title: Disparities in recommended preventive care usage among persons living with diabetes in the Appalachian region.
abstract: OBJECTIVE
  To examine disparities in the receipt of preventive care recommended by the American Diabetes Association (ADA) between Appalachian and non-Appalachian counties and within Appalachian counties.
  
  
  METHODS
  Behavioral Risk Factor Surveillance System (BRFSS) data for 2008-2010 were used to identify individuals with diabetes and their preventive care usage. Each Appalachian respondent county of residence was categorised into one of the five economic levels: distressed, at-risk, transitional, competitive and attainment counties. Competitive and attainment counties were combined and designated as competitive counties. We used logistic regressions to compare receipt of ADA preventive care recommendations by county economic level, adjusting for respondent demographic, socioeconomic, health and access-to-care factors.
  
  
  RESULTS
  Compared to the most affluent (competitive) counties, less affluent (distressed and at-risk) counties demonstrated equivalent or higher rates of self-care practices such as daily blood glucose monitoring and daily foot checks. But they showed 40-50% lower uptake of annual foot and eye examinations and 30% lower uptake of diabetes education and pneumococcal vaccinations compared to competitive counties. After adjusting for demographic factors, significant disparities still existed in the uptake of annual foot examinations, annual eye examinations, 2 or more A1c tests per year and pneumococcal vaccinations in distressed and at-risk counties compared to competitive counties. Appalachian counties as a whole were similar to non-Appalachian counties in the uptake of all recommendations with the absolute differences of ≤3%.
  
  
  CONCLUSIONS
  Our results show that there are significant disparities in the uptake of many recommended preventive services between less and more affluent counties in the Appalachian region.
authors.affiliation: Department of Public Health Sciences , School of Medicine, University of Virginia , Charlottesville, Virginia , USA.
authors.forename: Min-Woong
authors.initials: MW
authors.lastname: Sohn
authors.affiliation: Department of Systems and Information Engineering , School of Engineering, University of Virginia , Charlottesville, Virginia , USA.
authors.forename: Hyojung
authors.initials: H
authors.lastname: Kang
authors.affiliation: Department of Orthopaedic Surgery , School of Medicine, University of Virginia , Charlottesville, Virginia , USA.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Park
authors.affiliation: Department of Ophthalmology , School of Medicine, University of Virginia , Charlottesville, Virginia , USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Yates
authors.affiliation: Department of Medicine , School of Medicine, University of Virginia , Charlottesville, Virginia , USA.
authors.forename: Anthony
authors.initials: A
authors.lastname: McCall
authors.affiliation: Department of Public Health Sciences , School of Medicine, University of Virginia , Charlottesville, Virginia , USA.
authors.forename: George
authors.initials: G
authors.lastname: Stukenborg
authors.affiliation: Department of Public Health Sciences , School of Medicine, University of Virginia , Charlottesville, Virginia , USA.
authors.forename: Roger
authors.initials: R
authors.lastname: Anderson
authors.affiliation: Department of Public Health Sciences , School of Medicine, University of Virginia , Charlottesville, Virginia , USA.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Balkrishnan
authors.affiliation: Department of Public Health Sciences , School of Medicine, University of Virginia , Charlottesville, Virginia , USA.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Lobo
keywords: Adult Diabetes; Eye Exam; Foot Care; Preventive Medicine