What Happened to Disparities in CRC Screening Among FFS Medicare Enrollees Following Medicare Modernization?

The Medicare Modernization Act of 2003, implemented in 2006, increased managed care options for seniors. It introduced insurance plans for prescription drug coverage for all Medicare beneficiaries, whether they were enrolled in FFS or managed care (Medicare Advantage) plans. The availability of drug coverage beginning in 2006 served to free up budgets for FFS Medicare enrollees that could be used to make copayments for colorectal cancer (CRC) screening using endoscopy (colonoscopy or sigmoidoscopy). In 2007, Medicare eliminated the copayments required by seniors for CRC screening by endoscopy. Later in 2008, CRC screening by colonoscopy became part of the gold standard for CRC screening. This legitimized its use and offered even further encouragement to seniors, who may have been reluctant to undergo the procedure because of the non-pecuniary risks associated with it. In addition, 37 CRC screening interventions occurred during this timeframe to enhance compliance with screening standards. Using multilevel analysis of individuals' endoscopy utilization, derived from 100% FFS Medicare claims, along with county-level market and contextual factors, we compare the periods before and after the MMA (2001-2005 to 2006-2009) to determine whether disparities in the utilization of endoscopic CRC screening occurred or changed over the decade. We examined Blacks, Asians, and Hispanics relative to Whites, and Females relative to Males (with race or ethnicity combined). We examined each state separately for evidence of disparities within states, to avoid confounding by geographic disparities. We expected that the net effect of the policy changes and the targeted interventions over the decade would be to increase CRC screening by endoscopy, reducing disparities. We saw improvements over time (reduced disparities relative to Whites) for Blacks and Hispanics residing in several states, and improvements over time for Females relative to Males in many states. For the vast majority of states, however, disparities persisted with Whites and Males exhibiting greater rates of utilization than other groups. States that undertook the interventions were more likely to have had improvements in disparities or positive disparities for women and minorities. While some gains were made over this time period, the gains were unevenly distributed across the USA and more work needs to be done to reduce remaining disparities.

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

In the US, about one-third of new breast cancers (BCs) are diagnosed at a late stage, where morbidity and mortality burdens are higher. Health outcomes research has focused on the contribution of measures of social support, particularly the residential isolation or segregation index, on propensity to utilize mammography and rates of late-stage diagnoses. Although inconsistent, studies have used various approaches and shown that residential segregation may play an important role in cancer morbidities and mortality. Some have focused on any individuals living in residentially segregated places (place-centered), while others have focused on persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity (person-centered). This paper compares and contrasts these two approaches in the study of predictors of late-stage BC diagnoses in a cross-national study. We use 100% of U.S. Cancer Statistics (USCS) Registry data pooled together from 40 states to identify late-stage diagnoses among ~1 million new BC cases diagnosed during 2004-2009. We estimate a multilevel model with person-, county-, and state-level predictors and a random intercept specification to help ensure robust effect estimates. 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

Using residential segregation to predict colorectal cancer stage at diagnosis: two different approaches.

PURPOSE: Studies have found a variety of evidence regarding the association between residential segregation measures and health outcomes in the United States. Some have focused on any individuals living in residentially segregated places, whereas others have examined whether persons of specific races or ethnicities living in places with high segregation of their own race or ethnicity have differential outcomes. This article compares and contrasts these two approaches in the study of predictors of late-stage colorectal cancer (CRC) diagnoses in a cross-national study. We argue that it is very important when interpreting results from studies like this to carefully consider the geographic scope of the analysis, which can significantly change the context and meaning of the results. METHODS: We use US Cancer Statistics Registry data from 40 states to identify late-stage diagnoses among over 500,000 CRC cases diagnosed during 2004-2009. We pool data over the states and estimate a multilevel model with person, county, and state levels and a random intercepts specification to ensure robust effect estimates. The isolation index of residential segregation is defined for racial and ethnic groups at the county level using Census 2000 data. The association between isolation indices and late-stage CRC diagnosis was measured by (1) anyone living in minority-segregated areas (place-centered approach) and by (2) individuals living in areas segregated by one's own racial or ethnic peers (person-centered approach). RESULTS: Findings from the place-centered approach suggest that living in a highly segregated African American community is associated with lower likelihood of late-stage CRC diagnosis, whereas the opposite is true for people living in highly segregated Asian communities, and living in highly segregated Hispanic communities has no significant association. Using the person-centered approach, we find that living in places segregated by one's racial or ethnic peers is associated with lower likelihood of late-stage CRC diagnosis. CONCLUSIONS: In a model that covers a large geographic area across the nation, the place-centered approach is most likely picking up geographic disparities that may be deepened by targeted interventions in minority communities. By contrast, the person-centered approach provides a national average estimate suggesting that residential isolation may confer community cohesion or support that is associated with better CRC prevention.

An Exploratory Study Examining Risk Communication among Adolescent Children, Their Incarcerated Mothers, and Their Caregivers.

Adolescent children of incarcerated mothers (ACIM) are typically left in the care of adults (primary caregivers) who play a crucial role in children's care and guidance, as well as in the facilitation of contact and communication with incarcerated mothers. The purpose of this study was to explore the nature of relationships and communication among adolescent children of incarcerated mothers, primary caregivers, and incarcerated mothers using pilot data. Semi-structured individual interviews were conducted with youth aged 12-17 (n=7) and caregivers (n=6) recruited through a non-profit organization working with incarcerated mothers and their children. Incarcerated mothers and primary caregivers represent an important family unit for ACIMs and may play a role in preventing risk behavior. A conceptual framework is offered for further consideration of mother and caregiver communication with youth and youth risk.