Research article
Healthcare system factors and colorectal cancer screening

https://doi.org/10.1016/S0749-3797(02)00444-0Get rights and content

Abstract

Background: Developing effective programs to promote colorectal cancer (CRC) screening requires understanding of the effect of healthcare system factors on access to screening and adherence to guidelines.

Methods: This study assessed the role of insurance status, type of plan, the frequency of preventive health visits, and provider recommendation on utilization of CRC screening tests using a cross-sectional, random-digit-dial survey of 1002 Massachusetts residents aged ≥50.

Results: A broad definition of CRC screening status included colonoscopy or barium enema (screening or diagnostic) within 10 years, flexible sigmoidoscopy (FSIG) within 5 years, and fecal occult blood testing (FOBT) in the past year as options; 51.7% of subjects aged 50 to 64 and 61.5% of older subjects were current. The uninsured had the lowest current testing rate. Among insured participants, type of insurance had little impact on CRC testing; older subjects enrolled in HMOs had marginally higher rates, although not statistically significant. Increased frequency of preventive health visits and ever receiving a physician’s recommendation for FSIG or ever receiving FOBT cards were associated with higher rates of CRC screening among both age groups.

Conclusions: Even when broad criteria are used to define current CRC screening status, a substantial proportion of the age-eligible population remains underscreened. Obtaining regular preventive care and receiving a physician’s recommendation for screening appear to be potent facilitators of screening that should be considered in designing promotional efforts.

Introduction

While mammography and Papanicolaou tests are currently used at appropriate intervals by a majority of the eligible U.S. population, colorectal cancer (CRC) screening rates have not kept pace.1, 2 Approximately 20% of people aged ≥50 report having a fecal occult blood test (FOBT) within the previous year; 30% a flexible sigmoidoscopy (FSIG) within 5 years; 41% either; and 10% both.2, 3 Estimates for colonoscopy and barium enema (BE) are considerably lower.4 Low rates of CRC screening are disturbing, given the relatively high incidence of CRC5 and effectiveness of early detection.6

Numerous studies document barriers to and facilitators of breast and cervical cancer screening,7, 8 including health-system factors, such as insurance type and the level of coverage.9, 10, 11, 12 Other factors include clinician and patient characteristics,13, 14, 15 patient mix within care systems,16, 17 and access to a personal physician.18, 19, 20 These factors, however, have largely gone unstudied in CRC screening.21 This study explores the relationship of CRC screening with insurance coverage and type, access to a regular physician, and demographic factors. It differs from previous studies as it reflects recently released guidelines indicating that FOBT, FSIG, colonoscopy, and BE all have a legitimate role in CRC screening,22 and was conducted during a period of health-system turmoil.23

Section snippets

Study sample and data collection

Participants were Massachusetts residents, aged ≥50, who had a working residential telephone number and had never been diagnosed with CRC. A random-digit-dial telephone survey was conducted in English or Spanish from June to August 1998. Three samples—a basic random sample, a male oversample, and a racial/ethnic minority oversample targeting African Americans and Hispanics—were drawn using the Kish sampling method.24 Of people contacted and eligible, 64% (n = 1119) were surveyed. Of these, 117

Population characteristics and testing status

Of participants, 521 (Table 1) were aged 50 to 64 (52%) and 481 were aged ≥65 (48%). Both groups were predominantly white. About 10% indicated a family history of CRC. The younger group reported higher levels of education and income, more hours at work, and better health status. A larger proportion of elders were widowed. Significantly more elders reported having a regular physician, having checkups more often than yearly, and having received a physician recommendation for an FSIG.

Overall,

Discussion

While previous studies examined either FOBT or FSIG alone, we examined an overall CRC screening measure based on recent guidelines. Using this definition, 52% of people aged 50 to 64 and 62% of people aged ≥65 were currently screened for CRC. Relying on only a single testing modality as a measure of CRC screening compliance underestimates prevalence, as there are numerous pathways to current status.

In this study, the elderly enrolled in Medicare HMOs had somewhat higher screening rates, as has

Acknowledgements

This study was supported by the National Institutes of Health (grant number RO1 CA69653). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Cancer Institute. We thank Stephen Erban, MD, Graham Barnard, MD, and Barbara Estabrook, MS, for their contributions to the project and helpful reviews of this manuscript.

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