Geographic variation of racial/ethnic disparities in colorectal cancer testing among medicare enrollees

Geographic Distribution of Racial Differences in Renal Cell Carcinoma Mortality

OBJECTIVE

To examine the geographic variations in Renal cell carcinoma (RCC) -specific death disparities from competing causes among Hispanic, non-Hispanic White, non-Hispanic Black, and Asian/Pacific Islander RCC patients. RCC outcomes in specific racial/ethnic population warrants further research and it is unknown whether racial/ethnic differences in RCC survival vary geographically within the US.

METHODS

This retrospective cohort study was conducted to assess all RCC patients from 2014 to 2021. Data was extracted from the Surveillance, Epidemiology, and End Results (SEER) database. The primary outcome was RCC-related mortality.

RESULTS

The study included 85,975 patients with RCC from 16 geographic areas within the SEER database. Kaplan-Meier analysis showed that Hispanic patients had the worst survival outcome (P < .001 by log rank test). In the multivariable competing-risks regression, Hispanics had a higher risk of cancer-specific mortality (hazard ratio [HR] 1.29, 95% CI, 1.20-1.38, P ˂ .001) compared with non-Hispanic Whites. The increase in the risk of RCC-related death with Hispanic race/ethnicity was consistent across all major subgroups stratified by the covariables. In stratified analyses of geographic regions, there were 3 areas in which Hispanics had worse RCC-specific survival (Los Angeles: HR 1.22, 95% CI, 1.06-1.41, P = .005; Greater California: HR 1.125, 95% CI, 1.15-1.37, P < .001; Atlanta, Georgia: HR 1.95, 95% CI, 1.32-2.88, P = .001).

CONCLUSION

These results demonstrate that population-level variations in RCC survival among Hispanics and non-Hispanic Whites were associated with a small number of geographic regions. Targeted interventions in these regions may be conducive to alleviating RCC care differences at the national level.

National and subnational incidence, mortality and associated factors of colorectal cancer in China: A systematic analysis and modelling study

Background

Due to their known variation by geography and economic development, we aimed to evaluate the incidence and mortality of colorectal cancer (CRC) in China over the past decades and identify factors associated with CRC among the Chinese population to provide targeted information on disease prevention.

Methods

We conducted a systemic review and meta-analysis of epidemiolocal studies on the incidence, mortality, and associated factors of CRC among the Chinese population, extracting and synthesising data from eligible studies retrieved from seven global and Chinese databases. We pooled age-standardised incidence rates (ASIRs) and mortality rates (ASMRs) for each province, subregion, and the whole of China, and applied a joinpoint regression model and annual per cent changes (APCs) to estimate the trends of CRC incidence and mortality. We conducted random-effects meta-analyses to assess the effect estimates of identified associated risk factors.

Results

We included 493 articles; 271 provided data on CRC incidence or mortality, and 222 on associated risk factors. Overall, the ASIR of CRC in China increased from 2.75 to 19.39 (per 100 000 person-years) between 1972 and 2019 with a slowed-down growth rate (APC1 = 5.75, APC2 = 0.42), while the ASMR of CRC decreased from 12.00 to 7.95 (per 100 000 person-years) between 1974 and 2020 with a slight downward trend (APC = -0.89). We analysed 62 risk factors with synthesized data; 16 belonging to the categories of anthropometrics factors, lifestyle factors, dietary factors, personal histories and mental health conditions were graded to be associated with CRC risk among the Chinese population in the meta-analysis limited to the high-quality studies.

Conclusions

We found substantial variation of CRC burden across regions and provinces of China and identified several associated risk factors for CRC, which could help to guide the formulation of targeted disease prevention and control strategies.

Registration

PROSPERO: CRD42022346558.

Regional variation in healthcare usage for Medicare beneficiaries: a cross-sectional study based on the health and retirement study

OBJECTIVES

To investigate whether regional variation changes with different beneficiary health insurance coverage types.

DESIGN

A cross-sectional study of the Health and Retirement Study (HRS) in 2018 was used.

SETTING

Medicare beneficiaries only covered by Medicare (group 1) are compared with those covered by Medicare and other health insurance (group 2). Outcomes included healthcare usage measures: (1) whether beneficiaries have a hospital stay and (2) the number for those with at least one stay; (3) whether beneficiaries have a doctor's visit and (4) the number for those with at least one visit. We compared healthcare usage in both groups across the five regions: (1) New England and Mid-Atlantic; (2) East North Central and West North Central; (3) South Atlantic; (4) East South Central and West South Central; (5) Mountain and Pacific. We used logistic regression for binary outcomes and negative binomial regression for count outcomes in each group.

PARTICIPANTS

We identified 8749 Medicare beneficiaries, of which 4098 in group 1 and 4651 in group 2.

RESULTS

Residents in all non-reference regions had a significantly lower probability of seeking a doctor's visit in group 1 (OR with 95% CI 0.606 (0.374 to 0.982), 0.619 (0.392 to 0.977), 0.472 (0.299 to 0.746) and 0.618 (0.386 to 0.990) in the order of above regions, respectively), which is not significant in group 2. Residents in most non-reference regions (except South Atlantic) had a significantly fewer number of seeking a hospital stay in group 2 (incident rate ratio (IRR) with 95% CI 0.797 (0.691 to 0.919), 0.740 (0.643 to 0.865), 0.726 (0.613 to 0.859) in the order of above regions, respectively), which is not significant in group 1.

CONCLUSION

Regional variation in the likelihood of having a doctor's visit was reduced in Medicare beneficiaries covered by supplemental health insurance. Regional variation in hospital stays was accentuated among Medicare beneficiaries covered by supplemental health insurance.

Disparities in Screening for Colorectal Cancer Based on Limited Language Proficiency

BACKGROUND

This study analyzes the association between limited language proficiency and screening for colorectal cancer.

METHODS

This is a retrospective cohort study from the 2015 sample of the National Health Interview Survey database utilizing univariate and multivariate regression analysis. The study population includes subjects between 50 and 75 years of age. The main outcome analyzed was rates of screening colonoscopies between limited English-language proficiency (LEP) subjects and those fluent in English. Secondary outcomes included analysis of baseline, socioeconomic, access to health care variables, and other modalities for colorectal cancer screening between the groups.

RESULTS

Incidence of limited language proficiency was 4.8% (n = 1978, count = 4 453 599). They reported lower rates of screening colonoscopies (61% vs 34%, P < .001), less physician recommendation for a colonoscopy (87 vs 60%, P < .001), fewer polyps removed in the previous 3 years (24% vs 9.1%; P < .001), and fewer fecal occult blood samples overall (P < .001). Additionally, Hispanic non-LEP subjects have higher rates of colonoscopies compared to those with language barriers (50% vs 33%, P < .001). On multivariate analysis, LEP was associated with a lower likelihood to have a screening colonoscopy (OR .67 95% CI .49-.91). A second regression model with "Spanish language" and "other language" variables included, associated Spanish speakers with a lower likelihood for a screening colonoscopy (OR .71 95% CI .52-.97) when controlling for baseline, socioeconomic, and access to health care covariates.

DISCUSSION

Patients with limited English-language proficiency are associated with lower rates of screening for colorectal cancer, in particular the Spanish speaking subgroup.

Impact of COVID-19 on cervical cancer screening: Challenges and opportunities to improving resilience and reduce disparities

The COVID-19 pandemic has a major impact on a wide range of health outcomes. Disruptions of elective health services related to cervical screening, management of abnormal screening test results, and treatment of precancers, may lead to increases in cervical cancer incidence and exacerbate existing health disparities. Modeling studies suggest that a short delay of cervical screening in subjects with previously negative HPV results has minor effects on cancer outcomes, while delay of management and treatment can lead to larger increases in cervical cancer. Several approaches can mitigate the effects of disruption of cervical screening and management. HPV-based screening has higher accuracy compared to cytology, and a negative HPV result provides longer reassurance against cervical cancer; further, HPV testing can be conducted from self-collected specimens. Self-collection expands the reach of screening to underserved populations who currently do not participate in screening. Self-collection and can also provide alternative screening approaches during the pandemic because testing can be supported by telehealth and specimens collected in the home, substantially reducing patient-provider contact and risk of COVID-19 exposure, and also expanding the reach of catch-up services to address backlogs of screening tests that accumulated during the pandemic. Risk-based management allows prioritizing management of patients at highest risk of cervical cancer while extending screening intervals for those at lowest risk. The pandemic provides important lessons for how to make cervical screening more resilient to disruptions and how to reduce cervical cancer disparities that may be exacerbated due to disruptions of health services.

Epidemiological Determinants of Advanced Prostate Cancer in Elderly Men in the United States

In this study, we examined the effects of individual-level and area-level characteristics on advanced prostate cancer diagnosis among Medicare eligible older men (ages 70+ years). We analyzed patients from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2000-2007) linked to US Census and County Business Patterns data. Cluster-adjusted logistic regression models were used to quantify the effects of individual preventive health behavior, clinical and demographic characteristics, area-level health services supply, and socioeconomic characteristics on stage at diagnosis. The fully adjusted model was used to estimate county-specific effects and predicted probabilities of advanced prostate cancer. In the adjusted analyses, low intensity of annual prostate-specific antigen (PSA) testing and other preventive health behavior, high comorbidity, African American race, and lower county socioeconomic and health services supply characteristics were statistically significantly associated with a higher likelihood of distant prostate cancer diagnosis. The fully adjusted predicted proportions of advanced prostate cancer diagnosis across 158 counties ranged from 3% to 15% (mean: 6%, SD: 7%). County-level socioeconomic and health services supply characteristics, individual-level preventive health behavior, demographic and clinical characteristics are determinants of advanced stage prostate cancer diagnosis among older Medicare beneficiaries; other health care-related factors such as family history, lifestyle choices, and health-seeking behavior should also be considered as explanatory factors.

National racial/ethnic and geographic disparities in experiences with health care among adult Medicaid beneficiaries

OBJECTIVES

To investigate whether health care experiences of adult Medicaid beneficiaries differ by race/ethnicity and rural/urban status.

DATA SOURCES

A total of 270 243 respondents to the 2014-2015 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems Survey.

STUDY DESIGN

Linear regression was used to estimate case mix adjusted differences in patient experience between racial/ethnic minority and non-Hispanic white Medicaid beneficiaries, and between beneficiaries residing in small urban areas, small towns, and rural areas vs large urban areas. Dependent measures included getting needed care, getting care quickly, doctor communication, and customer service.

PRINCIPAL FINDINGS

Compared with white beneficiaries, American Indian/Alaska Native (AIAN) and Asian/Pacific Islander (API) beneficiaries reported worse experiences, while black beneficiaries reported better experiences. Deficits for AIAN beneficiaries were 6-8 points on a 0-100 scale; deficits for API beneficiaries were 13-22 points (P's < 0.001); advantages for black beneficiaries were 3-5 points (P's < 0.001). Hispanic white differences were mixed. Beneficiaries in small urban areas, small towns, and isolated rural areas reported significantly better experiences (2-3 points) than beneficiaries in large urban areas (P's < 0.05), particularly regarding access to care. Racial/ethnic differences typically did not vary by geography.

CONCLUSIONS

Improving experiences for racial/ethnic minorities and individuals living in large urban areas should be high priorities for policy makers exploring approaches to improve the value and delivery of care to Medicaid beneficiaries.

Translational Research: Bringing Science to the Provider Through Guideline Implementation

Significant variation exists in health care practice patterns that creates concerns regarding the quality of care delivered. Clinical practice based on high-quality evidence provides a rationale for clinical decision making. Resources, such as evidence-based guidelines, provide that evidence to clinicians and improve patient outcomes by decreasing unwanted variation in clinical practice. Because knowledge dissemination alone is ineffective to translate scientific evidence into clinical practice, the field of implementation science has emerged to facilitate this translation of research into routine clinical practice. This article provides an introduction to implementation science, and its application in dentistry to promote adoption of evidence-based guidelines.

Colorectal Cancer Screening in African American HOPE VI Public Housing Residents

This study explores whether colorectal cancer screening outreach via home visits and follow-up calls is effective among public housing African American residents. It reports on the proportion of returned Fecal Immunochemical Test kits, on the characteristics of study participants, and on their primary reasons for returning the kit. By conducting home visits and follow-up calls, our colorectal cancer-screening outreach resulted in a higher Fecal Immunochemical Test kit return rate than anticipated. Findings suggest that a more personalized outreach approach can yield higher colorectal cancer-screening rates among urban minority populations, which are at higher risk to be diagnosed with late-stage colorectal cancer.

Practice Pattern Variation in the Use of Transesophageal Echocardiography for Open Valve Cardiac Surgery

OBJECTIVE

The authors sought to assess for the presence of practice variation in the use of intraoperative transesophageal echocardiography (TEE) for open cardiac valve surgery.

DESIGN

This study was a retrospective cohort analysis.

SETTING

The administrative claims data used for this investigation were multi-institutional and a representative sample of commercially insured patients in the United States between 2010 and 2015.

PARTICIPANTS

The cohort consisted of adult patients, aged 18 years or older, undergoing open mitral valve (MV) or aortic valve (AV) surgery.

INTERVENTIONS

This was an observational analysis without interventions.

MEASUREMENTS AND MAIN RESULTS

Of 19,386 valve surgeries, 12,313 (64%) underwent AV replacement, 6,192 (32%) underwent MV repair or replacement, and 881 (<5%) underwent both MV and AV surgery. The overall rate of intraoperative TEE was 82% (95% confidence interval [CI]: 81%-82%), less frequently observed in AV procedures compared to MV or combined MV-AV procedures (80% v 85%, p < 0.001). Rates of intraoperative TEE claims varied markedly across U.S. states. After adjustment, the relative odds of an intraoperative TEE claim ranged across states from 0.26 (Louisiana, 95% CI: 0.18-0.36; p < 0.001) to 2.10 (North Carolina, 95% CI: 1.57-2.82; p < 0.001).

CONCLUSION

Among adult patients undergoing open AV or MV surgery in the United States, 82% had a claim for an intraoperative TEE with marked variability across U.S. states. Increasing adherence to intraoperative TEE guidelines for valve surgery may represent an unrecognized opportunity to improve the quality of cardiac surgical care.

Geographic Region Matters in the Relation Between Perceived Racial Discrimination and Psychiatric Disorders Among Black Older Adults

Purpose of the Study

This study examined whether the relation between perceived racial discrimination and psychiatric disorders varied by large geographic region among Black older adults in the United States.

Design and Methods

Black adults aged 55 or older who had experienced racial/ethnic-specific discrimination were drawn from the National Survey of American Life (NSAL). Logistic regression analysis was used to examine main and interaction effects.

Results

Results show that there was a significant main effect of perceived racial discrimination, indicating that greater perceived discrimination was significantly associated with increased odds of having any past-year psychiatric disorder. The interaction of region by perceived racial discrimination was significant: The effect of perceived racial discrimination on any past-year psychiatric disorder was stronger among Blacks in the West than those in the South.

Implications

Findings suggest that whereas, in general, perceived racial discrimination is a risk factor for poor mental health among older Blacks, this association may differ by geographic region. Additional research examining reasons for this variation is needed.

Correlates of Patient Intent and Preference on Colorectal Cancer Screening

INTRODUCTION

Information is limited on patient characteristics that influence their preference among screening options and intent to be screened for colorectal cancer (CRC). A mechanistic pathway to intent and preference was examined through a formal mediation analysis.

METHODS

From 2012 to 2014, a total of 570 adults aged 50-75 years were recruited from 15 primary care practices in Metro Detroit for a trial on decision aids for CRC screening. Confirmatory factor, regression, and mediation analyses were performed in 2015-2016 on baseline cross-sectional data. Main outcomes were patient intent and preference. Perceived risk and self-efficacy were secondary outcomes. Covariates included demographic information, health status, previous CRC screening experience, patient attitudes, and knowledge.

RESULTS

Mean age was 57.7 years, 56.1% were women, and 55.1% white and 36.6% black. Women had 32% and 41% lower odds than men of perceiving CRC to be high/moderate risk (OR=0.68, 95% CI=0.47, 0.97, p=0.03) and having high self-efficacy (OR=0.59, 95% CI=0.42, 0.85, p=0.006), respectively. Whites had 63% and 47% lower odds than blacks of having high self-efficacy (OR=0.37, 95% CI=0.25, 0.57, p<0.001) and intent to undergo CRC screening (OR=0.53, 95% CI=0.34, 0.84, p=0.007), respectively. Younger age, higher knowledge, lower level of test worries, and medium/high versus low self-efficacy increased the odds of intent of being screened. Self-efficacy, but not perceived risk, significantly mediated the association between race, attitude, and test worries and patient screening intent.

CONCLUSIONS

Self-efficacy mediated the association between race, attitude, and test worries and patient intent.

Not Near Enough: Racial and Ethnic Disparities in Access to Nearby Behavioral Health Care and Primary Care

BACKGROUND

Racial, ethnic, and geographical health disparities have been widely documented in the United States. However, little attention has been directed towards disparities associated with integrated behavioral health and primary care services.

METHODS

Access to behavioral health professionals among primary care physicians was examined using multinomial logistic regression analyses with 2010 National Plan and Provider Enumeration System, American Medical Association Physician Masterfile, and American Community Survey data.

RESULTS

Primary care providers practicing in neighborhoods with higher percentages of African Americans and Hispanics were less likely to have geographically proximate behavioral health professionals. Primary care providers in rural areas were less likely to have geographically proximate behavioral health professionals.

CONCLUSION

Neighborhood-level factors are associated with access to nearby behavioral health and primary care. Additional behavioral health professionals are needed in racial/ethnic minority neighborhoods and rural areas to provide access to behavioral health services, and to progress toward more integrated primary care.

Case-control study of candidate gene methylation and adenomatous polyp formation

PURPOSE

Colorectal cancer (CRC) is one of the most common and preventable forms of cancer but remains the second leading cause of cancer-related death. Colorectal adenomas are precursor lesions that develop in 70-90 % of CRC cases. Identification of peripheral biomarkers for adenomas would help to enhance screening efforts. This exploratory study examined the methylation status of 20 candidate markers in peripheral blood leukocytes and their association with adenoma formation.

METHODS

Patients recruited from a local endoscopy clinic provided informed consent and completed an interview to ascertain demographic, lifestyle, and adenoma risk factors. Cases were individuals with a histopathologically confirmed adenoma, and controls included patients with a normal colonoscopy or those with histopathological findings not requiring heightened surveillance (normal biopsy, hyperplastic polyp). Methylation-specific polymerase chain reaction was used to characterize candidate gene promoter methylation. Odds ratios (ORs) and 95 % confidence intervals (95% CIs) were calculated using unconditional multivariable logistic regression to test the hypothesis that candidate gene methylation differed between cases and controls, after adjustment for confounders.

RESULTS

Complete data were available for 107 participants; 36 % had adenomas (men 40 %, women 31 %). Hypomethylation of the MINT1 locus (OR 5.3, 95% CI 1.0-28.2) and the PER1 (OR 2.9, 95% CI 1.1-7.7) and PER3 (OR 11.6, 95% CI 1.6-78.5) clock gene promoters was more common among adenoma cases. While specificity was moderate to high for the three markers (71-97 %), sensitivity was relatively low (18-45 %).

CONCLUSION

Follow-up of these epigenetic markers is suggested to further evaluate their utility for adenoma screening or surveillance.

Assessing Colorectal Cancer Screening Adherence of Medicare Fee-for-Service Beneficiaries Age 76 to 95 Years

INTRODUCTION

There are concerns about potential overuse of colorectal cancer (CRC) screening services among average-risk individuals older than age 75 years.

MATERIALS AND METHODS

Using a 5% random noncancer sample of Medicare beneficiaries who resided in the SEER areas, we examined rates of CRC screening adherence, defined by the Medicare coverage policy, among average-risk fee-for-service beneficiaries age 76 to 95 years from 2002 to 2010. The two outcomes are the status of overall CRC screening adherence, and the status of adherence to colonoscopy (v other modalities) conditional on patient adherence.

RESULTS

Overall CRC screening adherence rates of Medicare beneficiaries age 76 to 95 years increased from 13.0% to 21.4% from 2002 to 2010. In 2002, 2.2% of beneficiaries were adherent to colonoscopy, and 10.7%, by other modalities; the corresponding rates were 19.5% and 1.9%, respectively, in 2010. Specifically, rates of adherence to colonoscopy were 1.1% for those age 86 to 90 years and almost nil for those age 91 to 95 years in 2002, but the rates became 13.5% and 8.2%, respectively, in 2010. Compared with white beneficiaries, black beneficiaries age 76 to 95 years had a 7-percentage-point lower adherence rate. However, overall adherence rates among blacks increased by 168.6% from 2002 to 2010, whereas rates among whites increased by 63.0%. Logistic regressions showed that blacks age 86 to 95 years were less likely than whites to be adherent (odds ratio, 0.56; 95% CI, 0.47 to 0.59) but were more likely to be adherent to colonoscopy (odds ratio, 2.34; 95% CI, 1.47 to 3.91).

CONCLUSION

High proportions of average-risk Medicare fee-for-service beneficiaries screened by colonoscopy may represent opportunities for improving appropriateness and allocative efficiency of CRC screening by Medicare.

Counties eliminating racial disparities in colorectal cancer mortality

BACKGROUND

Although colorectal cancer (CRC) mortality rates are declining, racial-ethnic disparities in CRC mortality nationally are widening. Herein, the authors attempted to identify county-level variations in this pattern, and to characterize counties with improving disparity trends.

METHODS

The authors examined 20-year trends in US county-level black-white disparities in CRC age-adjusted mortality rates during the study period between 1989 and 2010. Using a mixed linear model, counties were grouped into mutually exclusive patterns of black-white racial disparity trends in age-adjusted CRC mortality across 20 three-year rolling average data points. County-level characteristics from census data and from the Area Health Resources File were normalized and entered into a principal component analysis. Multinomial logistic regression models were used to test the relation between these factors (clusters of related contextual variables) and the disparity trend pattern group for each county.

RESULTS

Counties were grouped into 4 disparity trend pattern groups: 1) persistent disparity (parallel black and white trend lines); 2) diverging (widening disparity); 3) sustained equality; and 4) converging (moving from disparate outcomes toward equality). The initial principal component analysis clustered the 82 independent variables into a smaller number of components, 6 of which explained 47% of the county-level variation in disparity trend patterns.

CONCLUSIONS

County-level variation in social determinants, health care workforce, and health systems all were found to contribute to variations in cancer mortality disparity trend patterns from 1990 through 2010. Counties sustaining equality over time or moving from disparities to equality in cancer mortality suggest that disparities are not inevitable, and provide hope that more communities can achieve optimal and equitable cancer outcomes for all. Cancer 2016;122:1735-48. © 2016 American Cancer Society.

Diabetes Status and Being Up-to-Date on Colorectal Cancer Screening, 2012 Behavioral Risk Factor Surveillance System

Introduction

Although screening rates for colorectal cancer are increasing, 22 million Americans are not up-to-date with recommendations. People with diabetes are an important and rapidly growing group at increased risk for colorectal cancer. Screening status and predictors of being up-to-date on screening are largely unknown in this population.

Methods

This study used logistic regression modeling and data from the 2012 Behavioral Risk Factor Surveillance System to examine the association between diabetes and colorectal cancer screening predictors with being up-to-date on colorectal cancer screening according to criteria of the US Preventive Services Task Force for adults aged 50 or older. State prevalence rates of up-to-date colorectal cancer screening were also calculated and mapped.

Results

The prevalence of being up-to-date with colorectal cancer screening for all respondents aged 50 or older was 65.6%; for respondents with diabetes, the rate was 69.2%. Respondents with diabetes were 22% more likely to be up-to-date on colorectal cancer screening than those without diabetes. Among those with diabetes, having a routine checkup within the previous year significantly increased the odds of being up-to-date on colorectal cancer screening (odds ratio, 1.90). Other factors such as age, income, education, race/ethnicity, insurance status, and history of cancer were also associated with up-to-date status.

Conclusion

Regardless of diabetes status, people who had a routine checkup within the past year were more likely to be up-to-date than people who had not. Among people with diabetes, the duration between routine checkups may be of greater importance than the frequency of diabetes-related doctor visits. Continued efforts should be made to ensure that routine care visits occur regularly to address the preventive health needs of patients with and patients without diabetes.

Effects of personalized colorectal cancer risk information on laypersons' interest in colorectal cancer screening: The importance of individual differences

OBJECTIVE

To evaluate how personalized quantitative colorectal cancer (CRC) risk information affects laypersons' interest in CRC screening, and to explore factors influencing these effects.

METHODS

An online pre-post experiment was conducted in which a convenience sample (N=578) of laypersons, aged >50, were provided quantitative personalized estimates of lifetime CRC risk, calculated by the National Cancer Institute Colorectal Cancer Risk Assessment Tool (CCRAT). Self-reported interest in CRC screening was measured immediately before and after CCRAT use; sociodemographic characteristics and prior CRC screening history were also assessed. Multivariable analyses assessed participants' change in interest in screening, and subgroup differences in this change.

RESULTS

Personalized CRC risk information had no overall effect on CRC screening interest, but significant subgroup differences were observed. Change in screening interest was greater among individuals with recent screening (p=.015), higher model-estimated cancer risk (p=.0002), and lower baseline interest (p<.0001), with individuals at highest baseline interest demonstrating negative (not neutral) change in interest.

CONCLUSION

Effects of quantitative personalized CRC risk information on laypersons' interest in CRC screening differ among individuals depending on prior screening history, estimated cancer risk, and baseline screening interest.

PRACTICE IMPLICATIONS

Personalized cancer risk information has personalized effects-increasing and decreasing screening interest in different individuals.

Physician Non-adherence to Colonoscopy Interval Guidelines in the Veterans Affairs Healthcare System

BACKGROUND & AIMS

Colonoscopy can decrease colorectal cancer (CRC) mortality, although performing this procedure more frequently than recommended could increase costs and risks to patients. We aimed to determine rates and correlates of physician non-adherence to guidelines for repeat colonoscopy screening and polyp surveillance intervals.

METHODS

We performed a multi-center, retrospective, observational study using administrative claims, physician databases, and electronic medical records (EMR) from 1455 patients (50-64 y old) who underwent colonoscopy in the Veterans Affairs healthcare system in fiscal year 2008. Patients had no prior diagnosis of CRC or inflammatory bowel disease, and had not undergone colonoscopy examinations in the previous 10 years. We compared EMR-documented, endoscopist-recommended intervals for colonoscopies with intervals recommended by the 2008 Multi-Society Task Force guidelines.

RESULTS

The overall rate of non-adherence to guideline recommendations was 36% and ranged from 3% to 80% among facilities. Non-adherence was 28% for patients who underwent normal colonoscopies, but 45%-52% after colonoscopies that identified hyperplastic or adenomatous polyps. Most of all recommendations that were not followed recommended a shorter surveillance interval. In adjusted analyses, non-adherence was significantly higher for patients whose colonoscopies identified hyperplastic (odds ratio [OR] = 3.1; 95% CI, 1.7-5.5) or high-risk adenomatous polyps (OR = 3.0; 95% CI, 1.2-8.0), compared to patients with normal colonoscopy examinations, but not for patients with low-risk adenomatous polyps (OR = 1.8; 95% CI, 0.9-3.7). Nonadherence was also associated with bowel preparation quality, geographic region, Charlson comorbidity score, and colonoscopy indication.

CONCLUSIONS

In a managed care setting with salaried physicians, endoscopists recommend repeat colonoscopy sooner than guidelines for more than one third of patients. Factors associated with non-adherence to guideline recommendations were colonoscopy findings, quality of bowel preparation, and geographic region. Targeting endoscopist about non-adherence to colonoscopy guidelines could reduce overuse of colonoscopy and associated healthcare costs.

Cost-effectiveness of patient navigation to increase adherence with screening colonoscopy among minority individuals

BACKGROUND

Colorectal cancer (CRC) screening is underused by minority populations, and patient navigation increases adherence with screening colonoscopy. In this study, the authors estimated the cost-effectiveness of navigation for screening colonoscopy from the perspective of a payer seeking to improve population health.

METHODS

A validated model of CRC screening was informed with inputs from navigation studies in New York City (population: 43% African American, 49% Hispanic, 4% white, 4% other; base-case screening: 40% without navigation, 65% with navigation; navigation costs: $29 per colonoscopy completer, $21 per noncompleter, $3 per non-navigated individual). Two analyses compared: 1) navigation versus no navigation for 1-time screening colonoscopy in unscreened individuals aged ≥ 50 years; and 2) programs of colonoscopy with versus without navigation versus fecal occult blood testing (FOBT) or fecal immunochemical testing (FIT) for individuals ages 50 to 80 years.

RESULTS

In the base case: 1) 1-time navigation gained quality-adjusted life-years (QALYs) and decreased costs; 2) longitudinal navigation cost $9800 per QALY gained versus no navigation, and, assuming comparable uptake rates, it cost $118,700 per QALY gained versus FOBT but was less effective and more costly than FIT. The results were most dependent on screening participation rates and navigation costs: 1) assuming a 5% increase in screening uptake with navigation, and a navigation cost of $150 per completer, 1-time navigation cost $26,400 per QALY gained; and 2) longitudinal navigation with 75% colonoscopy uptake cost <$25,000 per QALY gained versus FIT when FIT uptake was <50%. Probabilistic sensitivity analyses did not alter the conclusions.

CONCLUSIONS

Navigation for screening colonoscopy appears to be cost-effective, and 1-time navigation may be cost-saving. In emerging health care models that reward outcomes, payers should consider covering the costs of navigation for screening colonoscopy.

IMMEDIATE PREOPERATIVE NUTRITIONAL STATUS OF PATIENTS WITH COLORECTAL CANCER: a warning

Context Weight loss and malnutrition are disorders observed in colorectal cancer patients. Objectives We sought to evaluate the immediate preoperative nutritional status of patients with colorectal cancer. Methods This is a cross-sectional clinical study conducted at a single center. Sixty-six consecutive patients in preoperative for elective surgical treatment were studied. The clinical history, socio-demographic data and nutritional status of the patients were evaluated using Subjective Global Assessment and objective (anthropometry) methods. The primary outcome measures were nutritional status classification as nourished or malnourished and the relationship between nutritional status and socio-demographic and clinical features. Results Most of patients exhibited left colon tumors and disease stage II. According to the Subjective Global Assessment, 36.4% of patients were malnourished. Malnutrition ranged from 7.6% to 53% depending on the evaluation method used, with poor correlation to Subjective Global Assessment. The prevalence of malnutrition was significantly greater in females and non-married patients and in those with two or more symptoms of colorectal cancer. Conclusions More than a third of patients in the immediate preoperative period for colorectal cancer exhibited malnutrition. Therefore, routine nutritional assessment is highly advisable so that appropriate measures may be taken to minimize the potential postoperative complications.

Rural disparities in receipt of colorectal cancer screening among adults ages 50-64 with disabilities

BACKGROUND

Colorectal cancer is the third leading cause of cancer deaths in the United States. Early detection can reduce mortality; however, only 59% of U.S. adults age 50 and over meet recommended colorectal cancer screening guidelines. Studies in the general population have observed that rural residents are less likely to have received colorectal cancer screening than residents of urban areas.

OBJECTIVE

To determine whether urban/rural disparities in colorectal cancer screening exist among people with disabilities, similar to the disparities found in the general population.

METHODS

We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. We conducted logistic regression analyses to examine the relationship between urban/rural residence and ever having received screening for colorectal cancer (via colonoscopy, sigmoidoscopy, or fecal occult blood test).

RESULTS

Among U.S. adults ages 50-64 with disabilities, those living in rural areas were significantly less likely to have ever received any type of screening for colorectal cancer. The urban/rural difference was statistically significant regardless of whether or not we controlled for demographic, socioeconomic, health, and health care access variables.

CONCLUSIONS

Disparity in screening for colorectal cancer places rural residents with disabilities at greater risk for late stage diagnosis and mortality relative to people with disabilities in urban areas. Thus, there is a need for strategies to improve screening among people with disabilities in rural areas.

Disparities in endoscopy use for colorectal cancer screening in the United States

It is well established that disparities exist for colorectal cancer (CRC) incidence rates and death. With screening, death from CRC may be considered a preventable occurrence. Endoscopy (flexible sigmoidoscopy and colonoscopy) is the only modality with therapeutic benefit of removal of pre-cancerous polyps. The Patient Protection and Affordable Care Act mandated that preventive screening services be covered, which includes endoscopy for colon cancer screening. Recent federal rules have eliminated cost sharing for polyp removal during screening colonoscopy in privately insured patients; however, this has not been mandated for Medicare patients. Understanding the current state of disparities in endoscopy use is important, as these policy changes will affect millions of patients. The purpose of this literature review was to summarize the known research on disparities in endoscopy use for colon cancer screening in the United States and highlight areas for future research.

Geographic residency status and census tract socioeconomic status as determinants of colorectal cancer outcomes

OBJECTIVES

We examined the impact of geographic residency status and census tract (CT)-level socioeconomic status (SES) on colorectal cancer (CRC) outcomes.

METHODS

This was a retrospective cohort study of patients diagnosed with CRC in Georgia for the years 2000 through 2007. Study outcomes were late-stage disease at diagnosis, receipt of treatment, and survival.

RESULTS

For colon cancer, residents of lower-middle-SES and low-SES census tracts had decreased odds of receiving surgery. Rural, lower-middle-SES, and low-SES residents had decreased odds of receiving chemotherapy. For patients with rectal cancer, suburban residents had increased odds of receiving radiotherapy, but low SES resulted in decreased odds of surgery. For survival, rural residents experienced a partially adjusted 14% (hazard ratio [HR] = 1.14; 95% confidence interval [CI] = 1.07, 1.22) increased risk of death following diagnosis of CRC that was somewhat explained by treatment differences and completely explained by CT-level SES. Lower-middle- and low-SES participants had an adjusted increased risk of death following diagnosis for CRC (lower-middle: HR = 1.16; 95% CI = 1.10, 1.22; low: HR = 1.24; 95% CI = 1.16, 1.32).

CONCLUSIONS

Future efforts should focus on developing interventions and policies that target rural residents and lower SES areas to eliminate disparities in CRC-related outcomes.

Reducing racial and ethnic disparities in colorectal cancer screening is likely to require more than access to care

Colorectal endoscopy, an effective screening intervention for colorectal cancer, is recommended for people age fifty or older, or earlier for those at higher risk. Rates of colorectal endoscopy are still far below those recommended by the US Preventive Services Task Force. This study examined whether factors such as the supply of gastroenterologists and the proportion of the local population without health insurance coverage were related to the likelihood of having the procedure, and whether these factors explained racial and ethnic differences in colorectal endoscopy. We found evidence that improving access to health care at the county and individual levels through expanded health insurance coverage could improve colorectal endoscopy use but might not be sufficient to reduce racial and ethnic disparities in colorectal cancer screening. Policy action to address these disparities will need to consider other structural and cultural factors that may be inhibiting colorectal cancer screening.

Characteristics of colorectal cancer survival in an urban county hospital

PURPOSE

Disparities in colorectal cancer (CRC) survival have been associated with race/ethnicity, screening, and insurance status, but less is known about how geographic and socioeconomic heterogeneity may modulate these factors. We examined CRC outcomes in an urban underserved population with sociodemographic factors distinctly different than those previously studied.

METHODS

In this 11-year retrospective study, the demographics and clinical features of 331 CRC patients from a Northern California urban county hospital were reviewed. Cox proportional hazards modeling was used to evaluate differences in 5-year mortality.

RESULTS

The study cohort consisted of 38 % Whites, 37 % Asians, 22 % Hispanics, and 4 % Blacks. Most of the patients either had government-sponsored insurance (62.5 %) or were uninsured (21.8 %). Compared to national SEER data, stage IV disease was more prevalent in our study cohort (37 vs 20 %) and the overall 5-year survival rate was worse (52.9 vs 64.3 %). CRC screening was associated with improved survival (hazard ratio (HR) 0.24, P=0.002), while insurance status was not. In the multivariate analysis, advanced age (HR 2.48, confidence interval (CI) 1.39-4.42, P=0.002) and late stage (stage IV: HR 32.46, CI 9.92-106.25, P<0.001) predicted worse outcomes. Contrary to some population-based studies, Hispanics in our cohort had significantly better overall mortality compared to Whites (HR 0.46, CI 0.29-0.74, P=0.001).

CONCLUSIONS

Disparities in CRC outcomes for urban underserved populations persist. However, there is geographic and socioeconomic heterogeneity in factors that have been previously shown to contribute to mortality. Screening and therapeutic strategies formulated from larger population-based studies may not be generalizable to these unique subpopulations.

The modifying effect of patient location on stage-specific survival following colorectal cancer using geosurvival models

Colorectal cancer (CRC) is the third leading cause of cancer death in the US, and stage at diagnosis is the primary prognostic factor. To date, the interplay between geographic place and individual characteristics such as cancer stage with CRC survival is unexplored. We used a Bayesian geosurvival statistical model to evaluate whether the spatial patterns of CRC survival at the census tract level varies by stage at diagnosis (in situ/local, regional, distant), controlling for patient characteristics, surveillance test use, and treatment using linked 1991-2005 SEER-Medicare data of patients ≥ 66 years old in two US metropolitan areas. The spatial pattern of survival varied by stage at diagnosis for both cancer sites and registries. Significant spatial effects were identified in all census tracts for colon cancer and the majority of census tracts for rectal cancer. Geographic disparities appeared to be highest for distant-stage rectal cancer. Compared to those with in situ/local stage in the same census tracts, patients with distant-stage cancer were at most 7.73 times and 4.69 times more likely to die of colon and rectal cancer, respectively. Moreover, frailty areas for CRC at in situ/local stage more likely have a higher relative risk at regional stage, but not at distant stage. We identified geographic areas with excessive risk of CRC death and demonstrated that spatial patterns varied by both cancer type and cancer stage. More research is needed to understand the moderating pathways between geographic and individual-level factors on CRC survival.

Predictors of colorectal cancer testing using the California Health Inventory Survey

AIM: To identify key variables associated with colon cancer testing using the 2009 California Health Inventory Survey (CHIS).

METHODS: The CHIS has been conducted biennially since 2001 using a two-stage, geographically stratified random-digit-dial sample design to produce a representative sample of the entire State. For this study we used survey data from 2001-2009 inclusive. We restricted our analysis to White, Black, and Hispanic/Latinos aged 50-80 years. Weighted data was used to calculate the proportion of participants who underwent some form of colon cancer testing (colonoscopy, flexible sigmoidoscopy or fecal occult blood testing) within the previous 5 years stratified by race/ethnicity. For inferential analysis, boot-strapping with replacement was performed on the weighted sample to attain variance estimates at the 95%CI. For mean differences among categories we used t-tests and for comparisons of categorical data we used Pearson’s χ². Binary logistic regression was used to identify independent variables associated with undergoing some form of testing. Trend analysis was performed to determine rates of testing over the study period stratified by race.

RESULTS: The CHIS database for 2009 had 30 857 unique respondents corresponding to a weighted sample size of 10.6 million Californians. Overall, 63.0% (63.0-63.1) underwent a colon cancer test within the previous 5 years; with 70.5% (70.5%-70.6%) of this subset having undergone colonoscopy. That is 44.5% (44.4%-44.5%) of all individuals 50-80 underwent colonoscopy. By multivariable regression, those tested were more likely to be male (OR = 1.06; 95%CI: 1.06-1.06), Black (OR = 1.30; 95%CI: 1.30-1.31), have a family member with colon cancer (OR = 1.71; 95%CI: 1.70-1.72), and have health insurance (OR = 2.71; 95%CI: 2.70-2.72). Progressive levels above the poverty line were also associated with receiving a test (100%-199%: 1.21; 1.20-1.21), (200%-299%:1.41; 1.40-1.42), (> 300:1.69; 1.68-1.70). The strongest variable was physician recommendation (OR = 3.90; 95%CI: 3.88-3.91). For the Hispanic/Latino group, additional variables associated with testing were success of physician-patient communication (OR = 2.44; 95%CI: 2.40-2.48) and naturalized citizenship status (OR = 1.91; 95%CI: 1.89-1.93). Trend analysis demonstrated increased colon cancer testing for all racial/ethnic subgroups from 2001-2009 although the rate remained considerably lower for the Hispanic/Latino subgroup.

CONCLUSION: Using CHIS we identified California citizens most likely to undergo colon cancer testing. The strongest variable associated with testing for all groups was physician recommendation.

No patients left behind: a systematic review of the cultural equivalence of distress screening instruments

Despite the widespread use of distress screening instruments in cancer care, the reliability and validity of these instruments for a diverse population of cancer patients have not been well established. This is a systematic review of the conceptual and statistical equivalence of screening instruments of 148 psycho-oncology studies that included distress screening instruments. The findings indicate that screening measures of distress have comparable reliability, sensitivity, and specificity for White, Latino, and Asian samples. However, it is unclear if equivalent psychometrics are found among minority ethnic groups (e.g., African American) and immigrants within countries. Given the ethnic diversity among cancer patients and the lack of representation of this diversity in the current research, it is critical that researchers begin to include cancer patients of minority ethnic/racial groups in their samples so that health care providers can screen for distress with cultural sensitivity.

Regional, racial, and gender differences in colorectal cancer screening in middle-aged African-Americans and Whites

African-Americans have higher incidence and mortality from colorectal cancer than non-African-Americans. Early detection with colorectal cancer (CRC) screening reduces untimely death because the test can detect abnormalities and precancerous polyps in the colon and rectum. However, African-Americans aged 50 and older continue to have low CRC screening adherence. A retrospective analysis was conducted on data from the 2010 National Health Interview Survey to examine trends in self-reported CRC screening by geographic region, race, and gender. African-Americans, particularly men, were less likely to have been screened for colon cancer compared to all races and genders in this study. Individuals in the south were more likely to receive CRC screening than other regions. Colon cancer education and interventions are needed among low-adherent groups to promote the benefits of early detection with CRC screening.

Regional variation of racial disparities in mental health service use among older adults

PURPOSE

Given the paucity of research on the role of geography in mental health care, this study examined whether racial differences in mental health service use varied across geographic regions among older adults.

DESIGN AND METHODS

Drawn from the Collaborative Psychiatric Epidemiology Surveys (CPES), blacks (n = 1,008) and whites (n = 1,870) aged 60 and older were selected for analysis. Logistic regression analyses were conducted.

RESULTS

Results showed significant racial disparities in mental health service use in the overall sample, as well as significant variation by region. Although no racial differences were observed in the Northeast, West, or Midwest regions, black elders in the South were significantly less likely than whites to use mental health services (odds ratios [OR], 2.08; 95% confidence interval [CI], 1.34-3.23).

IMPLICATIONS

The findings suggest that improving the access to mental health care in certain regions, the South in particular, may be essential to reduce racial disparities at the national level. Policy implications are discussed.

Inequities in access to pediatric epilepsy surgery: a bioethical framework

Epilepsy is a common childhood condition associated with a considerable medical and psychosocial burden. Children in whom medical treatment fails to reduce seizure burden represent an especially vulnerable patient population because prolonged, uncontrolled seizures are associated with poor developmental and neurocognitive outcomes. Surgical treatment in the form of cortical resection, functional disconnection, or neuromodulation may alleviate or significantly reduce the disease burden for a subset of these patients. However, there remains a dichotomy between the perceived benefits of surgery and the implementation of surgical strategies in the management of medically intractable epilepsy. The current paper presents an analysis of the bioethical implications of existing inequities in access to pediatric epilepsy surgery that result from inconsistent referral practices and discrepant evaluation techniques. The authors provide a basic bioethical framework composed of 5 primary expectations to inform public, institutional, and personal policies toward the provision of epilepsy surgery to afflicted children.

Prevalence of nontuberculous mycobacterial lung disease in U.S. Medicare beneficiaries

RATIONALE

Pulmonary nontuberculous mycobacteria (PNTM) are an important cause of morbidity among older adults in the United States, but national prevalence estimates are lacking.

OBJECTIVES

To describe the prevalence and trends of PNTM disease among adults aged 65 years or older throughout the United States.

METHODS

A nationally representative 5% sample of Medicare Part B beneficiaries was analyzed from 1997 to 2007. Demographic and medical claims data were compiled and prevalence estimates for PNTM and selected comorbidities were calculated and trends over time evaluated. Logistic regression was used to identify demographic and geographic factors associated with PNTM.

MEASUREMENTS AND MAIN RESULTS

From 1997 to 2007, the annual prevalence significantly increased from 20 to 47 cases/100,000 persons, or 8.2% per year. The period prevalence was 112 cases/100,000 persons, although prevalence was twofold higher among Asians/Pacific Islanders than among whites (228 vs. 116 cases/100,000 persons). Western states had the highest period prevalence at 149 cases/100,000 persons, with Hawaii having the highest prevalence at 396 cases/100,000 persons, followed by southeastern states, which had a period prevalence of 131 cases/100,000 persons. PNTM cases had more comorbid conditions than noncases and were 40% more likely to die than noncases. Women were 1.4 times more likely to be a PNTM case than men. Relative to whites, Asians/Pacific Islanders were twice as likely to be a case, whereas blacks were half as likely.

CONCLUSIONS

The prevalence of PNTM is increasing across all regions of the United States and among both men and women. Significant racial/ethnic and geographic differences suggest important gene-environment interactions.

Primary care colorectal cancer screening recommendation patterns: associated factors and screening outcomes

BACKGROUND

The relationship of a primary care provider's (PCP's) colorectal cancer (CRC) screening strategies to completion of screening is poorly understood.

OBJECTIVE

To describe PCP test recommendation patterns and associated factors and their relationship to patient test completion.

DESIGN

This cross-sectional study used a PCP survey, in-depth PCP interviews, and electronic medical records.

SETTING

Kaiser Permanente Northwest health maintenance organization.

PARTICIPANTS

Participants included 132 PCPs and 49,259 eligible patients aged 51 to 75.

MEASUREMENTS

The authors grouped PCPs by patterns of CRC screening recommendations based on reported frequency of recommending fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), and colonoscopy. They then compared PCP demographics, reported CRC screening test influences, concerns, decision-making and counseling processes, and actual rates of patient CRC screening completion by PCP group.

RESULTS

The authors identified 4 CRC screening recommendation groups: a "balanced" group (n = 54; 40.9%) that recommended the tests nearly equally, an FOBT group (n = 31; 23.5%) that largely recommended FOBT, an FOBT + FS group (n = 25; 18.9%), and a colonoscopy + FOBT group (n = 22; 16.7%) that recommended these tests nearly equally. Internal medicine (v. family medicine) PCPs were more common in groups more frequently recommending endoscopy. The FOBT and FOBT + FS groups were most influenced by clinical guidelines. Groups recommending more endoscopy were most concerned that FOBT generates a relatively high number of false positives and FOBT can miss cancers. The FOBT and FOBT + FS groups were more likely to recommend a specific screening strategy compared to the colonoscopy + FOBT and balanced groups, which were more likely to let the patient decide. CRC screening rates were 63.9% balanced, 62.9% FOBT, 61.7% FOBT + FS, and 62.2% colonoscopy + FOBT; rates did not differ significantly by group.

LIMITATIONS

Small numbers within PCP groups.

CONCLUSIONS

Specialty, the influence of guidelines, test concerns, and the "jointness" of the test selection decision distinguished CRC screening recommendation patterns. All patterns were associated with similar overall screening rates.

Colonoscopist and primary care physician supply and disparities in colorectal cancer screening

OBJECTIVE. : To determine whether racial/ethnic disparities in colonoscopy use vary by physician availability. DATA SOURCE. : We used 100 percent Texas Medicare claims data for 2003-2007. STUDY DESIGN. : We identified beneficiaries aged 66-79 in 2007, examined racial/ethnic differences in colonoscopy use from 2003 to 2007, and estimated the percentage of white, black, and Hispanic beneficiaries who underwent colonoscopy by level of physician availability and area income. PRINCIPAL FINDINGS. : For the 974,879 beneficiaries, colonoscopy use was higher in whites (40.7 percent) compared to blacks (35.0 percent) and Hispanics (28.7 percent, p< .001). For whites, increasing availability of colonoscopists and primary care physicians (PCPs) was associated with higher colonoscopy use. For blacks and Hispanics, colonoscopy use was unchanged or decreased with increases in colonoscopist and PCP availability. In multilevel models, the odds of colonoscopy were 20 percent lower for blacks (OR 0.80, 95 percent CI 0.79-0.82) and 32 percent lower for Hispanics (OR 0.68, 95 percent CI 0.66-0.69) compared to whites; adjusting for availability of colonoscopists or PCPs did not attenuate racial/ethnic disparities. We found greater racial/ethnic disparities in areas with greater colonoscopist and PCP availability. CONCLUSIONS. : Greater area availability of colonoscopists and PCPs is associated with increased use of colonoscopy in whites but decreased use in minorities, resulting in larger racial/ethnic disparities.

Colonoscopist and primary care physician supply and disparities in colorectal cancer screening

OBJECTIVE. : To determine whether racial/ethnic disparities in colonoscopy use vary by physician availability. DATA SOURCE. : We used 100 percent Texas Medicare claims data for 2003-2007. STUDY DESIGN. : We identified beneficiaries aged 66-79 in 2007, examined racial/ethnic differences in colonoscopy use from 2003 to 2007, and estimated the percentage of white, black, and Hispanic beneficiaries who underwent colonoscopy by level of physician availability and area income. PRINCIPAL FINDINGS. : For the 974,879 beneficiaries, colonoscopy use was higher in whites (40.7 percent) compared to blacks (35.0 percent) and Hispanics (28.7 percent, p< .001). For whites, increasing availability of colonoscopists and primary care physicians (PCPs) was associated with higher colonoscopy use. For blacks and Hispanics, colonoscopy use was unchanged or decreased with increases in colonoscopist and PCP availability. In multilevel models, the odds of colonoscopy were 20 percent lower for blacks (OR 0.80, 95 percent CI 0.79-0.82) and 32 percent lower for Hispanics (OR 0.68, 95 percent CI 0.66-0.69) compared to whites; adjusting for availability of colonoscopists or PCPs did not attenuate racial/ethnic disparities. We found greater racial/ethnic disparities in areas with greater colonoscopist and PCP availability. CONCLUSIONS. : Greater area availability of colonoscopists and PCPs is associated with increased use of colonoscopy in whites but decreased use in minorities, resulting in larger racial/ethnic disparities.