Location, Location, Location: Spatial Analysis and the Cancer Control Continuum

Racial Disparities in Breast Cancer Screening in State Medicaid Programs

Authors:

Florence Tangka (Presenter)
Centers for Disease Control and Prevention

Sujha Subramanian, RTI International
Lee Mobley, Georgia State University
Sonja Hoover, RTI International
Jiantong wang, RTI International
Ingrid Hall, Centers for Disease Control and Prevention
Simple Singh, Centers for Disease Control and Prevention

Public Health Statement: Breast cancer screening by mammography has been shown to reduce breast cancer morbidity and mortality. Are there racial/ethnic and geographic differences in the use of mammography among Medicaid beneficiaries at the state level?

Purpose: To assess racial/ethnic and geographic disparities in the use of breast cancer screening among Medicaid insured women at the state level.

Methods/Approach: We used 2006–2008 data from Medicaid claims and enrollment files for this analysis. We included Medicaid enrollees aged 40 through 64; and excluded individuals previously diagnosed with cancer, pregnant, residing in long-term care facilities, or who were dual Medicare/Medicaid enrollees; as well as enrollees with restricted benefits due to alien status, pregnancy-related services, and other services. We estimated separate regression models for each state, including person and county level covariates.

Results: Disparities existed in mammography utilization among racial or ethnic groups relative to whites and varied across the 44 states studied. African Americans and American Indians were significantly less likely than whites to utilize mammography in 30% and 39% of the 44 states analyzed respectively, while Hispanics and Asian Americans were the minority groups most likely to receive screening compared to whites.

Conclusions/Implications: Racial disparities in breast cancer screening exist at the state and potentially local levels, indicating that analyses conducted only using national data and not stratified by insurance coverage are insufficient to identify/target vulnerable populations for interventions to increase the use of mammography as recommended.

Medicare Modernization and the Diffusion of Endoscopy in FFS Medicare

Authors:

Srimoyee Bose (Presenter)
Georgia State University

Lee Mobley, Georgia State University
Pedro Amaral, Universidade Federal de Minas Gerais
Tzy-Mey Kuo, University of North Carolina at Chapel Hill
Mei Zhou, Georgia State University

Public Health Statement: Can policy changes impact CRC screening?

Purpose: To examine how FFS Medicare utilization of endoscopy procedures for colorectal cancer (CRC) screening changed after implementation of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) in 2006, which provided subsidized drug coverage and expanded the geographic availability of Medicare managed care plans across the U.S.

Methods/Approach: Using secondary data from 100% FFS Medicare enrollees, we analyzed endoscopy utilization during two intervals, 2001–2005 and 2006–2009. We examined change in predictors of county-level endoscopy utilization rates based on a conceptual model of market supply and demand with spillovers from managed care practices. The equations for each period were estimated jointly in a spatial lag regression model that properly accounts for both place and time effects, allowing robust assessment of changes over time.

Results: Endoscopy utilization by FFS Medicare increased, and became more accessible across the U.S. Medicare managed care plan spillovers onto FFS Medicare endoscopy utilization changed over time from a significant negative (restraining) effect in the early period to no significant effect by the later period.

Conclusions/Implications: The MMA eased budget constraints for seniors, making endoscopic CRC screening more affordable. The MMA policies also strengthened managed care business prospects, and enrollments in Medicare managed care escalated. The change in managed care spillover effects reflects the gradual acceptance of endoscopic CRC screening procedures, as they emerged as the gold standard during the period.

Modeling Geospatial Patterns of Late-Stage Diagnosis of Breast Cancer in the U.S.

Authors:

Lia Scott (Presenter)
Georgia State University

Yamisha Rutherford, Georgia State University
Lee Mobley, Georgia State University
Tzy-Mey Kuo, University of North Carolina at Chapel Hill
Srimoyee Bose, Georgia State University

Public Health Statement: Why are 33% of breast cancers diagnosed at a late stage?

Purpose: Use 100% of U.S. Cancer Statistics registry data from 40 states to identify predictors of late-stage diagnoses among ≈1 million new BC cases diagnosed during 2004–2009.

Methods/Approach: We estimate a multilevel model with person-, county-, and state-level predictors and a random intercepts specification to help ensure robust effect estimates.

Results: Person-level variables in both models suggest that non-white races or ethnicities have higher odds of late-stage diagnosis, and the odds of late-stage diagnosis decline with age, being highest among the <age 50 group. At the county level, for anyone living in an isolated Asian community, there is a large beneficial association with late-stage diagnosis, while for anyone living in an isolated white community there is a large detrimental association, after controlling statistically for distance to provider, rural aspect, poverty, uninsured, and other contextual factors that might impede timely utilization of mammography. At the state level, living in a state that allows unfettered access to a specialist is associated with a somewhat lower likelihood of being diagnosed at a late stage of BC.

Conclusions/Implications: Person-, county-, and state- level variables are all significant predictors of late-stage BC diagnosis. Highly residentially segregated white communities, which cover large portions of the U.S., show greater risk of late-stage diagnosis, which is interesting in the context of the recent increase in white mortality rate in the U.S. We present some ideas from social science to help explain why this large and significant reverse disparity exists in these BC outcomes.

County Health Insurance Coverage Estimates for Cancer Screening Program Planning and Evaluation

Authors:

David Powers (Presenter)
U.S. Census Bureau

Jasen Taciak, U.S. Census Bureau
Florence Tangka, Centers for Disease Control and Prevention
Janet Royalty, Centers for Disease Control and Prevention
Kristy Kenney, Centers for Disease Control and Prevention

Public Health Statement: The U.S. Census Bureau’s Small Area Health Insurance Estimates (SAHIE) program provides data for the CDC’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) at the county and state levels. Having sub-state insurance data helps with delivering targeted cancer screening interventions.

Purpose: NBCCEDP provides low-income, uninsured, and underserved women access to timely breast and cervical cancer screening and diagnostic services. NBCCEDP needs small area estimates of insurance coverage for planning breast cancer screening services for women aged 40-64 and cervical cancer screening services for women aged 18–64.

Methods/Approach: The SAHIE program provides county and state estimates of the percent and number of low-income uninsured women by age, sex, income, and (for states) by race and Hispanic origin. The updated 2013 SAHIE use timely Medicaid and Children’s Health Insurance Program data, and they provide a basis of comparison with the 2014 and 2015 SAHIE data. While the 2014 and 2015 SAHIE are also available for individuals aged 21–64, prior to 2014, SAHIE did not produce data for individuals aged 21–64.

Results: Between 2013 and 2014, roughly 47 percent (or n=1,471) of all U.S. counties had a statistically significant decline (p

Conclusions/Implications: Between 2013 and 2014, the number of uninsured women aged 40–64 declined in nearly half of all counties, and the number of uninsured women aged 18-64 declined in slightly more than half of all counties. Given that SAHIE data provide a consistent time series, the NBCCEDP could use these latest SAHIE figures for program planning, evaluation of the program’s current reach, and to monitor future trends. The final work presented will include 2015 data (not released yet), and will present a comparison for women aged 21–64.