Neighborhood Socioeconomic Status and Use of Colonoscopy in an Insured Population – A Retrospective Cohort Study

The University of Texas M. D. Anderson Cancer Center, United States of America
PLoS ONE (Impact Factor: 3.23). 05/2012; 7(5):e36392. DOI: 10.1371/journal.pone.0036392
Source: PubMed


Low-socioeconomic status (SES) is associated with a higher colorectal cancer (CRC) incidence and mortality. Screening with colonoscopy, the most commonly used test in the US, has been shown to reduce the risk of death from CRC. This study examined if, among insured persons receiving care in integrated healthcare delivery systems, differences exist in colonoscopy use according to neighborhood SES.
We assembled a retrospective cohort of 100,566 men and women, 50-74 years old, who had been enrolled in one of three US health plans for ≥1 year on January 1, 2000. Subjects were followed until the date of first colonoscopy, date of disenrollment from the health plan, or December 31, 2007, whichever occurred first. We obtained data on colonoscopy use from administrative records. We defined screening colonoscopy as an examination that was not preceded by gastrointestinal conditions in the prior 6-month period. Neighborhood SES was measured using the percentage of households in each subject's census-tract with an income below 1999 federal poverty levels based on 2000 US census data. Analyses, adjusted for demographics and comorbidity index, were performed using Weibull regression models.
The average age of the cohort was 60 years and 52.7% were female. During 449,738 person-years of follow-up, fewer subjects in the lowest SES quartile (Q1) compared to the highest quartile (Q4) had any colonoscopy (26.7% vs. 37.1%) or a screening colonoscopy (7.6% vs. 13.3%). In regression analyses, compared to Q4, subjects in Q1 were 16% (adjusted HR = 0.84, 95% CI: 0.80-0.88) less likely to undergo any colonoscopy and 30%(adjusted HR = 0.70, CI: 0.65-0.75) less likely to undergo a screening colonoscopy.
People in lower-SES neighborhoods are less likely to undergo a colonoscopy, even among insured subjects receiving care in integrated healthcare systems. Removing health insurance barriers alone is unlikely to eliminate disparities in colonoscopy use.

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    • "Audits were standardized through training and retraining and through the use of a common, structured electronic data collection instrument that was developed in Microsoft Access. The data collection tool was pre-populated with patient demographics, health care utilization history and the dates of CRC tests that were extracted from electronic databases using, in part, codes from the International Classification of Diseases, 9th Edition, Clinical Modification, Current Procedural Terminology and Healthcare Common Procedure Coding System [28]. For each test found in the medical records, the auditors collected up to three documented reasons, separately, from each of three data sources (progress notes, referral note, and procedure report) according to 28 pre-coded categories (see Additional file 1: Appendix B). "
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