Fax: (503) 494-2746
Influence of health insurance coverage on breast, cervical, and colorectal cancer screening in rural primary care settings
Article first published online: 30 MAY 2012
Copyright © 2012 American Cancer Society
Volume 118, Issue 24, pages 6217–6225, 15 December 2012
How to Cite
Carney, P. A., O'Malley, J., Buckley, D. I., Mori, M., Lieberman, D. A., Fagnan, L. J., Wallace, J., Liu, B. and Morris, C. (2012), Influence of health insurance coverage on breast, cervical, and colorectal cancer screening in rural primary care settings. Cancer, 118: 6217–6225. doi: 10.1002/cncr.27635
- Issue published online: 3 DEC 2012
- Article first published online: 30 MAY 2012
- Manuscript Accepted: 6 MAR 2012
- Manuscript Revised: 20 JAN 2012
- Manuscript Received: 13 OCT 2011
- cancer screening;
- health insurance;
- Papanicolaou (Pap) test;
The current study was performed to determine, in rural settings, the relation between the type and status of insurance coverage and being up-to-date for breast, cervical, and colorectal cancer screening.
Four primary care practices in 2 rural Oregon communities participated. Medical chart reviews that were conducted between October 2008 and August 2009 assessed insurance coverage and up-to-date status for breast, cervical, and colorectal cancer screening. Inclusion criteria involved having at least 1 health care visit within the past 5 years and being aged ≥ 55 years.
The majority of patients were women aged 55 years to 70 years, employed or retired, and who had private health insurance and an average of 2.5 comorbid conditions. The overall percentage of eligible women who were up-to-date for cervical cancer screening was 30%; approximately 27% of women were up-to-date for clinical breast examination, 37% were up-to-date for mammography, and 19% were up-to-date for both mammography and clinical breast examination. Approximately 38% of men and 35% of women were up-to-date for colorectal cancer screening using any test at appropriate screening intervals. In general, having any insurance versus being uninsured was associated with undergoing cancer screening. For each type of screening, patients who had at least 1 health maintenance visit were significantly more likely to be up-to-date compared with those with no health maintenance visits. A significant interaction was found between having health maintenance visits, having any health insurance, and being up-to-date for cancer screening tests.
Overall, the percentage of patients who were up-to-date for any cancer screening, especially cervical cancer screening, was found to be very low in rural Oregon. Patients with some form of health insurance were more likely to have had a health maintenance visit within the previous 2 years and to be up-to-date for breast, cervical, and/or colorectal cancer screening. Cancer 2012. © 2012 American Cancer Society.
Strong evidence indicates that breast, cervical, and colorectal cancer screening tests result in earlier detection and longer survival rates.1-3 Rates of breast, cervical, and colorectal cancer screening increased in the United States between 1987 and 2000.4 Recently, these trends have changed, with screening rates leveling off or, in the case of breast and cervical cancer screening, decreasing.4, 5 Possible explanations for these decreases in cancer screening include increases in uninsured or underinsured individuals.6-13 To the best of our knowedge, the majority of studies on this topic have focused on urban settings, whereas studies of rural populations are lacking.
More recently, health insurance companies have shifted costs through expanded cost-sharing mechanisms such as deductibles, copayments, and coinsurance to keep insurance prices affordable for employers and reduce expenditure risks.14, 15 Although saving money in the short term, widespread increases in cost-sharing could escalate future costs by creating disincentives for cancer screening. In September 2007, the American Cancer Society (ACS) announced that, after tobacco use, lack of affordable health care is the largest obstacle to success in the battle against cancer.16 The ACS simultaneously launched the biggest awareness campaign in its 94-year history, focusing on inadequate health insurance coverage and access to cancer care.16 Although important changes in health coverage have occurred under the Obama administration, these initiatives have not been fully implemented, and their long-term status is uncertain.17
The role of health insurance as a determinant of screening for breast, cervical, and colorectal cancer is an important area of research, given changes in health care access. Higher cancer mortality rates (1.2 to 2.1 times greater) among uninsured individuals compared with privately insured persons reflect a higher likelihood of being diagnosed with late-stage colorectal, breast, or cervical cancer.18 The population for whom cancer screening is of greatest significance, those aged ≥ 50 years, is also the group most likely to experience comorbid conditions, often resulting in significant out-of-pocket expenditures.19 The majority of these studies have used Medicare data, which exclude those aged 50 years to 64 years.20 Innovative research is needed to: 1) learn how patients will make cancer screening decisions in the future when faced with different cost considerations; 2) guide private and public insurers in the establishment of evidence-based and value-based reimbursement policies; and 3) help clinicians become better aware of the burden of cost on patients and interface with available community resources.
We conducted chart reviews of the primary care practices in 2 rural Oregon communities between October 2008 and July 2009 and identified patients aged ≥ 55 years. We then retrospectively reviewed their screening and insurance records to determine how insurance type and coverage influenced the receipt of cancer screening in this understudied population.
MATERIALS AND METHODS
The current study was conducted with the Oregon Rural Practice-based Research Network (ORPRN), a statewide network of 32 practices located in 26 rural Oregon communities. Characteristics of the practices are described elsewhere.21 Briefly, all practices serve Oregon rural communities with populations ranging from 357 to 20,500 individuals.21 Two rural communities were selected for this study. One had an area of 533 square miles with a population of 20,500 individuals, 27.2% of whom were Hispanic. The second community spanned 1781 square miles with a population of 19,868 individuals, 25% of whom were Hispanic. Each community had 2 primary care practices, for a total of 4 practices. Two practices were private and 2 were Federally Qualified Health Centers (FQHCs), with 1 private practice and 1 FQHC located within each community. All study activities were reviewed and approved by Oregon Health and Science University's Institutional Review Board.
Chart reviews took place between October 2008 and August 2009. Data were collected concerning patient insurance type and coverage; practice and practitioner characteristics; and up-to-date screening status for breast, cervical, and colorectal cancers. Criteria for inclusion in the chart review included having made at least 1 health care visit within the past 5 years and patient age ≥ 55 years at the time of chart review to ensure eligibility for the screening services under study. Charts were retrospectively reviewed for up to 10 years or as far back as 1998.
Data abstraction was performed on site using laptop computers and a database specifically designed and tested for this purpose. Variables collected included patient age; education; race/ethnicity; marital status; occupation; personal and family history of cancer; history of a prior abnormal screening test (breast, cervical, and colorectal); smoking status/history; alcohol use; exercise pattern; body mass index (BMI); health insurance status (insured/uninsured); type of insurance (preferred provider organization, Medicare, Medicaid, Oregon Health Plan, or other); length of each patient's relationship with a health care provider; documented comorbid conditions; and receipt of mammography, clinical breast examination, Papanicolaou (Pap) test, and any recommended form of colorectal cancer screening (fecal occult blood test [FOBT], colonoscopy, flexible sigmoidoscopy, or double contrast barium enema). Two trained chart abstractors conducted the chart reviews, and a third abstractor conducted a quality review of 10% of the chart abstractions performed by the first 2 reviewers. Concordance between the 2 independent abstractors using kappa coefficients ranged from 0.49 to 0.94 for all variables included in the analyses.
Data Definitions and Analyses
The data set used for analysis excluded patients for whom age was missing (5 patients) and 155 patients who had a personal history of breast, cervical, or colorectal cancer. The final analysis set contained data for 1563 males and 1870 females (total of 3433 patients). The data set contained information regarding the number of visits within the last 2 years for health maintenance visits. Insurance coverage and type were classified using the last recorded insurance coverage in the patient file or billing record. Because multiple coverage types were possible, for analytic purposes coverage was categorized as: 1) unknown (no record of insurance coverage and no notation of a lack of coverage); 2) uninsured (last recorded insurance status was uninsured); 3) Medicaid only or Medicare plus Medicaid; 4) Medicare only or Medicare plus private insurance; and 5) private insurance only.
Up-to-date status for cancer screening was defined using the ACS guidelines.4 Mammography and clinical breast examination screenings were classified as up-to-date for women if the medical record indicated that screenings had been performed within the prior year of the last contact with the clinic. We restricted analyses to women who had not undergone bilateral mastectomy. For women with 3 consecutive negative Pap tests, cervical cancer screening was classified as up-to-date if a Pap test had occurred within 3 years before the last contact with the clinic. Women without 3 prior negative screens were classified as up-to-date if they had received a Pap test within 1 year before the last contact with the clinic. We included women aged 55 years to 70 years who were not at an increased risk of cervical cancer because of a family history or a prior history of abnormal Pap tests. For women at an increased risk of cervical cancer, we extended the age range to include those aged ≥ 70 years. We restricted our analysis of cervical cancer screening to women who had not undergone total hysterectomy. For colorectal cancer screening, patients were classified as up-to-date if the medical record indicated the patient had undergone a colonoscopy within 10 years before their last contact with the clinic, a double contrast barium enema or flexible sigmoidoscopy within 5 years, or FOBT screening within the prior year.
Lastly, we explored the impact of changing screening guidelines to the less conservative US Preventive Services Task Force (USPSTF) guidelines22 because many clinicians follow those guidelines, which affected our analyses of breast, cervical, and colorectal cancer screening. Clinical breast examinations are not recommended by the USPSTF. In addition, mammography is recommended less frequently, and USPSTF cervical and colorectal cancer screening guidelines recommend suspending screening when patients reach aged 65 years and 75 years, respectively.
All analyses were performed using SAS statistical software (version 9.2; SAS Institute, Inc, Cary, NC). A random effects logistic regression model assessed the effect of insurance coverage on up-to-date cancer screening status, adjusted for potential confounding variables. Because of the possible correlation of patients in the same clinic, clinics were treated as a random effect in the model. In addition, the initial analysis suggested that a history of health maintenance visits was both a strong predictor and an effect modifier of up-to-date screening status and therefore the analyses were conducted overall and by history of health maintenance visits. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated for each level of insurance variable, adjusted for a set of preselected confounders. To maintain uniform adjustment for confounders, a single set of demographic variables was selected for adjustment on the basis of a statistically significant association with up-to-date screening status for any cancer in a model with only demographic variables. The selected confounders were age (category), ethnicity, BMI class, smoking status, number of patient visits, length of contact with the clinic, and family history of cancer.
Comorbidity adjustment variables were included in the analysis if the comorbidity variable was significantly associated with the cancer-specific screening status in a model that included demographic variables but excluded insurance status. Analyses of up-to-date for breast cancer screening were adjusted for asthma and arthritis comorbidities. Analyses of up-to-date for cervical cancer screening were adjusted for arthritis and hypertension comorbidities. Analyses of up-to-date for colorectal cancer screening were stratified by gender and both strata were adjusted for cardiovascular and digestive disease and a history of low back pain.
The median length of contact with all study clinics was 9.6 years for females and 10.3 years for males (interquartile range, 3 years-20 years for females and 4 years-19 years for males). The median number of patient visits within the past 10 years was 10 visits for males and 11 for females (data not shown). Approximately 2% of patients received care from multiple clinics. The majority of patients were female; aged 55 years to 70 years; employed or retired; had private health insurance (Table 1); and had an average of 2.5 comorbid conditions, including digestive disorders, chronic pain, and arthritis (range, 0 to 10 comorbid conditions). The number of health maintenance visits within the previous 2 years ranged from 0 to 7 visits in both men and women. Approximately 62% of men and 52% of women had no record of health maintenance visits within the last 2 years.
|Community A||621 (40%)||608 (33%)|
|Community B||942 (60%)||1262 (67%)|
|50-59||629 (40%)||717 (38%)|
|60-69||536 (34%)||647 (35%)|
|70-79||270 (17%)||301 (16%)|
|≥80||128 (8%)||205 (11%)|
|<18.5||4 (0.3%)||26 (1%)|
|18.5-30||658 (42%)||810 (43%)|
|>30||433 (28%)||556 (30%)|
|Not computable||468 (30%)||478 (26%)|
|White||888 (57%)||1132 (61%)|
|Other||47 (3%)||53 (3%)|
|Unknown/unspecified||628 (40%)||685 (37%)|
|Hispanic||184 (12%)||239 (13%)|
|Non-Hispanic||436 (28%)||632 (34%)|
|Unspecified||943 (60%)||999 (53%)|
|Married/partnered||1082 (69%)||1047 (56%)|
|Unpartnered||333 (21%)||649 (35%)|
|Unknown||148 (9%)||164 (9%)|
|Employed||735 (47%)||694 (37%)|
|Unemployed||72 (5%)||177 (9%)|
|Retired||509 (33%)||542 (29%)|
|Other||71 (5%)||80 (4%)|
|Unknown||176 (11%)||377 (20%)|
|Last reported insurance|
|Private only||831 (53%)||1009 (54%)|
|Medicare or Medicare plus private||251 (16%)||322 (17%)|
|Medicaid or Medicare plus Medicaid||83 (5%)||107 (6%)|
|Uninsured||111 (7%)||172 (9%)|
|Unknown||287 (18%)||266 (14%)|
|Nonsmoker||721 (46%)||1176 (63%)|
|Former smoker||489 (31%)||377 (20%)|
|Current smoker||264 (17%)||216 (12%)|
|Unknown||89 (6%)||101 (5%)|
|Nonuser||502 (32%)||952 (51%)|
|Former user||173 (11%)||73 (4%)|
|Current user||764 (49%)||673 (36%)|
|Unknown||124 (8%)||172 (9%)|
|Family history of cancerb|
|Breast||65 (4%)||200 (11%)|
|Cervical||6 (0.4%)||22 (1%)|
|Colorectal||29 (2%)||64 (3%)|
|Other cancer||394 (25%)||451 (24%)|
|None||1070 (69%)||1152 (62%)|
|Personal history of cancerb|
|Cervical||0 (0%)||23 (1%)|
|Other cancer||264 (17%)||189 (10%)|
|None||1299 (83%)||1658 (89%)|
|Cancer history in excluded patientsb|
|No. of excluded patients||23||132|
Table 2 represents the percentage of patients up-to-date for breast cancer screening overall and the odds of being up-to-date using clinical breast examination only, mammography screening only, and both clinical breast examination and mammography screening, according to receipt of any health maintenance visit and insurance type at last health care visit. Overall, 27% of women were up-to-date for clinical breast examination, 35% for mammography only, and 19% for both mammography and clinical breast examination, which were the ACS recommendations during the study period. The likelihood of receiving at least 1 health maintenance visit was found to be strongly associated with insurance status (OR for any health maintenance visits for uninsured compared with private insurance, 0.57; 95% CI, 0.38-0.87 [P = .01, results not shown]) and the likelihood of being up-to-date for breast cancer screening was higher among women who had at least 1 health maintenance visit compared with those with no visits for all 3 breast cancer screening outcomes.
|Last recorded insurance||Percentage UTDa, n/N (%)||Adjustedb ORs (95% CI) for UTD|
|Clinical Breast Examinations||Clinical Breast Examinations|
|Overall UTD||UTD by Health Maintenance Visits||Overall UTD||UTD by Health Maintenance Visitsc|
|No Visits||At Least 1 Visit||No Visits||At Least 1 Visit|
|Unknown insurance status||83/259 (32%)||2/133 (2%)||81/126 (64%)||0.57 (0.25-1.31)||0.19 (0.04-0.83)||1.93 (1.17-3.18)|
|Uninsured||41/130 (24%)||4/108 (4%)||37/63 (59%)||0.76 (0.39-1.48)||0.44 (0.14-1.34)||1.37 (0.74-2.53)|
|Medicaid or Medicaid plus private||28/107 (26%)||2/61 (3%)||26/46 (57%)||0.98 (0.41-2.31)||0.57 (0.13-2.61)||1.74 (0.88-3.47)|
|Medicare or Medicare plus private||76/319 (24%)||13/176 (7%)||63/143 (44%)||1.63 (1.04 - 2.56)||2.28 (1.11-4.72)||1.12 (0.73-1.75)|
|Private||283/1003 (28%)||33/485 (7%)||250/518 (48%)||Referent||Referent||Referent|
|Total||511/1859 (27%)||54/963 (6%)||457/896 (51%)|
|Mammography Screening||Mammography Screening|
|Overall UTD||UTD by Health Maintenance Visits||Overall UTD||UTD by Health Maintenance Visitsc|
|No Visits||At Least 1 Visit||No Visits||At Least 1 Visit|
|Unknown status||67/259 (26%)||8/133 (6%)||59/126 (47%)||0.59 (0.35-1.02)||0.38 (0.17-0.87)||0.95 (0.57-1.58)|
|Uninsured||38/171 (22%)||5/108 (5%)||33/63 (52%)||0.44 (0.24-0.79)||0.20 (0.08-0.51)||1.04 (0.57-1.89)|
|Medicaid or Medicaid plus private||31/107 (29%)||11/61 (18%)||20/46 (43%)||0.67 (0.41-1.09)||0.73 (0.36-1.47)||0.61 (0.32-1.16)|
|Medicare or Medicare plus private||103/319 (32%)||35/176 (20%)||68/143 (48%)||0.73 (0.53-1.02)||0.89 (0.56-1.41)||0.60 (0.39-0.90)|
|Private||443/1003 (44%)||126/485 (26%)||317/518 (61%)||Referent||Referent||Referent|
|Total||682/1859 (37%)||185/963 (19%)||497/896 (55%)|
The adjusted analysis indicated that, compared with women with private health insurance, women with private insurance and Medicare or Medicaid were more likely to be up-to-date for clinical breast examination (overall OR, 1.63; 95% CI, 1.04-2.56 [P = .03). Examination of the interaction between health maintenance visit history and insurance status indicated that this overall difference was because of a significant association between up-to-date status for clinical breast examination and Medicare status in women with no health maintenance visits (OR, 1.63; 95% CI, 1.04-4.72 [P = .0.03]). The women with unknown health insurance status with at least 1 health maintenance visit were more likely to be up-to-date for clinical breast examination compared with those with private health insurance who also had at least 1 health care visit (OR, 2.29; 95% CI, 1.11-4.72 [P = .03]), but the association was not found to be significant in women with no health maintenance visits (OR, 1.12; 95% CI, 0.73-1.74). A similar association of a decreased likelihood of up-to-date mammography screening or mammography with clinical breast examination in women with unknown or uninsured insurance status was observed in women who had no health maintenance visits, but there was no significant difference noted with regard to the likelihood of mammography status associated with uninsured or unknown insurance status in women who had at least 1 health maintenance visit. Using the USPSTF recommendations for mammography resulted in more women being up-to-date overall (50% vs 37%), but the relative differences associated with insurance coverage were unchanged.
Table 3 presents the percentage of women who were eligible for cervical cancer screening who were up-to-date for a Pap test and the adjusted relative OR of being up-to-date according to last recorded insurance type. The results are presented according to the receipt of any health maintenance visit. Overall, 30% of women were up-to-date for Pap testing. Similar to breast cancer screening, the percentage of women who were up-to-date was higher among those who had at least 1 health maintenance visit compared with those who had none. Uninsured women represented the group least likely to be up-to-date compared with those with private insurance, except among women with at least 1 preventive healthcare visit, in whom this was lowest among those with Medicare or Medicare plus private insurance. The OR for up-to-date Pap test screening in women with any health maintenance visit versus none was 23.1 (95% CI, 10.6-50.6 [P < .0001, results not shown]). As with mammography screening, the percentage of women who were up-to-date for cervical cancer screening increased from 30% to 52% when applying USPSTF recommendations. This difference was especially influenced by excluding those women aged ≥ 65 years as recommended by the USPSTF.
|Last recorded insurance||Percentage UTDa for Pap Test, n/N (%)||Adjustedb ORs (95% CI) for UTD|
|Overall UTD||UTD by Health Maintenance Visits||Overall UTD||UTD by Health Maintenance Visitsc|
|No Visits||At Least 1 Visit||No Visits||At Least 1 Visit|
|Unknown insurance status||47/167 (28%)||1/81 (1%)||46/86 (53%)||0.40 (0.13-1.32)||0.17 (0.02-1.37)||1.06 (0.55-2.03)|
|Uninsured||24/115 (21%)||2/73 (3%)||22/42 (52%)||0.48 (0.19-1.24)||0.28 (0.06-1.32)||0.87 (0.38-1.97)|
|Medicaid or Medicaid plus private||15/48 (31%)||1/22 (5%)||14/26 (54%)||0.79 (0.24-2.58)||0.67 (0.08-5.51)||0.95 (0.38-1.97)|
|Medicare or Medicare plus private||14/75 (19%)||2/28 (7%)||12/47 (26%)||0.62 (0.25-1.55)||1.14 (0.24-5.49)||0.32 (0.14-0.70)|
|Private||179/529 (34%)||19/235 (8%)||160/294 (54%)||Referent||Referent||Referent|
|Total||279/934 (30%)||25/439 (6%)||254/495 (51%)|
Table 4 presents the percentage of patients who were up-to-date for colorectal cancer screening (using any of 4 different tests at the appropriate recommended screening interval) and the adjusted relative ORs of being up-to-date according to last recorded insurance type. These results are also presented by subgroup according to the receipt of any health maintenance visit. Approximately 37% of men and 38% of women were up-to-date for colorectal cancer screening. Of those patients with any record of colorectal cancer screening, the most recent screening method used was FOBT for 25% of men and 20% of women, colonoscopy for 64% of men and 74% of women, flexible sigmoidoscopy for 10% of men and 3% of women, and double contrast barium enema for 1% of men and 3% of women. The OR for being up-to-date for colorectal cancer screening in women with any health maintenance visit versus none was 3.02 (95% CI, 2.13-4.27 [P ≤ .0001]) and it was 2.30 for men (95% CI, 1.50-3.55 [P < .0001]). A secondary analysis of female patients that added mammography status to the analysis described in Table 4 indicated that women who were up-to-date for mammography were much more likely to be up-to-date for colorectal cancer screening (OR, 1.74; 95% CI, 1.38-2.20 [P < .0001], results not shown).
|Percentage UTDa With CRC Screening, n/N UTD (% UTD)||Adjustedb ORs (95% CI) for UTD CRC Screening|
|Last recorded insurance||Overall UTD||UTD by Health Maintenance Visits||Overall UTD||UTD by Health Maintenance Visitsc|
|No Visits||At Least 1 Visit||No Visits||At Least 1 Visit|
|Unknown insurance status||43/287 (15%)||20/231 (9%)||23/56 (41%)||0.88 (0.52-1.51)||0.62 (0.33-1.16)||1.25 (0.61-2.58)|
|Uninsured||12/111 (11%)||9/98 (9%)||3/13 (23%)||0.43 (0.19-1.00)||0.46 (0.21-1.02)||0.40 (0.09-1.72)|
|Medicaid or Medicaid plus private||26/83 (31%)||12/51 (24%)||14/32 (44%)||0.60 (0.34-1.05)||0.80 (0.38-1.68)||0.45 (0.20-1.02)|
|Medicare or Medicare plus private||105/251 (42%)||49/151 (32%)||56/100 (56%)||0.77 (0.53-1.10)||1.00 (0.63-1.58)||0.59 (0.35-0.98)|
|Private||407/831 (49%)||156/442 (35%)||251/389 (65%)||Referent||Referent||Referent|
|Total||593/1563 (38%)||246/973 (25%)||347/590 (59%)|
|Unknown status||47/260 (18%)||7/133 (5%)||40/127 (31%)||0.43 (0.25-0.74)||0.28 (0.12-0.67)||0.62 (0.39-1.10)|
|Uninsured||23/172 (13%)||8/108 (7%)||15/64 (23%)||0.45 (0.25-0.79)||0.35 (0.16-0.79)||0.57 (0.28-1.16)|
|Medicaid or Medicaid plus private||47/107 (44%)||21/61 (34%)||26/46 (57%)||1.27 (0.80-2.04)||1.13 (0.61-2.09)||1.44 (0.74-2.86)|
|Medicare or Medicare plus private||131/322 (41%)||49/178 (28%)||82/144 (57%)||0.74 (0.54-1.03)||0.65 (0.41-1.01)||0.86 (0.56-1.31)|
|Private||425/1009 (42%)||152/488 (31%)||253/521 (49%)||Referent||Referent||Referent|
|Total||673/1870 (35%)||237/968 (24%)||436/902 (48%)|
We found very small differences in the current study results for colorectal cancer screening using the USPSTF guidelines versus ACS guidelines because the increase in the number of low-risk patients who were up-to-date according to the more lenient USPSTF FOBT guideline (biennial rather than annual) was offset by a decrease in the number of high-risk patients who were up-to-date according to the more restrictive ACS colonoscopy guideline (every 5 years rather than every 10 years). The association between USPSTF up-to-date status and insurance coverage (uninsured compared with private) was slightly increased compared with up-to-date status according to the ACS (OR, 0.41 [95%CI, 0.18-0.95] vs OR, 0.43 [95% CI, 0.19-1.00] for USPSTF and ACS, respectively, overall up-to-date status in males and OR, 0.44 [95% CI, 0.25-0.77] vs OR, 0.45 [95% CI, 0.25-0.79] for USPSTF and ACS, respectively, overall up-to-date status in females).
The current study focused on cancer screening and health insurance in rural residents. The majority of data regarding this underserved population are from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS), which indicated that 51.8% of rural female residents (aged > 50 years) have had a mammogram within the past year compared with 61.5% of their urban counterparts (P < .01).23 Similarly, other studies using BRFSS data indicate that 28.2% of rural US residents have undergone a sigmoidoscopy/colonoscopy within the past 5 years and 35.0% have had an FOBT at least once,9 compared with the general US population (45.6% and 52.1%, respectively, for sigmoidoscopy/colonoscopy and FOBT).4 Using medical record review data from 4 rural Oregon primary care practices, the results of the current study found breast cancer screening rates to be approximately 15% lower than previously reported. Rates were similarly low for Pap testing among age-eligible rural women and for colorectal cancer screening using any screening test. Data from this study suggest that BRFSS data likely overestimate screening rates, perhaps because of social response bias or because older patients who are eligible for screening do not recall accurately when their last screening test occurred. The current study findings did not change significantly when we used the USPSTF recommendations rather than those of the ACS. The only real change was an increase in the number of patients who were up-to-date for screening mammography and Pap test screening because the ACS recommends biennial rather than annual screening and the denominator greatly changed for cervical cancer screening because it is not recommended for patients aged ≥ 65 years.
The findings of the current study cannot be explained by a lack of access to health care because all study subjects were patients of established primary care practices and many had several health care visits occurring during the study period. Although patients had 2 to 3 comorbid conditions, we adjusted for this in our analysis and the screening rates were overall very low. We examined the impact of health insurance status and type as well as whether 1 or more health maintenance visits occurred within the past 2 years, both of which were found to be significantly associated with higher rates of cancer screening for tests that are not performed in the office, such as mammography and colonoscopy. Screening tests that are performed in the office, such as clinical breast examinations and Pap tests, were less likely to be affected by insurance status and more likely to be influenced by the patient having had a health maintenance visit. It is likely, as has been reported elsewhere,24 that clinicians in the current study face many competing demands during the medical encounter, such as multiple diverse patient issues and acute illnesses. These demands likely take precedence during the health care visit and, in the absence of a clinic visit devoted to health maintenance, may make it less likely that patients will receive preventive services.
Among women with at least 1 health maintenance visit, those with unknown insurance status were twice as likely to be up-to-date for a clinical breast examination compared with women with private insurance. We speculate that these women may have had a breast symptom and requested an examination that would not be as costly as a mammogram. Because their insurance status is unknown, some speculation is required on our part. Patients indicating they were self-paying were classified as uninsured, a different categorization entirely from unknown insurance status.
Similar to other studies,25 we found that very few patients had undergone flexible sigmoidoscopy for colorectal cancer screening and that most patients received either FOBT or colonoscopy. This shift may also represent the known benefits of polyp removal in reducing the incidence of colorectal cancer in the general population.26
We explored the hypothesis that being up-to-date for screening for 1 type of cancer increases the likelihood of being up-to-date for screening for other cancer types, because willingness to participate in 1 screening might extend to other types of screening. This is supported by the increased likelihood of up-to-date colorectal screening status in women who are up-to-date for mammography.
The recent health care reform law, the Patient Protection and Affordable Care Act,27 will likely increase reimbursements to primary care physicians for health maintenance visits and increase both office-based and off-site cancer screening. Changes in health policy alone could go a long way toward increasing the number of patients who are up-to-date for cancer screening, as well as increasing the number who are current for other preventive or health surveillance activities. Although uncertainty remains with regard to whether the legislation will be implemented in its original form, it is clear that having fully covered primary care health maintenance visits could improve the receipt of cancer screening in both urban and rural settings.27
The strengths of the current study include the use of medical records to assess cancer screening activities rather than physician or patient surveys, which may be affected by recall or social response bias. The accuracy of patient self-report of cancer screening tests has been studied extensively,28-30 including a recent meta-analysis30 that found that patient self-report consistently overestimated rates of cancer screening. Thus, we are confident that our use of medical charts for this analysis was the best approach. There is additional support for the representativeness of the current study population to a more general population with regard to employment status because we found our rates of employment comparable to those reported on a national survey.31 The tests currently under study require a laboratory report or a report in the medical record concerning clinical findings, which is more accurate than using the medical record for physician recommendations, in which documentation bias may be problematic. We studied 4 clinics operating in rural settings, 2 of which were private and 2 of which were FQHCs, providing diversity in the type of settings in which care is provided in rural areas.
The weaknesses of the current study include that we did not assess patient or physician perspectives regarding barriers to cancer screening, which should be further studied in rural settings. We also did not focus on the recommendations physicians gave to patients regarding cancer screening. Although we collected this information, we were concerned that physician recommendations collected by chart review would significantly underestimate actual recommendations, because it is not clear that all clinicians document the advice they provide. We also experienced some missing data related to race, ethnicity, and insurance status. Although we worked hard to abstract this information, it was not always available. This is due in part to the finding that assessing race and ethnicity is not required in private practice as it is in FQHCs, and because FQHCs tend to provide care for uninsured and underinsured individuals, insurance status is more likely to be missing. Lastly, this study did not examine cancer screening practices among patients who do not have an established relationship with a health care provider, although we expect screening rates would be even lower among patients who do not have access to health care.
The results of the current study indicate that the percentage of age-eligible patients being up-to-date for risk-appropriate cancer screening in rural primary care settings is lower than reported elsewhere. This is especially true for cervical and breast cancer screening and less so for colorectal cancer. Having some form of health insurance is associated with being more likely to have had a health maintenance visit within the past 2 years and being up-to-date for breast, cervical, and colorectal cancer screening.
Supported by the American Cancer Society (RSGI-07-1661-01CPHPS), Knight Cancer Institute (P30 CA069533C), Oregon Clinical and Translational Research Institute (UL1 RR024140), and Oregon Health and Science University's Research Program in Family Medicine.
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.
- 1Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force. Screening for Breast Cancer Systematic Evidence Review: Update for the U.S. Preventive Services Task Force. Evidence Syntheses, No. 74. Report No. 10-05142-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2009.
- 2Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force. Evidence Review: Screening for Cervical Cancer. Systematic Evidence Reviews, No. 25. Research Triangle Institute/University of North Carolina. Rockville, MD: Agency for Healthcare Research and Quality; 2002.
- 3Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force. Screening for Colorectal Cancer: An Updated Systematic Review. Evidence Syntheses, No. 65.1. Report No. 08-05-05124-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www.ncbi.nlm.nih.gov/books/NBK35179/. Accessed May 15, 2012.
- 15http://www.bos.frb.org/economic/conf/conf50/conf50a.pdf. Accessed March 18, 2011., . Reforming the U.S. Health Care System: Where There's a Will, There Could Be a Way.
- 16American Cancer Society. American Cancer Society Launches Nationwide Awareness Campaign to Spotlight Challenges to the U.S. Health Care System. 9/17/2007. http://www5.cancer.org/docroot/subsite/accesstocare/content/Press_Kit.asp. Accessed March 19, 2011.
- 17http://www.newsmax.com/Headline/dick-morris-obama-healthcare/2011/01/05/id/381993. Accessed March 19, 2011., . Dick Morris: GOP Will Succeed in Repealing Obamacare.
- 18Kaiser Commission on Medicaid and the Uninsured. The Uninsured: A Primer on Key Facts About Americans Without Health Insurance. Washington, DC: The Kaiser Commission; 2006. http://www.kff.org/uninsured/upload/7451.pdf. Accessed March 19, 2011.
- 20Research Data Assistance Center. Medicare Frequently Asked Questions (FAQ). http://www.resdac.org/medicare/medicarefaq.asp#Who%20are %20the%20Medicare%20beneficiaries. Accessed November 14, 2011.
- 22U.S. Preventive Services Task Force. Recommendations for Breast, Cervical and Colorectal Cancer Screening. http://www.uspreventive servicestaskforce.org/uspstopics.htm. Accessed November 17, 2011.
- 27Patient Protection and Affordable Care Act. http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act. Accessed May 15, 2012.
- 31National Institute on Aging. Growing Older in America: The Health and Retirement Study. Bethesda, MD: National Institute on Aging, National Institutes of Health, US Department of Health and Human Services; 2007.