Adult health screening and referral in the emergency department.

Introduction: The United States Public Health Service (USPHS) recommends using all available patient encounters to provide preventive healthcare to patients. Many studies have demonstrated the importance of performing preventive care in the emergency department (ED). These studies have used the ED as a location for patient identification and treatment, rather than as a referral site. The primary objective of this study was to identify and refer patients with unmet healthcare needs seen in the Emergency Department. A secondary objective was to determine if the patient would accept health referrals and follow-up with a doctor or clinic.

Methods: Age and gender-specific algorithms were developed from the USPHS Clinicians' Book of Preventative Health, Second Edition. A convenience sample of patients who presented to the emergency department was asked to participate in the study to obtain 50 subjects in each age and gender grouping. After one week the patients were followed up by telephone, and after one month the computer database was queried to confirm that an appointment had been made with a doctor or clinic as recommended.

Results: Three hundred and twelve patients in the Emergency Department were enrolled in the study. The demographic profile of the patients surveyed consisted of 152 (48.7%) African Americans, 81 (26.0%) Hispanics, and 12 (3.8%) Caucasians. Of those enrolled, 59.9% had a primary care physician, and 78.2% had insurance coverage. The study revealed that 28.8% of the subjects did not need a referral, 51.3% needed 1 to 3 referrals, and 19.9% needed 4 to 8 referrals. The most common needs were for tetanus immunizations (41.2%) and stool for occult blood (41.0%); the least common was for Pap smears (2.6%) and blood pressure (2.0%). Most patients accepted the referrals (88.3%), but only a fourth of those (22.6%) reported making a follow-up appointment. The appointment was confirmed in the computer system in 39.6% of the cases. The highest rate of follow-up was for prostate screening (41.4%); the least was for drug abuse (0.0%).

Conclusion: Most of the patients in this study were found to have unmet healthcare needs. Many of the patients were given referrals and followed up with the clinic or physician for the healthcare problems identified. This study reinforces the value of the USPHS guideline to use all available patient encounters for preventive healthcare.

Key Words: health screening, prevention, referrals

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The United States Public Health Service (USPHS) recommends using every opportunity to deliver preventive services to patients. (1) Some public health experts have recommended that preventive care be delivered in emergency departments (ED). (2-6) Emergency departments may play a public health role in the screening, education, intervention and facilitation of preventive care. (2)

Most studies and expert recommendations have focused on the use of the emergency department for providing these preventive interventions rather than focusing only on identification and referral. The Society of Academic Emergency Medicine's Public Health and Education Task Force promulgated a list of targeted ED interventions for all patients as well as for high-risk groups, including screening, counseling, immunization, chemoprophylaxis, health promotion, social services needs and surveillance. (3) In an evidence-based review of clinical preventive services by the same organization, alcohol, HIV and hypertension screening and intervention, pneumococcal vaccination and smoking cessation were judged useful services to offer in the ED setting. (4)

Studies have examined the acceptability of providing preventive care in the ED. Rodriquez, Kreider and Baraff found that there was a need and desire by physicians for preventive healthcare measures initiated or provided in the ED. (7) Williams and others surveyed emergency physicians (EPs) regarding their likelihood to recommend health promotion practices. While most EPs feel a responsibility for promoting the health of their patients, few routinely screened and counseled patients on prevention and many were not confident of their ability to help patients in this respect. (8)

The furnishing of preventive services in the ED has been met with varying levels of success. Published studies have examined the emergency department as a testing and treatment center for such diseases as syphilis, cervical cancer, and alcoholism, and as a resource for immunizations, smoking cessation programs and cholesterol level monitoring. (9-27) Instead of performing these services in the ED, we wondered if the ED might actually be a better environment for assessment and referral, rather than testing and treatment.

The purpose of this study was to determine if patients have unmet healthcare needs and to assess if patients with identified medical problems would accept referrals for follow-up. A secondary purpose was to determine if patients would follow-up with the clinic or doctor referrals.

Methods

The guidelines of the USPHS were followed for age- and gender-specific screening and referrals. (1) Most of the algorithm questions were taken verbatim from the handbook recommendations; when an exact recommendation was unavailable, interpretation of the recommendation was made. An algorithm and referral form was developed from the recommendations (samples in Appendix 1 and 2). Inclusion criteria required that all patients be stable, communicative adults not in need of immediate intervention. The exclusion criteria consisted of demented or unstable patients and those who refused or were unable to communicate. The algorithms questioned patients about key examinations or immunizations, such as tetanus, diphtheria and pneumococcal immunizations, colon, cervical, and breast cancer, smoking, blood pressure, tuberculosis, sexually transmitted diseases, cholesterol, and drug and alcohol abuse screenings (Appendix 3). Following the USPHS recommendations, some testing of high-risk populations was routinely performed, such as for tuberculosis. Tetanus immunization would apply if the patient did not present to the ED for wound care. Patients' self-reported healthcare compliance was used as source material. The CAGE assessment tool for alcohol and drug use was used as the means to determine substance abuse problems. (28-30) The patients were referred to their own private physicians or a to hospital-associated clinic with a sliding scale payment system.

The study was conducted for 9 months during 2003 at a level one pediatric and adult trauma center with 48,000 ED visits in a lower socioeconomic African-American and Hispanic inner city population. The inclusion criteria required that all patients be stable, communicative, over the age of 18, and not in need of immediate intervention. Patients who presented with a psychiatric illness, substance abuse or head injury were enrolled in the study unless they were unable to effectively communicate. The exclusion criteria eliminated pediatric, unstable and demented patients, as well as those unable to communicate and those that refused. Patients who had prior enrollment in the study were not eligible to be re-enrolled. Research fellows verbally administered the survey tool to patients who agreed to participate and informed the patients that they would be contacting them by phone in one week (Appendix 4). At the completion of the interview, patients were provided with a list of medical problems and referrals. The patients were contacted one week after their emergency department visit to determine if they followed up with the referrals (Appendix 4). The clinic database was also queried one month later to determine if the patient had visited one of the hospital-affiliated clinics.

Data was analyzed using SPSS (Chicago, IL, version 10.0) and test of significance using the paired t test, frequency test and crosstabs. The data was entered into an SPSS file (SPSS, version 10, Chicago, IL) based on demographic data, types and number of referrals, acceptance of the services and appointment completion. The data was categorized by age and gender, based on the USPHS-developed algorithms. The data was analyzed to determine if there were any correlations based upon age, gender, race, education, insurance coverage, primary care physician, healthcare referrals, acceptance of referrals and actual follow-up. Pearson Chi squared analysis were performed to determine significant differences at 0.05 or less between the groups based on the variables. To limit the degrees of freedom, some of the categories were lumped together, such as education attained. The institutional IRB determined the study to be exempt from written consent because it was considered part of a comprehensive medical evaluation.

Results

A total of 343 patients were approached to enroll in the study. Of those, 25 refused to participate and 6 left before the assessment was completed. Accordingly, 312 patients in the emergency department were enrolled in the study. The demographic profile of the patients surveyed consisted of 152 (48.7%) African Americans, 81 (26.0%) Hispanics, and 12 (3.8%) Caucasians. Age categories were as follows: 103 (33.0%) were 18 to 24 years old, 108 (34.6%) were 25 to 64 and 101 (32.4%) were 65 years of age or older. Of the patients surveyed, 59.9% had a primary care physician, and 78.2% had insurance coverage. In terms of referrals, 28.8% needed none, 51.3% needed 1 to 3, and 19.9% needed 4 to 8. Most patients accepted the referrals (88.3%), but a much smaller number responded that they made a follow-up appointment (22.6% yes, 38.0% no, and 39.4% uncertain). The appointment was confirmed in the computer system in 39.6% of the cases, with no follow-up in 10.6%, and the patient was not found in the computer system in 45.5%.

Referrals

Healthcare screening needs, ranked from most to least common, were prostate cancer screening in 26 of 67 patients (43.3%), tetanus immunization in 91 of 221 patients (41.2%), stool for occult blood in 55 of 134 patients (41.0%), pneumococcal immunization in 42 of 103 patients (40.8%), cholesterol screening in 67 of 170 patients (39.4%), influenza immunization in 41 of 121 (33.9%), mammography in 24 of 76 patients (31.6%), cigarette smoking referral in 81 of 312 patients (26.0%), sexually transmitted diseases in 16 of 71 patients (22.5%), tuberculosis screening in 64 of 312 patients (20.5%), Pap smears in 39 of 157 patients (2.6%), alcohol abuse in 32 of 312 patients (10.3%), other substance abuse in 10 of 312 patients (3.2%), and blood pressure screening in 6 of 312 patients (2.0%) (Table 1). The greatest rate of follow-up was for prostate screening (41.4% followed up, con-firmed in 44.8% of the patients); the least was for drug abuse (0.0% followed up, confirmed in 10.0% of the patients).

Correlation

Correlations between important variables such as age, gender, race, education, primary care physician, insurance coverage, number of referrals, acceptance of referrals and making an appointment are found in Table 2. Significant relations were found between having a primary care physician and age (P = 80, P = 0.000), number of referrals (P = 4.821, P = 0.001) but not acceptance of referrals or making the appointment (P < 0.05). Significant correlations were found between insurance status and age (P = 33.662, P = 0.000), gender (P = 23.889, P = 0.001) and acceptance of referrals (P = 18.008, P = 0.001) but not race, number of referrals or education (P < 0.05).

Discussion

This study demonstrated that there was a large population of patients in the emergency department who had unmet healthcare needs and were willing to accept referrals from the emergency department. There was a smaller number who followed up with the referral source. There are three important public issues revealed by this study: (1) There are a large number of adult patients who present to the emergency department with unmet healthcare needs, implying that the ED might be a valuable source of connecting these patients with healthcare providers; (2) Patients with primary care physicians tend to have more unmet healthcare needs, whereas insurance status tended to have little effect on the unmet needs; and (3) The difficulty in getting referred patients to follow-up with primary care providers.

The US Public Health Service states, "The illness visit provides the only opportunity to reach individuals who, due to limited access to care, would be otherwise unlikely to receive preventive services." This study demonstrated that 72% of the population had some unmet healthcare needs, implying that the emergency department provides a significant environment to reach patients in need of preventive healthcare services as noted by the USPHS.

The use of the emergency department for patient screening and referral was labor intensive, and a continuation of the screening and referral process is costly. More cost-effective means to administer this tool in the ED setting could improve nationwide acceptance. A recent study at the University of Chicago demonstrated that emergency department patients are willing and interested in performing a self-assessment and health education tool while waiting to be seen in the emergency department. The major goal of this program was to demonstrate that patients were willing to be educated on health risk topics. (31) Another study utilized a computer-directed assessment of patients' medical needs before surgery. (32) Kempner used a self-administered questionnaire for psychosocial screening in the pediatric age population. (33) Lutner found that patients would use a small handheld device to ask health-related questions. (34) Further study is needed to determine if a self-directed computer health screening and referral program would be more cost-effective in administering the program.

Review of the correlations demonstrated some interesting results concerning the influence of insurance and primary care physicians (PCP) on the number of referrals and the acceptance of these referrals. Patients with a PCP had more referrals than those without a PCP. This finding would suggest that the PCPs were not effective at preventive care identification and treatment. Insurance status was not found to be related to the number of referrals but was related to acceptance of referrals. It is probable that patients did not understand that the follow-up clinics used a sliding scale payment for patients without insurance. With similar findings, Thomas et al (35) found that insurance status was correlated with filling prescriptions, but not correlated with patients following up after an ED visit.

Identification and referral for healthcare needs as noted in our study was not difficult to accomplish, but patient follow-up was a more difficult task. Almost 40% of the patients with healthcare problems identified by the survey tool actually followed up with the referral source. We considered this number a tremendous success when compared with other studies that provided referrals to patients for their presenting emergency department complaint. In a study of emergency department patients following up for chest pain, Fields et al found that only 17% of patients followed up within seven days. (36) Murray and LeBlanc had a success rate of 81.7% emergency department follow ups. They found that when patients did not have to pay for appointments, and appointments were made for the patient before their departure from the ED, they had a greater number of patient follow ups. (37) Magnusson and Hedges found that contact with a consultant and making an appointment for a return visit were associated with improved compliance. (38) Vukmir and others found that patients given computerized discharge instructions were associated with improved compliance with ED referral recommendations, from 26.2 to 36.2%. (39)

Limitations

Although the USPHS Task Force published an extensive text on the guide to clinical preventive services, it has two major flaws: the means and frequency to ask patients about certain medical problems and the counseling that is recommended for a number of disorders is not noted in the guide. The text was written for clinicians to determine the need for and frequency of preventive services and not for an examiner to ask patients their recollection of these services. For instance, patients may not recollect when they were tested, nor the level of their cholesterol. The recommendations are not explicit regarding the frequency of screening for tuberculosis, blood pressure, sexually transmitted diseases and cholesterol. Although it was recommended that clinicians perform counseling for injury prevention, diet and exercise, substance use, dental health, sexual behavior or postmenopausal chemoprophylaxis, the type and means of counseling was not described. Interventions for high risk populations are similarly not well described for such items as high-risk sexual behavior, injection or street drug use. Refinement of the USPHS recommendations for patient use rather than clinician assessment of these preventable conditions and recommended counseling programs would be valuable.

There were other limitations to this study. It is by no means certain that we were able to identify all of the patients with either unmet healthcare needs or all of the healthcare problems found in the community but not noted in the USPHS recommendations. In one paper on this topic, Jacobs and others evaluated the preventive healthcare needs in an immigrant population presenting to an ED. They found a significant difference between the preventive needs of immigrant and nonimmigrant populations. (40) The convenience sample of the patients in the inner city may not properly represent the population in the United States. The study was limited by the number of respondents in each group for analysis purposes. Patients who did not respond, provided inaccurate contact information or refused to enroll also limited the study. Provision of inaccurate contact information by patients was studied by Adams and Thompson. In this study, they found that only 54.9% of all patients could be contacted after three or fewer phone calls. (41) Referrals were made to services in the healthcare system, but the quality of the services provided was not determined. The study did determine whether the appointment was made, but did not determine if the appointment was completed and whether the required test or immunization was actually performed.

Conclusion

A large number of patients in this study, in all age groups and both genders, had unmet preventive healthcare needs identified in the emergency department. Many patients accepted and some followed up with these referrals. This study reinforces the USPHS recommendations and implies that the emergency department may be a valuable environment to screen for patients' unmet healthcare needs.

Acknowledgments

Karin Rhodes from the University of Chicago for her advice, and Leslie Bender, medical student from Chicago Medical School for her assistance with patient enrollment.

References

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2. The role of emergency physicians in promoting health and preventing disease. Available at: http://www.acep.org/1,174,0.html. Accessed January 14, 2003.

3. American College of Emergency Physicians. The role of the emergency physician in promoting health and preventing disease. Available at: http://www.acep.org/1,174,0.html. Accessed January 14, 2003.

4. Rhodes KV, Gordon JA, Lowe RA. Preventative care in the emergency department, Part I: Clinical preventative services--are they relevant to Emergency Medicine? Acad Emerg Med 2000;7:1036-1041.

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7. Rodriguez RM, Kreider WJ, Baraff LJ. Need and desire for preventive care measures in emergency department patients. Ann Emerg Med 1995;26:615-620.

8. Williams JM, Chinnis AC, Gutman D. Health promotion practices of emergency physicians. Am J Emerg Med 2000;18:17-21.

9. Richman PB, Dinowitz S, Nashed AH, et al. The emergency department as a potential site for smoking cessation intervention: a randomized, controlled trial. Acad Emerg Med 2000;7:348-353.

10. Berstein E, Berstein J, Levenson S. Project ASSERT: An ED-based intervention to increase access to primary care, preventive services and the substance abuse treatment system. Ann Emerg Med 1997;30:181-189.

11. Chandra A, Compton S, Sachor M, et al. Untreated hypercholesterolemia in an emergency department chest pain observation unit population. Acad Emerg Med 2002;9:699-702.

12. Polis MA, Davey VJ, Collins ED, et al. The emergency department as part of a successful strategy for increasing adult immunization. Ann Emerg Med 1988;17:1016-1018.

13. Hibbs JR, Ceglowski WS, Goldberg M, et al. Emergency department-based surveillance for syphilis during an outbreak in Philadelphia. Ann Emerg Med 1993;22:1286-1290.

14. Madden C, Cole TB. Emergency intervention to break the cycle of drunken driving and recurrent injury. Ann Emerg Med 1995;26:177-179.

15. Baraff LJ, Penna RD, Williams N, Sanders A. Practice guidelines for the ED management of falls in community-dwelling elderly persons. Kaiser Permanente Medical Group. Ann Emerg Med 1997;30:480-492.

16. Ernst AA, Samuels JD, Winsemius DK. Emergency department screening for syphilis in patients with other suspected sexually transmitted diseases. Ann Emerg Med 1991;20:627-630.

17. Slobodkin D, Zielske PG, Kitlas JL, et al. Demonstration of the feasibility of emergency department immunization against influenza and pneumococcus. Ann Emerg Med 1998;32:537-543.

18. Rodriguez RM, Baraff LJ. Emergency department immunization of the elderly with pneumococcal and influenza vaccines. Ann Emerg Med 1993;22:1729-1732.

19. Stack SJ, Martin DR, Plouffe JF. An emergency department-based pneumococcal vaccination program could save money and lives. Ann Emerg Med 1999;33:299-303.

20. Ernst AA, Romolu R, Nick TL. Emergency department screening for syphilis in pregnant care. Ann Emerg Med 1993;22:781-785.

21. Hogness CG, Engelstad LP, Linck LM, et al. Cervical cancer screening in an urban emergency department. Ann Emerg Med 1992;21:933-939.

22. D'Onofrio G, Bernstein E, Bernstein J, et al. Patients with alcohol problems in the emergency department, part 1: improving detection. Acad Emerg Med 1998;5:1200-1209.

23. Schriger DL, Gibbons PS, Langone CA, et al. Enabling the diagnosis of occult psychiatric illness in the emergency department: a randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system. Ann Emerg Med 2001;37:132-140.

24. Robinson PF, Gausche M, Gerardi MJ, et al. Immunization of the pediatric patient in the emergency department. Ann Emerg Med 1996;28:334-341.

25. Cherpitel CJ, Soghikian K Hurley LB. Alcohol-related health services use and identification of patients in the emergency department. Ann Emerg Med 1996;28:418-423.

26. Lo Vecchio F, Bhatia A, Sciallo D. Screening for domestic violence in the emergency department. Eur J Emerg Med 1998;5:441-444.

27. Feldhaus KM, Koziol-McLain J, Amsbury HL, et al. Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. JAMA 1997;277:1357-1361.

28. Buchsbaum DG, Buchanan RG, Centor RM, et al. Screening for alcohol abuse using CAGE scores and likelihood ratios. Ann Intern Med 1991;115:774-777.

29. Bush B, Shaw S, Cleary P, et al. Screening for alcohol abuse using the CAGE questionnaire. Am J Med 1987;82:231-235.

30. Ewing JA. Detecting alcoholism: The CAGE questionnaire. JAMA 1984;252:1905-1907.

31. Rhodes KV, Lauderdale DS, Stocking CB, et al. Better health while you wait: a controlled trial of a computer-based intervention for screening and health promotion in the emergency department. Ann Emerg Med 2001;37:284-291.

32. Raines JR, Ellis LB. A conversational microcomputer based health risk appraisal. Computer Programs Biomed 1987;14:175-184.

33. Kemper KJ. Self-administered questionnaire for structured psychosocial screening in pediatrics. Pediatrics 1992;89:433-436.

34. Lutner RE, Roizen MF, Stocking CB, et al. The automated interview versus the personal interview. Do patient responses to preoperative health questions differ? Anesthesiology 1991;75:394-400.

35. Thomas EJ, Burstin HR, O'Neil AC, et al. Patient noncompliance with medical advice after the emergency department visit. Ann Emerg Med 1996;27:49-55.

36. Fields DL, Hedges JR. Arnold, KJ, Goodstein-Wayne, B, Rouan, GW. Limitations of chest pain follow-up from an urban teaching hospital emergency department. J Emerg Med 1988;6:363-368.

37. Murray MJ, LeBlanc CH. Clinic follow-up from the emergency department: do patients show up? Ann Emerg Med 1996;27:56-58.

38. Magnusson AR, Hedges JR, Vanko M, et al. Follow-up compliance after emergency department evaluation. Ann Emerg Med 1993;22:560-567.

39. Vukmir RB, Kremen R, Ellis GL, et al. Compliance with emergency department referral: the effect of computerized discharge instructions. Ann Emerg Med 1993;22:819-823.

40. Jacobs DH, Tovar JM, Hung OL, et al. Behavioral risk factor and preventive health practice survey of immigrants in the emergency department. Acad Emerg Med 2002;9:599-608.

41. Adams SL, Thompson DA. Inability to follow up ED patients by telephone: There must be 50 ways to leave your number. Acad Emerg Med 1996;3:271-273.

Appendix 1

Sample Male Algorithm

[GRAPHIC OMITTED]

Appendix 2

Sample Female Algorithm

[GRAPHIC OMITTED]

Appendix 3

Indicated Testing Based on Age and Gender

                              18-24  18-24   25-64  25-64   65+   65+
                              male   female  male   female  male  female

Tuberculosis                  X      X       X      X       X
Pap smear                            X              X             X
Mammography                                         X             X
Sexually transmitted disease  X      X
Tetanus                       X      X       X      X       X     X
Pneumococcal                                 X      X       X     X
Influenza                                    X      X       X     X
Cigarettes                    X      X       X      X       X     X
Stool for occult blood                       X      X       X     X
Cholesterol                                         X       X     X
Blood pressure                X      X       X      X       X     X
Alcohol Abuse                 X      X       X      X       X     X
Drug Abuse                    X      X       X      X       X     X
Prostate                                     X              X

Appendix 4

Patient Approach

1. This study does not require consent. However, involvement in this program is voluntary and at any time the patient can stop or withdraw from the study. Please read to the patient the following statements.

2. "Welcome to the emergency department. This survey is a health screening and referral interview. It will take about 10 to 15 minutes to complete. You will be asked questions about your physical health and the healthcare that you receive. After you have answered all of the questions, you will get your results and referral recommendations. If you agree, we will assist you in obtaining referrals and a copy of this survey will be given to you. Involvement in this program is voluntary and at any time you can stop or withdraw from the study."

3. Administer the health risk questionnaire as written.

4. Select the correct algorithm for the patients' gender and age group. At this time only adults will be enrolled into the program.

5. Ask the patient each question, noting their answers and making the appropriate referrals based on their response.

6. Complete the patient data collection sheet.

7. If the patient has a doctor, they get referred back to their doctor with the referrals sheet.

8. If the patient does not have a doctor, they will get a referral to an affiliated clinic or access clinic.

9. Give the patient a copy of the results.

10. Put all data into the notebook marked health screening.

11. Call the patient back in one week and determine whether the patient has made an appointment or has seen their physician to complete the assessment as noted.

12. Confirm the appointment by cross checking in the database that the patient went to the clinic that they had stated.

Leslie S. Zun, MD, MBA, and LaVonne Downey, PhD

From the Department of Emergency Medicine. Finch University/Chicago Medical School, and the Department of Emergency Medicine, Mount Sinai Hospital. Roosevelt University, Chicago, IL.

Reprint requests to Leslie S. Zun, MD, MBA, Chairman, Department of Emergency Medicine, Mount Sinai Hospital Medical Center, 15th and California, Chicago, IL 60608. Email: [e-mail]

Presented at the 2nd Mediterranean Emergency Medicine Congress in Barcelona, Spain.

Dr. Zun is a consultant for Lilly and Sanofi-Aventis and is on the Speaker's Bureau for Lilly, Sanofi-Aventis, and Pfizer. Dr. Downey has no disclosures to declare.

Accepted March 31, 2006.

RELATED ARTICLE: Key Points

* Most adults seen in the emergency department have unmet healthcare needs.

* The recommendation by the United States Public Health Service (USPHS) for using all opportunities to provide preventive care was reinforced by the study.

* The highest need was for tetanus immunizations and stool for occult blood. The least needed services were Pap smears and blood pressure checks.

* Many emergency room patients accepted the referrals but a smaller number actually followed up.

Table 1. Healthcare needs and referral results

                        Needed          Followed-up    Confirmed

Tuberculosis            64/312 (20.5%)  11/64 (17.1%)  23/64 (35.9%)
Pap smear               39/157 (2.6%)    4/39 (10.2%)  18/39 (46.2%)
Mammography             24/76 (31.6%)    2/24 (8.3%)    8/24 (33.3%)
Sexually transmitted    16/71 (22.5%)    4/16 (25.0%)   4/16 (25.0%)
  diseases
Immunizations
  Tetanus               91/221 (41.2%)  23/91 (25.3%)  31/91 (34.1%)
  Pneumococcal          42/103 (40.8%)  10/42 (23.8%)  22/42 (52.4%)
  Influenza             41/121 (33.9%)   5/41 (12.2%)  19/41 (46.3%)
Cigarettes              81/312 (26.0%)  13/81 (16.0%)  21/81 (25.9%)
Stool for occult blood  55/134 (41.0%)  15/55 (27.3%)  29/55 (52.7%)
Cholesterol             67/170 (39.4%)  11/67 (16.4%)  15/67 (22.4%)
Blood pressure           6/312 (2.0%)    0/6 (0.0%)     1/6 (16.7%)
Alcohol abuse           32/312 (10.3%)   4/32 (12.5%)   8/32 (25.0%)
Drug abuse              10/312 (3.2%)    0/10 (0.0%)    1/10 (10.0%)
Prostate                29/67 (43.3%)   12/29 (41.4%)  13/29 (44.8%)

Table 2. Correlations

                         PCP         Insurance   Referrals   Acceptance

Age                      P = 80      P = 33.662  P = 23.889  P = 55.230
                         p = 0.000   p = 0.000   p = 0.001   p = 0.000
Gender                   P = 0.342   P = 17.717  P = 0.534   P = 9.122
                         p = 0.001   p = 0.001   p = 0.465   p = 0.003
Race                     P = 5.974   P = 3.636   P = 3.722   P = 10.598
                         p = 0.113   p = 0.726   p = 0.293   p = 0.014
Education                P = 23.318  P = 14.203  P = 7.246   P = 7.682
                         p = 0.000   p = 0.288   p = 0.064   p = 0.053
Referrals                P = 4.821   P = 0.577               P = 326.3
                         p = 0.028   p = 0.749               p = 0.001
Primary Care Physicians              P = 1.138   P = 4.821   P = 0.707
                                     p = 0.566   p = 0.028   p = 0.400
Insurance                P = 1.138               P = 11.461  P = 18.008
                         p = 0.566               p = 0.649   p = 0.001

                         Appointment

Age                      P = 42.610
                         p = 0.000
Gender                   P = 6.152
                         p = 0.04
Race                     P = 4.066
                         p = 0.668
Education                P = 17.33
                         p = 0.05
Referrals                P = 378.63
                         p = 0.001
Primary Care Physicians  P = 0.132
                         p = 936
Insurance                P = 7.909
                         p = 0.095