Int J Health Geogr - Community contextual predictors of endoscopic colorectal cancer screening in the USA: spatial multilevel regression analysis.


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CKGROUND: Colorectal cancer (CRC) is the second leading cause of cancer death in the United States, and endoscopic screening can both detect and prevent cancer, but utilization is suboptimal and varies across geographic regions. We use multilevel regression to examine the various predictors of individuals' decisions to utilize endoscopic CRC screening. Study subjects are a 100% population cohort of Medicare beneficiaries identified in 2001 and followed through 2005. The outcome variable is a binary indicator of any sigmoidoscopy or colonoscopy use over this period. We analyze each state separately and map the findings for all states together to reveal patterns in the observed heterogeneity across states.RESULTS: We estimate a fully adjusted model for each state, based on a comprehensive socio-ecological model. We focus the discussion on the independent contributions of each of three community contextual variables that are amenable to policy intervention. Prevalence of Medicare managed care in one's neighborhood was associated with lower probability of screening in 12 states and higher probability in 19 states. Prevalence of poor English language ability among elders in one's neighborhood was associated with lower probability of screening in 15 states and higher probability in 6 states. Prevalence of poverty in one's neighborhood was associated with lower probability of screening in 36 states and higher probability in 5 states.CONCLUSIONS: There are considerable differences across states in the socio-ecological context of CRC screening by endoscopy, suggesting that the current decentralized configuration of state-specific comprehensive cancer control programs is well suited to respond to the observed heterogeneity. We find that interventions to mediate language barriers are more critically needed in some states than in others. Medicare managed care penetration, hypothesized to affect information about and diffusion of new endoscopic technologies, has a positive association in only a minority of states. This suggests that managed care plans' promotion of this cost-increasing technology has been rather limited. Area poverty has a negative impact in the vast majority of states, but is positive in five states, suggesting there are some effective cancer control policies in place targeting the poor with supplemental resources promoting CRC screening.

Resumo Limpo

ckground colorect cancer crc second lead caus cancer death unit state endoscop screen can detect prevent cancer util suboptim vari across geograph region use multilevel regress examin various predictor individu decis util endoscop crc screen studi subject popul cohort medicar beneficiari identifi follow outcom variabl binari indic sigmoidoscopi colonoscopi use period analyz state separ map find state togeth reveal pattern observ heterogen across statesresult estim fulli adjust model state base comprehens socioecolog model focus discuss independ contribut three communiti contextu variabl amen polici intervent preval medicar manag care one neighborhood associ lower probabl screen state higher probabl state preval poor english languag abil among elder one neighborhood associ lower probabl screen state higher probabl state preval poverti one neighborhood associ lower probabl screen state higher probabl statesconclus consider differ across state socioecolog context crc screen endoscopi suggest current decentr configur statespecif comprehens cancer control program well suit respond observ heterogen find intervent mediat languag barrier critic need state other medicar manag care penetr hypothes affect inform diffus new endoscop technolog posit associ minor state suggest manag care plan promot costincreas technolog rather limit area poverti negat impact vast major state posit five state suggest effect cancer control polici place target poor supplement resourc promot crc screen

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