Research article
Racial and Ethnic Trends of Colorectal Cancer Screening Among Medicare Enrollees

https://doi.org/10.1016/j.amepre.2009.10.037Get rights and content

Background

Colorectal cancer (CRC) screening rates have remained lower than the Healthy People 2010 goal, particularly among minority populations.

Purpose

This study aimed to examine the racial–ethnic trends in CRC screening and the continued impact of healthcare access indicators on screening differences after Medicare expanded coverage.

Methods

The study used data from the Medicare Current Beneficiary Survey for 2000, 2003, and 2005. The sample was restricted to non-Hispanic whites, non-Hispanic blacks, and Hispanics. The primary outcome was the proportion of enrollees who underwent lower-gastrointestinal endoscopy within 5 years and/or home fecal occult blood test within 1 year.

Results

Over the 6-year period under study, the proportion screened increased among each of the three racial–ethnic groups, but lower proportions of blacks and Hispanics underwent screening compared with whites at each time point. Hispanic–white differences persisted but black–white differences narrowed in 2003 and widened in 2005. In each survey year, racial differences attenuated after adjustment for type of supplemental health insurance and disappeared after further adjustment for educational and income levels.

Conclusions

Despite expanding benefits for CRC screening, which would be expected to disproportionally benefit racial and ethnic minorities, racial disparities in use of screening persist in part because of differences in the types of health insurance coverage, education, and income. There was a slight reversal of the initial attenuation of the black–white difference after the Medicare policy change. Efforts are needed to increase the reach of CRC screening to minority populations, particularly those lacking adequate health insurance coverage or with less education or income.

Introduction

In the U.S., racial disparities in colorectal cancer (CRC) incidence and mortality have persisted, particularly for blacks.1 Lower screening rates among some minority populations2, 3 are believed to be an important contributor to CRC disparities.1, 4, 5 The cost of medical care, lack of adequate health insurance coverage, or lack of a usual source of health care impede CRC screening.6, 7, 8, 9, 10, 11, 12, 13 However, few studies have addressed the influence of these factors on racial–ethnic differences in CRC screening over time.14

Medicare's policy change in July 2001 to expand CRC screening coverage for average-risk enrollees by reimbursing up to 80% of Medicare-allowed cost of colonoscopy provides an opportunity to conduct such a study.15 This policy change has likely contributed to an increase in use of CRC screening.3, 6, 10, 12, 16, 17, 18 This additional coverage primarily benefits those with previously limited coverage (i.e., fee-for-service plan holders)19, 20 and would be expected to increase use of CRC screening among racial minorities and low-income enrollees as they are more likely to be on Medicare without supplemental insurance.21

A previous study12 found narrowing of black–white differences in screening in 2003 but a widening of the Hispanic–white differences. In contrast, another study16 found a more rapid uptake of colonoscopy among whites and a widening racial gap in use of colonoscopy over the 1995–2003 period. Therefore, it is currently unclear whether the racial–ethnic gaps in screening prior to 2001 continued to exist after the Medicare policy change.22 There are also limited data on the impact of healthcare access factors on racial–ethnic differences in the period before and after Medicare policy change.

This study examined (1) racial and ethnic trends in CRC screening and (2) the impact of healthcare access indicators on racial–ethnic differences in the period before and after Medicare expanded coverage for screening.

Section snippets

Study Participants and Data Collection

Data for this study were obtained from the Medicare Current Beneficiary Survey (MCBS),23 an ongoing in-person interview of nationally representative samples of Medicare enrollees since 1991. The sampling scheme and methods for data collection in the MCBS have been described in detail.23 This study used the MCBS access-to-care files on noninstitutionalized beneficiaries who did not report a history of end-stage renal disease or CRC during 2000, 2003, and 2005 when questions on CRC were included

Characteristics

The sample consisted of 8025 enrollees who were interviewed in 2000, 7545 in 2003, and 7248 in 2005. Compared to whites, among blacks and Hispanics there was a higher proportion of women. Table 1 shows selected characteristics of the study population stratified by race–ethnicity. Blacks and Hispanics were less educated, had lower household incomes, and were less likely to have private or HMO insurance, or to have a PCP for usual health care.

In 2000, 36% of the enrollees with less than a high

Discussion

This study found that use of CRC screening among the Medicare beneficiaries studied has continued to increase from 2000 to 2005. However, the rates of increase varied by race and ethnicity, resulting in complex patterns of disparities over time. Compared to whites, blacks had a greater increase in use of CRC screening between 2000 and 2003, resulting in a smaller black–white difference in 2003 as has been reported in previous studies.12 However, the gap widened slightly in 2005: Among blacks,

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