Is the type of Medicare insurance associated with colorectal cancer screening prevalence and selection of screening strategy?

Mammography Use Among Medicare Beneficiaries After Elimination of Cost Sharing

BACKGROUND

We examined mammography use before and after Medicare eliminated cost sharing for screening mammography in January 2011.

METHODS

Using National Health Interview Survey data, we examined changes in mammography use between 2010 and 2013 among Medicare beneficiaries aged 65-74 years. Logistic regression and predictive margins were used to examine changes in use after adjusting for covariates.

RESULTS

In 2013, 74.7% of women reported a mammogram within 2 years, a 3.5 percentage point increase (95% confidence interval, -0.3, 7.2) compared with 2010. Increases occurred among women aged 65-69 years, unmarried women, and women with usual sources of care and 2-5 physician visits in the prior year. After adjustment, mammography use increased in 2013 versus 2010 (74.8% vs. 71.3%, P=0.039). Interactions between year and income, insurance, race, or ethnicity were not significant.

CONCLUSIONS

There was a modest increase in mammography use from 2010 to 2013 among Medicare beneficiaries aged 65-74 years, possibly consistent with an effect of eliminating Medicare cost sharing during this time. Findings suggest that eliminating cost sharing might increase use of recommended screening services.

Between-ward disparities in colorectal cancer incidence and screening in Washington DC

This study aims to investigate the incidence and determinants of colorectal cancer (CRC) and its screening in District of Columbia (DC), and identify modifiable risk factors. Data (2000–2009) from the DC Cancer Registry, Behavioral Risk Factor Surveillance System (BRFSS-DC) and Surveillance Epidemiology and End Results (SEER) were used to estimate CRC incidence in eight DC Wards. Risk factors and CRC screening were analyzed using uni-, bi-, and multivariable statistical methods with survey procedures in SAS (version 9.2) including binary, unconditional multivariable logistic regression analysis. Factors measured included stage of diagnosis, age, gender, race/ethnicity, smoking, alcohol, exercise, body weight, health insurance, education, employment, and income. Over the study time, CRC screening increased from 48.4% to 68.6%. Mean age at diagnosis was 67 years. CRC incidence is high in DC. Furthermore, CRC incidence rates in DC below 50 years age were higher than the SEER18 average. Disparities exist between CRC incidence and screening among DC Wards. Identified risk factors for CRC are smoking, obesity, and low physical activity; screening was less prevalent among the uninsured and low socio-economic group. Local variations in CRC occurrence exist and may vary from average national experiences. Identification of local regions which vary from national trends in disease occurrence is important for comprehensive understanding of the disease in the community.

U.S. Preventive Services Task Force recommendations and cancer screening among female Medicare beneficiaries

BACKGROUND

Medicare covers several cancer screening tests not currently recommended by the U.S. Preventive Services Task Force (Task Force). In September 2002, the Task Force relaxed the upper age limit of 70 years for breast cancer screening recommendations, and in March 2003 an upper age limit of 65 years was introduced for cervical cancer screening recommendations. We assessed whether mammogram and Pap test utilization among women with Medicare coverage is influenced by changes in the Task Force's recommendations for screening.

METHODS

We identified female Medicare beneficiaries aged 66-80 years and used bivariate probit regression to examine the receipt of breast (mammogram) and cervical (Pap test) cancer screening reflecting changes in the Task Force recommendations. We analyzed 9,760 Medicare Current Beneficiary Survey responses from 2001 to 2007.

RESULTS

More than two-thirds reported receiving a mammogram and more than one-third a Pap test in the previous 2 years. Lack of recommendation was given as a reason for not getting screened among the majority (51% for mammogram and 75% for Pap). After controlling for beneficiary-level socioeconomic characteristics and access to care factors, we did not observe a significant change in breast and cervical cancer screening patterns following the changes in Task Force recommendations.

CONCLUSIONS

Although there is evidence that many Medicare beneficiaries adhere to screening guidelines, some women may be receiving non-recommended screening services covered by Medicare.

Racial and ethnic variations in the effects of family history of colorectal cancer on screening compliance

BACKGROUND & AIMS

Individuals with a family history of colorectal cancer (CRC) have a higher risk of developing CRC than the general population, and studies have shown that they are more likely to undergo CRC screening. We assessed the overall and race- and ethnicity-specific effects of a family history of CRC on screening.

METHODS

We analyzed data from the 2009 California Health Interview Survey to estimate overall and race- and ethnicity-specific odds ratios (ORs) for the association between family history of CRC and CRC screening.

RESULTS

The unweighted and weighted sample sizes were 23,837 and 8,851,003, respectively. Individuals with a family history of CRC were more likely to participate in any form of screening (OR, 2.3; 95% confidence limit [CL], 1.7, 3.1) and in colonoscopy screening (OR, 2.7; 95% CL, 2.2, 3.4) than those without a family history, but this association varied among racial and ethnic groups. The magnitude of the association between family history and colonoscopy screening was highest among Asians (OR, 6.1; 95% CL, 3.1, 11.9), lowest among Hispanics (OR, 1.4; 95% CL, 0.67, 2.8), and comparable between non-Hispanic whites (OR, 3.1; 95% CL, 2.6, 3.8) and non-Hispanic blacks (OR 2.6; 95% CL, 1.2, 5.7) (P for interaction < .001).

CONCLUSIONS

The effects of family history of CRC on participation in screening vary among racial and ethnic groups, and have the lowest effects on Hispanics, compared with other groups. Consequently, interventions to promote CRC screening among Hispanics with a family history should be considered.

Colorectal cancer screening in an equal access healthcare system

INTRODUCTION

The military health system (MHS) a unique setting to analyze implementation programs as well as outcomes for colorectal cancer (CRC). Here we look at the efficacy of different CRC screening methods, attributes and results within the MHS, and current barriers to increase compliance.

MATERIALS AND METHODS

A literature search was conducted utilizing PubMed and the Cochrane library. Key-word combinations included colorectal cancer screening, racial disparity, risk factors, colorectal cancer, screening modalities, and randomized control trials. Directed searches were also performed of embedded references.

RESULTS

Despite screening guidelines from several national organizations, extensive barriers to widespread screening remain, especially for minority populations. These barriers are diverse, ranging from education and access problems to personal beliefs. Screening rates in MHS have been reported to be generally higher at 71% compared to national averages of 50-65%.

CONCLUSION

CRC screening can be highly effective at improving detection of both pre-malignant and early cancers. Improved patient education and directed efforts are needed to improve CRC screening both nationally and within the MHS.

The "Welcome to Medicare" visit: a missed opportunity for cancer screening among women?

BACKGROUND

On January 1, 2005, Medicare began covering a "Welcome to Medicare" visit (WMV) for new enrollees with fee-for-service (FFS) Medicare (Parts A and B). The new benefit was expected to increase demand for mammography and Pap tests among women transitioning onto Medicare. This study examined whether Medicare's coverage of a WMV influenced the use of mammography and Pap tests among women aged 65 and 66 years with FFS Medicare.

METHODS

Medicare Current Beneficiary Survey (MCBS) data from 2001 to 2007 were linked with Medicare claims. Utilization rates for preventive visits, mammography, and Pap tests were measured among women entering Medicare. Multivariate logistic regressions were estimated to quantify the effects of the new Medicare benefit on the use of these screening tests, controlling for patient characteristics.

RESULTS

Regression-adjusted mammography and Pap test rates did not increase after WMV coverage was introduced. The 2005 reform had nonsignificant trivial effects on the use of both tests, most likely because few of the women who were eligible for a WMV took advantage of it.

CONCLUSIONS

Medicare coverage of a WMV had no impact on mammography screenings or Pap tests among women who were eligible for the benefit.

Computational modeling and multilevel cancer control interventions

This chapter presents an overview of computational modeling as a tool for multilevel cancer care and intervention research. Model-based analyses have been conducted at various "beneath the skin" or biological scales as well as at various "above the skin" or socioecological levels of cancer care delivery. We review the basic elements of computational modeling and illustrate its applications in four cancer control intervention areas: tobacco use, colorectal cancer screening, cervical cancer screening, and racial disparities in access to breast cancer care. Most of these models have examined cancer processes and outcomes at only one or two levels. We suggest ways these models can be expanded to consider interactions involving three or more levels. Looking forward, a number of methodological, structural, and communication barriers must be overcome to create useful computational models of multilevel cancer interventions and population health.

Self-reported cancer screening among elderly Medicare beneficiaries: a rural-urban comparison

PURPOSE

We examined the rural-urban disparity of screening for breast cancer and colorectal cancer (CRC) among the elder Medicare beneficiaries and assessed rurality's independent impact on receipt of screening.

METHODS

Using 2005 Medicare Current Beneficiary Survey, we applied weighted logistic regression to estimate the overall rural-urban disparity and rurality's independent impact on cancer screening, controlling for patient, and area factors.

RESULTS

From urban, large rural, small rural, and isolated rural areas, the rates for mammogram last year were 53%, 52%, 45%, and 44%, respectively. They were 56%, 50%, 48%, and 43% for CRC screening, respectively. After controlling for patient and area level characteristics, rurality is significantly associated with CRC screening, but not mammogram.

CONCLUSIONS

We found rural-urban disparities for both mammogram and CRC screenings. Patient and area factors totally eliminated the rural-urban disparity for mammogram but not CRC screening. Health promotions to improve cancer screening should focus more on small and isolated rural areas.

Managed care and the diffusion of endoscopy in fee-for-service Medicare

OBJECTIVE

To determine whether Medicare managed care penetration impacted the diffusion of endoscopy services (sigmoidoscopy, colonoscopy) among the fee-for-service (FFS) Medicare population during 2001-2006.

METHODS

We model utilization rates for colonoscopy or sigmoidoscopy as impacted by both market supply and demand factors. We use spatial regression to perform ecological analysis of county-area utilization rates over two time intervals (2001-2003, 2004-2006) following Medicare benefits expansion in 2001 to cover colonoscopy for persons of average risk. We examine each technology in separate cross-sectional regressions estimated over early and later periods to assess differential effects on diffusion over time. We discuss selection factors in managed care markets and how failure to control perfectly for market selection might impact our managed care spillover estimates.

RESULTS

Areas with worse socioeconomic conditions have lower utilization rates, especially for colonoscopy. Holding constant statistically the socioeconomic factors, we find that managed care spillover effects onto FFS Medicare utilization rates are negative for colonoscopy and positive for sigmoidoscopy. The spatial lag estimates are conservative and interpreted as a lower bound on true effects. Our findings suggest that managed care presence fostered persistence of the older technology during a time when it was rapidly being replaced by the newer technology.

Community contextual predictors of endoscopic colorectal cancer screening in the USA: spatial multilevel regression analysis

Background

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States, and endoscopic screening can both detect and prevent cancer, but utilization is suboptimal and varies across geographic regions. We use multilevel regression to examine the various predictors of individuals' decisions to utilize endoscopic CRC screening. Study subjects are a 100% population cohort of Medicare beneficiaries identified in 2001 and followed through 2005. The outcome variable is a binary indicator of any sigmoidoscopy or colonoscopy use over this period. We analyze each state separately and map the findings for all states together to reveal patterns in the observed heterogeneity across states.

Results

We estimate a fully adjusted model for each state, based on a comprehensive socio-ecological model. We focus the discussion on the independent contributions of each of three community contextual variables that are amenable to policy intervention. Prevalence of Medicare managed care in one's neighborhood was associated with lower probability of screening in 12 states and higher probability in 19 states. Prevalence of poor English language ability among elders in one's neighborhood was associated with lower probability of screening in 15 states and higher probability in 6 states. Prevalence of poverty in one's neighborhood was associated with lower probability of screening in 36 states and higher probability in 5 states.

Conclusions

There are considerable differences across states in the socio-ecological context of CRC screening by endoscopy, suggesting that the current decentralized configuration of state-specific comprehensive cancer control programs is well suited to respond to the observed heterogeneity. We find that interventions to mediate language barriers are more critically needed in some states than in others. Medicare managed care penetration, hypothesized to affect information about and diffusion of new endoscopic technologies, has a positive association in only a minority of states. This suggests that managed care plans' promotion of this cost-increasing technology has been rather limited. Area poverty has a negative impact in the vast majority of states, but is positive in five states, suggesting there are some effective cancer control policies in place targeting the poor with supplemental resources promoting CRC screening.

Primary care, economic barriers to health care, and use of colorectal cancer screening tests among Medicare enrollees over time

PURPOSE

Colorectal cancer (CRC) screening remains underutilized. The objective of this study was to examine the impact of primary care and economic barriers to health care on CRC testing relative to the 2001 Medicare expansion of screening coverage.

METHODS

Medicare Current Beneficiary Survey data were use to study community-dwelling enrollees aged 65 to 80 years, free of renal disease and CRC, and who participated in the survey in 2000 (n = 8,330), 2003 (n = 7,889), or 2005 (n = 7,614). Three outcomes were examined: colonoscopy/sigmoidoscopy within 5 years (recent endoscopy), endoscopy more than 5 years previously, and fecal occult blood test (FOBT) within 2 years.

RESULTS

Endoscopy use increased and FOBT use decreased during the 6-year period, with no significant independent differences between those receiving care from primary care physicians and those receiving care from other physicians. Beneficiaries without a usual place of health care were the least likely to undergo CRC testing, and that gap widened with time: adjusted odds ratio (AOR) = 0.27 (95% confidence interval [CI], 0.19-0.39) for FOBT, and AOR = 0.35 (95% CI, 0.27-0.46) for endoscopy in 2000 compared with AOR = 0.18 (95% CI, 0.11-0.30) for FOBT and AOR = 0.22 (95% CI, 0.17-0.30) for endoscopy in 2005. Disparities in use of recent endoscopy by type of health insurance coverage in both 2000 and 2005 were greater for enrollees with a high school education or higher than they were for less-educated enrollees. There were no statistically significant differences by delayed care due to cost after adjustment for health insurance.

CONCLUSION

Despite expanding coverage for screening, complex CRC screening disparities persisted based on differences in the usual place and cost of health care, type of health insurance coverage, and level of education.

Racial and ethnic trends of colorectal cancer screening among Medicare enrollees

BACKGROUND

Colorectal cancer (CRC) screening rates have remained lower than the Healthy People 2010 goal, particularly among minority populations.

PURPOSE

This study aimed to examine the racial-ethnic trends in CRC screening and the continued impact of healthcare access indicators on screening differences after Medicare expanded coverage.

METHODS

The study used data from the Medicare Current Beneficiary Survey for 2000, 2003, and 2005. The sample was restricted to non-Hispanic whites, non-Hispanic blacks, and Hispanics. The primary outcome was the proportion of enrollees who underwent lower-gastrointestinal endoscopy within 5 years and/or home fecal occult blood test within 1 year.

RESULTS

Over the 6-year period under study, the proportion screened increased among each of the three racial-ethnic groups, but lower proportions of blacks and Hispanics underwent screening compared with whites at each time point. Hispanic-white differences persisted but black-white differences narrowed in 2003 and widened in 2005. In each survey year, racial differences attenuated after adjustment for type of supplemental health insurance and disappeared after further adjustment for educational and income levels.

CONCLUSIONS

Despite expanding benefits for CRC screening, which would be expected to disproportionally benefit racial and ethnic minorities, racial disparities in use of screening persist in part because of differences in the types of health insurance coverage, education, and income. There was a slight reversal of the initial attenuation of the black-white difference after the Medicare policy change. Efforts are needed to increase the reach of CRC screening to minority populations, particularly those lacking adequate health insurance coverage or with less education or income.

Factors associated with colon cancer stage at diagnosis

We analyzed data from 1998-2004 from the National Cancer Data Base to evaluate associations between patient/treatment facility factors and stage at diagnosis for all colon cancers combined and by anatomic location. Compared to patients with private insurance, uninsured patients were significantly more likely to present with advanced-stage disease; Medicaid patients had likelihoods of advanced-stage colon cancer in-between those of privately insured and uninsured patients. Increased odds of advanced-stage colon cancer at diagnosis were also observed among Black (vs. White) patients, women (vs. men), and patients from low socioeconomic status (SES) regions (vs. those from higher SES regions). While the likelihood of advanced-stage disease at diagnosis decreased in later years overall, this decrease was not observed among patients with ascending colon cancers. Screening disparities may lead to more advanced stage at diagnosis among colon cancer patients; programs to improve access to screening among underserved populations may address this disparity.

Predictors of endoscopic colorectal cancer screening over time in 11 states

Objectives

We study a cohort of Medicare-insured men and women aged 65+ in the year 2000, who lived in 11 states covered by Surveillance, Epidemiology, and End Results (SEER) cancer registries, to better understand various predictors of endoscopic colorectal cancer (CRC) screening.

Methods

We use multilevel probit regression on two cross-sectional periods (2000–2002, 2003–2005) and include people diagnosed with breast cancer, CRC, or inflammatory bowel disease (IBD) and a reference sample without cancer.

Results

Men are not universally more likely to be screened than women, and African Americans, Native Americans, and Hispanics are not universally less likely to be screened than whites. Disparities decrease over time, suggesting that whites were first to take advantage of an expansion in Medicare benefits to cover endoscopic screening for CRC. Higher-risk persons had much higher utilization, while older persons and beneficiaries receiving financial assistance for Part B coverage had lower utilization and the gap widened over time.

Conclusions

Screening for CRC in our Medicare-insured sample was less than optimal, and reasons varied considerably across states. Negative managed care spillovers were observed, demonstrating that policy interventions to improve screening rates should reflect local market conditions as well as population diversity.