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Sokale IO, Rosales O, Montealegre JR, Oluyomi AO, Thrift AP. Trends in Up-To-Date Colorectal Cancer Screening Among U.S. Adults Aged 50-75 Years and Variations by Race/Ethnicity and U.S. Census Bureau Divisions. AJPM FOCUS 2023; 2:100055. [PMID: 37789945 PMCID: PMC10546535 DOI: 10.1016/j.focus.2022.100055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction Mortality rates from colorectal cancer have declined over the past decades owing to population-based life-saving screening interventions. However, screening inequalities continue among racial and ethnic minorities despite having a higher disease burden. In this study, we assessed the patterns of up-to-date colorectal cancer screening rates among racial/ethnic groups across the U.S. Census Bureau Divisions. Methods This population-based cross-sectional study used weighted data from 4 cycles of the Behavioral Risk Factors Surveillance System (2014, 2016, 2018, and 2020) of adults aged 50‒75 years without a previous diagnosis of colorectal cancer. The primary outcome was guideline-recommended up-to-date colorectal cancer screening. We used logistic regression models to examine temporal trends in up-to-date colorectal cancer screening from 2014 to 2020. In addition, we conducted detailed descriptive statistics of up-to-date screening rates, comparing trends in 2020 with those in 2014 overall by race/ethnicity and U.S. census divisions. Results The overall proportion of individuals with up-to-date colorectal cancer screening increased from 66.5% in 2014 to 72.5% in 2020 (p<0.001). For racial/ethnic subgroups, from 2014 to 2020, screening rates increased significantly among non-Hispanic Whites (68.5%‒74.5%, p<0.001), non-Hispanic Blacks (68.0%‒74.6%, p<0.001), and Hispanics (51.5%‒62.8%, p<0.001). However, increases were not observed in all U.S. Census Bureau Divisions. Conclusions Although colorectal cancer screening rates improved over time, they fall short of the 80% target. Substantial racial/ethnic and geographic disparities remain. Future studies investigating the factors influencing these disparities are needed.
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Affiliation(s)
- Itunu O. Sokale
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Omar Rosales
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Jane R. Montealegre
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Abiodun O. Oluyomi
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Aaron P. Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
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Bitler MP, Carpenter CS, Horn D. Effects of the Colorectal Cancer Control Program. HEALTH ECONOMICS 2021; 30:2667-2685. [PMID: 34342362 PMCID: PMC8497428 DOI: 10.1002/hec.4397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 03/19/2021] [Accepted: 06/24/2021] [Indexed: 06/13/2023]
Abstract
Although colorectal cancer (CRC) screening is highly effective, screening rates lag far below recommended levels, particularly for low-income people. The Colorectal Cancer Control Program (CRCCP) funded $100 million in competitively awarded grants to 25 states from 2009-2015 to increase CRC screening rates among low-income, uninsured populations, in part by directly providing and paying for screening services. Using data from the 2001-2015 Behavioral Risk Factor Surveillance System (BRFSS) and a difference-in-differences strategy, we find no effects of CRCCP on the use of relatively cheap fecal occult blood tests (FOBT). We do, however, find that the CRCCP significantly increased the likelihood that uninsured 50-64-year-olds report ever having a relatively expensive endoscopic CRC screening (sigmoidoscopy or colonoscopy) by 2.9 percentage points, or 10.7%. These effects are larger for women, minorities, and individuals who did not undertake other types of preventive care. We do not find that the CRCCP led to significant changes in CRC cancer detection. Our results indicate that the CRCCP was effective at increasing CRC screening rates among the most vulnerable.
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Affiliation(s)
| | | | - Danea Horn
- Department of Agricultural and Resource Economics, UC Davis
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3
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Abstract
BACKGROUND The strain on public resources to meet the healthcare needs of populations through publicly-provided health insurance programmes is increasing and many governments turn to private health insurance (PHI) to ease the pressure on government budgets. With the goal of improving access to basic health care for citizens through PHI programmes, several high-income countries have developed strong regulations for PHI schemes. Low- and middle-income countries have the opportunity to learn from this experience to optimise PHI. If poorly regulated, PHI can hardly achieve an adequate quantity or quality of population coverage, as can be seen in the USA where a third of adults younger than 65 years of age have no insurance, sporadic coverage or coverage that exposes them to high out-of-pocket healthcare costs. OBJECTIVES To assess the effects of policies that regulate private health insurance on utilisation, quality, and cost of health care provided. SEARCH METHODS In November 2019 we searched CENTRAL; MEDLINE; Embase; Sociological Abstracts and Social Services Abstracts; ICTRP; ClinicalTrials.gov; and Web of Science Core Collection for papers that have cited the included studies. This complemented the search conducted in February 2017 in IBSS; EconLit; and Global Health. We also searched selected grey literature databases and web-sites. SELECTION CRITERIA: Randomised trials, non-randomised trials, interrupted time series (ITS) studies, and controlled before-after (CBA) studies conducted in any population or setting that assessed one or more of the following interventions that governments use to regulate private health insurance: legislation and licensing, monitoring, auditing, and intelligence. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of the evidence resolving discrepancies by consensus. We planned to summarise the results (using random-effects or fixed-effect meta-analysis) to produce an overall summary if an average intervention effect across studies was considered meaningful, and we would have discussed the implications of any differences in intervention effects across studies. However, due to the nature of the data obtained, we have provided a narrative synthesis of the findings. MAIN RESULTS We included seven CBA studies, conducted in the USA, and that directly assessed state laws on cancer screening. Only for-profit PHI schemes were addressed in the included studies and no study addressed other types of PHI (community and not for-profit). The seven studies were assessed as having 'unclear risk' of bias. All seven studies reported on utilisation of healthcare services, and one study reported on costs. None of the included studies reported on quality of health care and patient health outcomes. We assessed the certainty of evidence for patient health outcomes, and utilisation and costs of healthcare services as very low. Therefore, we are uncertain of the effects of government mandates on for-profit PHI schemes. AUTHORS' CONCLUSIONS Our review suggests that, from currently available evidence, it is uncertain whether policies that regulate private health insurance have an effect on utilisation of healthcare services, costs, quality of care, or patient health outcomes. The findings come from studies conducted in the USA and might therefore not be applicable to other countries; since the regulatory environment could be different. Studies are required in countries at different income levels because the effects of government regulation of PHI are likely to differ across these income and health system settings. Further studies should assess the different types of regulation (including regulation and licensing, monitoring, auditing, and intelligence). While regulatory research on PHI remains relatively scanty, future research can draw on the rich body of research on the regulation of other health financing interventions such as user fees and results-based provider payments.
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Affiliation(s)
- Nkengafac Villyen Motaze
- Centre for the Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- National Institute for Communicable Diseases (NICD), A Division of the National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Primus Che Chi
- Health Systems and Research Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Pierre Ongolo-Zogo
- Centre for the Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Jean Serge Ndongo
- Centre for the Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Charles S Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town , Cape Town, South Africa
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4
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Preston MA, Ross L, Chukmaitov A, Smith SA, Odlum ML, Dahman B, Sheppard VB. Health Insurance Coverage Mandates: Colorectal Cancer Screening in the Post-ACA Era. Cancer Prev Res (Phila) 2020; 14:123-130. [PMID: 32917646 DOI: 10.1158/1940-6207.capr-20-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 07/30/2020] [Accepted: 09/02/2020] [Indexed: 11/16/2022]
Abstract
Building a culture of precision public health requires research that includes health delivery model with innovative systems, health policies, and programs that support this vision. Health insurance mandates are effective mechanisms that many state policymakers use to increase the utilization of preventive health services, such as colorectal cancer screening. This study estimated the effects of health insurance mandate variations on colorectal cancer screening post Affordable Care Act (ACA) era. The study analyzed secondary data from the Behavioral Risk Factor Surveillance System (BRFSS) and the NCI State Cancer Legislative Database (SCLD) from 1997 to 2014. BRFSS data were merged with SCLD data by state ID. The target population was U.S. adults, age 50 to 74, who lived in states where health insurance was mandated or nonmandated before and after the implementation of ACA. Using a difference-in-differences (DD) approach with a time-series analysis, we evaluated the effects of health insurance mandates on colorectal cancer screening status based on U.S. Preventive Services Task Force guidelines. The adjusted average marginal effects from the DD model indicate that health insurance mandates increased the probability of up-to-date screenings versus noncompliance by 2.8% points, suggesting that an estimated 2.37 million additional age-eligible persons would receive a screening with such health insurance mandates. Compliant participants' mean age was 65 years and 57% were women (n = 32,569). Our findings are robust for various model specifications. Health insurance mandates that lower out-of-pocket expenses constitute an effective approach to increase colorectal cancer screenings for the population, as a whole. PREVENTION RELEVANCE: The value added includes future health care reforms that increase access to preventive services, such as CRC screening, are likely with lower out-of-pocket costs and will increase the number of people who are considered "up-to-date". Such policies have been used historically to improve health outcomes, and they are currently being used as public health strategies to increase access to preventive health services in an effort to improve the nation's health.
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Affiliation(s)
- Michael A Preston
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia. .,Department of Health Behavior and Policy, Office of Health Equity & Disparities Research, VCU Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
| | - Levi Ross
- Department of Health Science, The University of Alabama, Tuscaloosa, Alabama
| | - Askar Chukmaitov
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Sharla A Smith
- Department of Population Health, University of Kansas School of Medicine-Wichita, Wichita, Kansas
| | | | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia.,Department of Health Behavior and Policy, Office of Health Equity & Disparities Research, VCU Massey Cancer Center, Virginia Commonwealth University, Richmond, Virginia
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5
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Keum N, Giovannucci E. Global burden of colorectal cancer: emerging trends, risk factors and prevention strategies. Nat Rev Gastroenterol Hepatol 2019; 16:713-732. [PMID: 31455888 DOI: 10.1038/s41575-019-0189-8] [Citation(s) in RCA: 1202] [Impact Index Per Article: 240.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2019] [Indexed: 02/06/2023]
Abstract
Globally, colorectal cancer (CRC) is the third most commonly diagnosed malignancy and the second leading cause of cancer death. Arising through three major pathways, including adenoma-carcinoma sequence, serrated pathway and inflammatory pathway, CRC represents an aetiologically heterogeneous disease according to subtyping by tumour anatomical location or global molecular alterations. Genetic factors such as germline MLH1 and APC mutations have an aetiologic role, predisposing individuals to CRC. Yet, the majority of CRC is sporadic and largely attributable to the constellation of modifiable environmental risk factors characterizing westernization (for example, obesity, physical inactivity, poor diets, alcohol drinking and smoking). As such, the burden of CRC is shifting towards low-income and middle-income countries as they become westernized. Furthermore, the rising incidence of CRC at younger ages (before age 50 years) is an emerging trend. This Review provides a comprehensive summary of CRC epidemiology, with emphasis on modifiable lifestyle and nutritional factors, chemoprevention and screening. Overall, the optimal reduction of CRC incidence and mortality will require concerted efforts to reduce modifiable risk factors, to leverage chemoprevention research and to promote population-wide and targeted screening.
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Affiliation(s)
- NaNa Keum
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Food Science and Biotechnology, Dongguk University, Goyang, South Korea
| | - Edward Giovannucci
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA. .,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA. .,Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA.
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6
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Song LD, Newhouse JP, Garcia‐De‐Albeniz X, Hsu J. Changes in screening colonoscopy following Medicare reimbursement and cost-sharing changes. Health Serv Res 2019; 54:839-850. [PMID: 30941767 PMCID: PMC6606542 DOI: 10.1111/1475-6773.13150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To compare existing algorithms for classifying screening vs diagnostic colonoscopies and to quantify the increase in screening colonoscopy rates when Medicare began reimbursement in 2001 and when the Affordable Care Act (ACA) eliminated cost-sharing. DATA SOURCES Twenty percent random sample of fee-for-service (FFS) Medicare claims, 2000-2012. STUDY DESIGN Using recent administrative codes as tarnished gold standards, we examined the sensitivity and specificity of five published algorithms for classifying colonoscopies and calculated annual screening colonoscopy rates. We estimated the change in rates after Medicare began reimbursement and used difference-in-differences analysis to estimate the effects of eliminating cost-sharing by comparing states with and without a mandate to cover screening colonoscopy prior to the ACA. FINDINGS Model-based algorithms have higher sensitivity (0.53-0.99) than expert-based algorithms (0.35-0.39), but lower specificity (0.43-0.65 vs 0.79-0.88). All algorithms detected increases in screening from both Medicare's reimbursement change (range: 24-93/10 000) and the 2011 cost-sharing change (range: 1.1-34/10 000). Difference-in-difference estimates of the ACA's effect varied from 51 to 155 tests per 10 000 depending on the algorithm. CONCLUSIONS Screening colonoscopy rates increased after eliminating cost-sharing in 2011, but the increase's size varied depending on the algorithm used to classify the indication. Improvements are needed in Medicare coding for screening.
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Affiliation(s)
- Lina D. Song
- PhD Program in Health PolicyThe Graduate School of Arts and SciencesHarvard UniversityCambridgeMassachusetts
- Health Policy Research CenterMongan Institute, Massachusetts General HospitalBostonMassachusetts
| | - Joseph P. Newhouse
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusetts
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusetts
- The John F. Kennedy School of GovernmentHarvard UniversityCambridgeMassachusetts
- Faculty of Arts and SciencesHarvard UniversityCambridgeMassachusetts
| | - Xabier Garcia‐De‐Albeniz
- Health Policy Research CenterMongan Institute, Massachusetts General HospitalBostonMassachusetts
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusetts
| | - John Hsu
- Health Policy Research CenterMongan Institute, Massachusetts General HospitalBostonMassachusetts
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusetts
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7
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Preston MA, Mays GP, Bursac Z, Thomas BR, Laryea J, Tilford JM, Odlum M, Smith SA, Henry-Tillman RS. Insurance coverage mandates: Impact of physician utilization in moderating colorectal cancer screening rates. Am J Surg 2018; 215:1004-1010. [PMID: 29555083 DOI: 10.1016/j.amjsurg.2018.02.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 02/27/2018] [Indexed: 12/26/2022]
Abstract
Precision public health requires research that supports innovative systems and health delivery approaches, programs, and policies that are part of this vision. This study estimated the effects of health insurance mandate (HiM) variations and the effects of physician utilization on moderating colorectal cancer (CRC) screening rates. A time-series analysis using a difference-in-difference-in-differences (DDD) approach was conducted on CRC screenings (1997-2014) using a multivariate logistic framework. Key variables of interest were HiM, CRC screening status, and physician utilization. The adjusted average marginal effects from the DDD model indicate that physician utilization increased the probability of being "up-to-date" vs. non-compliance by 9.9% points (p = 0.007), suggesting that an estimated 8.85 million additional age-eligible persons would receive a CRC screening with HiM and routine physician visits. Routine physician visits and mandates that lower out-of-pocket expenses constitute an effective approach to increasing CRC screenings for persons ready to take advantage of such policies.
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Affiliation(s)
- Michael A Preston
- University of Arkansas for Medical Sciences, Department of Surgery, Health Initiatives and Disparities Research, 4301 West Markham Street #827, Little Rock, AR 72205-7199, USA.
| | - Glen P Mays
- University of Kentucky, Department of Health Management & Policy, College of Public Health, 111 Washington Avenue #201, Lexington, KY 40536-003, USA.
| | - Zoran Bursac
- University of TN Health Science Center, Center for Population Sciences, Department of Preventive Medicine, 66 N Pauline St., Suite 307, Memphis, TN 38163, USA.
| | - Billy R Thomas
- University of Arkansas for Medical Sciences, Department of Pediatrics Neonatology, College of Medicine, 4301 West Markham Street, Little Rock, AR 72205-7199, USA.
| | - Jonathan Laryea
- University of Arkansas for Medical Sciences, Department of Surgery, Health Initiatives and Disparities Research, 4301 West Markham Street #827, Little Rock, AR 72205-7199, USA.
| | - J Mick Tilford
- University of Arkansas for Medical Sciences, Department of Health Policy & Management, College of Public Health, 4301 West Markham Street, Little Rock, AR 72205-7199, USA.
| | - Michelle Odlum
- Columbia University, School of Nursing, 617 West 168th Street, Rm 225, New York, NY 10032, USA.
| | - Sharla A Smith
- University of Kansas School of Medicine-Wichita, Department of Preventive Medicine & Public Health, 1010 N. Kansas Street, Wichita, KS 67214, USA.
| | - Ronda S Henry-Tillman
- University of Arkansas for Medical Sciences, Department of Surgery, Health Initiatives and Disparities Research, 4301 West Markham Street #827, Little Rock, AR 72205-7199, USA.
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8
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Preferences for Colorectal Cancer Screening Tests: Differences Between Insured and Uninsured Beneficiaries of Iranian Health Transformation Plan. HEALTH SCOPE 2018. [DOI: 10.5812/jhealthscope.63213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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9
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Yoshida Y, Schmaltz CL, Jackson-Thompson J, Simoes EJ. The impact of screening on cancer incidence and mortality in Missouri, USA, 2004-2013. Public Health 2017; 154:51-58. [PMID: 29197686 DOI: 10.1016/j.puhe.2017.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/14/2017] [Accepted: 10/19/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Population-based evidence regarding impact of cancer screenings and cancer rates in Missouri is lacking. This study examined whether screenings of breast cancer, cervical cancer, and colorectal cancer impact early-stage cancer incidence and mortality in Missouri. STUDY DESIGN This is an ecological study based on county-specific estimates of selected cancer screening prevalence and early-stage cancer incidence and cancer mortality. METHODS County-specific prevalence of clinical breast examination, mammography, Pap test, sigmoidoscopy or colonoscopy, and fecal occult blood test (FOBT) were generated from Missouri County-Level Study (2003, 2007, and 2011). County-specific crude incidence and mortality were calculated (2004-2013). Pearson's correlation and Poisson regression were used to test association between cancer rate and screening prevalence. Covariates included county-level mean age, percentage of whites, percentage with low income, percentage with less than high school education high school, percentage with no insurance, and percentage having difficulties accessing care. RESULTS In the adjusted model, 'ever had Pap test' was significantly associated with an increase of 8% in early-stage cervical cancer incidence. Having clinical breast examination or Pap test in the past was also associated with decreases in mortality by 3% and 4%, respectively, although the association was not significant for Pap test. In addition, having mammography was statistically significantly associated with early-stage breast cancer incidence, and having FOBT or sigmoidoscopy or colonoscopy was associated with decreased colorectal cancer mortality; however, magnitude for these associations was only around 1%. CONCLUSIONS This study provides ecological evidence of the effectiveness of screening services in predicting early stage cancer incidence and in reducing mortality across Missouri counties. Further incentive to promote these screenings in Missouri is needed.
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Affiliation(s)
- Y Yoshida
- Department of Health Management and Informatics, School of Medicine, University of Missouri-Columbia, Columbia, MO, USA; Missouri Cancer Registry and Research Center, University of Missouri-Columbia, Columbia, MO, USA.
| | - C L Schmaltz
- Department of Health Management and Informatics, School of Medicine, University of Missouri-Columbia, Columbia, MO, USA; Missouri Cancer Registry and Research Center, University of Missouri-Columbia, Columbia, MO, USA
| | - J Jackson-Thompson
- Department of Health Management and Informatics, School of Medicine, University of Missouri-Columbia, Columbia, MO, USA; Missouri Cancer Registry and Research Center, University of Missouri-Columbia, Columbia, MO, USA; MU Informatics Institute, University of Missouri-Columbia, Columbia, MO, USA
| | - E J Simoes
- Department of Health Management and Informatics, School of Medicine, University of Missouri-Columbia, Columbia, MO, USA.
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10
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Rogal SS, Yakovchenko V, Waltz TJ, Powell BJ, Kirchner JE, Proctor EK, Gonzalez R, Park A, Ross D, Morgan TR, Chartier M, Chinman MJ. The association between implementation strategy use and the uptake of hepatitis C treatment in a national sample. Implement Sci 2017; 12:60. [PMID: 28494811 PMCID: PMC5425997 DOI: 10.1186/s13012-017-0588-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 04/25/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) is a common and highly morbid illness. New medications that have much higher cure rates have become the new evidence-based practice in the field. Understanding the implementation of these new medications nationally provides an opportunity to advance the understanding of the role of implementation strategies in clinical outcomes on a large scale. The Expert Recommendations for Implementing Change (ERIC) study defined discrete implementation strategies and clustered these strategies into groups. The present evaluation assessed the use of these strategies and clusters in the context of HCV treatment across the US Department of Veterans Affairs (VA), Veterans Health Administration, the largest provider of HCV care nationally. METHODS A 73-item survey was developed and sent to all VA sites treating HCV via electronic survey, to assess whether or not a site used each ERIC-defined implementation strategy related to employing the new HCV medication in 2014. VA national data regarding the number of Veterans starting on the new HCV medications at each site were collected. The associations between treatment starts and number and type of implementation strategies were assessed. RESULTS A total of 80 (62%) sites responded. Respondents endorsed an average of 25 ± 14 strategies. The number of treatment starts was positively correlated with the total number of strategies endorsed (r = 0.43, p < 0.001). Quartile of treatment starts was significantly associated with the number of strategies endorsed (p < 0.01), with the top quartile endorsing a median of 33 strategies, compared to 15 strategies in the lowest quartile. There were significant differences in the types of strategies endorsed by sites in the highest and lowest quartiles of treatment starts. Four of the 10 top strategies for sites in the top quartile had significant correlations with treatment starts compared to only 1 of the 10 top strategies in the bottom quartile sites. Overall, only 3 of the top 15 most frequently used strategies were associated with treatment. CONCLUSIONS These results suggest that sites that used a greater number of implementation strategies were able to deliver more evidence-based treatment in HCV. The current assessment also demonstrates the feasibility of electronic self-reporting to evaluate ERIC strategies on a large scale. These results provide initial evidence for the clinical relevance of the ERIC strategies in a real-world implementation setting on a large scale. This is an initial step in identifying which strategies are associated with the uptake of evidence-based practices in nationwide healthcare systems.
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Affiliation(s)
- Shari S Rogal
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA. .,Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA. .,Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Vera Yakovchenko
- Center for Healthcare Organization and Implementation Research, Edith Norse Rogers Memorial VA Hospital, Bedford, MA, USA
| | - Thomas J Waltz
- Department of Psychology, Eastern Michigan University, Ypsilanti, MI, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Byron J Powell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - JoAnn E Kirchner
- Department of Veterans Affairs Medical Center, HSR&D and Mental Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | - Enola K Proctor
- Brown School, Washington University in St. Louis, St. Louis, MO, USA
| | - Rachel Gonzalez
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Angela Park
- New England Veterans Engineering Resource Center, VA Boston Healthcare System, Boston, MA, USA
| | - David Ross
- HIV, Hepatitis and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA
| | - Timothy R Morgan
- Gastroenterology Section, VA Long Beach Healthcare System, Long Beach, CA, USA
| | - Maggie Chartier
- HIV, Hepatitis and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA
| | - Matthew J Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive, Pittsburgh, PA, 15240, USA.,RAND Corporation, Pittsburgh, PA, USA
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11
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Zhao G, Okoro CA, Dhingra SS, Xu F, Zack M. Trends of lack of health insurance among US adults aged 18-64 years: findings from the Behavioral Risk Factor Surveillance System, 1993-2014. Public Health 2017; 146:108-117. [PMID: 28404462 PMCID: PMC10979389 DOI: 10.1016/j.puhe.2017.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 12/12/2016] [Accepted: 01/01/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the prevalence of lack of health insurance and its changes over time among adult residents (aged 18-64 years) in 50 states and the District of Columbia (DC). STUDY DESIGN Cross-sectional surveys. METHODS We aggregated annual state-based Behavioral Risk Factor Surveillance System (BRFSS) data from 1993 through 2014 to provide nationwide and state-based prevalence estimates for lack of insurance among adults aged 18-64 years. The adjusted prevalence was estimated using log-linear regression analyses with a robust variance estimator after controlling for demographic variables. The trend was assessed separately for the periods 1993-2010 and 2011-2014 due to methodologic changes in the BRFSS. RESULTS From 1993 through 2010, the adjusted prevalence of lack of health insurance increased by 0.54% (P < 0.0001) annually (range: 16.3% in 1995 to 19.1% in 2005); this prevalence decreased significantly in 2014 (15.1%). In 2014, Georgia, Mississippi, and Texas had the highest adjusted prevalences (range: 23.0-24.6%) of lack of health insurance, and DC, Massachusetts, and Rhode Island had the lowest (range: 6.2-10.1%). The changes in the prevalence of lack of insurance over time varied significantly by state. CONCLUSIONS The nationwide prevalence of lack of health insurance decreased significantly in the past few years, especially in 2014 when about one-seventh of Americans aged 18-64 years reported lack of health insurance coverage. The huge variations in the prevalence of lack of health insurance and its changes over time among states suggest continuing efforts to ensure healthcare access for all Americans are needed to improve the overall health of the population.
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Affiliation(s)
- G Zhao
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
| | - C A Okoro
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - S S Dhingra
- Northrop Grumman Corporation, Atlanta, GA 30345, USA
| | - F Xu
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - M Zack
- Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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12
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Hamman MK, Kapinos KA. Affordable Care Act Provision Lowered Out-Of-Pocket Cost And Increased Colonoscopy Rates Among Men In Medicare. Health Aff (Millwood) 2017; 34:2069-76. [PMID: 26643627 DOI: 10.1377/hlthaff.2015.0571] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Colorectal cancer screening is one of the few cancer screenings with an "A" rating from the US Preventive Services Task Force, meaning that the procedure confers a substantial health benefit. However, 40 percent of people who should receive colorectal cancer screenings do not receive them. Colonoscopies are the most thorough method of screening because they allow physicians to view the entire length of the colon and remove polyps as needed. Billing methods that distinguish between screening and therapeutic procedures have kept expected colonoscopy costs high. However, the Affordable Care Act partially closed the so-called colonoscopy loophole and reduced expected out-of-pocket expenses for all Medicare beneficiaries. Using data from the Behavioral Risk Factor Surveillance System, we found that annual colonoscopy rates among men ages 66-75 increased significantly (by 4.0 percentage points) after the Affordable Care Act policy change, and we found some evidence of even larger increases among socioeconomically disadvantaged men. We found no significant increases among women, a result that may be explained by health behavior and other factors and that requires further study. Our research indicates that cost may be an important barrier to colorectal cancer screening, at least among men, and that making further policy changes to close remaining loopholes may improve screening rates.
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Affiliation(s)
- Mary K Hamman
- Mary K. Hamman is an assistant professor of economics at the University of Wisconsin-La Crosse
| | - Kandice A Kapinos
- Kandice A. Kapinos is an economist at the RAND Corporation in Arlington, Virginia
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13
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Cooper GS, Kou TD, Dor A, Koroukian SM, Schluchter MD. Cancer preventive services, socioeconomic status, and the Affordable Care Act. Cancer 2017; 123:1585-1589. [PMID: 28067955 DOI: 10.1002/cncr.30476] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Out-of-pocket expenditures are thought to be an important barrier to the receipt of cancer preventive services, especially for those of a lower socioeconomic status (SES). The Affordable Care Act (ACA) eliminated out-of-pocket expenditures for recommended services, including mammography and colonoscopy. The objective of this study was to determine changes in the uptake of mammography and colonoscopy among fee-for-service Medicare beneficiaries before and after ACA implementation. METHODS Using Medicare claims data, this study identified women who were 70 years old or older and had not undergone mammography in the previous 2 years and men and women who were 70 years old or older, were at increased risk for colorectal cancer, and had not undergone colonoscopy in the past 5 years. The receipt of procedures in the 2-year period before the ACA's implementation (2009-2010) and after its implementation (2011 to September 2012) was also identified. Multivariate generalized estimating equation models were used to determine the independent association and county-level quartile of median income and education with the receipt of testing. RESULTS For mammography, a lower SES quartile was associated with less uptake, but the post-ACA disparities were smaller than those in the pre-ACA period. In addition, mammography rates increased from the pre-ACA period to the post-ACA period in all SES quartiles. For colonoscopy, in both the pre- and post-ACA periods, there was an association between uptake and educational level and, to some extent, income. However, there were no appreciable changes in colonoscopy and SES after implementation of the ACA. CONCLUSIONS The removal of out-of-pocket expenditures may overcome a barrier to the receipt of recommended preventive services, but for colonoscopy, other procedural factors may remain as deterrents. Cancer 2017;123:1585-1589. © 2017 American Cancer Society.
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Affiliation(s)
- Gregory S Cooper
- Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Tzuyung Doug Kou
- Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Avi Dor
- Department of Health Policy, George Washington University, Washington, DC
| | - Siran M Koroukian
- Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mark D Schluchter
- Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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14
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Brownson RC, Dodson EA, Kerner JF, Moreland-Russell S. Framing research for state policymakers who place a priority on cancer. Cancer Causes Control 2016; 27:1035-41. [PMID: 27299656 DOI: 10.1007/s10552-016-0771-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 06/02/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Despite the potential for reducing the cancer burden via state policy change, few data exist on how best to disseminate research information to influence state legislators' policy choices. We explored: (1) the relative importance of core framing issues (source, presentation, timeliness) among policymakers who prioritize cancer and those who do not prioritize cancer and (2) the predictors of use of research in policymaking. METHODS Cross-sectional data were collected from US state policymakers (i.e., legislators elected to state houses or senates) from January through October 2012 (n = 862). One-way analysis of variance was performed to investigate the association of the priority of cancer variable with outcome variables. Multivariate logistic regression models examined predictors of the influence of research information. RESULTS Legislators who prioritized cancer tended to rate characteristics that make research information useful higher than those who did not prioritize cancer. Among differences that were statistically significant were three items in the "source" domain (relevance, delivered by someone respected, supports one's own position), one item in the "presentation" domain (telling a story related to constituents) and two items in the "timeliness" domain (high current state priority, feasible when information is received). Participants who prioritized cancer risk factors were 80 % more likely to rate research information as one of their top reasons for choosing an issue on which to work. CONCLUSIONS Our results suggest the importance of narrative forms of communication and that research information needs to be relevant to the policymakers' constituents in a brief, concise format.
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Affiliation(s)
- Ross C Brownson
- Department of Surgery and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA. .,Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, 63130, USA.
| | - Elizabeth A Dodson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, 63130, USA
| | - Jon F Kerner
- Canadian Partnership Against Cancer, Toronto, ON, Canada
| | - Sarah Moreland-Russell
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, MO, 63130, USA
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15
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Xu WY, Dowd B, Abraham J. Lessons from state mandates of preventive cancer screenings. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2016; 17:203-215. [PMID: 25773049 DOI: 10.1007/s10198-015-0672-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 02/09/2015] [Indexed: 06/04/2023]
Abstract
We use the 1997-2008 Medical Expenditure Panel Survey (MEPS) and variation in the timing of state mandates for coverage of colorectal, cervical, and prostate cancer screenings to investigate the behavioral and financial effects of mandates on privately insured adults. We find that state mandates did not result in increased rates of cancer screening. However, coverage of preventive care, whether mandated or not, moves the cost of care from the consumer's out-of-pocket expense to the premium, resulting in a cross-subsidy of users of the service by non-users. While some cross-subsidies are intentional, others may be unintentional. We find that users of cancer screening have higher levels of income and education, while non-users tend to be racial minorities, lack a usual source of care, and live in communities with fewer physicians per capita. These results suggest that coverage of preventive care may transfer resources from more advantaged individuals to less advantaged individuals.
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Affiliation(s)
- Wendy Yi Xu
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH, USA.
| | - Bryan Dowd
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jean Abraham
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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16
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Porter NR, Eberth JM, Samson ME, Garcia-Dominic O, Lengerich EJ, Schootman M. Diabetes Status and Being Up-to-Date on Colorectal Cancer Screening, 2012 Behavioral Risk Factor Surveillance System. Prev Chronic Dis 2016; 13:E19. [PMID: 26851338 PMCID: PMC4747441 DOI: 10.5888/pcd13.150391] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction Although screening rates for colorectal cancer are increasing, 22 million Americans are not up-to-date with recommendations. People with diabetes are an important and rapidly growing group at increased risk for colorectal cancer. Screening status and predictors of being up-to-date on screening are largely unknown in this population. Methods This study used logistic regression modeling and data from the 2012 Behavioral Risk Factor Surveillance System to examine the association between diabetes and colorectal cancer screening predictors with being up-to-date on colorectal cancer screening according to criteria of the US Preventive Services Task Force for adults aged 50 or older. State prevalence rates of up-to-date colorectal cancer screening were also calculated and mapped. Results The prevalence of being up-to-date with colorectal cancer screening for all respondents aged 50 or older was 65.6%; for respondents with diabetes, the rate was 69.2%. Respondents with diabetes were 22% more likely to be up-to-date on colorectal cancer screening than those without diabetes. Among those with diabetes, having a routine checkup within the previous year significantly increased the odds of being up-to-date on colorectal cancer screening (odds ratio, 1.90). Other factors such as age, income, education, race/ethnicity, insurance status, and history of cancer were also associated with up-to-date status. Conclusion Regardless of diabetes status, people who had a routine checkup within the past year were more likely to be up-to-date than people who had not. Among people with diabetes, the duration between routine checkups may be of greater importance than the frequency of diabetes-related doctor visits. Continued efforts should be made to ensure that routine care visits occur regularly to address the preventive health needs of patients with and patients without diabetes.
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Affiliation(s)
- Nancy R Porter
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Jan M Eberth
- Assistant Professor of Epidemiology, Department of Epidemiology and Biostatistics, University of South Carolina, Arnold School of Public Health, Columbia, South Carolina.
| | - Marsha E Samson
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Oralia Garcia-Dominic
- Highmark Blue Shield, Camp Hill, Pennsylvania; College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; Penn State Hershey Cancer Institute, Hershey, Pennsylvania; College of Health and Human Development, and The Pennsylvania State University, University Park, Pennsylvani
| | - Eugene J Lengerich
- College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; Penn State Hershey Cancer Institute, Hershey, Pennsylvania; College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania
| | - Mario Schootman
- Saint Louis University, Saint Louis, Missouri, and Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, Saint Louis, Missouri
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17
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Hamman MK, Kapinos KA. Colorectal Cancer Screening and State Health Insurance Mandates. HEALTH ECONOMICS 2016; 25:178-191. [PMID: 25521438 DOI: 10.1002/hec.3132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Revised: 10/17/2014] [Accepted: 11/05/2014] [Indexed: 06/04/2023]
Abstract
Colorectal cancer (CRC) is the third most deadly cancer in the USA. CRC screening is the most effective way to prevent CRC death, but compliance with recommended screenings is very low. In this study, we investigate whether CRC screening behavior changed under state mandated private insurance coverage of CRC screening in a sample of insured adults from the 1997 to 2008 Behavioral Risk Factor Surveillance Survey (BRFSS). We present difference-in-difference-in-differences (DDD) estimates that compare insured individuals age 51 to 64 to Medicare age-eligible individuals (ages 66 to 75) in mandate and non-mandate states over time. Our DDD estimates suggest endoscopic screening among men increased by 2 to 3 percentage points under mandated coverage among 51 to 64 year olds relative to their Medicare age-eligible counterparts. We find no clear evidence of changes in screening behavior among women. DD estimates suggest no evidence of a mandate effect on either type of CRC screening for men or women.
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Affiliation(s)
- Mary K Hamman
- Department of Economics, University of Wisconsin, La Crosse, La Crosse, WI, USA
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18
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Steffen LE, Boucher KM, Damron BH, Pappas LM, Walters ST, Flores KG, Boonyasiriwat W, Vernon SW, Stroup AM, Schwartz MD, Edwards SL, Kohlmann WK, Lowery JT, Wiggins CL, Hill DA, Higginbotham JC, Burt R, Simmons RG, Kinney AY. Efficacy of a Telehealth Intervention on Colonoscopy Uptake When Cost Is a Barrier: The Family CARE Cluster Randomized Controlled Trial. Cancer Epidemiol Biomarkers Prev 2015; 24:1311-8. [PMID: 26101306 PMCID: PMC4734378 DOI: 10.1158/1055-9965.epi-15-0150] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/02/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND We tested the efficacy of a remote tailored intervention Tele-Cancer Risk Assessment and Evaluation (TeleCARE) compared with a mailed educational brochure for improving colonoscopy uptake among at-risk relatives of colorectal cancer patients and examined subgroup differences based on participant reported cost barriers. METHODS Family members of colorectal cancer patients who were not up-to-date with colonoscopy were randomly assigned as family units to TeleCARE (N = 232) or an educational brochure (N = 249). At the 9-month follow-up, a cost resource letter listing resources for free or reduced-cost colonoscopy was mailed to participants who had reported cost barriers and remained nonadherent. Rates of medically verified colonoscopy at the 15-month follow-up were compared on the basis of group assignment and within group stratification by cost barriers. RESULTS In intent-to-treat analysis, 42.7% of participants in TeleCARE and 24.1% of participants in the educational brochure group had a medically verified colonoscopy [OR, 2.37; 95% confidence interval (CI) 1.59-3.52]. Cost was identified as a barrier in both groups (TeleCARE = 62.5%; educational brochure = 57.0%). When cost was not a barrier, the TeleCARE group was almost four times as likely as the comparison to have a colonoscopy (OR, 3.66; 95% CI, 1.85-7.24). The intervention was efficacious among those who reported cost barriers; the TeleCARE group was nearly twice as likely to have a colonoscopy (OR, 1.99; 95% CI, 1.12-3.52). CONCLUSIONS TeleCARE increased colonoscopy regardless of cost barriers. IMPACT Remote interventions may bolster screening colonoscopy regardless of cost barriers and be more efficacious when cost barriers are absent.
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Affiliation(s)
- Laurie E Steffen
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Kenneth M Boucher
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah. Department of Oncologic Sciences, University of Utah, Salt Lake City, Utah
| | | | - Lisa M Pappas
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Scott T Walters
- Department of School of Public Health Behavioral and Community Health, University of North Texas Health Science Center, Fort Worth, Texas
| | - Kristina G Flores
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Sally W Vernon
- Division of Health Promotion and Behavioral Sciences, The University of Texas School of Public Health, Houston, Texas
| | - Antoinette M Stroup
- Department of Epidemiology, Rutgers School of Public Health, Piscataway Township, New Jersey. Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Marc D Schwartz
- Department of Oncology, Georgetown University, Washington, DC. Lombardi Comprehensive Cancer Center, Washington, DC
| | - Sandra L Edwards
- Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Wendy K Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jan T Lowery
- Department of Epidemiology, University of Colorado School of Public Health, Aurora, Colorado
| | - Charles L Wiggins
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Deirdre A Hill
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - John C Higginbotham
- Community and Rural Medicine Institute for Rural Health Research, College of Community Health Sciences, University of Alabama, Tuscaloosa, Alabama
| | - Randall Burt
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Anita Y Kinney
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.
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19
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Hamman MK, Kapinos KA. Mandated coverage of preventive care and reduction in disparities: evidence from colorectal cancer screening. Am J Public Health 2015; 105 Suppl 3:S508-16. [PMID: 25905835 DOI: 10.2105/ajph.2015.302578] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We identified correlates of racial/ethnic disparities in colorectal cancer screening and changes in disparities under state-mandated insurance coverage. METHODS Using Behavioral Risk Factor Surveillance System data, we estimated a Fairlie decomposition in the insured population aged 50 to 64 years and a regression-adjusted difference-in-difference-in-difference model of changes in screening attributable to mandates. RESULTS Under mandated coverage, blood stool test (BST) rates increased among Black, Asian, and Native American men, but rates among Whites also increased, so disparities did not change. Endoscopic screening rates increased by 10 percentage points for Hispanic men and 3 percentage points for non-Hispanic men. BST rates fell among Hispanic relative to non-Hispanic men. We found no changes for women. However, endoscopic screening rates improved among lower income individuals across all races and ethnicities. CONCLUSIONS Mandates were associated with a reduction in endoscopic screening disparities only for Hispanic men but may indirectly reduce racial/ethnic disparities by increasing rates among lower income individuals. Findings imply that systematic differences in insurance coverage, or health plan fragmentation, likely existed without mandates. These findings underscore the need to research disparities within insured populations.
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Affiliation(s)
- Mary K Hamman
- Mary K. Hamman is with the Department of Economics, College of Business Administration, University of Wisconsin-La Crosse. Kandice A. Kapinos is with the RAND Corporation, Arlington, VA
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20
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Charters TJ, Strumpf EC, Sewitch MJ. Effectiveness of an organized colorectal cancer screening program on increasing adherence in asymptomatic average-risk Canadians. BMC Health Serv Res 2013; 13:449. [PMID: 24168208 PMCID: PMC4231607 DOI: 10.1186/1472-6963-13-449] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 09/27/2013] [Indexed: 01/22/2023] Open
Abstract
Background Colorectal cancer (CRC) is the third most commonly diagnosed cancer and second highest cause of cancer-related mortality in Canada. Despite the availability of screening services and establishment of guidelines, utilization of colorectal cancer screening in Canada remains low. In 2008, the province of Ontario launched ColonCancerCheck, an organized colorectal cancer screening program aimed at increasing CRC screening adherence. In this study, we adopt a quasi-experimental approach to estimate and describe the impact of ColonCancerCheck on screening behavior in the asymptomatic average risk population. Methods Annual screening rates from the target population were estimated using five cycles of the Canadian Community Health Survey, a cross-sectional nationally representative survey of health status, healthcare use, and determinants of health in the Canadian population. We used a difference-in-differences design to measure the overall impact of ColonCancerCheck on past-year fecal occult blood testing (FOBT) and endoscopy in Ontario relative to the rest of Canada. Several verification tests validated the suitability of our model specification. Results The difference-in-differences analysis shows that ColonCancerCheck increased FOBT screening in the average risk population by 5.2 percentage points (95% CI [3.2, 7.2]), an increase of 33% relative to pre-program screening rates. The program had no observed effect on endoscopy screening and we found no evidence that ColonCancerCheck differentially altered the screening practices of population sub-groups. Conclusions Our findings suggest ColonCancerCheck has been successful at increasing use of FOBT in the asymptomatic average risk population.
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Affiliation(s)
- Thomas J Charters
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall 41, 1020 Pine Ave, West, Montreal, QC H3A 1A2, Canada.
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Bansal N, Sonnenberg EM, Meise CK, Reinke CE, Karakousis GC, Bartlett EK, Mahmoud NN, Roses RE, Kelz RR. The effect of colorectal cancer screening mandates on access to care and clinical outcomes: a retrospective study of patients undergoing operations of the colon and rectum. Surgery 2013; 154:335-44. [PMID: 23889960 DOI: 10.1016/j.surg.2013.04.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 04/19/2013] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Policies that mandate colorectal screening coverage by private insurers are associated with increased use of screening procedures. We seek to understand whether such mandates have improved access to care and short-term operative outcomes for patients undergoing operations of the colon and rectum (OCR). METHODS Privately insured OCR patients, ages 50-64, enrolled in the Nationwide Inpatient Sample (NIS) (2000-2009) were identified. Patients were classified as "exposed" if they underwent OCR in a state that implemented a mandate ≥ 2 years before their procedure. Three outcomes were examined: admission source, postoperative complications, and postoperative mortality. Univariate analyses were performed by the use of logistic regression models. Multivariable logistic regression models were developed to evaluate the relationship between exposure status, admission source, postoperative complications, and postoperative mortality, with adjustment for confounders. RESULTS We identified 99,405 patients who underwent OCR during the study period. Of these patients, 39% were "exposed," 23% were admitted from the ED, 32% developed a postoperative complication, and 2% died during the admission. After adjusting for confounders, exposed patients were less likely to access OCR through the emergency department (odds ratio 0.87; 95% confidence interval 0.83-0.91) and less likely to develop postoperative complications (odds ratio 0.94; 95% confidence interval 0.89-0.98). There was no detectable difference in postoperative mortality. CONCLUSION Implementation of policies mandating coverage of colorectal screening modestly reduced emergent admission for OCR among privately insured patients. Additional studies are required to examine the screening status of patients to determine causality. Remaining states should consider implementing similar policies.
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Affiliation(s)
- Neha Bansal
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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22
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Greene P, Mehta P, Yeary KHCK, Bursac Z, Zhang J, Goldsmith G, Henry-Tillman R. Using population data to reduce disparities in colorectal cancer screening, Arkansas, 2006. Prev Chronic Dis 2012; 9:E138. [PMID: 22898236 PMCID: PMC3475514 DOI: 10.5888/pcd9.110256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Colorectal cancer is a common disease, and incidence and death rates are higher in medically underserved populations. The colorectal cancer death rate in Arkansas exceeds the national rate. The objective of this study was to examine population characteristics relevant to the design and implementation of a state-sponsored colorectal cancer screening program that is responsive to medically underserved populations. Methods Trained interviewers in 2006 conducted a random-digit–dialed telephone survey comprising items selected from the Health Information National Trends Survey to characterize demographic factors, health care variables, and colorectal screening history in a sample (n = 2,021) representative of the Arkansas population. Univariate and multivariate analyses identified associations among population characteristics and screening status. Results Participants who were aged 50 to 64, who did not have health insurance, or who had an annual household income of $15,000 or less were significantly less likely than their counterparts to be in compliance with screening guidelines. Those who reported having a health care provider, having 5 or more health care visits during the past year, and receiving physician advice for colorectal screening were more likely to be in compliance with screening guidelines. Although a larger percentage of white participants were in compliance with screening guidelines, blacks had higher screening rates than whites when we controlled for screening advice. Conclusion Survey results informed efforts to decrease disparities in colorectal cancer screening in Arkansas. Efforts should focus on reimbursing providers and patients for screening costs, encouraging the use of physicians as a point of entry to screening programs, and promoting a balanced approach (ie, multiple options) to screening recommendations. Our methods established a model for developing screening programs for medically underserved populations.
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Affiliation(s)
- Paul Greene
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301 W Markham no. 820, Little Rock, AR 72205, USA.
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Bandi P, Cokkinides V, Smith RA, Jemal A. Trends in colorectal cancer screening with home-based fecal occult blood tests in adults ages 50 to 64 years, 2000-2008. Cancer 2012; 118:5092-9. [PMID: 22434529 DOI: 10.1002/cncr.27529] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 01/27/2012] [Accepted: 02/13/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND National surveys have reported declines in rates of home-based fecal occult blood test (FOBT) screening for colorectal cancer (CRC) in the last decade. However, socioeconomic status (SES) and racial/ethnic differences in FOBT trends and their changes relative to endoscopic CRC screening have not been evaluated. METHODS Data on adults ages 50 to 64 years from the 2000, 2005, and 2008 National Health Interview Surveys were used. Weighted analyses and multivariate logistic regression were used to study trends in the use of FOBT and endoscopic CRC screening during this period. RESULTS Between 2000 and 2008, significant declines in FOBT prevalence occurred in higher SES groups, but not in lower SES groups (uninsured and publicly insured, those without a usual source of care, lower educated, lower income, and immigrants to the United States) or Hispanics. Endoscopic CRC screening during the period studied consistently increased in all higher SES subgroups. In contrast, few lower SES subgroups (publicly insured, lower educated, near poor individuals, long-term immigrants) and Hispanics experienced increases in CRC endoscopic screening, and these increases were smaller than those observed in higher SES subgroups. CONCLUSIONS Socially and economically disadvantaged groups experienced little or no change in FOBT prevalence, and few of these groups experienced contemporaneous increases in CRC endoscopic screening. These trends suggest the continued availability and acceptance of FOBT in these groups. If national CRC screening goals are to be achieved in populations with lower access to colonoscopy, then annual high-sensitivity FOBT should be promoted as an immediately accessible and viable alternative.
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Affiliation(s)
- Priti Bandi
- Surveillance Research Program, American Cancer Society, Atlanta, GA 30303-1002, USA.
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Paskett ED. Cancer health [corrected] disparities: moving from why they occur to how they can be prevented. J Clin Oncol 2011; 30:354-6. [PMID: 22184382 DOI: 10.1200/jco.2011.39.5947] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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