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Joshu CE, Calkins KL, Rudolph JE, Xu X, Wentz E, Coburn SB, Kaur M, Pirsl F, Moore RD, Lau B. Lower endoscopy, early-onset, and average-onset colon cancer among Medicaid beneficiaries with and without HIV. AIDS 2024; 38:85-94. [PMID: 37788111 PMCID: PMC10841159 DOI: 10.1097/qad.0000000000003740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
BACKGROUND Studies suggest a lower colorectal cancer (CRC) risk and lower or similar CRC screening among people with HIV (PWH) compared with the general population. We evaluated the incidence of lower endoscopy and average-onset (diagnosed at ≥50) and early-onset (diagnosed at <50) colon cancer by HIV status among Medicaid beneficiares with comparable sociodemographic factors and access to care. METHODS We obtained Medicaid Analytic eXtract (MAX) data from 2001 to 2015 for 14 states. We included 41 727 243 and 42 062 552 unique individuals with at least 7 months of continuous eligibility for the endoscopy and colon cancer analysis, respectively. HIV and colon cancer diagnoses and endoscopy procedures were identified from inpatient and other nondrug claims. We used Cox proportional hazards regression models to assess endoscopy and colon cancer incidence, controlling for age, sex, race/ethnicity, calendar year and state of enrollment, and comorbidities conditions. RESULTS Endoscopy and colon cancer incidence increased with age in both groups. Compared with beneficiaries without HIV, PWH had an increased hazard of endoscopy; this association was strongest among those 18-39 years [hazard ratio: 1.85, 95% confidence interval (95% CI) 1.77-1.92] and attenuated with age. PWH 18-39 years also had increased hazard of early-onset colon cancer (hazard ratio: 1.66, 95% CI:1.05-2.62); this association was attenuated after comorbidity adjustment. Hazard ratios were null among all beneficiaries less than 50 years of age. PWH had a lower hazard of average-onset colon cancer compared with those without HIV (hazard ratio: 0.79, 95% CI: 0.66-0.94). CONCLUSION PWH had a higher hazard of endoscopy, particularly at younger ages. PWH had a lower hazard of average-onset colon cancer. Early-onset colon cancer was higher among the youngest PWH but not associated with HIV overall.
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Affiliation(s)
- Corinne E Joshu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
- Department of Oncology, Johns Hopkins University School of Medicine
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Keri L Calkins
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
- Mathematica, Ann Arbor, Michigan
| | | | - Xiaoqiang Xu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eryka Wentz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Sally B Coburn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Maneet Kaur
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Filip Pirsl
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
| | - Richard D Moore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health
- Department of Oncology, Johns Hopkins University School of Medicine
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Bissig S, Syrogiannouli L, Schneider R, Tal K, Selby K, Del Giovane C, Bulliard JL, Senn O, Ducros C, Schmid CP, Marbet U, Auer R. Change in colorectal cancer (CRC) testing rates associated with the introduction of the first organized screening program in canton Uri, Switzerland: Evidence from insurance claims data analyses from 2010 to 2018. Prev Med Rep 2022; 28:101851. [PMID: 35757577 PMCID: PMC9218582 DOI: 10.1016/j.pmedr.2022.101851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
First colorectal cancer (CRC) screening program in Switzerland launched in one canton in 2013. Launched in the context of high prevalent opportunistic CRC testing. Led to an increase in fecal occult blood testing and not colonoscopy. Claims data analyses enable estimating the net effect of programs in general population.
The first canton in Switzerland to implement an organized colorectal cancer screening program (OSP) was Uri. Starting in 2013, it offered 50–69-year-olds free testing with colonoscopy every 10 years or fecal occult blood test (FOBT) every 2 years. We tested the association between the OSP and testing rates over time. We analyzed claims data of 50–69-year-olds from Uri and neighboring cantons (NB) provided by a large health insurance and complemented it with data from the OSP. We fitted multivariate adjusted logistic regression models to compare overall testing rates and by method (colonoscopy or FOBT/both) We computed the 2018 rate of the population up-to-date with testing (colonoscopy within 9 years/FOBT within 2 years). Yearly overall testing rates in Uri increased from 8.7% in 2010 to 10.8% in 2018 and from 6.5% to 7.9% in NB. In Uri, the proportion tested with FOBT/both increased from 4.7% to 6.0% but decreased from 2.8% to 1.1% in NB. Testing by FOBT/both increased more between 2015 and 2018 than 2010–2012 in Uri than in NB (OR:2.1[95%CI:1.8–2.4]), it increased less for colonoscopy (OR:0.60[95%CI:0.51–0.70]), with no change in overall CRC testing (OR:0.91[95%CI:0.81–1.02]). In 2018 in Uri, 42.5% were up-to-date with testing (FOBT/both:9.2%, colonoscopy:35.7%); in NBs, 40.7% (FOBT/both:2.7%, colonoscopy:39%). Yearly FOBT rates in Uri were always higher than in NB. Though the OSP in Uri was not associated with a greater increase in overall testing rates, the OSP was associated with increased FOBT.
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Key Words
- AL, Swiss analysis list for laboratory measures
- CRC, colorectal cancer
- FOBT, gFOBT, iFOBT, fecal occult blood test, guaiac or immunochemical based (also called FIT)
- FSO, federal statistics office
- NB, neighboring cantons
- OSP, organized screening program
- PCG, pharmacy based cost groups
- SHS, swiss health survey
- TARMED, Swiss ambulant procedures codes
- Uri, the canton of Uri
- claims data
- colonoscopy
- colorectal cancer
- fecal occult blood test
- health insurance
- organized screening program
- screening
- testing rates
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Affiliation(s)
- Sarah Bissig
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | | | - Rémi Schneider
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Kali Tal
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Jean-Luc Bulliard
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University and University Hospital of Zurich, Zurich, Switzerland
| | - Cyril Ducros
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Christian P.R. Schmid
- CSS Institute for Empirical Health Economics, Tribschenstrasse 21, Lucerne, Switzerland
| | - Urs Marbet
- Division of Gastroenterology and Hepatology Cantonal Hospital of Uri, Altdorf, Switzerland
| | - Reto Auer
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- Corresponding author at: Institute of primary health care (BIHAM), University of Bern, Mittelstrasse 43, CH - 3012 Bern, Switzerland.
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Schneider R, Näpflin M, Syrogiannouli L, Bissig S, Tal K, Bulliard JL, Ducros C, Senn O, Selby K, Bähler C, Blozik E, Auer R. Change in Colorectal Cancer Tests Submitted for Reimbursement in Switzerland 2012-2018: Evidence from Claims Data of a Large Insurance. Int J Public Health 2021; 66:1604073. [PMID: 34744596 PMCID: PMC8565273 DOI: 10.3389/ijph.2021.1604073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 10/13/2021] [Indexed: 12/22/2022] Open
Abstract
Objectives: Guidelines recommend colorectal cancer (CRC) screening by fecal occult blood test (FOBT) or colonoscopy. In 2013, Switzerland introduced reimbursement of CRC screening by mandatory health insurance for 50-69-years-olds, after they met their deductible. We hypothesized that the 2013 reimbursement policy increased testing rate. Methods: In claims data from a Swiss insurance, we determined yearly CRC testing rate among 50-75-year-olds (2012–2018) and the association with socio-demographic, insurance-, and health-related covariates with multivariate-adjusted logistic regression models. We tested for interaction of age (50–69/70–75) on testing rate over time. Results: Among insurees (2012:355′683; 2018:348′526), yearly CRC testing rate increased from 2012 to 2018 (overall: 8.1–9.9%; colonoscopy: 5.0–7.6%; FOBT: 3.1–2.3%). Odds ratio (OR) were higher for 70–75-year-olds (2012: 1.16, 95%CI 1.13–1.20; 2018: 1.05, 95%CI 1.02–1.08). Deductible interacted with changes in testing rate over time (p < 0.001). The increase in testing rate was proportionally higher among 50-69-years-olds than 70-75-year-olds over the years. Conclusions: CRC testing rate in Switzerland increased from 2012 to 2018, particularly among 50-69-years-olds, the target population of the 2013 law. Future studies should explore the effect of encouraging FOBT or waiving deductible.
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Affiliation(s)
- Rémi Schneider
- Berner Institut für Hausarztmedizin, Medizinische Fakultät, Universität Bern, Bern, Switzerland
| | - Markus Näpflin
- Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland
| | - Lamprini Syrogiannouli
- Berner Institut für Hausarztmedizin, Medizinische Fakultät, Universität Bern, Bern, Switzerland
| | - Sarah Bissig
- Berner Institut für Hausarztmedizin, Medizinische Fakultät, Universität Bern, Bern, Switzerland
| | - Kali Tal
- Berner Institut für Hausarztmedizin, Medizinische Fakultät, Universität Bern, Bern, Switzerland
| | - Jean-Luc Bulliard
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Cyril Ducros
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Oliver Senn
- Institut für Hausarztmedizin, Universitätsklinikum Zürich, Zürich, Switzerland
| | - Kevin Selby
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Caroline Bähler
- Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland
| | - Reto Auer
- Berner Institut für Hausarztmedizin, Medizinische Fakultät, Universität Bern, Bern, Switzerland
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Mojica CM, Lind B, Gu Y, Coronado GD, Davis MM. Predictors of Colorectal Cancer Screening Modality Among Newly Age-Eligible Medicaid Enrollees. Am J Prev Med 2021; 60:72-79. [PMID: 33223363 PMCID: PMC8493888 DOI: 10.1016/j.amepre.2020.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This study examines individual- and practice-level predictors of screening modality among 1,484 Medicaid enrollees who initiated colorectal cancer screening (fecal immunochemical test/fecal occult blood tests or colonoscopy) within a year of turning age 50 years. Understanding screening modality patterns for patients and health systems can help optimize colorectal cancer screening initiatives that will lead to high screening completion rates. METHODS Multivariable logistic regression was conducted in 2019 to analyze Medicaid claims data (January 2013-June 2015) to explore predictors of colonoscopy screening (versus fecal testing). RESULTS Overall, 64% of enrollees received a colonoscopy and 36% received a fecal immunochemical test/fecal occult blood test. Male (OR=1.21, 95% CI=1.08, 1.37) compared with female enrollees and those with 4-6 (OR=1.57, 95% CI=1.15, 2.15), 7-10 (OR=2.23, 95% CI=1.64, 3.03), and ≥11 (OR=1.79, 95% CI=1.22, 2.65) primary care visits compared with 0-3 visits had higher odds of colonoscopy screening. Non-White, non-Hispanic enrollees (OR=0.71, 95% CI=0.58, 0.87) compared with White, non-Hispanics Whites had lower odds of colonoscopy screening. Practices with an endoscopy facility within their ZIP code (OR=1.50, 95% CI=1.08, 2.08) compared with practices without a nearby endoscopy facility had higher odds of colonoscopy screening. CONCLUSIONS Among newly age-eligible Medicaid enrollees who received colorectal cancer screening, non-White, non-Hispanic individuals were less likely and male enrollees and those with ≥4 primary care visits were more likely to undergo colonoscopy versus fecal immunochemical test/fecal occult blood test. Colonoscopy also was the more common modality among adults whose primary care clinic had an endoscopy facility in the same ZIP code. Future research is needed to fully understand patient, provider, and practice preferences regarding screening modality.
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Affiliation(s)
- Cynthia M Mojica
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon.
| | - Bonnie Lind
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | - Yifan Gu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | | | - Melinda M Davis
- Department of Family Medicine, School of Public Health, Oregon Health & Science University, Portland, Oregon; 5Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon
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Mojica CM, Bradley SM, Lind BK, Gu Y, Coronado GD, Davis MM. Initiation of Colorectal Cancer Screening Among Medicaid Enrollees. Am J Prev Med 2020; 58:224-231. [PMID: 31786031 PMCID: PMC7359742 DOI: 10.1016/j.amepre.2019.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Few studies have explored how individual- and practice-level factors influence colorectal cancer screening initiation among Medicaid enrollees newly age eligible for colorectal cancer screening (i.e., turning 50 years). This study explored colorectal cancer screening initiation among newly age-eligible Medicaid enrollees in Oregon. METHODS Medicaid claims data (January 2013 to June 2015) were used to conduct multivariable logistic regression (in 2018 and 2019) to explore individual- and practice-level factors associated with colorectal cancer screening initiation among 9,032 Medicaid enrollees. RESULTS A total of 17% of Medicaid enrollees initiated colorectal cancer screening; of these, 64% received a colonoscopy (versus fecal testing). Colorectal cancer screening initiation was positively associated with turning 50 years in 2014 (versus 2013; OR=1.21), being Hispanic (versus non-Hispanic white; OR=1.41), urban residence (versus rural; OR=1.23), and having 4 to 7 (OR=1.90) and 8 or more (OR=2.64) primary care visits compared with 1 to 3 visits in the year after turning 50 years. Having 3 or more comorbidities was inversely associated with initiation (OR=0.75). The odds of screening initiation were also higher for practices with 3 to 4 (OR=1.26) and 8 or more (OR=1.34) providers compared with 1 to 2 providers, and negatively associated with percentage of Medicaid panel age eligible for colorectal cancer screening (OR=0.92). CONCLUSIONS Both individual- and practice-level factors are associated with disparities in colorectal cancer screening initiation among Oregon Medicaid enrollees. Future work promoting colorectal cancer screening might focus on additional barriers to the timely initiation of colorectal cancer screening and explore the effect of practice in-reach and population outreach strategies.
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Affiliation(s)
- Cynthia M Mojica
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon.
| | - Savannah M Bradley
- Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Bonnie K Lind
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | - Yifan Gu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | | | - Melinda M Davis
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon; Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon; Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon
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Witwer E, Baldwin LM, Cole A. Qualitative Assessment of Washington State Medicaid Health Plan Readiness to Implement Systems-Based Approaches to Colorectal Cancer Screening. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 56:46958019880743. [PMID: 31596155 PMCID: PMC6785922 DOI: 10.1177/0046958019880743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Implementation of population-based colorectal cancer screening programs by
Medicaid health plans could address colorectal cancer screening disparities. Our
objective is to identify facilitators and barriers to implementation of a
population-based colorectal cancer screening program by Washington State
Medicaid health plans. We conducted semi-structured interviews with leadership
from 2 statewide and 3 national Medicaid plans. We organized the interview
questions around the Consolidated Framework for Implementation Research (CFIR).
We analyzed interview transcripts, guided by directed content analysis, and
identified facilitators and barriers to Medicaid health plan implementation of
population-based colorectal cancer screening programs. Robust health plan (inner
setting) quality improvement infrastructures were facilitators. Lack of
statewide Medicaid policy incentives (external setting) to increase colorectal
cancer screening were barriers to potential implementation. Efforts to address
identified barriers through local and national policies and statewide data
sharing efforts may support Medicaid health plan implementation of
population-based colorectal cancer screening programs.
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O’Leary MC, Lich KH, Gu Y, Wheeler SB, Coronado GD, Bartelmann SE, Lind BK, Mayorga ME, Davis MM. Colorectal cancer screening in newly insured Medicaid members: a review of concurrent federal and state policies. BMC Health Serv Res 2019; 19:298. [PMID: 31072316 PMCID: PMC6509857 DOI: 10.1186/s12913-019-4113-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/22/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) screening is underutilized by Medicaid enrollees and the uninsured. Multiple national and state policies were enacted from 2010 to 2014 to increase access to Medicaid and to promote CRC screening among Medicaid enrollees. We aimed to determine the impact of these policies on screening initiation among newly enrolled Oregon Medicaid beneficiaries age-eligible for CRC screening. METHODS We identified national and state policies affecting Medicaid coverage and preventive services in Oregon during 2010-2014. We used Oregon Medicaid claims data from 2010 to 2015 to conduct a cohort analysis of enrollees who turned 50 and became age-eligible for CRC screening (a prevention milestone, and an age at which guideline-concordant screening can be assessed within a single year) during each year from 2010 to 2014. We calculated risk ratios to assess whether first year of Medicaid enrollment and/or year turned 50 was associated with CRC screening initiation. RESULTS We identified 14,576 Oregon Medicaid enrollees who turned 50 during 2010-2014; 2429 (17%) completed CRC screening within 12 months after turning 50. Individuals newly enrolled in Medicaid in 2013 or 2014 were 1.58 and 1.31 times more likely, respectively, to initiate CRC screening than those enrolled by 2010. A primary care visit in the calendar year, having one or more chronic conditions, and being Hispanic was also associated with CRC screening initiation. DISCUSSION The increased uptake of CRC screening in 2013 and 2014 is associated with the timing of policies such as Medicaid expansion, enhanced federal matching for preventive services offered to Medicaid enrollees without cost sharing, and formation of Medicaid accountable care organizations, which included CRC screening as an incentivized quality metric.
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Affiliation(s)
- Meghan C. O’Leary
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC 27599 USA
| | - Kristen Hassmiller Lich
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC 27599 USA
| | - Yifan Gu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR USA
| | - Stephanie B. Wheeler
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC 27599 USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
- Center for Health Promotion & Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | | | | | - Bonnie K. Lind
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR USA
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR USA
| | - Maria E. Mayorga
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC USA
| | - Melinda M. Davis
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR USA
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR USA
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Cole AP, Krasnova A, Ramaswamy A, Fletcher SA, Friedlander DF, McNabb-Baltar J, Melnitchouk N, Lipsitz SR, Sun M, Kibel AS, Golshan M, Haider AH, Weissman JS, Trinh QD. Recommended Cancer Screening in Accountable Care Organizations: Trends in Colonoscopy and Mammography in the Medicare Shared Savings Program. J Oncol Pract 2019; 15:e547-e559. [PMID: 30998420 DOI: 10.1200/jop.18.00352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Accountable care organizations (ACOs) are a delivery and payment model designed to encourage integrated, high-value care. We designed a study to test the association between ACOs and two recommended cancer screening tests, colonoscopy for colorectal cancer and mammography for breast cancer. METHODS Using the random 20% sample of Medicare claims, beneficiaries were attributed to ACO or non-ACO cohorts on the basis of providers' enrollment in the Medicare Shared Savings Program. An inverse probability of treatment weighting was used to balance patient characteristics between ACO and non-ACO cohorts. A propensity score-weighted, difference-in-differences analysis was then performed using the same provider groups in 2010-pre-ACO-as a baseline. A secondary analysis for older-nonrecommended-age ranges was performed. RESULTS Prevalence of colonoscopy in recommended age ranges in ACOs from 2010 to 2014 increased from 15.3% (95% CI, 14.9% to 15.6%) to 17.9% (95% CI, 17.3% to 18.5%). This differed significantly from the change in non-ACOs (difference in differences, 1.2%; P < .001). Among women in ACOs, mammography prevalence rose from 53.7% (95% CI, 53.0% to 54.4%) to 54.9% (95% CI, 54.2% to 55.7%). In contrast to colonoscopy, the difference in mammography prevalence was not significantly different in ACO versus non-ACOs (difference in differences, 0.49%; P < .13). A similar pattern was also observed in older-nonrecommended-age ranges with significant difference in differences (ACO v non-ACO) in colonoscopy, but not mammography. CONCLUSION The impact of ACOs on cancer screening varies between screening tests. Our results are consistent with a greater effect of ACOs on high-cost, high-complexity screening services, which may be more sensitive to integrated care delivery models.
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Affiliation(s)
| | | | - Ashwin Ramaswamy
- 1 Brigham and Women's Hospital, Boston, MA.,2 Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - Sean A Fletcher
- 1 Brigham and Women's Hospital, Boston, MA.,2 Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | | | | | | | | | - Maxine Sun
- 1 Brigham and Women's Hospital, Boston, MA.,2 Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - Adam S Kibel
- 1 Brigham and Women's Hospital, Boston, MA.,2 Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | - Mehra Golshan
- 1 Brigham and Women's Hospital, Boston, MA.,2 Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
| | | | | | - Quoc-Dien Trinh
- 1 Brigham and Women's Hospital, Boston, MA.,2 Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
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Doria-Rose VP, Kamineni A, Barrett MJ, Ko CW, Weiss NS. Case-Control Studies of the Efficacy of Screening Tests That Seek to Prevent Cancer Incidence: Results of an Approach That Utilizes Administrative Claims Data That Do Not Provide Information Regarding Test Indication. Am J Epidemiol 2019; 188:703-708. [PMID: 30698635 DOI: 10.1093/aje/kwy274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 01/01/2023] Open
Abstract
Case-control studies evaluating a screening test's efficacy in reducing cancer mortality require accurate classification of test indication to obtain a valid result. However, for analogous studies of cancer incidence, determination of test indication is not as critical because, to define exposure, we need consider only tests that can identify precursor lesions whose treatment might prevent cancer, not tests leading to cancer diagnosis. This study utilizes US Surveillance, Epidemiology, and End Results (SEER)-Medicare data, which do not include information about colonoscopy indication, to evaluate the efficacy of colonoscopy in preventing colorectal cancer (CRC) incidence. Cases were Medicare enrollees diagnosed with CRC between 1996 and 2013; up to 3 controls were matched to each case. Colonoscopy receipt prior to presumed onset of occult cancer was associated with an approximately 60% reduction in CRC incidence (odds ratio = 0.41, 95% confidence interval: 0.40, 0.42). The association was robust to differing exposure windows and estimates of occult cancer duration and is similar to those from CRC incidence studies in which exam indication was available. Our results suggest that, when it is impractical/impossible to determine whether tests were conducted for screening, the efficacy of a test in preventing cancer incidence can still be estimated using a case-control study design.
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Affiliation(s)
- V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | - Cynthia W Ko
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Noel S Weiss
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
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Davis MM, Shafer P, Renfro S, Hassmiller Lich K, Shannon J, Coronado GD, McConnell KJ, Wheeler SB. Does a transition to accountable care in Medicaid shift the modality of colorectal cancer testing? BMC Health Serv Res 2019; 19:54. [PMID: 30665396 PMCID: PMC6341697 DOI: 10.1186/s12913-018-3864-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/28/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Health care reform is changing preventive services delivery. This study explored trajectories in colorectal cancer (CRC) testing over a 5-year period that included implementation of 16 Medicaid Accountable Care Organizations (ACOs, 2012) and Medicaid expansion (2014) - two provisions of the Affordable Care Act (ACA) - within the state of Oregon, USA. METHODS Retrospective analysis of Oregon's Medicaid claims for enrollee's eligible for CRC screening (50-64 years) spanning January 2010 through December 2014. Our analysis was conducted and refined April 2016 through June 2018. The analysis assessed the annual probability of patients receiving CRC testing and the modality used (e.g., colonoscopy, fecal testing) relative to a baseline year (2010). We hypothesized that CRC testing would increase following Medicaid ACO formation - called Coordinated Care Organizations (CCOs). RESULTS A total of 132,424 unique Medicaid enrollees (representing 255,192 person-years) met inclusion criteria over the 5-year study. Controlling for demographic and regional factors, the predicted probability of CRC testing was significantly higher in 2014 (+ 1.4 percentage points, p < 0.001) compared to the 2010 baseline but not in 2012 or 2013. Increased fecal testing using Fecal Occult Blood Tests (FOBT) or Fecal Immunochemical Tests (FIT) played a prominent role in 2014. The uptick in statewide fecal testing appears driven primarily by a subset of CCOs. CONCLUSIONS Observed CRC testing did not immediately increase following the transition to CCOs in 2012. However increased testing in 2014, may reflect a delay in implementation of interventions to increase CRC screening and/or a strong desire by newly insured Medicaid CCO members to receive preventive care.
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Affiliation(s)
- Melinda M. Davis
- Department of Family Medicine, OHSU-PSU School of Public Health, and Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L222, Portland, OR 97239 USA
| | - Paul Shafer
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Stephanie Renfro
- Center for Health Systems Effectiveness, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Kristen Hassmiller Lich
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Jackilen Shannon
- OHSU-PSU School of Public Health, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Gloria D. Coronado
- Center for Health Research Northwest, Kaiser Permanente, 3800 N. Interstate Avenue, Portland, OR 97227-1098 USA
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239 USA
| | - Stephanie B. Wheeler
- Department of Health Policy & Management, Lineberger Comprehensive Cancer Center, and Center for Health Promotion & Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
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11
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Simkin J, Ogilvie G, Hanley B, Elliott C. Differences in colorectal cancer screening rates across income strata by levels of urbanization: results from the Canadian Community Health Survey (2013/2014). Canadian Journal of Public Health 2018; 110:62-71. [PMID: 30353502 DOI: 10.17269/s41997-018-0143-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/27/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Canadian colorectal cancer screening rates differ across income strata. In the United States, disparities across income strata worsen in rural areas. In Canada, differences in screening across income strata have not been explored by levels of urbanization. This project aimed to estimate up-to-date colorectal cancer (UTD-CRC) screening across income strata by levels of urbanization. METHODS Data from the Canadian Community Health Survey (2013/2014) were used to estimate the prevalence of UTD-CRC screening by income quintiles for Canadians aged 50-74 years. UTD-CRC screening was defined as fecal occult blood testing within 2 years or colonoscopy/sigmoidoscopy within 10 years before the survey. Levels of urbanization were defined per Statistics Canada Metropolitan Influenced Zone classifications. Weighted proportions of UTD-CRC screening were calculated and logistic regression was used to assess the effect of income by levels of urbanization. RESULTS Self-reported UTD-CRC screening prevalence among Canadians was 52.0%. UTD-CRC screening rates by income ranged from 47.8% (Q1-low) to 54.0% (Q5-high). Across all levels of urbanization, higher income was associated with increased odds of UTD-CRC screening compared to the lowest income quintile (Urban-ORQ5 = 1.49, 95% CI 1.17-1.89; Rural-ORQ5 = 1.42, 95% CI 1.02-1.99; Remote-ORQ5 = 1.54, 95% CI 1.02-2.31). Higher education (ORpost-secondary = 1.30, 95% CI 1.14-1.49), increasing age (OR70-74 = 2.88, 95% CI 2.39-3.47), and not identifying as an immigrant (OR = 1.45, 95% CI 1.19-1.75) were associated with an increased odds of UTD-CRC screening. DISCUSSION Half of Canadians report UTD-CRC screening but across levels of urbanization, higher income was associated with higher screening rates. Efforts are needed to understand and address inequities, particularly among low-income populations.
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Affiliation(s)
- Jonathan Simkin
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada. .,Department of Health and Social Services, Government of Yukon, Whitehorse, Yukon, Canada. .,Women's Health Research Institute, BC Women's Hospital + Health Centre, Room H203E, 4500 Oak Street, Vancouver, British Columbia, V6H 3N1, Canada.
| | - Gina Ogilvie
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,Women's Health Research Institute, BC Women's Hospital + Health Centre, Room H203E, 4500 Oak Street, Vancouver, British Columbia, V6H 3N1, Canada
| | - Brendan Hanley
- Department of Health and Social Services, Government of Yukon, Whitehorse, Yukon, Canada
| | - Catherine Elliott
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Health and Social Services, Government of Yukon, Whitehorse, Yukon, Canada
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12
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Slater JS, Parks MJ, Nelson CL, Hughes KD. The Efficacy of Direct Mail, Patient Navigation, and Incentives for Increasing Mammography and Colonoscopy in the Medicaid Population: A Randomized Controlled Trial. Cancer Epidemiol Biomarkers Prev 2018; 27:1047-1056. [PMID: 29891726 DOI: 10.1158/1055-9965.epi-18-0038] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/24/2018] [Accepted: 06/05/2018] [Indexed: 12/20/2022] Open
Abstract
Background: Despite lower cancer screening rates and survival rates in the Medicaid population compared with those with private insurance, there is a dearth of population-based, evidence-based interventions targeting Medicaid clients to address this problem.Methods: This study reports results of a population-based randomized controlled trial (RCT) among all individuals enrolled in Minnesota's Medicaid program who were overdue for breast cancer (n = 22,113) and/or colorectal cancer (n = 94,294) screening. Individuals were randomized to intervention or control groups. The intervention group received persuasive and innovative direct mail materials coupled with a $20 incentive for using their Medicaid benefit to get screened. Direct mail materials provided a phone number to a call center staffed by patient navigators who addressed barriers and scheduled appointments via three-way calls. The control group received the intervention 15 months later. Primary outcomes were completion of mammography or colonoscopy within 12 weeks of the intervention. Billing claims served as evidence of screening.Results: Multivariate logistic regression showed significant differences for both breast cancer (P < 0.001) and colorectal cancer (P < 0.01). The odds of receiving a mammogram for the treatment group were significantly higher than the control group [OR = 1.30; 95% confidence interval (95% CI) = 1.16-1.46], and the treatment group was more likely to receive a colonoscopy than the control group (OR = 1.12; 95% CI = 1.04-1.21).Conclusions: This population-based intervention increased breast cancer and colorectal cancer screening in a Medicaid population overdue for screening.Impact: These findings may have broad application for reaching individuals who generally remain outside the health care system despite having public health insurance. Cancer Epidemiol Biomarkers Prev; 27(9); 1047-56. ©2018 AACR.
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Affiliation(s)
- Jonathan S Slater
- Minnesota Department of Health, Cancer Control Section, St. Paul, Minnesota.
| | - Michael J Parks
- Minnesota Department of Health, Cancer Control Section, St. Paul, Minnesota
| | - Christina L Nelson
- Minnesota Department of Health, Cancer Control Section, St. Paul, Minnesota
| | - Kelly D Hughes
- Minnesota Department of Health, Cancer Control Section, St. Paul, Minnesota
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13
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Davis MM, Renfro S, Pham R, Hassmiller Lich K, Shannon J, Coronado GD, Wheeler SB. Geographic and population-level disparities in colorectal cancer testing: A multilevel analysis of Medicaid and commercial claims data. Prev Med 2017; 101:44-52. [PMID: 28506715 PMCID: PMC6067672 DOI: 10.1016/j.ypmed.2017.05.001] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 04/25/2017] [Accepted: 05/07/2017] [Indexed: 12/12/2022]
Abstract
Morbidity and mortality from colorectal cancer (CRC) can be attenuated through guideline concordant screening and intervention. This study used Medicaid and commercial claims data to examine individual and geographic factors associated with CRC testing rates in one state (Oregon). A total of 64,711 beneficiaries (4516 Medicaid; 60,195 Commercial) became newly age-eligible for CRC screening and met inclusion criteria (e.g., continuously enrolled, no prior history) during the study period (January 2010-December 2013). We estimated multilevel models to examine predictors for CRC testing, including individual (e.g., gender, insurance, rurality, access to care, distance to endoscopy facility) and geographic factors at the county level (e.g., poverty, uninsurance). Despite insurance coverage, only two out of five (42%) beneficiaries had evidence of CRC testing during the four year study window. CRC testing varied from 22.4% to 46.8% across Oregon's 36 counties; counties with higher levels of socioeconomic deprivation had lower levels of testing. After controlling for age, beneficiaries had greater odds of receiving CRC testing if they were female (OR 1.04, 95% CI 1.01-1.08), commercially insured, or urban residents (OR 1.14, 95% CI 1.07-1.21). Accessing primary care (OR 2.47, 95% CI 2.37-2.57), but not distance to endoscopy (OR 0.98, 95% CI 0.92-1.03) was associated with testing. CRC testing in newly age-eligible Medicaid and commercial members remains markedly low. Disparities exist by gender, geographic residence, insurance coverage, and access to primary care. Work remains to increase CRC testing to acceptable levels, and to select and implement interventions targeting the counties and populations in greatest need.
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Affiliation(s)
- Melinda M Davis
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States; Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, United States; OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, United States.
| | - Stephanie Renfro
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States.
| | - Robyn Pham
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, United States.
| | - Kristen Hassmiller Lich
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
| | - Jackilen Shannon
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, United States.
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente, Portland, OR, United States.
| | - Stephanie B Wheeler
- Department of Health Policy & Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Center for Health Promotion & Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
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14
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Fedewa SA, Flanders WD, Ward KC, Lin CC, Jemal A, Goding Sauer A, Doubeni CA, Goodman M. Racial and Ethnic Disparities in Interval Colorectal Cancer Incidence: A Population-Based Cohort Study. Ann Intern Med 2017; 166:857-866. [PMID: 28531909 PMCID: PMC5897770 DOI: 10.7326/m16-1154] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Interval colorectal cancer (CRC) accounts for 3% to 8% of all cases of CRC in the United States. Data on interval CRC by race/ethnicity are scant. OBJECTIVE To examine whether risk for interval CRC among Medicare patients differs by race/ethnicity and whether this potential variation is accounted for by differences in the quality of colonoscopy, as measured by physicians' polyp detection rate (PDR). DESIGN Population-based cohort study. SETTING Medicare program. PARTICIPANTS Patients aged 66 to 75 years who received colonoscopy between 2002 and 2011 and were followed through 2013. MEASUREMENTS Kaplan-Meier curves and adjusted Cox models were used to estimate cumulative probabilities and hazard ratios (HRs) of interval CRC, defined as a CRC diagnosis 6 to 59 months after colonoscopy. RESULTS There were 2735 cases of interval CRC identified over 235 146 person-years of follow-up. A higher proportion of black persons (52.8%) than white persons (46.2%) received colonoscopy from physicians with a lower PDR. This rate was significantly associated with interval CRC risk. The probability of interval CRC by the end of follow-up was 7.1% in black persons and 5.8% in white persons. Compared with white persons, black persons had significantly higher risk for interval CRC (HR, 1.31 [95% CI, 1.13 to 1.51]); the disparity was more pronounced for cancer of the rectum (HR, 1.70 [CI, 1.25 to 2.31]) and distal colon (HR, 1.45 [CI, 1.00 to 2.11]) than for cancer of the proximal colon (HR, 1.17 [CI, 0.96 to 1.42]). Adjustment for PDR did not alter HRs by race/ethnicity, but differences between black persons and white persons were greater among physicians with higher PDRs. LIMITATION Colonoscopy and polypectomy were identified by using billing codes. CONCLUSION Among elderly Medicare enrollees, the risk for interval CRC was higher in black persons than in white persons; the difference was more pronounced for cancer of the distal colon and rectum and for physicians with higher PDRs. PRIMARY FUNDING SOURCE American Cancer Society.
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Affiliation(s)
- Stacey A Fedewa
- From Surveillance and Health Services Research, American Cancer Society, and Emory University, Atlanta, Georgia, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - W Dana Flanders
- From Surveillance and Health Services Research, American Cancer Society, and Emory University, Atlanta, Georgia, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin C Ward
- From Surveillance and Health Services Research, American Cancer Society, and Emory University, Atlanta, Georgia, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chun Chieh Lin
- From Surveillance and Health Services Research, American Cancer Society, and Emory University, Atlanta, Georgia, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahmedin Jemal
- From Surveillance and Health Services Research, American Cancer Society, and Emory University, Atlanta, Georgia, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann Goding Sauer
- From Surveillance and Health Services Research, American Cancer Society, and Emory University, Atlanta, Georgia, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chyke A Doubeni
- From Surveillance and Health Services Research, American Cancer Society, and Emory University, Atlanta, Georgia, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Goodman
- From Surveillance and Health Services Research, American Cancer Society, and Emory University, Atlanta, Georgia, and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Wheeler SB, Kuo TM, Meyer AM, Martens CE, Hassmiller Lich KM, Tangka FK, Richardson LC, Hall IJ, Smith JL, Mayorga ME, Brown P, Crutchfield TM, Pignone MP. Multilevel predictors of colorectal cancer testing modality among publicly and privately insured people turning 50. Prev Med Rep 2017; 6:9-16. [PMID: 28210537 PMCID: PMC5300695 DOI: 10.1016/j.pmedr.2016.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 09/14/2016] [Accepted: 11/24/2016] [Indexed: 12/24/2022] Open
Abstract
Understanding multilevel predictors of colorectal cancer (CRC) screening test modality can help inform screening program design and implementation. We used North Carolina Medicare, Medicaid, and private, commercially available, health plan insurance claims data from 2003 to 2008 to ascertain CRC test modality among people who received CRC screening around their 50th birthday, when guidelines recommend that screening should commence for normal risk individuals. We ascertained receipt of colonoscopy, fecal occult blood test (FOBT) and fecal immunochemical test (FIT) from billing codes. Person-level and county-level contextual variables were included in multilevel random intercepts models to understand predictors of CRC test modality, stratified by insurance type. Of 12,570 publicly-insured persons turning 50 during the study period who received CRC testing, 57% received colonoscopy, whereas 43% received FOBT/FIT, with significant regional variation. In multivariable models, females with public insurance had lower odds of colonoscopy than males (odds ratio [OR] = 0.68; p < 0.05). Of 56,151 privately-insured persons turning 50 years old who received CRC testing, 42% received colonoscopy, whereas 58% received FOBT/FIT, with significant regional variation. In multivariable models, females with private insurance had lower odds of colonoscopy than males (OR = 0.43; p < 0.05). People living 10-15 miles away from endoscopy facilities also had lower odds of colonoscopy than those living within 5 miles (OR = 0.91; p < 0.05). Both colonoscopy and FOBT/FIT are widely used in North Carolina among insured persons newly age-eligible for screening. The high level of FOBT/FIT use among privately insured persons and women suggests that renewed emphasis on FOBT/FIT as a viable screening alternative to colonoscopy may be important.
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Affiliation(s)
- Stephanie B. Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, United States
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, United States
| | - Tzy-Mey Kuo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States
| | - Anne Marie Meyer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7435, McGavran Greenberg Hall, Chapel Hill, NC 27599-7435, United States
| | - Christa E. Martens
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States
| | - Kristen M. Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, United States
| | - Florence K.L. Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States
| | - Lisa C. Richardson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States
| | - Ingrid J. Hall
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States
| | - Judith Lee Smith
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States
| | - Maria E. Mayorga
- Department of Industrial & Systems Engineering, North Carolina State University, Campus Box 7906, Raleigh, NC 27965-7906, United States
| | - Paul Brown
- University of California at Merced, SSM Building Room 308a, Merced, CA 95343, United States
| | - Trisha M. Crutchfield
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, United States
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, United States
| | - Michael P. Pignone
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States
- Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, United States
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, United States
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
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16
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Using Procedure Codes to Define Radiation Toxicity in Administrative Data: The Devil is in the Details. Med Care 2017; 55:e36-e43. [PMID: 25517072 DOI: 10.1097/mlr.0000000000000262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Systematic coding systems are used to define clinically meaningful outcomes when leveraging administrative claims data for research. How and when these codes are applied within a research study can have implications for the study validity and their specificity can vary significantly depending on treatment received. SUBJECTS Data are from the Surveillance, Epidemiology, and End Results-Medicare linked dataset. STUDY DESIGN We use propensity score methods in a retrospective cohort of prostate cancer patients first examined in a recently published radiation oncology comparative effectiveness study. RESULTS With the narrowly defined outcome definition, the toxicity event outcome rate ratio was 0.88 per 100 person-years (95% confidence interval, 0.71-1.08). With the broadly defined outcome, the rate ratio was comparable, with 0.89 per 100 person-years (95% confidence interval, 0.76-1.04), although individual event rates were doubled. Some evidence of surveillance bias was suggested by a higher rate of endoscopic procedures the first year of follow-up in patients who received proton therapy compared with those receiving intensity-modulated radiation treatment (11.15 vs. 8.90, respectively). CONCLUSIONS This study demonstrates the risk of introducing bias through subjective application of procedure codes. Careful consideration is required when using procedure codes to define outcomes in administrative data.
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17
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Sherer EA, Fisher DA, Barnd J, Jackson GL, Provenzale D, Haggstrom DA. The accuracy and completeness for receipt of colorectal cancer care using Veterans Health Administration administrative data. BMC Health Serv Res 2016; 16:50. [PMID: 26869265 PMCID: PMC4751682 DOI: 10.1186/s12913-016-1294-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 02/05/2016] [Indexed: 12/02/2022] Open
Abstract
Background The National Comprehensive Cancer Network and the American Society of Clinical Oncology have established guidelines for the treatment and surveillance of colorectal cancer (CRC), respectively. Considering these guidelines, an accurate and efficient method is needed to measure receipt of care. Methods The accuracy and completeness of Veterans Health Administration (VA) administrative data were assessed by comparing them with data manually abstracted during the Colorectal Cancer Care Collaborative (C4) quality improvement initiative for 618 patients with stage I-III CRC. Results The VA administrative data contained gender, marital, and birth information for all patients but race information was missing for 62.1 % of patients. The percent agreement for demographic variables ranged from 98.1–100 %. The kappa statistic for receipt of treatments ranged from 0.21 to 0.60 and there was a 96.9 % agreement for the date of surgical resection. The percentage of post-diagnosis surveillance events in C4 also in VA administrative data were 76.0 % for colonoscopy, 84.6 % for physician visit, and 26.3 % for carcinoembryonic antigen (CEA) test. Conclusions VA administrative data are accurate and complete for non-race demographic variables, receipt of CRC treatment, colonoscopy, and physician visits; but alternative data sources may be necessary to capture patient race and receipt of CEA tests.
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Affiliation(s)
- Eric A Sherer
- Department of Chemical Engineering, Louisiana Tech University, Ruston, LA, USA. .,Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA.
| | - Deborah A Fisher
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Barnd
- Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA
| | - George L Jackson
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Dawn Provenzale
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - David A Haggstrom
- Center for Health Information and Communication, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, IN, USA.,Indiana University Cancer Center, Indianapolis, IN, USA
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18
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Samadder NJ, Curtin K, Pappas L, Boucher K, Mineau GP, Smith K, Fraser A, Wan Y, Provenzale D, Kinney AY, Ulrich C, Burt RW. Risk of Incident Colorectal Cancer and Death After Colonoscopy: A Population-based Study in Utah. Clin Gastroenterol Hepatol 2016; 14:279-86.e1-2. [PMID: 26343183 PMCID: PMC7416738 DOI: 10.1016/j.cgh.2015.08.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 08/24/2015] [Accepted: 08/27/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Colonoscopy is widely recommended for colorectal (CRC) screening in the United States, but evidence of effectiveness is limited. We examined whether exposure to colonoscopy decreases the odds of incident CRC and death from CRC in Utah. METHODS We performed a case-control study of Utah residents, 54 to 90 years old, who received a CRC diagnosis from 2000 through 2010 (cases). Age- and sex-matched controls with no history of CRC (controls) were selected for each case. We determined receipt of colonoscopy 6 months to 10 years before the reference date for each case and control through administrative claims data. Colonoscopy exposure was compared by using conditional logistic regression. RESULTS We identified 5128 cases and 20,512 controls; 741 cases (14%) and 5715 controls (28%) received a colonoscopy. Exposure to colonoscopy reduced the odds for a diagnosis of CRC; the odds ratios (ORs) were 0.41 for any CRC (95% confidence interval [CI], 0.38-0.44), 0.58 for proximal colon cancer (95% CI, 0.51-0.65), and 0.29 for distal colon or rectal cancer (95% CI, 0.25-0.33). This finding was consistent among sexes, age groups, and cancer stages. Similarly, in a subgroup analysis, colonoscopy was associated with decreased odds of death from CRC (OR, 0.33; 95% CI, 0.28-0.39) in both the proximal colon (OR, 0.43; 95% CI, 0.34-0.55) and distal colon or rectum (OR, 0.23; 95% CI, 0.18-0.30). CONCLUSIONS In the population of Utah, colonoscopy is associated with a large reduction in risk of new-onset CRC and death from CRC. This reduction in risk for CRC was greatest for the distal colon and rectum, with a more modest reduction for proximal colon cancer.
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Affiliation(s)
- N. Jewel Samadder
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT,Medicine (Gastroenterology), University of Utah, Salt Lake City, UT
| | - Karen Curtin
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT,Medicine (Genetic Epidemiology), University of Utah, Salt Lake City, UT,Utah Population Database all at University of Utah, Salt Lake City, UT
| | - Lisa Pappas
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Ken Boucher
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT,Population Sciences, University of Utah, Salt Lake City, UT
| | - Geraldine P. Mineau
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT,Departments of Oncological Sciences, University of Utah, Salt Lake City, UT,Utah Population Database all at University of Utah, Salt Lake City, UT
| | - Ken Smith
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT,Departments of Oncological Sciences, University of Utah, Salt Lake City, UT,Family and Consumer Studies, University of Utah, Salt Lake City, UT,Utah Population Database all at University of Utah, Salt Lake City, UT
| | - Alison Fraser
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT,Utah Population Database all at University of Utah, Salt Lake City, UT
| | - Yuan Wan
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT,Utah Population Database all at University of Utah, Salt Lake City, UT
| | - Dawn Provenzale
- Durham Epidemiologic Research and Information Center (ERIC), Durham VAMC, Durham, NC, Department of Medicine (Gastroenterology), Duke University, Durham, NC, USA
| | - Anita Y. Kinney
- Department of Medicine (Epidemiology) and Cancer Center, University of New Mexico, Albuquerque, NM, USA
| | - Cornelia Ulrich
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT,Population Sciences, University of Utah, Salt Lake City, UT,National Center for Tumor Disease, German Cancer Research Center, Heidelberg, Germany
| | - Randall W. Burt
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT,Departments of Oncological Sciences, University of Utah, Salt Lake City, UT,Medicine (Gastroenterology), University of Utah, Salt Lake City, UT
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Longitudinal Rates of Colon Cancer Screening Use in Winnipeg, Canada: The Experience of a Universal Health-Care System with an Organized Colon Screening Program. Am J Gastroenterol 2015; 110:1640-6. [PMID: 26169513 PMCID: PMC4685313 DOI: 10.1038/ajg.2015.206] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We examined trends in colorectal cancer (CRC) screening (fecal occult blood test (FOBT), colonoscopy, and flexible sigmoidoscopy (FS)) and differences in CRC screening by income in a population with an organized CRC screening program and universal health-care coverage. METHODS Individuals who had an FOBT, colonoscopy, or FS were identified from the provincial Physician Claims database and the population-based colon cancer screening registry. Trends in age-standardized rates were determined. Logistic regression was performed to explore the association between CRC screening and income quintiles by year. RESULTS Up-to-date CRC screening (FOBT, colonoscopy, or FS) increased over time for men and women, all age groups, and all income quintiles. Up-to-date CRC screening was very high among 65- to 69- and 70- to 74-year-olds (70% and 73%, respectively). There was a shift toward the use of an FOBT for CRC screening for individuals in the lower income quintiles. The disparity in colonoscopy/FS coverage by income quintile was greater in 2012 than in 1995. Overall, there was no reduction in disparities by income in up-to-date CRC screening nor did the rate of increase in up-to-date CRC screening or FOBT use change after the introduction of the organized provincial CRC screening program. CONCLUSIONS CRC screening is increasing over time for both men and women and all age groups. However, a disparity in up-to-date CRC screening by income persisted even with an organized CRC screening program in a universal health-care setting.
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Goodman M, Fletcher RH, Doria-Rose VP, Jensen CD, Zebrowski AM, Becerra TA, Quinn VP, Zauber AG, Corley DA, Doubeni CA. Observational methods to assess the effectiveness of screening colonoscopy in reducing right colon cancer mortality risk: SCOLAR. J Comp Eff Res 2015; 4:541-51. [PMID: 26201973 PMCID: PMC4666780 DOI: 10.2217/cer.15.39] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AIMS Screening colonoscopy's effectiveness in reducing risk of death from right colon cancers remains unclear. Methodological challenges of existing observational studies addressing this issue motivated the design of 'Effectiveness of Screening for Colorectal Cancer in Average-Risk Adults (SCOLAR)'. METHODS SCOLAR is a nested case-control study based on two large integrated health systems. This affords access to a large, well-defined historical cohort linked to integrated data on cancer outcomes, patient eligibility, test indications and important confounders. RESULTS We found electronic data adequate for excluding ineligible patients (except family history), but not the detailed information needed for test indication assignment. CONCLUSION The lessons of SCOLAR's design and implementation may be useful for future studies seeking to evaluate the effectiveness of screening tests in community settings.
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Affiliation(s)
- Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Robert H Fletcher
- Department of Population Health, Harvard Medical School, Boston, MA 02115, USA
| | - V Paul Doria-Rose
- Division of Cancer Control & Population Sciences, National Cancer Institute, Bethesda, MD 20892, USA
| | | | - Alexis M Zebrowski
- Department of Family Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tracy A Becerra
- Department of Research & Evaluation, Kaiser Permanente, Pasadena, CA 91107, USA
| | - Virginia P Quinn
- Department of Research & Evaluation, Kaiser Permanente, Pasadena, CA 91107, USA
| | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | | | - Chyke A Doubeni
- Department of Family Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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21
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Validation of colonoscopic findings from a structured endoscopic documentation database against manually collected medical records data. Surg Endosc 2015; 30:1607-13. [PMID: 26173545 DOI: 10.1007/s00464-015-4389-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 07/01/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Endoscopic documentation software can generate research data on large numbers of subjects automatically. There are increasing numbers of published studies based on endoscopic databases such as the Clinical Outcomes Research Initiative. However, no study has yet validated such data. We compared colonoscopic findings reported by an endoscopic documentation software (Provation) against manually collected medical records data from two similar patient cohorts in the same endoscopy unit. METHODS In November 2011, our unit switched from dictation-based text documentation to the Provation system. As a quality control initiative, we collected data on 9614 patients who had undergone colonoscopies from January 2010 to November 2011, using manual electronic chart review. We compared these data against those generated by Provation on 7091 similar patients who underwent colonoscopy from November 2011 to March 2013. RESULTS Age, sex and procedural indication distribution were similar between the Manual and Provation cohorts, as were the large (≥1 cm) polyp (7.6 vs. 8.1%; p = 0.25) and advanced neoplasia (8.3 vs. 8.2%; p = 0.80) prevalences. However, there were significant differences in the polyp (46.9 vs. 49.8%) and adenoma prevalences (31.3 vs. 26.8%; p < 0.001). Furthermore, the Manual cohort had a higher prevalence of diverticulosis and hemorrhoids, and a lower colonoscopy completion rate. Stratification by indication resulted in additional discrepancies between the two cohorts for screening and surveillance patients. There were also differences in the anatomic (right vs. left colon) distribution of large polyps. CONCLUSIONS There were significant discrepancies between data from Provation and manually collected medical records data. Although the two cohorts were enrolled during slightly different time periods, they came from the same endoscopy unit, had the same endoscopists and indications, and demonstrated similar demographics, making it unlikely for there to be true differences between the cohorts independent of documentation method. Thus, caution is advised when using endoscopic data for research.
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22
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Lai SM, Jungk J, Garimella S. Colorectal Cancer Identification Methods Among Kansas Medicare Beneficiaries, 2008-2010. Prev Chronic Dis 2015; 12:E107. [PMID: 26160293 PMCID: PMC4509094 DOI: 10.5888/pcd12.140543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Population-based data are limited on how often colorectal cancer (CRC) is identified through screening or surveillance in asymptomatic patients versus diagnostic workup for symptoms. We developed a process for assessing CRC identification methods among Medicare-linked CRC cases from a population-based cancer registry to assess identification methods (screening/surveillance or diagnostic) among Kansas Medicare beneficiaries. Methods New CRC cases diagnosed from 2008 through 2010 were identified from the Kansas Cancer Registry and matched to Medicare enrollment and claims files. CRC cases were classified as diagnostic-identified versus screening/surveillance-identified using a claims-based algorithm for determining CRC test indication. Factors associated with screening/surveillance-identified CRC were analyzed using logistic regression. Results Nineteen percent of CRC cases among Kansas Medicare beneficiaries were screening/surveillance-identified while 81% were diagnostic-identified. Younger age at diagnosis (65 to 74 years) was the only factor associated with having screening/surveillance-identified CRC in multivariable analysis. No association between rural/urban residence and identification method was noted. Conclusion Combining administrative claims data with population-based registry records can offer novel insights into patterns of CRC test use and identification methods among people diagnosed with CRC. These techniques could also be extended to other screen-detectable cancers.
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Affiliation(s)
- Sue-Min Lai
- Kansas Cancer Registry, Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Mail Stop 1008, 3901 Rainbow Blvd, Kansas City, KS 66160-7313.
| | - Jessica Jungk
- Kansas Cancer Registry, Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, Kansas
| | - Sarma Garimella
- Kansas Cancer Registry, Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, Kansas
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23
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Hwang S, Jayadevappa R, Zee J, Zivin K, Bogner HR, Raue PJ, Bruce ML, Reynolds CF, Gallo JJ. Concordance Between Clinical Diagnosis and Medicare Claims of Depression Among Older Primary Care Patients. Am J Geriatr Psychiatry 2015; 23:726-34. [PMID: 25256215 PMCID: PMC4634645 DOI: 10.1016/j.jagp.2014.08.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 08/05/2014] [Accepted: 08/22/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To identify patient characteristics associated with concordance of Medicare claims with clinically identified depression. METHODS The authors studied a cohort of 742 older primary care patients linked to Medicare claims data using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depressive disorder and clinically significant minor depression. RESULTS Among 474 patients with depression, 198 patients had a Medicare claim for depression (sensitivity: 42%; 95% confidence interval [CI]: 37%-46%). Among 268 patients who did not meet criteria for depression, 235 patients did not have a Medicare claim for depression (specificity: 88%; 95% CI: 83%-91%). After adjustment for demographic and clinical characteristics, non-white participants were nearly twice as likely not to have Medicare claims for depression among patients who met criteria for depression ("false negatives"). Smoking status, depression severity (Hamilton Depression Rating Scale), cardiovascular disease, and more primary care physician office visits were also significantly associated with decreased odds to be false negatives. In contrast, after covariate adjustment, white race and chronic pulmonary disease were associated with increased odds of a Medicare claim for depression among patients who did not meet criteria for depression ("false positives"). Using weights based on the screened sample, the positive predictive value of a Medicare claim for depression was 66% (95% CI [63%, 69%]), whereas the negative predictive value was 77% (95% CI [76%, 78%]). CONCLUSION Investigators using Medicare data to study depression must recognize that diagnoses of depression from Medicare data may be biased by patient ethnicity and the presence of medical comorbidity.
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Affiliation(s)
- Seungyoung Hwang
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Jarcy Zee
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kara Zivin
- VA Ann Arbor Health System and University of Michigan Medical School, Ann Arbor, Michigan
| | - Hillary R. Bogner
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Joseph J. Gallo
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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24
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Adams KF, Johnson EA, Chubak J, Kamineni A, Doubeni CA, Buist DSM, Williams AE, Weinmann S, Doria-Rose VP, Rutter CM. Development of an Algorithm to Classify Colonoscopy Indication from Coded Health Care Data. EGEMS 2015; 3:1171. [PMID: 26290883 PMCID: PMC4537082 DOI: 10.13063/2327-9214.1171] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Electronic health data are potentially valuable resources for evaluating colonoscopy screening utilization and effectiveness. The ability to distinguish screening colonoscopies from exams performed for other purposes is critical for research that examines factors related to screening uptake and adherence, and the impact of screening on patient outcomes, but distinguishing between these indications in secondary health data proves challenging. The objective of this study is to develop a new and more accurate algorithm for identification of screening colonoscopies using electronic health data. Methods: Data from a case-control study of colorectal cancer with adjudicated colonoscopy indication was used to develop logistic regression-based algorithms. The proposed algorithms predict the probability that a colonoscopy was indicated for screening, with variables selected for inclusion in the models using the Least Absolute Shrinkage and Selection Operator (LASSO). Results: The algorithms had excellent classification accuracy in internal validation. The primary, restricted model had AUC= 0.94, sensitivity=0.91, and specificity=0.82. The secondary, extended model had AUC=0.96, sensitivity=0.88, and specificity=0.90. Discussion: The LASSO approach enabled estimation of parsimonious algorithms that identified screening colonoscopies with high accuracy in our study population. External validation is needed to replicate these results and to explore the performance of these algorithms in other settings.
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25
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Singh H, Bernstein CN, Samadder JN, Ahmed R. Screening rates for colorectal cancer in Canada: a cross-sectional study. CMAJ Open 2015; 3:E149-57. [PMID: 26389092 PMCID: PMC4565170 DOI: 10.9778/cmajo.20140073] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Implementation of population-based colorectal cancer (CRC) screening programs should reduce disparities in participation in CRC screening. We estimated CRC screening rates in 2012 in Canada and assessed predictors of screening in provinces with and without well-established population-based screening programs. METHODS We used data from the Canadian Community Health Survey for 2012 to calculate the prevalence of up-to-date CRC screening, defined as fecal occult blood testing (FOBT) within 2 years before the survey or flexible sigmoidoscopy or colonoscopy within 10 years before the survey, or both. Weighted proportions of individuals with up-to-date screening were calculated and logistic regression analysis performed to assess predictors of up-to-date CRC screening, including differences in participation by income level. RESULTS The prevalence of up-to-date CRC screening among people 50-74 years of age in 2012 was 55.2%, ranging from 41.3% in the territories to 67.2% in the province of Manitoba. The rate for sigmoidoscopy or colonoscopy was 37.2% (highest in Ontario, at 43.3%), and for FOBT it was 30.1% (highest in Manitoba, at 51.7%). About 41% of those who had an FOBT also had a sigmoidoscopy or colonoscopy. Individuals in the highest income group were more likely than those in lower-income groups to be up to date with CRC screening, even in provinces with well-established population-based screening programs. INTERPRETATION More than half of Canadians were up to date with CRC screening in 2012, but there were large differences among provinces. Differences by income group in provinces with population-based screening programs need particular attention.
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Affiliation(s)
- Harminder Singh
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Man
- Internal Medicine, University of Manitoba, Winnipeg, Man
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Man
| | - Charles N. Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, Man
- Internal Medicine, University of Manitoba, Winnipeg, Man
| | - Jewel N. Samadder
- Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Rashid Ahmed
- Community Health Sciences, University of Manitoba, Winnipeg, Man
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Man
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Kruse GR, Khan SM, Zaslavsky AM, Ayanian JZ, Sequist TD. Overuse of colonoscopy for colorectal cancer screening and surveillance. J Gen Intern Med 2015; 30:277-83. [PMID: 25266407 PMCID: PMC4351286 DOI: 10.1007/s11606-014-3015-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/08/2014] [Accepted: 08/14/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources. OBJECTIVE Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse. DESIGN, SETTING, AND PARTICIPANTS Our approach was a retrospective cohort study using electronic health record data for patients 50-65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice. MAIN OUTCOME MEASURES We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies. KEY RESULTS We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88%) and many surveillance colonoscopies (49%) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1-10.0; hyperplastic polyp: 5.7 years, IQR: 4.9-9.7; low-risk adenoma: 5.1 years, IQR: 3.3-6.3; high-risk adenoma: 2.9 years, IQR: 2.0-3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95% CI: 3.15-12.50) and surveillance colonoscopy (OR 13.47, 95% CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam. CONCLUSIONS Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.
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Affiliation(s)
- Gina R Kruse
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA,
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27
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Pruitt SL, Davidson NO, Gupta S, Yan Y, Schootman M. Missed opportunities: racial and neighborhood socioeconomic disparities in emergency colorectal cancer diagnosis and surgery. BMC Cancer 2014; 14:927. [PMID: 25491412 PMCID: PMC4364088 DOI: 10.1186/1471-2407-14-927] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 11/26/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Disparities by race and neighborhood socioeconomic status exist for many colorectal cancer (CRC) outcomes, including screening use and mortality. We used population-based data to determine if disparities also exist for emergency CRC diagnosis and surgery. METHODS We examined two emergency CRC outcomes using 1992-2005 population-based U.S. SEER-Medicare data. Among CRC patients aged ≥66 years, we examined racial (African American vs. white) and neighborhood poverty disparities in two emergency outcomes defined as: 1) newly diagnosed CRC or 2) CRC surgery associated with: obstruction, perforation, or emergency inpatient admission. Multilevel logistic regression (patients nested in census tracts) analyses adjusted for sociodemographic, tumor, and clinical covariates. RESULTS Of 83,330 CRC patients, 29.1% were diagnosed emergently. Of 55,046 undergoing surgery, 26.0% had emergency surgery. For both outcomes, race and neighborhood poverty disparities were evident. A significant race by poverty interaction (p < .001) was noted: poverty rate was associated with both outcomes among African Americans, but not whites. Compared to whites in low poverty (<10%) neighborhoods, African Americans in high poverty (≥20%) neighborhoods had increased odds of emergency diagnosis (AOR: 1.50, 95% CI: 1.38-1.63) and surgery (AOR: 1.63, 95% CI: 1.47-1.81). CONCLUSIONS Emergency CRC outcomes are associated with high poverty residence among African Americans in this population-based study, potentially contributing to observed disparities in CRC morbidity and mortality. Targeted efforts to increase CRC screening among African Americans living in high poverty neighborhoods could reduce preventable disparities.
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Affiliation(s)
- Sandi L Pruitt
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd E1, 410D Dallas, TX, USA.
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Lansdorp-Vogelaar I, Fedewa S, Lin CC, Virgo KS, Jemal A. Utilization of surveillance after polypectomy in the medicare population--a cohort study. PLoS One 2014; 9:e110937. [PMID: 25393312 PMCID: PMC4230916 DOI: 10.1371/journal.pone.0110937] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 09/19/2014] [Indexed: 02/01/2023] Open
Abstract
Background Surveillance in patients with previous polypectomy was underused in the Medicare population in 1994. This study investigates whether expansion of Medicare reimbursement for colonoscopy screening in high-risk individuals has reduced the inappropriate use of surveillance. Methods We used Kaplan-Meier analysis to estimate time to surveillance and polyp recurrence rates for Medicare beneficiaries with a colonoscopy with polypectomy between 1998 and 2003 who were followed through 2008 for receipt of surveillance colonoscopy. Generalized Estimating Equations were used to estimate risk factors for: 1) failing to undergo surveillance and 2) polyp recurrence among these individuals. Analyses were stratified into three 2-year cohorts based on baseline colonoscopy date. Results Medicare beneficiaries undergoing a colonoscopy with polypectomy in the 1998–1999 (n = 4,136), 2000–2001 (n = 3,538) and 2002–2003 (n = 4,655) cohorts had respective probabilities of 30%, 26% and 20% (p<0.001) of subsequent surveillance events within 3 years. At the same time, 58%, 52% and 45% (p<0.001) of beneficiaries received a surveillance event within 5 years. Polyp recurrence rates after 5 years were 36%, 30% and 26% (p<0.001) respectively. Older age (≥ 70 years), female gender, later cohort (2000–2001 & 2002–2003), and severe comorbidity were the most important risk factors for failure to undergo a surveillance event. Male gender and early cohort (1998–1999) were the most important risk factors for polyp recurrence. Conclusions Expansion of Medicare reimbursement for colonoscopy screening in high-risk individuals has not reduced underutilization of surveillance in the Medicare population. It is important to take action now to improve this situation, because polyp recurrence is substantial in this population.
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Affiliation(s)
| | - Stacey Fedewa
- Surveillance & Health Services Research, Intramural Research Department, American Cancer Society, Atlanta, GA, United States of America; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Chun Chieh Lin
- Surveillance & Health Services Research, Intramural Research Department, American Cancer Society, Atlanta, GA, United States of America
| | - Katherine S Virgo
- Department of Health Policy and Management, Emory University, Atlanta, GA, United States of America
| | - Ahmedin Jemal
- Surveillance & Health Services Research, Intramural Research Department, American Cancer Society, Atlanta, GA, United States of America
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Abstract
BACKGROUND Diverticulosis, a prevalent condition at screening colonoscopy, has been associated with colorectal cancers that develop after a clearing colonoscopy, or interval cancers. AIMS To quantify the overall risk of diverticulosis in the development of interval cancers and examine this association in relevant subgroups. METHODS Using a linked database containing SEER tumor registry data and Medicare claims, we identified patients aged ≥69 years with colorectal cancer who underwent colonoscopy within 6 months of diagnosis. Patients with an additional colonoscopy from 36 to 6 months prior to cancer diagnosis were characterized as having interval cancers. We compared characteristics of patients with interval cancers and detected cancers according to a diagnosis of diverticulosis not associated with a colonoscopy procedure from 1991 through the date of the most recent colonoscopy in both univariate and multivariate models. RESULTS A previous diagnosis of diverticulosis was documented in 14,452 (26.9 %) patients with detected cancers compared to 2,905 (69.3 %) patients with interval cancers (p < 0.001); these results were consistent in multivariable analysis. Moreover, the association was found as well in the proximal colon (OR 2.88, 95 % CI 2.66, 3.12), distal colon (OR 3.56, 95 % CI 3.09, 4.11), and rectum (OR 4.07, 95 % CI 3.34, 4.95). The vast majority of diverticulosis diagnoses were without complications such as hemorrhage or diverticulitis. CONCLUSIONS Diverticulosis was strongly associated with interval colorectal cancers in all segments of the colon. Given its known predominance in the left colon, the findings argue against impaired visualization of lesions at colonoscopy as the only pathogenic factor.
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Wheeler SB, Kuo TM, Goyal RK, Meyer AM, Hassmiller Lich K, Gillen EM, Tyree S, Lewis CL, Crutchfield TM, Martens CE, Tangka F, Richardson LC, Pignone MP. Regional variation in colorectal cancer testing and geographic availability of care in a publicly insured population. Health Place 2014; 29:114-23. [PMID: 25063908 DOI: 10.1016/j.healthplace.2014.07.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 06/25/2014] [Accepted: 07/01/2014] [Indexed: 12/15/2022]
Abstract
Despite its demonstrated effectiveness, colorectal cancer (CRC) testing is suboptimal, particularly in vulnerable populations such as those who are publicly insured. Prior studies provide an incomplete picture of the importance of the intersection of multilevel factors affecting CRC testing across heterogeneous geographic regions where vulnerable populations live. We examined CRC testing across regions of North Carolina by using population-based Medicare and Medicaid claims data from disabled individuals who turned 50 years of age during 2003-2008. We estimated multilevel models to examine predictors of CRC testing, including distance to the nearest endoscopy facility, county-level endoscopy procedural rates, and demographic and community contextual factors. Less than 50% of eligible individuals had evidence of CRC testing; men, African-Americans, Medicaid beneficiaries, and those living furthest away from endoscopy facilities had significantly lower odds of CRC testing, with significant regional variation. These results can help prioritize intervention strategies to improve CRC testing among publicly insured, disabled populations.
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Affiliation(s)
- Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, USA.
| | - Tzy-Mey Kuo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Ravi K Goyal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Anne-Marie Meyer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, USA
| | - Emily M Gillen
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, USA
| | - Seth Tyree
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Carmen L Lewis
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, 5045 Old Clinic Building, CB#7110, Chapel Hill, NC 27599-5039, USA
| | - Trisha M Crutchfield
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, USA
| | - Christa E Martens
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA
| | - Florence Tangka
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Lisa C Richardson
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Michael P Pignone
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, USA; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, USA; Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, 5045 Old Clinic Building, CB#7110, Chapel Hill, NC 27599-5039, USA
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Dodou D, de Winter JCF. Agreement between self-reported and registered colorectal cancer screening: a meta-analysis. Eur J Cancer Care (Engl) 2014; 24:286-98. [PMID: 24754544 DOI: 10.1111/ecc.12204] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2014] [Indexed: 12/29/2022]
Abstract
This random-effects meta-analysis investigates the accuracy of self-reported colorectal cancer screening history as a function of screening mode (colonoscopy, flexible sigmoidoscopy, faecal occult blood testing - FOBT, double-contrast barium enema - DCBE) and survey mode (written, telephone, face-to-face). Summary estimates of sensitivity, specificity, positive predictive value (PPV) and area under the receiver operating characteristic curve (AUC) were calculated. Medical record data were used as reference. We included 23 studies comprising 11,592 subjects. Colonoscopy yielded higher AUC [0.948, 95% confidence interval (CI) = 0.918, 0.968] than flexible sigmoidoscopy (0.883, 95% CI = 0.849, 0.911) and FOBT (0.869, 95% CI = 0.833, 0.898). Colonoscopy showed the highest sensitivity (0.888, 95% CI = 0.835, 0.931), whereas specificity was comparable between screening modes (ranging from 0.802 for FOBT to 0.904 for DCBE). AUC was not significantly different between survey modes. Prevalence of screening history correlated positively with sensitivity and negatively with specificity, possibly because of errors in the medical records. In conclusion, the accuracy of self-reported cancer screening is generally moderate, and higher for colonoscopy than for sigmoidoscopy and FOBT.
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Affiliation(s)
- D Dodou
- Department of BioMechanical Engineering, Delft University of Technology, Delft, the Netherlands
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Salloum RG, Kohler RE, Jensen GA, Sheridan SL, Carpenter WR, Biddle AK. U.S. Preventive Services Task Force recommendations and cancer screening among female Medicare beneficiaries. J Womens Health (Larchmt) 2014; 23:211-7. [PMID: 24195774 PMCID: PMC3952589 DOI: 10.1089/jwh.2013.4421] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Ramzi G. Salloum
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Racquel E. Kohler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gail A. Jensen
- Institute of Gerontology and Department of Economics, Wayne State University, Detroit, Michigan
| | - Stacey L. Sheridan
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - William R. Carpenter
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Andrea K. Biddle
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Mittal S, Lin YL, Tan A, Kuo YF, El-Serag HB, Goodwin JS. Limited life expectancy among a subgroup of medicare beneficiaries receiving screening colonoscopies. Clin Gastroenterol Hepatol 2014; 12:443-450.e1. [PMID: 23973925 PMCID: PMC3944371 DOI: 10.1016/j.cgh.2013.08.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/08/2013] [Accepted: 08/13/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND & AIMS Life expectancy is an important consideration when assessing appropriateness of preventive programs for older individuals. Most studies on this subject have used age cutoffs as a proxy for life expectancy. We analyzed patterns of utilization of screening colonoscopy in Medicare enrollees by using estimated life expectancy. METHODS We used a 5% random national sample of Medicare claims data to identify average-risk patients who underwent screening colonoscopies from 2008 to 2010. Colonoscopies were considered to be screening colonoscopies in the absence of diagnoses for nonscreening indications, which were based on either colonoscopies or any claims in the preceding 3 months. We estimated life expectancies by using a model that combined age, sex, and comorbidity. Among patients who underwent screening colonoscopies, we calculated the percentage of those with life expectancies <10 years. RESULTS Among the 57,597 Medicare beneficiaries 66 years old or older who received at least 1 screening colonoscopy, 24.8% had an estimated life expectancy of <10 years. There was a significant positive association between total Medicare per capita costs in hospital referral regions and the proportion of patients with limited life expectancies (<10 years) at the time of screening colonoscopy (R = 0.25; P < .001, Pearson correlation test). In a multivariable analysis, men were substantially more likely than women to have limited life expectancy at the time of screening colonoscopy (odds ratio, 2.25; 95% confidence interval, 2.16-2.34). CONCLUSIONS Nearly 25% of Medicare beneficiaries, especially men, had life expectancies <10 years at the time of screening colonoscopies. Life expectancy should therefore be incorporated in decision-making for preventive services.
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Affiliation(s)
- Sahil Mittal
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.
| | - Yu-Li Lin
- Department of Medicine and Sealy Center of Aging, University of Texas Medical Branch, Galveston, Texas
| | - Alai Tan
- Department of Medicine and Sealy Center of Aging, University of Texas Medical Branch, Galveston, Texas
| | - Yong-Fang Kuo
- Department of Medicine and Sealy Center of Aging, University of Texas Medical Branch, Galveston, Texas
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas; Houston VA Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - James S Goodwin
- Department of Medicine and Sealy Center of Aging, University of Texas Medical Branch, Galveston, Texas
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Fassil H, Adams KF, Weinmann S, Doria-Rose VP, Johnson E, Williams AE, Corley DA, Doubeni CA. Approaches for classifying the indications for colonoscopy using detailed clinical data. BMC Cancer 2014; 14:95. [PMID: 24529031 PMCID: PMC3927818 DOI: 10.1186/1471-2407-14-95] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 02/11/2014] [Indexed: 01/28/2023] Open
Abstract
Background Accurate indication classification is critical for obtaining unbiased estimates of colonoscopy effectiveness and quality improvement efforts, but there is a dearth of published systematic classification approaches. The objective of this study was to evaluate the effects of data-source and adjudication on indication classification and on estimates of the effectiveness of screening colonoscopy on late-stage colorectal cancer diagnosis risk. Methods This was an observational study in members of four U.S. health plans. Eligible persons (n = 1039) were age 55–85 and had been enrolled for 5 years or longer in their health plans during 2006–2008. Patients were selected based on late-stage colorectal cancer diagnosis in a case–control design; each case patient was matched to 1–2 controls by study site, age, sex, and health plan enrollment duration. Reasons for colonoscopies received in the 10-year period before the reference date were collected from three medical records sources (progress notes; referral notes; procedure reports) and categorized using an algorithm, with committee adjudication of some tests. We evaluated indication classification concordance before and after adjudication and used logistic regressions with the Wald Chi-square test to compare estimates of the effects of screening colonoscopy on late-stage colorectal cancer diagnosis risk for each of our data sources to the adjudicated indication. Results Classification agreement between each data-source and adjudication was 78.8-94.0% (weighted kappa = 0.53-0.72); the highest agreement (weighted kappa = 0.86-0.88) was when information from all data sources was considered together. The choice of data-source influenced the association between screening colonoscopy and late-stage colorectal cancer diagnosis; estimates based on progress notes were closest to those based on the adjudicated indication (% difference in regression coefficients = 2.4%, p-value = 0.98), as compared to estimates from only referral notes (% difference in coefficients = 34.9%, p-value = 0.12) or procedure reports (% difference in coefficients = 27.4%, p-value = 0.23). Conclusion There was no single gold-standard source of information in medical records. The estimates of colonoscopy effectiveness from progress notes alone were the closest to estimates using adjudicated indications. Thus, the details in the medical records are necessary for accurate indication classification.
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Affiliation(s)
| | | | | | | | | | | | | | - Chyke A Doubeni
- Department of Family Medicine and Community Health, and the Center for Clinical Epidemiology and Biostatistics at the Perelman School of Medicine, University of Pennsylvania, 222 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, USA.
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Adverse events Following Computed Tomographic Colonography compared to Optical Colonoscopy in the Elderly. Prev Med Rep 2014; 1:3-8. [PMID: 25530940 PMCID: PMC4266938 DOI: 10.1016/j.pmedr.2014.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To evaluate gastrointestinal and cardiovascular adverse event risks associated with optical colonoscopy (OC) among Medicare outpatients who received computed tomography colonography (CTC) as their initial method of colorectal evaluation. METHODS Medicare claims were compared between 6,114 outpatients ≥ 66 years who received initial CTC and 149,202 outpatients who received initial OC between January 2007 and December 2008. OC patients were matched on county of residence and year of evaluation. Outcomes included lower gastrointestinal bleeding, gastrointestinal perforation, other gastrointestinal events and cardiovascular events resulting in an emergency department visit or hospitalization within 30 days. RESULTS Among 1,000 outpatients undergoing initial CTC, 12.4 experienced lower gastrointestinal bleeding, 0.7 perforation, 18.0 other gastrointestinal events and 45.5 cardiovascular events within 30 days. After multivariate adjustment, risks of lower gastrointestinal bleeding, other gastrointestinal events and cardiovascular events were higher with initial OC than CTC, with or without subsequent OC (OR 1.91 95CI [1.47,2.49], OR 1.35 95CI [1.07,1.69] and OR 1.38 95CI [1.18,1.62], respectively); however, perforation risk did not differ (p=0.10). This pattern is similar in older and symptomatic populations. CONCLUSION Rates of gastrointestinal bleeding, other gastrointestinal events and cardiovascular events are lower following initial CTC than OC, but rates of perforation do not differ.
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Keller SC, Momplaisir F, Lo Re V, Newcomb C, Liu Q, Ratcliffe SJ, Long JA. Colorectal cancer incidence and screening in US Medicaid patients with and without HIV infection. AIDS Care 2013; 26:716-22. [PMID: 24188387 DOI: 10.1080/09540121.2013.855700] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Non-AIDS defining malignancies, particularly colorectal cancer (CRC), may be more prevalent among persons living with HIV (PLWH). Further, PLWH may be less likely to receive CRC screening (CRCS). We studied the epidemiology of CRC and CRCS patterns in PLWH and HIV-uninfected persons in a large US Medicaid population. We performed a matched cohort study examining CRC incidence in 2006 and CRCS between 1999 and 2007. Study participants were continuously enrolled in the Medicaid programs of California, Florida, New York, Ohio, and Pennsylvania. All PLWH enrollees were matched to five randomly sampled HIV-uninfected enrollees on 5-year age group, gender, and state. Adjusted odds ratios (AORs) for incident CRC (adjusted for comorbidity index) and the presence of CRCS (adjusted for comorbidity index and years in the data-set) among PLWH compared to HIV-uninfected enrollees were calculated. PLWH were not more likely to be diagnosed with CRC after adjusting for comorbidity index (unadjusted OR: 1.73, 95% confidence interval [CI]: 1.37-2.19; AOR 1.29; 95% CI: 0.98-1.70). While CRCS rates were low overall, PLWH were more likely to have received CRCS in unadjusted analyses (35.8% vs. 33.7%; OR 1.10, 95% CI: 1.07-1.13). This relationship was reversed after adjusting for comorbidity index and years in the data-set (AOR: 0.80, 95% CI: 0.77-0.83). Limitations of the study include a focus on the Medicaid population, an inability to detect fecal occult blood tests (FOBT), and having half of patients between 50 and 55 years of age. In conclusion, PLWH were not more likely to be diagnosed with CRC, but in adjusted analyses, were less likely to have received CRCS. As we showed a low rate of CRCS overall in this Medicaid population, researchers, clinicians, and policy-makers should improve access to and uptake of CRCS among all Medicaid patients, and particularly among PLWH.
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Affiliation(s)
- Sara C Keller
- a Division of Infectious Diseases, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
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Perencevich M, Ojha RP, Steyerberg EW, Syngal S. Racial and ethnic variations in the effects of family history of colorectal cancer on screening compliance. Gastroenterology 2013; 145:775-81.e2. [PMID: 23796457 PMCID: PMC3783551 DOI: 10.1053/j.gastro.2013.06.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 06/13/2013] [Accepted: 06/18/2013] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Molly Perencevich
- Division of Gastroenterology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Rohit P. Ojha
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ewout W. Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sapna Syngal
- Division of Gastroenterology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
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Abstract
BACKGROUND The use of screening colonoscopy among older persons is controversial due to variability in life expectancy and sex-based differences in colorectal cancer incidence. We assessed the relation between sex, age, and receipt of screening colonoscopy overall and within strata of life expectancy. METHODS We used Medicare data to identify beneficiaries during the years 2001 to 2005 who had not undergone a colonoscopy in the prior 3 years. Medicare claims were used to identify screening colonoscopy use; life expectancy was estimated using a life table approach. We used Poisson regression to examine sex and age differences in screening colonoscopy, adjusted for patient demographic characteristics. RESULTS Our sample consisted of 161,229 patients (61.9% female; mean age 76.9 y). The screening colonoscopy rates for females and males were 16.9 and 24.4 screening colonoscopies per 1000 person-years, respectively (P<0.001). The screening colonoscopy rate was highest for patients with the longest life expectancy (10 to 15 y: 27.2 screening colonoscopies per 1000 person-years) compared with 3.4 per 1000 person-years in the life expectancy <5-year group. Within specific life expectancy categories, older patients had significantly lower screening rates; in the 10- to 15-year life expectancy category, patients 75 to 79 years old had a lower rate (21.9 screening colonoscopies per 1000 person-years) than patients 68 to 69 years old (34.1 screening colonoscopies per 1000 person-years; P<0.001). CONCLUSIONS In a large cohort of Medicare beneficiaries, there was evidence of screening colonoscopy use even among patients with a short life expectancy. After accounting for life expectancy, females and older persons were less likely to undergo screening colonoscopy.
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Reiter PL, Katz ML, Oliveri JM, Young GS, Llanos AA, Paskett ED. Validation of self-reported colorectal cancer screening behaviors among Appalachian residents. Public Health Nurs 2013; 30:312-22. [PMID: 23808856 PMCID: PMC3809100 DOI: 10.1111/phn.12038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We determined the validity of self-reported colorectal cancer (CRC) screening data provided by Appalachian Ohio residents and identified correlates of providing accurate data. DESIGN AND SAMPLE We conducted cross-sectional telephone interviews between September 2009 and April 2010. Our study included Appalachian Ohio residents (n = 721) ages 51-75 years. MEASURES We compared self-reported CRC screening data to medical records to determine validity. Multivariable logistic regression was used to identify correlates of providing accurate self-reported screening data. RESULTS About 68% of participants self-reported having any CRC screening test within recommended guidelines, whereas medical records indicated that only 49% were within guidelines (concordance = 0.76). Concordance was higher for flexible sigmoidoscopy and fecal occult blood test compared with colonoscopy, although sensitivity and positive predictive value were much higher for colonoscopy. Participants overreported CRC screening behaviors for all tests. Participants who had a regular checkup in the last 2 years (OR = 2.78, 95% CI: 1.15-6.73), or who self-rated their health as good or better (OR = 1.88, 95% CI: 1.12-3.16) were more likely to provide accurate screening data. CONCLUSIONS Many participants failed to provide accurate CRC screening data, and validity varied greatly across individual CRC screening tests. Future CRC screening studies among Appalachian residents should use medical records, if possible, to determine screening histories.
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Affiliation(s)
- Paul L Reiter
- Division of Cancer Prevention and Control, College of Medicine, The Ohio State University, Columbus, Ohio 43201, USA.
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Pruitt SL, Harzke AJ, Davidson NO, Schootman M. Do diagnostic and treatment delays for colorectal cancer increase risk of death? Cancer Causes Control 2013; 24:961-77. [PMID: 23446843 PMCID: PMC3708300 DOI: 10.1007/s10552-013-0172-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 02/08/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Using 1998-2005 SEER-Medicare data, we examined the effect of diagnostic and treatment delays on all-cause and colorectal cancer (CRC)-specific death among US adults aged ≥ 66 years with invasive colon or rectal cancer. We hypothesized that longer delays would be associated with a greater risk of death. METHODS We defined diagnostic and treatment delays, respectively, as days between (1) initial medical consult for CRC symptoms and pathologically confirmed diagnosis (maximum: 365 days) and (2) pathologically confirmed diagnosis and treatment (maximum: 120 days). Cases (CRC deaths) and controls (deaths due to other causes or censored) were matched on survival time. Logistic regression analyses adjusted for sociodemographic, tumor, and treatment factors. RESULTS Median diagnostic delays were 60 (colon) and 40 (rectal) days and treatment delays were 13 (colon) and 16 (rectal) days in 10,663 patients. Colon cancer patients with the longest diagnostic delays (8-12 months vs. 14-59 days) had higher odds of all-cause (aOR: 1.31 CI: 1.08-1.58), but not CRC-specific death. Colon cancer patients with the shortest treatment delays (<1 vs. 1-2 weeks) had higher odds of all-cause (aOR: 1.23 CI: 1.01-1.49), but not CRC-specific death. Among rectal cancer patients, delays were not associated with risk of all-cause or CRC-specific death. CONCLUSIONS Longer delays of up to 1 year after symptom onset and 120 days for treatment did not increase odds of CRC-specific death. There may be little clinical benefit in detecting and treating existing symptomatic disease earlier. Screening prior to symptom onset must remain the primary goal to reduce CRC incidence, morbidity, and mortality.
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Affiliation(s)
- Sandi L Pruitt
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX 75390-9169, USA.
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Measurement of colorectal cancer test use with medical claims data in a safety-net health system. Am J Med Sci 2013; 345:99-103. [PMID: 22814361 DOI: 10.1097/maj.0b013e31824dd1b6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Optimizing colorectal cancer (CRC) screening requires identification of unscreened individuals and tracking screening trends. A recent National Institutes of Health State of the Science Conference, "Enhancing Use and Quality of CRC Screening," cited a need for more population data sources for measurement of CRC screening, particularly for the medically underserved. Medical claims data (claims data) are created and maintained by many health systems to facilitate billing for services rendered and may be an efficient resource for identifying unscreened individuals. The aim of this study, conducted at a safety-net health system, was to determine whether CRC test use measured by claims data matches medical chart documentation. METHODS The authors randomly selected 400 patients from a universe of 20,000 patients previously included in an analysis of CRC test use based on claims data 2002-2006 in Tarrant Co, TX. Claims data were compared with medical chart documentation by estimation of agreement and examination of test use over/underdocumentation. RESULTS The authors found that agreement on test use was very good for fecal occult blood testing (κ = 0.83, 95% confidence interval: 0.75-0.90) and colonoscopy (κ = 0.91, 95% confidence interval: 0.85-0.96) and fair for sigmoidoscopy (κ = 0.39, 95% confidence interval: 0.28-0.49). Over- and underdocumentations of the 2 most commonly used CRC tests--colonoscopy and fecal occult blood testing--were rare. CONCLUSIONS Use of claims data by health systems to measure CRC test use is a promising alternative to measuring CRC test use with medical chart review and may be used to identify unscreened patients for screening interventions and track screening trends over time.
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Different screening definitions have little impact on polypectomy rate estimates. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 26:791-4. [PMID: 23166901 DOI: 10.1155/2012/986153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Polypectomy rate is a surrogate quality indicator for screening colonoscopy. Various methods for identifying screening colonoscopies have been used and it is unclear how different definitions affect the estimated polypectomy rate. OBJECTIVE To estimate polypectomy rates and how they vary according to the definition of a screening colonoscopy, using patient- and endoscopist-reported indications. METHODS A cross-sectional analysis of endoscopists and their patients 50 to 75 years of age who underwent colonoscopy was conducted. Based on questionnaire responses, four patient indications were derived: perceived screening; perceived nonscreening; medical history indicating nonscreening; and combination of the three indications. Endoscopist indication was derived from a questionnaire completed immediately after colonoscopy. Polypectomy status was obtained from provincial physician billing records. Polypectomy rates were computed, while accounting for physician and hospital level clustering, using all four patient indications, endoscopist indication, and the agreement between patient and endoscopist indications. The effect of indications on polypectomy rate was estimated adjusting for age, sex and family history of colorectal cancer. RESULTS A total of 2134 patients and 45 endoscopists were included. The proportion of colonoscopies classified as screening according to the nine indications ranged from 32.2% to 70.9%. Polypectomy rates ranged between 22.6% and 26.2% for screening colonoscopy, and between 27.1% and 30.8% for nonscreening colonoscopy. Adjusted ORs for indication ranged between 0.74 and 0.94. DISCUSSION Although the proportion of colonoscopies identified as screening varied considerably among the indications, the estimated polypectomy rates were similar. CONCLUSION The findings suggest that the way screening is defined does not greatly affect the estimates of polypectomy rate.
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Li X, Hilsden R, Hossain S, Fleming J, Winget M. Validation of administrative data sources for endoscopy utilization in colorectal cancer diagnosis. BMC Health Serv Res 2012; 12:358. [PMID: 23062117 PMCID: PMC3508878 DOI: 10.1186/1472-6963-12-358] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 10/05/2012] [Indexed: 11/25/2022] Open
Abstract
Background Validation of administrative data is important to assess potential sources of bias in outcome evaluation and to prevent dissemination of misleading or inaccurate information. The purpose of the study was to determine the completeness and accuracy of endoscopy data in several administrative data sources in the year prior to colorectal cancer diagnosis as part of a larger project focused on evaluating the quality of pre-diagnostic care. Methods Primary and secondary data sources for endoscopy were collected from the Alberta Cancer Registry, cancer medical charts and three different administrative data sources. 1672 randomly sampled patients diagnosed with invasive colorectal cancer in years 2000–2005 in Alberta, Canada were included. A retrospective validation study of administrative data for endoscopy in the year prior to colorectal cancer diagnosis was conducted. A gold standard dataset was created by combining all the datasets. Number and percent identified, agreement and percent unique to a given data source were calculated and compared across each dataset and to the gold standard with respect to identifying all patients who underwent endoscopy and all endoscopies received by those patients. Results The combined administrative data and physician billing data identified as high or higher percentage of patients who had one or more endoscopy (84% and 78%, respectively) and total endoscopy procedures (89% and 81%, respectively) than the chart review (78% for both). Conclusions Endoscopy data has a high level of completeness and accuracy in physician billing data alone. Combined with hospital in/outpatient data it is more complete than chart review alone.
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Affiliation(s)
- Xue Li
- Division of Community Oncology, Cancer Care, Alberta Health Services, Edmonton, Alberta, Canada
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Abstract
OBJECTIVES The objectives of this research study are to describe the proportion of Medicaid-insured colorectal cancer survivors who had a colonoscopy between 3 and 18 months after surgery of the colon or rectum and to determine if patient, health services, and community characteristics are associated with colonoscopy follow-up after treatment. METHODS A retrospective cohort study among 1044 Medicaid-insured individuals diagnosed with local or regional colorectal cancer was conducted. Multivariable logistic regression analyses assessed patient, hospital, and community characteristics associated with colonoscopy. RESULTS About 42% of the study population had a colonoscopy 3 to 18 months after surgery. Factors associated with receipt of colonoscopy in the multivariable model include having colon (vs rectal) cancer, having local (vs regional) cancer, and having received chemotherapy as part of first course of therapy. Being 75 or older (vs <65), having first course of therapy at a hospital with the highest surgical volume (vs lowest surgical volume), and living in an urban (vs rural) environment were associated with a decreased likelihood of colonoscopy. Colonoscopy utilization patterns diverge after 65 years of age when persons become dually insured by Medicare. By age 80 years, there seems to be an almost 3-fold difference in receipt of colonoscopy-those with comorbidity are more likely to be screened than those without comorbidity. CONCLUSIONS Less than half of Medicaid-insured colorectal cancer survivors received a colonoscopy in 3 to 18 months after colorectal resection. Improvements in screening in this high-risk population should be the target of future interventions to reduce the probability of recurrence.
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Cooper GS, Xu F, Barnholtz Sloan JS, Schluchter MD, Koroukian SM. Prevalence and predictors of interval colorectal cancers in medicare beneficiaries. Cancer 2012; 118:3044-52. [PMID: 21989586 PMCID: PMC3258472 DOI: 10.1002/cncr.26602] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 08/16/2011] [Accepted: 08/18/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND After a colonoscopy that is negative for cancer, a subset of patients may be diagnosed with colorectal cancer, also termed interval cancer. The frequency and predictors have not been well studied in a population-based US cohort. METHODS The authors used the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 57,839 patients aged ≥ 69 years who were diagnosed with colorectal cancer between 1994 and 2005 and who underwent colonoscopy within 6 months of cancer diagnosis. Colonoscopy performed between 6 and 36 months before cancer diagnosis was a proxy for interval cancer. RESULTS By using the case definition, 7.2% of patients developed interval cancers. Factors that were associated with interval cancers included proximal tumor location (distal colon: multivariable odds ratio [OR], 0.42; 95% confidence interval [CI], 0.390-0.46; rectum: OR, 0.47; 95% CI, 0.42-0.53), increased comorbidity (OR, 1.89; 95% CI, 1.68 2.14 for ≥ 3 comorbidities), a previous diagnosis of diverticulosis (OR, 6.00; 95% CI, 5.57-6.46), and prior polypectomy (OR, 1.74; 95% CI, 1.62-1.87). Risk factors at the endoscopist level included a lower polypectomy rate (OR, 0.70; 95% CI, 0.63-0.78 for the highest quartile), higher colonoscopy volume (OR, 1.27; 95% CI, 1.13-1.43), and specialty other than gastroenterology (colorectal surgery: OR, 1.45; 95% CI, 1.16-1.83; general surgery: OR, 1.42; 95% CI, 1.24-1.62; internal medicine: OR, 1.38; 95% CI, 1.17-1.63; family practice: OR, 1.16; 95% CI, 1.00-1.35). CONCLUSIONS A significant proportion of patients developed interval colorectal cancer, particularly in the proximal colon. Contributing factors likely included both procedural and biologic factors, emphasizing the importance of meticulous examination of the mucosa.
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Affiliation(s)
- Gregory S Cooper
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, Ohio 44106-5066, USA.
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Fan L, Mohile S, Zhang N, Fiscella K, Noyes K. Self-reported cancer screening among elderly Medicare beneficiaries: a rural-urban comparison. J Rural Health 2012; 28:312-9. [PMID: 22757956 DOI: 10.1111/j.1748-0361.2012.00405.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Lin Fan
- Department of Community and Preventive Medicine, University of Rochester, Rochester, New York, USA.
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Higgins AY, B Doubeni AR, Phillips KL, Laiyemo AO, Briesacher B, Tjia J, Doubeni CA. Self-reported colorectal cancer screening of Medicare beneficiaries in family medicine vs. internal medicine practices in the United States: a cross-sectional study. BMC Gastroenterol 2012; 12:23. [PMID: 22436107 PMCID: PMC3352176 DOI: 10.1186/1471-230x-12-23] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 03/21/2012] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The benefit of screening for decreasing the risk of death from colorectal cancer (CRC) has been shown, yet many patients in primary care are still not undergoing screening according to guidelines. There are known variations in delivery of preventive health care services among primary care physicians. This study compared self-reported CRC screening rates and patient awareness of the need for CRC screening of patients receiving care from family medicine (FPs) vs. internal medicine (internists) physicians. METHODS Nationally representative sample of non-institutionalized beneficiaries who received medical care from FPs or internists in 2006 (using Medicare Current Beneficiary Survey). The main outcome was the percentage of patients screened in 2007. We also examined the percentage of patients offered screening. RESULTS Patients of FPs, compared to those of internists, were less likely to have received an FOBT kit or undergone home FOBT, even after accounting for patients' characteristics. Compared to internists, FPs' patients were more likely to have heard of colonoscopy, but were less likely to receive a screening colonoscopy recommendation (18% vs. 27%), or undergo a colonoscopy (43% vs. 46%, adjusted odds ratios [AOR], 95% confidence interval [CI]-- 0.65, 0.51-0.81) or any CRC screening (52% vs. 60%, AOR, CI--0.80, 0.68-0.94). Among subgroups examined, higher income beneficiaries receiving care from internists had the highest screening rate (68%), while disabled beneficiaries receiving care from FPs had the lowest screening rate (34%). CONCLUSION Patients cared for by FPs had a lower rate of screening compared to those cared for by internists, despite equal or higher levels of awareness; a difference that remained statistically significant after accounting for socioeconomic status and access to healthcare. Both groups of patients remained below the national goal of 70 percent.
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Affiliation(s)
- Angela Y Higgins
- Department of Family Medicine and Community Health, University of Massachusetts (UMass) Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Anna R B Doubeni
- Department of Family Medicine and Community Health, University of Massachusetts (UMass) Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Karon L Phillips
- Program on Aging and Care, Scott & White Memorial Hospital, 2401 South 31st. Street, Temple, TX 76508, USA
| | - Adeyinka O Laiyemo
- Division of Gastroenterology, Department of Medicine, Howard University College of Medicine, 2041 Georgia Avenue, NW, Washington, DC 20060, USA
| | - Becky Briesacher
- Meyers Primary Care Institute and Division of Geriatrics, UMass Medical School, 377 Plantation Street, Worcester, MA 01605, USA
| | - Jennifer Tjia
- Meyers Primary Care Institute and Division of Geriatrics, UMass Medical School, 377 Plantation Street, Worcester, MA 01605, USA
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Massachusetts (UMass) Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
- Meyers Primary Care Institute and Division of Geriatrics, UMass Medical School, 377 Plantation Street, Worcester, MA 01605, USA
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Singh A, Kuo YF, Riall TS, Raju GS, Goodwin JS. Predictors of colorectal cancer following a negative colonoscopy in the Medicare population. Dig Dis Sci 2011; 56:3122-8. [PMID: 21681506 PMCID: PMC3337678 DOI: 10.1007/s10620-011-1788-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 06/02/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND The incidence of colorectal cancer following a normal colonoscopy in the Medicare population is not known. METHODS A 5% national sample of Medicare enrollees from 1996 to 2005 was used to identify patients undergoing complete colonoscopy. A colonoscopy not associated with any procedure (e.g., biopsy, polypectomy or fulguration) was defined as a negative colonoscopy. Patients with history of inflammatory bowel disease, colorectal cancer or death within 12 months of colonoscopy were excluded. A multivariable model was constructed to evaluate the factors associated with a new diagnosis of colorectal cancer in the period from 12 to 120 months following the negative colonoscopy. RESULTS Among 200,857 patients (mean age 74 years, 61% female, 92% White) with a negative colonoscopy, the incidence of colorectal cancer was 1.8 per 1,000 person-years. The incidence rate for matched follow-up periods decreased from 2.0/1,000 person-years for patients undergoing colonoscopy during 1996-2000 to 1.2/1,000 person years during 2001-2005. Multivariate analysis revealed a significant regional variation in the incidence of colorectal cancer following a negative colonoscopy. The incidence was higher in patients >85 years, males and patients who underwent a negative colonoscopy by a non-gastroenterologist or endoscopist in the lowest volume quartile. On stratified analyses, endoscopist volume was a significant predictor for non-gastroenterologists only. CONCLUSIONS The specialty and experience of the endoscopist are significant predictors of the incidence rate of colorectal cancer in Medicare patients with a negative colonoscopy.
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Affiliation(s)
- Amanpal Singh
- Division of Gastroenterology, Department of Internal Medicine, University of Texas Medical Branch (UTMB), 301 University Blvd., Galveston, TX 77555-0764, USA.
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White A, Vernon SW, Franzini L, Du XL. Racial and ethnic disparities in colorectal cancer screening persisted despite expansion of Medicare's screening reimbursement. Cancer Epidemiol Biomarkers Prev 2011; 20:811-7. [PMID: 21546366 DOI: 10.1158/1055-9965.epi-09-0963] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE We examined the effect of Medicare's expansion of colorectal cancer (CRC) screening test reimbursement on racial/ethnic disparities in CRC screening. METHODS CRC screening was ascertained for Medicare beneficiaries (n = 30,893), aged 70 to 89, who had no history of any tumor and resided in 16 Surveillance, Epidemiology and End Results regions of the United States from 1996 to 2005. CRC screening tests were identified in the 5% sample of Medicare claims. Age-gender-adjusted percentages and -adjusted odds of receiving any guideline-specific CRC screening [i.e., annual fecal occult blood test (FOBT), sigmoidoscopy every 5 years or colonoscopy every 10 years] by race/ethnicity and Medicare coverage expansion period (i.e., prior to FOBT coverage, FOBT coverage only, and post-colonoscopy coverage) were reported. RESULTS CRC screening increased as Medicare coverage expanded for white and black Medicare beneficiaries. However, blacks were less likely than whites to receive screening prior to FOBT coverage (OR = 0.74, 95% CI: 0.61-0.90), during FOBT coverage only (OR = 0.66, 95% CI: 0.52-0.83) and after colonoscopy coverage (OR = 0.80, 95% CI: 0.68-0.95). Hispanics were less likely to receive screening after colonoscopy coverage (OR = 0.73, 95% CI: 0.54-0.99). CONCLUSIONS Despite the expansion of Medicare coverage for CRC screening tests, racial/ethnic differences in CRC screening persisted over time in this universally insured population, especially for blacks and Hispanics. Future studies should explore other factors beyond health insurance that may contribute to screening disparities in this and younger populations. IMPACT Although CRC screening rates increased over time, they were still low according to recommendations. More effort is needed to increase CRC screening among all Medicare beneficiaries.
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Affiliation(s)
- Arica White
- Division of Epidemiology, School of Public Health, University of Texas Health Science Center, Houston, Texas, USA.
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Jayadevappa R, Malkowicz SB, Chhatre S, Johnson JC, Gallo JJ. The burden of depression in prostate cancer. Psychooncology 2011; 21:1338-45. [PMID: 21837637 DOI: 10.1002/pon.2032] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 06/05/2011] [Accepted: 06/08/2011] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We sought to analyze the prevalence and incremental burden of depression among elderly with prostate cancer. METHODS We adopted a retrospective cohort design using the Surveillance, Epidemiology and End Results-Medicare linked database between 1995 and 2003. Patients with prostate cancer diagnosed between 1995 and 1998 were identified and followed retrospectively for 1 year pre-diagnosis and up to 8 years post diagnosis. In this cohort of patients with prostate cancer, depression during treatment phase (1 year after diagnosis of prostate cancer) or in the follow-up phase was identified using the International Classification of Diseases-Ninth Revision depression-related codes. Poisson, general linear (log-link) and Cox regression models were used to determine the association between depression status during treatment and follow-up phases and outcomes-health resource utilization, cost and mortality. RESULTS Of the 50,147 patients newly diagnosed with prostate cancer, 4285 (8.54%) had a diagnosis of depression. A diagnosis of depression during treatment phase was associated with higher odds of emergency room visits (odds ratio (OR) = 4.45, 95% CI = 4.13, 4.80), hospitalizations (OR = 3.22, CI = 3.08, 3.37), outpatient visits (OR = 1.71, CI = 1.67, 1.75) and excess risk of death over the course of the follow-up interval (hazard ratio = 2.82, CI = 2.60, 3.06). Health care costs associated with depression remained elevated compared with costs for men without depression, over the course of the follow-up. CONCLUSIONS Depression during the treatment phase was associated with significant health resource utilization, costs and mortality among men with prostate cancer. These findings emphasize the need to effectively identify and treat depression in the setting of prostate cancer.
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Affiliation(s)
- Ravishankar Jayadevappa
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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