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Colorectal Cancer Screening, Medicare and Disability
Presented at APHAs 135th Annual Meeting & Exposition Washington, DC, 2007 by Brian S. Armour, PhD1 1. National Center on Birth Defects and Developmental Disabilities, CDC. SAFER · HEALTHIER · PEOPLETM
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Vilma Cokkinides, PhD††
Joint Work Lesley A. Wolf, MPH† Vilma Cokkinides, PhD†† Carol Friedman, DO§ Lisa Richardson, MD§ † Science Applications International Corporation for the Division of Health and Human Development, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia. †† Program Director, Risk Factor Surveillance, Department of Epidemiology and Surveillance Research, American Cancer Society, Atlanta, Georgia. § Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
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Colorectal Cancer (CRC)
U.S. in 2005 Primarily affects people aged 50 years and older Approx. 150,000 people dx. Late Stage CRC is fatal Approx 56,000 deaths 2nd leading cause of death among women 3rd leading cause of death among men
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Routine screening can reduce incidence and mortality
CRC Continued Routine screening can reduce incidence and mortality Screening Methods Fecal Occult Blood Test (FOBT) Flexible Sigmoidoscopy Colonoscopy Double Contrast Barium Enema
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Disability U.S. Census Bureau in 2000 Disability & Medicare’s Solvency
50 million people with disabilities (PWDs) 14 million PWDs aged 65+ Disability & Medicare’s Solvency Freedman disability rates ↓ among elderly Bhattacharya disability rates ↑ among working age population Skinner 2006 – rate changes second order concern
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Cancer Screenings PWDs receive preventive cancer screening services at rates lower than Pw/oD’s CRC screening rates are low Increased risk for PWDs Secondary medical conditions—obesity & constipation Behavioral health risks—physical inactivity & smoking Sensory deficits Gender and racial differences in CRC screening For PWDs CRC empirical evidence is mixed Concern PWDs are at increased risk for CRC
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Why are CRC screening rates low?
Lack of health plan coverage Medicare expanded coverage screening colonoscopy July 2001 To improve CRC screening rates, Medicare reimbursement for screening colonoscopy was expanded in July 2001 to include beneficiaries at average risk for CRC
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Medicare’s 2001 coverage expansion
Objective Medicare’s 2001 coverage expansion Gender differences Racial differences What about people with disabilities? Ceteris Paribus
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Descriptive Stats –BRFSS 2001 & 2004
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Descriptive Stats –BRFSS 2001 & 2004
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Descriptive Stats –BRFSS 2001 & 2004
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Key Independent Variables
Model Dependent Variable CRC screening FOBT in the past year Lower endoscopy in the past 10 years Key Independent Variables Disability Year (2004) Interaction term disability*year
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Model Other Independent Variables Age, Age2 Gender Race Annual income
Education Marital status Employment status Smoked cigarettes BMI Had PCP Health status Regional dichotomous variables
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Selected Logistic Regression Results – CRC Screening of U. S
Selected Logistic Regression Results – CRC Screening of U.S. Adults Aged 65 years or older—BRFSS 2001 & 2004 Characteristic Adjusted Odds Ratio 95% CI Disability 1.25 ( ) Year (2004) 1.22 ( ) Disability*Year 0.85 ( ) Medicare Population Characteristics 1 Percent increase in percentage Black -0.29 percentage points Population Characteristics increase Poverty Rate by 1 percent -1.11 percentage points Medical system Characteristics Increase of 100 docs/100,000 .04 percentage points Increase of 100 nurses/100,000 .02 percentage points %for profits – increase by 1% percentage point decrease Why do Racial Disparities Exist? Black patients receive lower quality of care than whites within hospitals Hospitals that treat the majority of black patients have lower quality of care Racial disparities exist in health care- data at the patient level is needed to determine what is driving this outcome
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Discussion Why growth rate in endoscopy use lower for PWDs?
Other barriers to care remain Inability to access services lack of transportation lack of assistive technology in physician offices Difficulty communicating with providers Crowding out of preventive care Lack of care coordination between PCPs and specialists Why growth rate in endoscopy use lower for older adults with disabilities after accounting for other important confounders? If people with disabilities faced the same barriers to screening as those without disabilities, then we surmised that the Medicare program expansion for screening colonoscopies would have increased CRC screenings for people with and those without disabilities by the same rate.
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Limitations BRFSS is a telephone survey Data is self-reported
CRC procedures for screening vs. Dx. Causality Disability severity Unable ID type of health insurance Unable distinguish the effects of the Medicare program expansion from temporal trends
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Adults with Disabilities Age 65+
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Endoscopy Adults with Disabilities Age 65+
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Future Work Public Health Research Policy Perspective QI opportunities
Disability Severity, Permanence, Duration CRC Screening Flex Sig. vs. Colonoscopy Dx. vs. Screening Barriers to Care Policy Perspective Dampened affect for PWDs Alignment of incentives
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Disclaimer “The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention (CDC) and should not be construed to represent any agency determination or policy.”
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Contact Brian Armour
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