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

Abstract

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

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

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

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

Figure 1.

Patterns of colorectal testing by usual place of medical care among Medicare enrollees aged 65 to 80 years: MCBS 2000–2005. Endoscopy = sigmoidoscopy or colonoscopy; FOBT = home fecal occult blood test; MCBS = Medicare Current Beneficiary Survey; unscreened = enrollees who had never before been screened or only reported FOBT more than 2 years previously. Note: colorectal cancer testing categories are mutually exclusive.

Figure 2.

Patterns of colorectal testing by type of insurance coverage among Medicare enrollees aged 65 to 80 years: MCBS 2000–2005. Endoscopy = sigmoidoscopy or colonoscopy; FOBT = home fecal occult blood test; MCBS = Medicare Current Beneficiary Survey; unscreened = enrollees who had never before been screened or only reported FOBT more than 2 years previously. Note: The colorectal cancer testing categories are mutually exclusive.