Use of Selected Recommended Clinical Preventive Services — Behavioral Risk Factor Surveillance System, United States, 2018

Clinical preventive services play an important role in preventing deaths, and Healthy People 2020 has set national goals for using clinical preventive services to improve population health (1). The Patient Protection and Affordable Care Act (ACA) requires many health plans to cover certain recommended clinical preventive services without cost-sharing when provided in-network (covered clinical preventive services).* To ascertain prevalence of the use of selected recommended clinical preventive services among persons aged ≥18 years, CDC analyzed data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), a state-based annual nationwide survey conducted via landline and mobile phones in the United States, for 10 clinical preventive services covered in-network with no cost-sharing pursuant to the ACA. The weighted prevalence of colon, cervical, and breast cancer screening, pneumococcal and tetanus vaccination, and diabetes screening ranged from 66.0% to 79.2%; the prevalence of the other four clinical preventive services were <50%: 16.5% for human papillomavirus (HPV) vaccination, 26.6% for zoster (shingles) vaccination, 33.2% for influenza vaccination, and 45.8% for HIV testing. Prevalence of HIV testing had the widest variation (3.1-fold differences) across states among the 10 services included in this report. The prevalence of use of clinical preventive services varied by insurance status, income level, and rurality, findings that are consistent with previous studies (2-6). The use of nine of the 10 services examined was lower among the uninsured, those with lower income, and those living in rural communities. Among those factors examined, insurance status was the dominant factor strongly associated with use of clinical preventive services, followed by income-level and rurality. Understanding factors influencing use of recommended clinical preventive services can potentially help decision makers better identify policies to increase their use including strategies to increase insurance coverage.

Clinical preventive services play an important role in preventing deaths, and Healthy People 2020 has set national goals for using clinical preventive services to improve population health (1). The Patient Protection and Affordable Care Act (ACA) requires many health plans to cover certain recommended clinical preventive services without cost-sharing when provided in-network (covered clinical preventive services).* To ascertain prevalence of the use of selected recommended clinical preventive services among persons aged ≥18 years, CDC analyzed data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), a state-based annual nationwide survey conducted via landline and mobile phones in the United States, for 10 clinical preventive services covered in-network with no costsharing pursuant to the ACA. The weighted prevalence of colon, cervical, and breast cancer screening, pneumococcal and tetanus vaccination, and diabetes screening ranged from 66.0% to 79.2%; the prevalence of the other four clinical preventive services were <50%: 16.5% for human papillomavirus (HPV) vaccination, 26.6% for zoster (shingles) vaccination, 33.2% for influenza vaccination, and 45.8% for HIV testing. Prevalence of HIV testing had the widest variation (3.1-fold differences) across states among the 10 services included in this report. The prevalence of use of clinical preventive services varied by insurance status, income level, and rurality, findings that are consistent with previous studies (2)(3)(4)(5)(6). The use of nine of the 10 services examined was lower among the uninsured, those with lower income, and those living in rural communities. Among those factors examined, insurance status was the dominant factor strongly associated with use of clinical preventive services, followed by income-level and rurality. Understanding Six of the 10 recommended clinical preventive services that health plans are required to cover without cost-sharing were included in the 2018 BRFSS core questionnaire, which was used by all 50 states, the District of Columbia (DC), Guam, and Puerto Rico; these include colon, cervical, and breast cancer screening; HIV testing; and pneumococcal and influenza vaccination. The other four services were included in the optional modules, which are asked by some states; these include diabetes screening (asked by 28 states, DC, Guam, and Puerto Rico), HPV vaccination (asked by eight states), shingles vaccination (asked by four states), and tetanus vaccination (asked by four states). † Survey participants were classified as having used a clinical preventive service if they reported using a clinical preventive service as recommended at the time of interview. Because of changes over time to recommendations and to policies and practices that affect use of clinical preventive services, continued monitoring of their use could offer decision makers updated information for achieving public health goals.
In  Table 2). The variation in use differed substantially by type of service, with breast and cervical cancer screenings having the least cross-state variation among the six services asked by all states. Variation across states was widest for prevalence of HIV testing and pneumococcal vaccination use (3.1-fold and 2.5-fold, respectively).
The highest adjusted use was observed in the insured-higher income-urban group for six of the 10 services (all but HIV testing, diabetes screening, HPV vaccination, and tetanus vaccination). Insurance status was the factor most strongly associated with use of clinical preventive services, followed by income level and rurality, respectively. Uninsured persons used seven of the 10 clinical preventive services less frequently than those with insurance, regardless of income level and rurality. Among those with insurance, use of six of the 10 services was higher among persons with higher incomes, regardless of whether they lived in rural or urban counties ( Figure) Table 1, https://stacks.cdc.gov/view/cdc/104150).    Abbreviations: HPV= human papillomavirus; IHR = insured and higher income and rural; IHU = insured and higher income and urban; ILR = insured and lower income and rural; ILU = insured and lower income and urban; UHR = uninsured and higher income and rural; UHU = uninsured and higher income and urban; ULR = uninsured and lower income and rural; ULU = uninsured and lower income and urban. * Adjusted by age, sex (except for cervical cancer screening and breast cancer screening), race/ethnicity, education level, marital status, self-reported health status, and state. Similar findings were observed in pneumococcal, HPV, zoster (shingles), and tetanus vaccinations (panels available in Supplementary Figure, https:// stacks.cdc.gov/view/cdc/104149).

Discussion
In 2018, use of nine recommended clinical preventive services was lower among persons without insurance, those with lower income, and those living in rural communities, whereas use of HIV testing was higher among persons with lower income. Geographic variation in use of clinical preventive services existed across states. These differences varied by type of services, with variation being greatest for HIV testing use. Insurance status had the strongest association with use of clinical preventive services followed by income and rurality.
Use of nearly all recommended clinical preventive services was higher in 2018 than it was during 2011-2012 (3,4). These results were consistent with previous studies, which showed that the prevalence of use of clinical preventive services was lower among persons who were uninsured, lived in households with lower income, and lived in nonmetropolitan areas (3)(4)(5).
Geographic variation was also consistent with previous studies, which suggests that state-level variation could be used to identify state-and locality-specific strategies to increase use of clinical preventive services (6,8). In addition, policies that address health insurance coverage and benefits or reduce specific barriers to care for persons with lower income or living in rural areas could potentially be effective at increasing use of clinical preventive services. The finding that use of HIV testing was higher among persons of lower income was consistent with previous studies (2,3) and might reflect the success of a testing strategy that focused HIV screening efforts in communities that are disproportionately comprised of persons of lower income (9). Fear and misperceptions about HIV risk and the testing process itself might be additional barriers to increasing HIV testing (10).

Summary
What is already known on this topic?
Ongoing federal and state health reform efforts, particularly the Patient Protection and Affordable Care Act, have affected use of clinical preventive services in the United States.
What is added by this report?
Analysis of 2018 Behavioral Risk Factor Surveillance System data indicated use increased for selected recommended clinical preventive services; however, use of nine of the 10 services examined was lower among the uninsured, those with lower income, and those living in rural communities. Among those factors examined, insurance status had the strongest association with use of clinical preventive services, followed by income level and rurality.
What are the implications for public health practice?
Understanding factors influencing use of clinical preventive services can potentially help decision makers better identify policies to increase their use including strategies to increase insurance coverage.
The findings in this report are subject to at least six limitations. First, the analysis was based on self-reported use data, which could be subject to recall and social desirability bias. Second, use of some services as measured by BRFSS was not entirely aligned with the recommendations; BRFSS questions, recommendations, and important distinctions are provided (Supplementary Table 2, https://stacks.cdc.gov/ view/cdc/104148). Third, FPL was estimated based on the categorical income value provided by BRFSS rather than a precise estimate of household income. Fourth, whether BRFSS participants received services from in-network providers could not be determined, nor could whether survey participants were enrolled in insurance plans subject to ACA requirements to provide clinical preventive services without cost-sharing be determined (1). Therefore, use among the insured group was potentially underestimated compared with a sample comprised entirely of persons with ACA-compliant plans. Fifth, this is a cross-sectional study, and causal relationship cannot be determined even when relevant confounders are adequately controlled. Finally, only a limited number of states participated in BRFSS optional modules for diabetes screening and for HPV, shingles and tetanus vaccinations, and so data might not be nationally representative of prevalence, even though the results were consistent with previous studies (3,4).
As the health care policy landscape continues to shift, understanding factors associated with use of recommended clinical preventive services could help decision makers better identify policy levers to increase use of clinical preventive services. The ongoing monitoring of trends could improve understanding of how modifiable factors affect use of clinical preventive services, especially during the pandemic, because a decrease in use of routine vaccinations was observed. Although insurance status, income level, rurality, and state of residence appear to be associated with use, examining other barriers could also help better identify strategies to achieve public health goals.