Elsevier

Preventive Medicine

Volume 112, July 2018, Pages 199-206
Preventive Medicine

Colorectal cancer screening in the United States: Trends from 2008 to 2015 and variation by health insurance coverage

https://doi.org/10.1016/j.ypmed.2018.05.001Get rights and content

Highlights

  • Colorectal cancer screening rates increased from 2008 to 2015.

  • Approximately 61% of adult ages 50–74 screened for colorectal cancer in 2015.

  • The majority of adults screened for colorectal cancer using colonoscopy.

  • Among adults ages 50–64, screening rates were lowest among the uninsured.

Abstract

Regular colorectal cancer (CRC) screening is recommended for reducing CRC incidence and mortality. This paper provides an updated analysis of CRC screening in the United States (US) and examines CRC screening by several features of health insurance coverage.

Recommendation-consistent CRC screening was calculated for adults aged 50–75 in 2008, 2010, 2013 and 2015 using data from the National Health Interview Survey. CRC screening prevalence in 2015 was described overall and by sociodemographic subgroups. CRC screening by health insurance coverage was further examined using multivariable logistic regression, stratified by age (50–64 years and 65–75 years) and adjusted for age, race/ethnicity, sex, education, income, time in US, and comorbid conditions.

Recommendation-consistent screening increased from 51.6% in 2008 to 58.3% in 2010 (p < 0.001). Use plateaued from 2010 to 2013 but increased to 61.3% in 2015 (p < 0.001). In 2015, adults aged 50–64 years with traditional employer-sponsored private insurance were more likely to be screened (62.2%) than those with traditional private direct purchase plans (50.9%) and the uninsured (24.8%) (p < 0.01, respectively). After multivariable adjustment, differences between traditional employer-sponsored private insurance and the uninsured remained statistically significant. Adults aged 65–75 with Medicare and private insurance were more likely to be screened (76.3%) than those with Medicare, no supplemental insurance (68.8%) or Medicare and Medicaid (65.2%) (p < 0.001). After multivariable adjustment, the differences between Medicare and private insurance and Medicare no supplemental insurance remained statistically significant.

CRC screening rates have increased over time, but certain segments of the population, especially the uninsured, continue to screen below recommended levels.

Introduction

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in men and women and the second leading cause of death from cancers affecting both men and women in the United States (Siegel et al., 2016; U.S. Cancer Statistics Working Group, 2017). Regular screening may prevent CRC and is recommended for detecting early stage disease and reducing CRC mortality (Lin et al., 2016). Since 2008 (and through 2015), the US Preventive Services Task Force (USPSTF) has recommended that adults aged 50–75, who are not considered high risk, screen for CRC using one of three approaches: annual high-sensitivity fecal occult blood testing (FOBT), sigmoidoscopy every 5 years combined with high-sensitivity FOBT every 3 years, or colonoscopy every 10 years (Screening for colorectal cancer, 2008). The USPSTF considers CRC screening a grade “A” recommendation, indicating that the net benefit is substantial.

Recommendation-consistent CRC screening use has increased substantially over the last two decades, rising from 38.6% in 2000 to 54.6% in 2008 (Sinicrope et al., 2012; Klabunde et al., 2011; Fedewa et al., 2015). However, rates remain below the National Colorectal Cancer Roundtable goal of 80% of eligible adults having recommendation-consistent CRC screening by 2018 (80% by 2018: working toward the shared goal of 80% screened for colorectal cancer by 2018, n.d.). Likewise, for most population subgroups, screening rates are below the Healthy People 2020 target of 70.5% (Healthy people 2020 cancer objectives, n.d.). The lowest screening rates are observed among the uninsured and underinsured, people without a usual source of care, and recent immigrants, (Sinicrope et al., 2012; Klabunde et al., 2011; Fedewa et al., 2015) which suggests that screening decisions may be influenced by access to health care and cost considerations (Wools et al., 2016; Honein-AbouHaidar et al., 2016; Gupta et al., 2014).

With recent changes to health insurance coverage in the United States, evaluating the trends in CRC screening use and factors associated with recommendation-consistent use can be informative. For example, non-grandfathered health insurance plans, with plan-years beginning on or after September 23, 2010, are required to provide coverage without patient cost-sharing for preventive services that have a rating of “A” or “B” in the recommendations of the USPSTF (Patient Protection and Affordable Care Act, 42 U.S.C. § 18001, 2010). Likewise, effective January 1, 2011, the Medicare program eliminated cost-sharing for most preventive services with a USPSTF grade of “A” or “B” (Patient Protection and Affordable Care Act, 42 U.S.C. § 18001, 2010). Changes to health insurance laws have also expanded access to health insurance options for people who were previously uninsured (Blumenthal and Collins, 2014). However, cost-sharing for adults with Medicaid coverage continues to vary by state. It is worth noting that coverage requirements apply only to preventive CRC screening. CRC tests performed for surveillance or diagnostic purposes or when a polyp is detected and removed during screening colonoscopy may have cost-sharing requirements imposed (Coverage of Colonoscopies Under the Affordable Care Act's prevention benefit, 2012). Nevertheless, despite expanded access to health insurance and the absence of cost-sharing for most health plans, many eligible adults are not screening according to USPSTF recommendations (White et al., 2017).

This paper had two main objectives. The first was to characterize national trends in recommendation-consistent CRC screening from 2008 to 2015, reflecting a time-period that encompasses changes to health care legislation in the United States. The second was to explore potential differences in the prevalence of CRC screening according to type of health insurance coverage, using data from 2015, the most recent year of cancer screening data available from the National Health Interview Survey (NHIS).

Section snippets

Data source

Data were obtained from the 2008, 2010, 2013, and 2015 NHIS and NHIS Cancer Control Supplement. The NHIS is administered by the National Center for Health Statistics, and data are collected on a broad range of health topics through in-person household interviews. The Cancer Control Supplement is administered periodically to a single adult in each household that participated in NHIS (i.e., the sample adult) and captures information about practices, knowledge, and attitudes regarding

Trends in CRC screening

Fig. 1 shows trends in CRC screening rates. In 2008, 51.6% of adults were up-to-date with CRC screening. From 2008 to 2010, screening rates increased by 6.7 percentage points to 58.3% (p < 0.05). Although CRC rates were essentially unchanged from 2010 to 2013 (58.3% to 57.3%), they increased an additional four percentage points to 61.3% between 2013 and 2015 (p < 0.05). Recommendation-consistent CRC screening is largely driven by colonoscopy, which was used more frequently than other screening

Discussion

Since 2008, the proportion of the adult population aged 50–75 years in the United States who received recommendation-consistent CRC screening increased by almost 10 percentage points, to 61.3% in 2015. Concerns about a plateau in screening rates from 2010 to 2013, previously expressed in another report, were not borne out in our study, (Sabatino et al., 2015) as overall screening rates increased by four percentage points from 2013 to 2015 (White et al., 2017). Between 2008 and 2015, the

Limitations

This study had several limitations. CRC screening was self-reported and not verified by medical records or claims data. Individuals were considered to have screened according to recommendations if they had the recommended tests for any reason. Thus, “screening” prevalence includes people who may have had the test for diagnostic purposes. Health insurance coverage was measured at the time of the interview, which may not have been the type of insurance payer at the time the person received

Conclusions

We conducted a more detailed analysis of CRC screening use by health insurance type in 2015 than has been previously undertaken. We distinguished between employer-sponsored private insurance and direct-purchase private plans, and we further examined traditional and high-deductible options within these plans. Our findings document that CRC screening rates in the U.S. continue to increase. Although segments of the population are screening at recommended levels, screening rates among groups that

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    The authors declare there is no conflict of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the National Institutes of Health, or the Department of Health and Human Services.

    1

    Permanent address: K Yabroff is currently affiliated with the Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA. C Altice is currently affiliated with the Division of MCH Workforce Development, Maternal and Child Health Bureau, Health Resources and Service Administration

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