Community contextual predictors of endoscopic colorectal cancer screening in the USA: spatial multilevel regression analysis.
BACKGROUND
Colorectal cancer (CRC) is the second leading cause of cancer death in the United States, and endoscopic screening can both detect and prevent cancer, but utilization is suboptimal and varies across geographic regions. We use multilevel regression to examine the various predictors of individuals' decisions to utilize endoscopic CRC screening. Study subjects are a 100% population cohort of Medicare beneficiaries identified in 2001 and followed through 2005. The outcome variable is a binary indicator of any sigmoidoscopy or colonoscopy use over this period. We analyze each state separately and map the findings for all states together to reveal patterns in the observed heterogeneity across states.


RESULTS
We estimate a fully adjusted model for each state, based on a comprehensive socio-ecological model. We focus the discussion on the independent contributions of each of three community contextual variables that are amenable to policy intervention. Prevalence of Medicare managed care in one's neighborhood was associated with lower probability of screening in 12 states and higher probability in 19 states. Prevalence of poor English language ability among elders in one's neighborhood was associated with lower probability of screening in 15 states and higher probability in 6 states. Prevalence of poverty in one's neighborhood was associated with lower probability of screening in 36 states and higher probability in 5 states.


CONCLUSIONS
There are considerable differences across states in the socio-ecological context of CRC screening by endoscopy, suggesting that the current decentralized configuration of state-specific comprehensive cancer control programs is well suited to respond to the observed heterogeneity. We find that interventions to mediate language barriers are more critically needed in some states than in others. Medicare managed care penetration, hypothesized to affect information about and diffusion of new endoscopic technologies, has a positive association in only a minority of states. This suggests that managed care plans' promotion of this cost-increasing technology has been rather limited. Area poverty has a negative impact in the vast majority of states, but is positive in five states, suggesting there are some effective cancer control policies in place targeting the poor with supplemental resources promoting CRC screening.
Mobley
Lee R
LR
RTI International, Discovery and Analytical Sciences Division, 3040 Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709-2194, USA. lmobley@rti.org
Kuo
Tzy-Mey
TM
Urato
Matthew
M
Subramanian
Sujha
S
D000368:Aged; D020776:Endoscopes, Gastrointestinal / Q000706:statistics & numerical data*; D005260:Female; D005544:Forecasting; D006801:Humans; D007414:Intestinal Neoplasms / Q000175:diagnosis*; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D012044:Regression Analysis; D012111:Residence Characteristics; D014481:United States
Cancer. 2004 May 15;100(10):2093-103
15139050
Am J Prev Med. 2005 Jul;29(1):54-60
15958253
CA Cancer J Clin. 2009 Jul-Aug;59(4):225-49
19474385
J Natl Cancer Inst. 2000 Apr 5;92(7):557-63
10749911
Gastroenterology. 2004 Dec;127(6):1841-4
15578522
Prev Med. 2004 Mar;38(3):269-75
14766108
J Natl Cancer Inst. 2000 Oct 18;92(20):1691-2
11036117
BMC Gastroenterol. 2005 Mar 08;5:10
15755323
Prev Med. 2010 Jan-Feb;50(1-2):3-10
20006644
Aliment Pharmacol Ther. 2004 Sep 1;20(5):507-15
15339322
Am J Gastroenterol. 2004 Aug;99(8):1544-50
15307875
Cancer. 1980 Mar 15;45(5 Suppl):1099-102
6965607
Med Care. 2005 May;43(5):445-52
15838408
Cancer Epidemiol Biomarkers Prev. 2006 Feb;15(2):389-94
16492934
J Natl Cancer Inst. 2002 Dec 18;94(24):1837-46
12488477
Med Care Res Rev. 2008 Jun;65(3):315-37
18259047
J Gen Intern Med. 2010 Aug;25(8):833-9
20383599
MMWR Surveill Summ. 2004 Jul 23;53(5):1-100
15269697
Cancer Causes Control. 2010 Mar;21(3):445-61
19946738
J Health Econ. 2008 Dec;27(6):1451-61
18801588
Med Care. 2008 Sep;46(9 Suppl 1):S84-90
18725838
Gastroenterology. 2004 Dec;127(6):1661-9
15578502
Am J Prev Med. 2005 Dec;29(5):404-11
16376703
Gastroenterology. 2005 Oct;129(4):1163-70
16230070
J Natl Cancer Inst. 2009 Oct 21;101(20):1412-22
19779203
Cancer. 2006 Sep 1;107(5 Suppl):1196-204
16802326
Ann Intern Med. 1999 Mar 16;130(6):525-30
10075621
Ann Intern Med. 2008 Nov 4;149(9):638-58
18838718
J Gastroenterol Hepatol. 2004 Jan;19(1):38-47
14675241
Gastroenterology. 2005 Oct;129(4):1151-62
16230069
Med Care. 2008 Oct;46(10):1108-15
18815533
Am J Public Health. 2003 Aug;93(8):1335-41
12893624
Health Care Financ Rev. 2006 Spring;27(3):95-109
17290651
Health Serv Res. 2003 Feb;38(1 Pt 1):287-309
12650392
Z Gastroenterol. 2008 Apr;46 Suppl 1:S20-2
18368634
Annu Rev Public Health. 2003;24:435-56
12471276
Cancer Detect Prev. 2006;30(2):134-43
16638628
Med Care. 2008 Sep;46(9 Suppl 1):S1-4
18725819
Prev Chronic Dis. 2009 Oct;6(4):A127
19755003
Prev Chronic Dis. 2006 Apr;3(2):A50
16539791