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Journal ofHea1th Education No.20,pp.29-43.December 2003

Age and Utilization ofPreventive Health

Services among the Elderly in Five Texas Sites

long-Long Guo:

Carole K.

HoI祉1個7.

Michele M.

Smith ,·叫*

Nell H. Gottlieb

,··

Philip P.

Huan色的*

Chiu-h4ieh Huang'....

Abstract

Objectives: This paper explores the relationship between age and the receipt of selected

preventive health services (PHS) among the elderly and determines whether the

implementation of the

Put Prevention into Practice" office-based system would increase the

delivery rates of PHS among the elderly. Method: The population consisted of a representative sample of elderly aged 65 years and older who had presented at three specific time points at two community health centers and three family practice residency programs in Texas. Results:

Overall,significant age-related inverse relationships among the elderly were shown in 9 of the

30 time/PHS pairs examined. The delivery rates of pneumococcal immunization and

assessment of tobacco/smoking, physical activity, and nutrition significantly increased from

Associate Professor,CHES,Department ofHealth Education,National Taiwan Normal University

Professor and Coordinator,Department of Kinesiology and Health Education,The University of Texas at Austin

Associate Professor,Department ofKinesiology and Health Education,The University ofTexas at Austin Put Prevention into Practice Project Director,Curriculum& Instruction Department,The University of Texas at Austin

Age and Utilization ofPreventive Health Services among the Elderly in Texas Five Sites

• Assistant Professor, School of Nursing, Chang Gung University (通訊作者: e-mail: 黃久美

chiumieh@mail.cgu.edu.tw)

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time 1 to time 2 for the elderly. Tetanus-Diphtheria immunization was the only service to significantly increase from time 2 to time 3. Discussion: We found that PHS were not universally delivered to all older adults. For those PHS that are recommended for routine use

among older adults, the clinician is required to deliver individualized PHS based on the

patient's risk status. Other services,however,should be systematically provided for high-risk

patients.

Key words: aged,preventive health services,longitudinal study

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Introduction

Increased age is associated with a rise in the incidence and mortality of chronic

diseases; 79% persons over 70 repo巾d at least one of seven chronic conditions (National

Center for Health Statistics,1999). Reducing the morbidity experienced by older persons by

increasing the average age of onset of disability and the age of death will greatly increase

quality of life and reduce health care costs (Fries, 1993). This Compression of Morbidity

paradigm has been well suppo此ed through randomized trials of primary prevention (Fries,

1993). Although this paradigm provides a theoretical foundation for delivering preventive

health services (PHS) to the elderly,many health professionals may not think of the elderly

as appropriate targets for health promotion efforts (Lavizzo-Mourey,Day,Diserens & Grisso,

1989; Walker,Volkan,Sechrist & Pender, 1988). Studies indicate that the delivery rates of

PHS show a trend toward an inverse relationship with age after controlling for demographic

and health-related variables among people aged 60 and over (Ives,Lave,Traven, Schulz &

Kuller, 1996; Mayer et祉, 1992). This may indicate that health professionals do not assess

the status of recommended PHS for their elderly clients,especially for the oldest old (aged

85 and over) .

The Texas Department ofHealth (TDH) initiated a demonstration project in 1993 to test the effectiveness of the national Put Prevention into Practice (PPIP) office system change

program. The PPIP program utilizes a set of office tools that targets providers (and staff),

patients,and the office system to increase the provision of PHS in primary care practices

(Goodson, Gottlieb & Smith, 1999; Gottlieb, Huang, Blozis, Guo & Smith, 2001). The

pu中osesof this report are to explore whether there are inverse relationships between age and the receipt of selected PHS among the elderly and to examine PPIP intervention effects for the elderly in the receipt of selected PHS.

Methods

Pre and Post-Intervention Design

The details of methods for the intervention and its evaluation have been published

elsewhere (Goodson et aI., 1999; Gottlieb et aI., 200 I). In 1994, the Texas Department of

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Health (TDH) used federal preventive health block grant monies to fund, through a competitive process, three community health centers (CHCs) and four family practice residency (FPR) programs to conduct PPIP implementation. For three years,each site received $42,000-$49,000 per year,free materials and offer of technical assistance from the TDR Two ofthe sites did not show progress in implementation and withdrew from the program at the end

of the second ye-ar. The data reported here are from the five sites that completed the three years of non-competitive continuation funding. All these sites reported use of the flowsheet, the health risk profile (a Texas-designed risk appraisal form to be administered by allied health

staff), and the Personal Health Guide, with one site modifying the health risk profile and another modifying the Personal Health Guide.

Table I displays the characteristics of the five sites that completed the three years of funding and the two sites that did not. The family practice residency program clinics were

over three times as large as the community health centers and were more often located in large urban areas. The CHCs were much less complex organizations than the FPRs.

Table I. Characteristics of sites funded to conduct PPIP*

Site Type Status Setting Staff Small city; 2 6Ftand IPT SiteA CHC Completed freestanding physicians; 13nurses;

clinics 7 clerks City; freestanding 4 FT and 2 PT Site B CHC Completed physicians; 5 nurses;

clinic

20 clerks I FT and I PT Town; physician; I Site C CHC Completed

freestanding clinic physician assistant; 5-6 nurses; 4-5

clerks City; freestanding 19 resident,4 FT Site D FPR Completed clinic linked to and 3 PT faculty

hospital physicians Site E FPR Completed City; in medical 29 residents; 9

center faculty physicians City; medical

72 residents; 17 center with 5

Site F FPR Dropped-out

freestanding faculty and 117 clinics teaching staff Small city; in 12 (24 in 7/94) Site G FPR Dropped-out hospital with 3 residents and 5 (8)

outlying clinics faculty physicians

*PPIP: Put Prevention into Practice,CHC: community health center; FPR,family practice residency; FT: full-time; PT,part.time

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All patient subjects were adults aged 19 years and older. Data were collected using an explicit protocol based on the Battelle Adult Chart Review Form by a single registered nurse

(Hersey, 1995). Charts were selected from actual appointment logs (available for two

community health centers and 1 residency program) or computer printouts of appointments for the equivalent periods. The appointment logs were sampled by taking the patients with

appointments at 8 am, lOam, 2 pm and 4 pm. For sites at which patient ages were

unavailable, charts were over-sampled in order to eliminate children's charts from the

selected pool later. The computerized printouts (one residency and one community health

center) listed patients alphabetically by month and included provider names. In this case,the

sampling list was created by choosing the first patient in each letter group per month. 372

charts were selected at baseline, and 376 charts were selected at 33-39 months following

implementation of PPIP),with 61 % from community health centers at baseline and 60% at

follow-up. A small number (3.2%,n=12) ofpatients were present in both samples.

The present study involved chart review for a representative sample of elderly aged 65 years and older over a three-year period at two community health centers and three family practice residency programs in Texas. The baseline chart audit period was September 1993

through February 1994, Time 1. The official start date of the Texas PPIP Demonstration

Project was April 1994. Time 2 and Time 3 were for patients with appointments during the periods December 1995 through May 1996 and December 1996 through May 1997 respectively in the chart audit processes.

The selected PHS included blood pressure,Papanicoloaou test,mammogram screening,

smoking assessment and counseling, physical activity assessment and counseling, nutrition

assessment and counseling, and tetanus-diphtheria (Td), pneumococcal and influenza

immunization. Assessments referred to providers assessed the patients' smoking, physical

activity and nutrition status. Counseling refeπed to that providers recommended medical

suggestions to patients based on the information from the book entitled

Put Prevention into

Practice: clinician's handbook ofpreventive services" (U.S. Department ofHealth & Human

Services,1994) (See Table 2).

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Table

2.

Standards for Screening Tests,Immunizations,and Risk Assessment for Elderly Patients

Screening Test, Guideline used for Analyses (Authority) Operationalization for Analyses

ImII1unization, or Counseling

Blood pressure Adults EPeVY它可 2 years if < 130/85 Adults 67+ within previous 2

monitoring (NHBP years

Papanicolaou's Women annuaIly at onset of sexual Women age 68+ within previous

smear aanctniuvaitlye-If3or more satisrfamcetodreyvnormal 3 years

~~~~-~、、3wbe perfo ery lJ

years (USPSTF)

Smoking pFroorvpidaetients who smoke,clinicians should Assessment and counseling for

assessment and smokingli status SaPsSsTesFs)IIlJent and tobacco risk within the previous

counseling cessation counseling (U 12 months

Physical activaintdy Counseling to promote regfourlara plhaydsuiclatsl Ass戶essm戶、nt. and couns戶el出ngm-CIDV且

assessment exercise )IS3 recommended l physical actimviotynthstsatus wi the

counseling (USPSTF previous 12

Nu甘ition Limit fat and cholesterol; maintain caloric Assessment and counseling for

assessment and balance, emphasiz~ grams, 企uit, nu甘ition risk within the previous

counseling vegetabies (USPSTF)3 12 months

Tetanus-Diphther AIladults every 10 years (ACP)1 Adults age 66+, within previous

la 10 years

Pneumovax AIladults age 65+one time (USPSTF)3 Recorded ever for patients age

66+

Influenza AIladults age 65+ once/year (USPSTF)3 Adults age 66+, within previous

year I.ACP=American College of Physicians

2.NHBPEP=National High Blood Pressure Education Program ofthe National Heart,Lung,and Blood Institute 3.USPSTF= U.S. Preventive Services Task Force

Data Analyses

Hierarchical linear analyses (multi-level modeling) were used to take into account the

nested nature of the data (charts within clinics) and the potential for autocorrelation,that is,

the effect of multiple charts coming from the same clinic. The GENMOD function of SAS

version 8.0/PC (SAS Institute Inc., 1999) was appropriate to examine the relationships

between advancing age and delivery rates of selected PHS for the elderly at the three time

points and to evaluate the intervention effects of PPIP. First,age was used as a continuous

variable in logit regression models. Linear relationships were anticipated between advancing age and the reception of timely PHS among elderly adults. The general equation between advancing age and the receipt oftimely PHS among elderly adults is:

log{p /(l-p)} =叫+戶)(age)(elderly adults only) for time I,time2and time 3 (Allison,

1999)

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Exponentiating the coefficients of

I3

s in the logit regression models yielded odds ratios

for the PHS variables. For each PHS

,

odds ratios were also calculated for time 2 vs. time I

and time 3 vs. time 2 after adjusting for the nested structure.

Covariates including patients' gender,reasons for visit (acute condition or check-up or

treatment of a chronic condition), number of clinic visit in the past 12 month and medical

and risk factor history form use) were controlled at the equation mentioned above in order to examine the effects of PPIP intervention and age.

Results

Relationship Between Age and the Delivery Rates of Selected PHS

As shown in Table 3,there were significant inverse relationships between age and the

selected PHS among the elderly on delivery rates for 9 ofthe 30 time/PHS pairs examined. Screening Tests.Because blood pressure (BP) screening was universally delivered to the

elderly subj凹的, there is no variance to be analyzed. When the elderly patients were older,

they were less likely to receive cholesterol screening at time I (odds ratio

=

0.84) and time 3

(odds ratio

=

0.92) (Table 3). That is,the increase of one year of age among elderly adults

was associated with a 16% (1-0.84

=

0.16) decrease in the probability of receiving

cholesterol screening at time 1. Similarly,a one year increase in age was associated with a

8% (1-0.92

=

0.08) decrease in the possibility of receiving this service among elderly

patients at time 3. However,the age-related inverse relationship between advancing age and

receipt of cholesterol screening was not significant at time 2. The association between advancing age and receipt of the Papanicolaou test was only significant at time 2 (odds ratio

= 0.79). The older the elderly women were, the less likely they were to receive a

Papanicolaou test at time 2 (Table 3). The associations between advancing age and receipt of a yearly mammogram were not significant at any of the three time points.

Life Style Assessments and Counseling. As age increased,elderly adults were less likely to

receive smoking assessment at time 3 (odds ratio

=

0.89) but there were no significant

associations between age and receipt of smoking assessment at times 1 and 2 (Table 3). Also,

elderly adults of increasing age were less likely to receive smoking counseling at time I

(odds ratio = 0.78); there were no significant associations between age and reception of

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smoking counseling at times 2 and 3. As age increased, elderly adults were less likely to

receive physical activity assessment at all three time points (Table 3). There was a negative

association between age and physical activity counseling at time 1(odds ratio

=

0.71),but

there were no significant associations between age and reception of physical activity

counseling at times2and3.The older elderly were less likely to receive nutrition assessment

(odds ratio

=

0.94) at time 3 but there were no significant associations between age and

receipt of nutrition assessment at times 1 and 2 (Table 3). No differences were found

between age and nutrition counseling at the three time points.

Immunizations.The negative association between advancing age and reception of Td

immunization at time 2 was the only Age/Td relationship that reached a significant level

(odds ratio

=

0.83)(Table 3). No age-related inverse relationship existed for the delivery of

pueumococal and influenza immunizations.

Table 3. The association between advancing age and delivery rates of selected preventive

health services among elderly patients at time 1,time 2and time3

Time1 n Odds Ratio· (95% C.I.) Time2 P 旦 OddsRatio (95%C.I.) Time3 P 旦 OddsRatio p (95%c.l.) Screening Tests

Papanicolaou test (women only) 37 0.99(0. 呵, 1.03) 0.66 Life Style Assessment and Counseling

Tobacco/ Smoking cessation 68 0.97 (0.90,1.05) 0.57

assessment

Tobacco/ Smoking counseling Physical activity assessment

正 U I AV 、 ay 句3 AV I OO AV J •• 、 句3 ny AV ny 勻, u 句3 AV AV 、‘', p oo ny AV ' 勻3 正 U AV ( ny 司 I AV AY 勻, u

Physical activity counseling

71 0.98 (0.92, 1.04) 0.46 65 0.89 0.94) 68 0.78 (0.73,0.83) <.001 71 0.99 (0.90, 1.09) 0.88 65 0.97 (0.8, 1.09) 0.14 68 0.95 (0.92,0.98) <.01 71 0.92 (0.91,0.94) <.001 65 0.94 (0.91,<.001 0.98) 68 0.71 (0.51,0.99) 0.04 71 0.90 (0.80,1.02) 0.09 65 0.94 1.02) 68 0.97 (0.90, 1.05) 0.36 71 0.95 (0.88, 1.03) 0.29 65 0.94 0.98) 68 0.97 (0.92, 1.03) 0.31 71 0.98 (0.94, 1.02) 0.45 65 0.90 1.01) (0.84,<.001 (0.87,0.11 Nutrition assessment (0.91,<.01 Nutrition counseling (0.80,0.08 Immunizations Tetanus-Diphtheria ImmunizatIOn Pneumococcal immunization 27 1.01 (0.99, 1.03) 0.91 23 0.83 (0.71,0.97) 0.02 21 0.90 (0.80,0.10 1.02) 68 0.97 (0.94, 1.00) 0.07 71 0.99 (0.92, 1.07) 0.80 65 0.97 (0.92,0.29 1.03) 680.95 (0.90,1.01) 0.10 71 0.99 (0.93,1.05) 0.74 65 0.96 (0.91,0.12 1.02) Influenza immunization

Odds ratios area句usted for clinics. This table indicates that a one-age increase in the older adults is associated with the decrease with certain percentage in the receipt of selected PHS

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PPIP Intervention Effects

As shown in Table 4, a自er adjusting for the nested nature of data, at time 2 in comparison to time 1,elderly adults were more likely to receive yearly mammography (odds ratio = 2.45,95% C.1. for odds = 1.25-4.80),assessment for tobacco/smoking (odds ratio = 2.66, 95% c.1. for odds = 1.18-6.02), physical activity assessment (odds ratio = 6.34, 95% c.1. for odds = 2.54-15.78), nutrition assessment (odds ratio = 17.96,95% c.1. for odds = 4.89-66.03) and pneumococcal immunization (odds ratio = 2.21, 95% c.1. for odds = 1.02-4.79). The delivery rate of tetanus-diphtheria (Td) immunization for elderly adults was significantly increased from time 2 to time 3 (odds ratio = 3.23, 95% c.1. for odds = 1.35-7.71), while the documentation of the other PHS did not significantly change. Blood pressure (BP) screening was universal: 100% at baseline and time 2. There was only one

elderly subject not documented to receive timely BP screening at time 3 (98.2%,n =51). Table 4. Delivery rates and comparative odds ratios ofsel郎tedpreventive health services

among elderly patients at and between three time points)

Time 1 Time 2 Time 3 Time 2 vs. Time I Time 3 vs. Time 2 %(n2) %(n) %(n) Odds Ratio Odds Ratio

(95% C.l.) (95%c.1.) Screening Tests

NA3

Blood pressure screening 100 100 (65) 98.2 NA (61) (51)

Papanicolaou test (women only) 48.7 55.2 72.4 1.09 (0.22,5.36) 2.44 (0.58,10.18) (37) (29) (29)

Assessments and Counseling Activities

Tobacco/Smoking cessation 45.6 69.0 69.2 2.66(1.18,6.02) 1.02 (0.47,2.23) assessment (68) (71) (65)

Tobacco/Smoking cessation 1.5 7.0 (71) 10.8 4.85 (0.47,49.92) 1.74 (0.45,6.74) counseling (68) (65)

Physical activity assessment 17.6 59.2 53.9 6.34 (2.54,15.78) 0.81 (0.48,1.37) (68) (71) (65)

Physical activity counseling 10.3 18.3 24.6 3.76 (0.47,30.39) 1.45 (0.32,3.37) (68) (71) (65) Nutrition assessment 8.8 56.3 56.9 17.96 (4.89,66.03) 1.06 (0.60,1.88) (68) (71) (65) Nutrition counseling 13.2 32.4 23.1 3.67 (0.72,18.70) 0.71 (0.30,1.69) (68) (71) (65) Immunization Tetanus-Diphtheria 18.5 17.4 47.6 1.01 (0.30,3.39) 3.23(1.35,7.71) (27) (23) (21) Pneumococcus 23.5 36.6 43.1 2.21 (1.02,4.79) 1.40 (0.92,2.11) (68) (71) (65) Influenza 45.6 46.5 46.2 0.94 (0.39,2.27) 1.17 (0.65,2.12) (68) (71) (65)

I. Odds ratios are adjusted for clinics. 2.n=total number of subjects

3.NA: not applicable

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Discussion

Systems-level interventions to increase the delivery of preventive services improve the

quality of care of the elderly, as measured by delivery of PHS,as well as the general adult

population (Goodson et aI., 1999; Gottlieb et aI.,2001). Such interventions,which are rarely

used in Medicare managed care populations, have potential to increase preventive care to

this overlooked population (Herman, Speroff & Cebul, 1994; Herman, Speroff & Cebul,

1995). Just as with other populations the increases occurred primarily during the first year of

the program and did not increase significantly thereafter (Dickey & Petitti, 1992; Dietrich,

Sox,Tosteson &Woodru缸~ 1994; Melnikow,Kohatsu & Chan,2000).

Examination of the pattern of differences in the delivery of PHS by age at all time points showed that there were no cases of an increase in delivery of a PHS with age among

elderly patients,although blood pressure was universally measured. Decreases with age were

most prevalent in the assessment and counseling for lifestyle behavior, and least in the

delivery of immunizations.

With respect to screening tests,the decreases in cholesterol and Papanicolaou screening

are consistent with the recommendations ofthe US Preventive Services Task Force,in which

the elderly are not recommended to receive these services as they are unlikely to be of

continued benefit. Although other studies have found decreases in mammography rates with

aging among the elderly (Potosky, Breen, Graubard & Parsons, 1998; The NCI Breast

Cancer Screening Consortium, 1990),we found no difference. The USPSTF guidelines do

not recommend screening after age 70. The rates of mammography among women over 70,

however,were low, consistent with quality care. The universally measured blood pressure

provides an example of what can be accomplished with a functioning system for a

recommended PHS,although it is delivered more frequently than recommended by USPSTF

(U.S. Preventive Services Task Force,1996).

Although the rates for immunizations never reached 50%,this set of PHS showed the

fewest inverse relationships between age and delivery of the service. Both pneumococcal and

influenza immunizations are recommended specifically for the elderly, and providers were

not influenced by the patient's age in their delivery in this study. The rates for

tetanus-diphtheria immunization were (except for time 3) low (under 20%),but only a

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age groups,is being given to older patients without regard to age. However,recent US data show the delivery rates of pneumococcal and influenza immunizations to be highest for the

older old(National Center for HealthStatist帥, 1999).

The health care providers were more likely to assess than counsel their elderly patients

on tobacco,physical activity,and nutrition,just as for the general population (McPhee,Bird,

Fordham, Rodnick & Osborn, 1991; Milan, Marcus, Goldstein & Taylor, 1994). An

age-related decrease in services was noted most evidently for physical activity assessment.

Bergman-Evans and Walker reported decreases with age for smoking cessation and physical activity counseling using a nationally representative sample from 1991. Durham and colleagues indicated that the older adults with increasing age were less likely to participate in

a study of utilization of preventive services that included health risk assessment, clinical

screening and health promotion counseling (Durham et aI., 1991). German and colleagues

also reported that the oldest old are less likely to make preventive visits (German et aI.,

1995). The lower participation rate for the older and oldest old may decrease the opportunity to receive lifestyle counseling compared to the young old. Elderly adults represent the most

sedentary segment of the adult population (King,Rejeski& Buchner, 1998),and it has been

reported that the proportion of elderly adults who exercise declines with age (National

Center for Health Statistics, 1994). Prior findings also reveal that activity limitations

increase with age,and the oldest-old are more likely than the young old and older old to be

unable to perform physical activities (National Center for Health Statistics, 1999). These

phenomena may discourage providers from offering physical activity counseling.

For those PHS that are not recommended for routine use among older adults, the

clinician is required to deliver individualized preventive care based on the patient's risk

status (Goldberg & Chavin, 1997). Other services, however, should be systematically

provided for all patients,and office systems,including preauditing of charts (Cardozo et aI.,

1998; Holmboe, Scranton, Sumption & Hawkins, 1998), physician prompts (Balas et aI.,

2000), flow sheets (Herman et aI., 1994), and reminders (Chambers, Balaban, Carlson &

Grasberger, 1991; Chang,Zimmer

(12)

weakness was that the study was not designed specifically to examine PHS delivery among

the elderly,and the sample size,particularly for women 's services,may have had insufficient

power to detect small differences (Lipsey, 1990). The major limitation of this study is the

lack of a randomized controlled design, which reduces the possibility to link the results to

the PPIP intervention. Explicitly, a secular trend towards increasing preventive health

services and changes in the case mix of patients, providers, insurance coverage, and

management policies that could account for the findings may have occurred. Thus, our

findings are generalizable only to those Texas health care sites sampled.

From the viewpoint of family practice, great potential exists for the improvement of

health status for the elderly population,who are now living longer. Concern over the health

care cost of this increased longevity will be a new challenge to family physician and public

health workers. Preventive care can serve as a potential solution to cost issues (Fries,Bloch,

Harrington, Richardson & Beck, 1993; Makela, Jokinen, Pyhala, Makela & Ruutu, 1990;

Messonnier, Corso, Teutsch, Haddix & Harris, 1999) and should be intensively pursued to

make increased longevity less costly and less characterized by dysfunction,frailty and low

quality of life.

Acknowledge

This research was supported by a contract from the Texas Department of Health to the

second author. (Reprint requests to Dr. Jong-Long Guo, Department of Health Education,

National Taiwan Normal Universi旬, 162 Sec 1,Hoping E Rd. Taipei,Taiwan)

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年齡與預防保健服務利用之關係一以美國德

州五醫院老年門診病患為例

享F畫畫隆、 Nell

H.

Gottlieb 、 Carole

K.

Holahan 、 Philip

P.

Huang 、 Michele

Murphy Smith

、費久失

摘要

本研究推估美國德州 IPut Prevention Into PracticeJ 預防保健公共衛生計畫是否應加

老人的預防保健服務量,並探討年齡與接受預防保健服務之關係。以查閱病人病歷為資 料來源,為一為期三年的縱貫性研究,於三所家庭醫學科和兩所社區衛生中心的老年病 患為研究對象。於第一年至第二年間,肺炎和流行性感冒疫苗和吸菸、運動和營養評估 的服務量皆有顯著增加。於第二年和第三年間,破傷風一白喉混合疫苗的服務量則有顯 著增加。所有病患幾乎皆接受定期血壓測量(每兩年至少一次)。此外,在三年間所研 究的 10 項預防保健服務,其中的共有9 次( 9/30) 顯示出老人的年齡與接受的服務量有 顯著的負向關係。研究結果顯示老人仍未全面性的接受預防保健服務,雖然老人並未被 建議必須例行性的接受部分預防保健服務,這些預防保健服務的提供必須因人而異。而 老人被建議接受的預防服務項目,建議醫師應該於門診中例行提供,以促進老年人的身 體健康。本研究經驗可供台灣未來推行預防保健服務之參考。 關鍵詞:老年人、預防保健服務、縱貫性研究 - 43 一

數據

Table I displays the characteristics of the five sites that completed the three years of funding and the two sites that did not
Table 2. Standards for Screening Tests , Immunizations , and Risk Assessment for Elderly Patients

參考文獻

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