.4    (40.8%-56.0%)   13.1    ( 8.0%-18.2%)    52.8   (44.2%-61.3%)    63.2    (52.2%-74.2%)
New Mexico        69.4    (62.3%-76.5%)   40.3    (32.9%-47.7%)    68.0   (58.8%-77.1%)    80.1    (69.9%-90.3%)
New York          56.6    (51.3%-61.9%)   26.9    (22.0%-31.8%)    64.8   (58.3%-71.3%)    64.2    (56.8%-71.6%)
North Carolina    52.9    (49.0%-56.8%)   31.7    (28.2%-35.2%)    65.5   (61.0%-70.0%)    73.2    (67.7%-78.7%)
North Dakota      57.4    (52.5%-62.3%)   33.3    (28.4%-38.2%)    62.9   (57.0%-68.9%)    66.2    (58.6%-73.8%)
Ohio              62.7    (56.0%-69.4%)   40.4    (33.3%-47.5%)    64.6   (56.9%-72.3%)    66.4    (56.2%-76.6%)
Oklahoma          61.0    (56.3%-65.7%)   36.9    (32.2%-41.6%)    58.5   (52.3%-64.6%)    71.4    (62.0%-80.8%)
Oregon            67.3    (63.2%-71.4%)   46.1    (41.6%-50.6%)    76.9   (72.2%-81.6%)    80.7    (74.4%-87.0%)
Pennsylvania      58.7    (54.2%-63.2%)   38.7    (33.8%-43.6%)    60.5   (55.4%-65.6%)    61.7    (55.0%-68.4%)
Rhode Island      66.8    (61.3%-72.3%)   31.0    (25.5%-36.5%)    70.1   (63.3%-76.8%)    59.3    (50.3%-68.3%)
South Carolina    51.7    (46.0%-57.4%)   26.8    (21.9%-31.7%)    70.6   (63.8%-77.4%)    77.6    (68.6%-86.6%)
South Dakota      60.1    (55.2%-65.0%)   31.2    (26.3%-36.1%)    60.7   (54.1%-67.3%)    69.1    (61.3%-76.9%)
Tennessee         63.6    (58.1%-69.1%)   29.5    (24.6%-34.4%)    64.7   (58.5%-71.0%)    66.9    (58.7%-75.1%)
Texas             57.3    (50.4%-64.2%)   45.6    (38.3%-52.9%)    63.8   (56.1%-71.4%)    64.9    (54.1%-75.7%)
Utah              70.3    (65.4%-75.2%)   42.9    (37.4%-48.4%)    67.2   (61.3%-73.1%)    72.0    (64.2%-79.8%)
Vermont           64.0    (59.1%-68.9%)   36.0    (31.1%-40.9%)    65.9   (59.7%-72.0%)    77.5    (70.8%-84.2%)
Virginia          53.2    (46.3%-60.1%)   40.2    (32.9%-47.5%)    72.1   (63.9%-80.4%)    79.5    (70.5%-88.5%)
Washington        67.5    (63.0%-72.0%)   46.7    (41.8%-51.6%)    75.3   (70.2%-80.4%)    77.0    (69.6%-84.4%)
West Virginia     53.6    (49.3%-57.9%)   37.1    (32.6%-41.6%)    61.7   (56.6%-66.9%)    65.7    (59.2%-72.2%)
Wisconsin         56.7    (50.8%-62.6%)   35.8    (30.1%-41.5%)    59.6   (52.2%-67.0%)    71.7    (63.1%-80.3%)
Wyoming           66.5    (61.4%-71.6%)   44.4    (39.1%-49.7%)    59.6   (52.1%-67.0%)    63.5    (54.7%-72.3%)
----------------------------------------------------------------------------------------------------------------
 * All persons responding to the BRFSS questionnaire were asked "Do you have any kind of health-care coverage, including health
   insurance, prepaid plans such as HMOs {health-maintenance organizations}, or government plans such as Medicare?" A "yes"
   response was used as a proxy for Medicare coverage.
 + Vaccination received during the 12 months preceding the survey.
 & Vaccination received during their lifetime.
 @ Service received during the previous 2 years.
** Service received during the previous 3 years. Excludes women with no uterine cervix.
++ Confidence interval.
&& Female respondents from California were excluded from these estimates because of the different wording of the survey questions
   in that state.
===================================================================================================================================

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