title: Multilevel predictors of colorectal cancer testing modality among publicly and privately insured people turning 50.
abstract: Understanding multilevel predictors of colorectal cancer (CRC) screening test modality can help inform screening program design and implementation. We used North Carolina Medicare, Medicaid, and private, commercially available, health plan insurance claims data from 2003 to 2008 to ascertain CRC test modality among people who received CRC screening around their 50th birthday, when guidelines recommend that screening should commence for normal risk individuals. We ascertained receipt of colonoscopy, fecal occult blood test (FOBT) and fecal immunochemical test (FIT) from billing codes. Person-level and county-level contextual variables were included in multilevel random intercepts models to understand predictors of CRC test modality, stratified by insurance type. Of 12,570 publicly-insured persons turning 50 during the study period who received CRC testing, 57% received colonoscopy, whereas 43% received FOBT/FIT, with significant regional variation. In multivariable models, females with public insurance had lower odds of colonoscopy than males (odds ratio [OR] = 0.68; p < 0.05). Of 56,151 privately-insured persons turning 50 years old who received CRC testing, 42% received colonoscopy, whereas 58% received FOBT/FIT, with significant regional variation. In multivariable models, females with private insurance had lower odds of colonoscopy than males (OR = 0.43; p < 0.05). People living 10-15 miles away from endoscopy facilities also had lower odds of colonoscopy than those living within 5 miles (OR = 0.91; p < 0.05). Both colonoscopy and FOBT/FIT are widely used in North Carolina among insured persons newly age-eligible for screening. The high level of FOBT/FIT use among privately insured persons and women suggests that renewed emphasis on FOBT/FIT as a viable screening alternative to colonoscopy may be important.
authors.affiliation: Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, United States; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States; Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, United States; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, United States.
authors.forename: Stephanie B
authors.initials: SB
authors.lastname: Wheeler
authors.affiliation: Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States.
authors.forename: Tzy-Mey
authors.initials: TM
authors.lastname: Kuo
authors.affiliation: Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States; Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7435, McGavran Greenberg Hall, Chapel Hill, NC 27599-7435, United States.
authors.forename: Anne Marie
authors.initials: AM
authors.lastname: Meyer
authors.affiliation: Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States.
authors.forename: Christa E
authors.initials: CE
authors.lastname: Martens
authors.affiliation: Department of Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7411, McGavran Greenberg Hall, Chapel Hill, NC 27599-7411, United States.
authors.forename: Kristen M
authors.initials: KM
authors.lastname: Hassmiller Lich
authors.affiliation: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States.
authors.forename: Florence K L
authors.initials: FK
authors.lastname: Tangka
authors.affiliation: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States.
authors.forename: Lisa C
authors.initials: LC
authors.lastname: Richardson
authors.affiliation: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States.
authors.forename: Ingrid J
authors.initials: IJ
authors.lastname: Hall
authors.affiliation: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, United States.
authors.forename: Judith Lee
authors.initials: JL
authors.lastname: Smith
authors.affiliation: Department of Industrial & Systems Engineering, North Carolina State University, Campus Box 7906, Raleigh, NC 27965-7906, United States.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Mayorga
authors.affiliation: University of California at Merced, SSM Building Room 308a, Merced, CA 95343, United States.
authors.forename: Paul
authors.initials: P
authors.lastname: Brown
authors.affiliation: Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, United States; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, United States.
authors.forename: Trisha M
authors.initials: TM
authors.lastname: Crutchfield
authors.affiliation: Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, CB#7295, Chapel Hill, NC 27599-7295, United States; Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Airport Road, CB#7590, Chapel Hill, NC 27599-7590, United States; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Boulevard, CB#7426, Chapel Hill, NC 27599-7426, United States; Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Pignone
keywords: Cancer screening tests; Colonoscopy; Colorectal cancer; Fecal occult blood test; Medicaid; Medicare; Multilevel analysis