Community contextual predictors of endoscopic colorectal cancer screening in the USA: spatial multilevel regression analysis.
Community contextual predictors of endoscopic colorectal cancer screening in the USA: spatial multilevel regression analysis.
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DOI：
10.1186/1476-072x-9-44
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发表时间：
2010-09-03
影响因子：
4.9
通讯作者：
Subramanian S
中科院分区：
文献类型：
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作者：
Mobley LR;Kuo TM;Urato M;Subramanian S
结直肠癌(CRC)是美国第二大癌症死亡原因，内窥镜筛查既可以检测癌症，也可以预防癌症，但利用率并不理想，而且因地理区域而异。我们使用多水平回归来检验个体决定使用内窥镜结直肠癌筛查的各种预测因素。研究对象是2001年确定并一直跟踪到2005年的100%人群队列的医疗保险受益人。结果变量是在此期间使用任何乙状结肠镜检查或结肠镜检查的二元指标。我们分别分析每个状态，并将所有状态的发现映射在一起，以揭示观察到的跨州异质性的模式。我们根据一个全面的社会生态模型，为每个州估计了一个完全调整的模型。我们集中讨论了三个社区背景变量中的每一个对政策干预的独立贡献。社区医疗保险管理保健的流行与12个州的较低筛查概率和19个州的较高概率相关。社区老年人英语语言能力差的发生率与15个州的筛查概率较低和6个州的筛查概率较高有关。一个人所在社区的贫困发生率与36个州的筛查概率较低和5个州的较高概率有关。在通过内窥镜进行结直肠癌筛查的社会生态背景下，各州之间存在着相当大的差异，这表明目前各州特定的全面癌症控制计划的分散配置非常适合于对观察到的异质性做出反应。我们发现，在一些州比在另一些州更迫切需要干预来调解语言障碍。医疗保险管理的医疗渗透率，假设会影响关于新内窥镜技术的信息和传播，只在少数州有积极的关联。这表明，管理式医疗计划对这项成本增加的技术的推广相当有限。地区贫困在绝大多数州都有负面影响，但在五个州是积极的，这表明有一些针对穷人的有效癌症控制政策，并提供补充资源促进结直肠癌筛查。
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. 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. 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.