Currently Viewing:
The American Journal of Managed Care March 2013
Rates of Guideline Adherence Among US Community Oncologists Treating NSCLC
Zhaohui Wang, MD, PhD; Inga Aksamit, RN, MBA; Lisa Tuscher, BA; and Kim Bergstrom, PharmD
Effectiveness and Cost-Effectiveness of Diabetes Prevention Among Adherent Participants
William H. Herman, MD, MPH; Sharon L. Edelstein, ScM; Robert E. Ratner, MD; Maria G. Montez, RN, MSHP; Ronald T. Ackermann, MD, MPH; Trevor J. Orchard, MD; Mary A. Foulkes, PhD; Ping Zhang, PhD; Christopher D. Saudek, MD†; and Morton B. Brown, PhD; The Diabetes Prevention Program Research Group
Mental Health in ACOs: Missed Opportunities and Low-Hanging Fruit
Allison N. O'Donnell, MPH; Brent C. Williams, MD; Daniel Eisenberg, PhD; and Amy M. Kilbourne, PhD, MPH
Drug Adherence After Price Changes in a Previously Compliant Population
James J. Hill III, MD, MPH; Deron Galusha, MS; Martin D. Slade, MPH; and Mark R. Cullen, MD
Measuring Quality in the Early Years of Health Insurance Exchanges
Ledia M. Tabor, MPH; Phyllis Torda, MA; Sarah S. Thomas, MS; and Jennifer L. Zutz, MHSA
Currently Reading
Multilevel Predictors of Colorectal Cancer Screening Use in California
Salma Shariff-Marco, PhD, MPH; Nancy Breen, PhD; David G. Stinchcomb, MS, MA; and Carrie N. Klabunde, PhD
Factors Associated With Primary Hip Arthroplasty After Hip Fracture
Ishveen Chopra, MS; Khalid M. Kamal, PhD; Jayashri Sankaranarayanan, MPharm, PhD; and Gibbs Kanyongo, PhD
Measuring Concurrent Oral Hypoglycemic and Antidepressant Adherence and Clinical Outcomes
Hillary R. Bogner, MD, MSCE; Heather F. de Vries, MSPH; Alison J. O'Donnell, BA; and Knashawn H. Morales, ScD
Computed Tomography Scan Use Variation: Patient, Hospital, and Geographic Factors
Eric A. Vance, PhD; Xiaojin Xie, MS; Andrew Henry, BS; Christian Wernz, PhD; and Anthony D. Slonim, MD, DrPH
Low Clinical Utility of Folate Determinations in Primary Care Setting
Shlomo Vinker, MD; Eli Krantman, MD; Michal Shani, MD; and Sasson Nakar, MD
Trends in Inpatient Hospital Prices, 2008 to 2010
Jeff Lemieux, MA; and Teresa Mulligan, MHSA

Multilevel Predictors of Colorectal Cancer Screening Use in California

Salma Shariff-Marco, PhD, MPH; Nancy Breen, PhD; David G. Stinchcomb, MS, MA; and Carrie N. Klabunde, PhD
We studied contextual factors and found that locality, availability of primary care, and HMO membership influenced use of colorectal cancer screening in California.
Limitations of our study include use of cross-sectional data, which does not allow causal inference. While our study findings are specific to California, the contextual factors we examined are not unique to California and could be studied in a similar fashion in other geographic locations. Although self-report of CRC screening tests may overestimate prevalence of CRC screening use, there is mixed evidence about the extent of this problem.64-66 A recent study showed that data from the 2007 CHIS overestimated being up-to-date by 6% to 14% across racial/ethnic groups.65 Skip patterns in the CHIS survey made analysis of CRC screening measures difficult. As a result of our study, CRC screening measures in CHIS were improved. Finally, adding data on additional resources (eg, endoscopy) as well as other contexts (eg, workplace) would offer a more extensive range of factors that may influence CRC screening use.

Our multilevel analysis showed that contextual factors including locality, availability of primary care, and HMO membership influenced use of CRC screening in California. Our results show that both levels of residential geography influence CRC screening use and suggest that multilevel analysis is a promising line of research for cancer screening. Accounting for contextual factors at different geographic scales can provide a richer characterization of the healthcare  resources and market characteristics that influence individual behaviors. Moreover, insights from this study could guide interventions aimed at increasing CRC screening uptake by prioritizing appropriate subgroups and geographic areas. A better understanding of contextual factors of the healthcare and social environment will be important in informing policy decisions for healthcare resource allocation and delivery. Future studies on CRC screening that address multilevel predictors should account for the hierarchical structure of the data by using multilevel analysis or by accounting for clustering within neighborhoods when multilevel analysis is not possible. More experimentation to find the appropriate geographic areas is needed in order to evaluate policy and interventions that address factors to improve screening.

We would like to acknowledge the Cancer Prevention Fellowship Program, Office of Preventive Oncology, National Cancer Institute for providing financial support for Salma Shariff-Marco in her postdoctoral fellowship. We would also like to acknowledge Tim McNeel, William Waldron, and Jeremy Lyman at Information Management Services, Inc, for their support in merging our data sets, developing programs for the descriptive analysis, and generating the maps for the Figure; and Penny Randall-Levy of the Scientific Consulting Group, Inc, for her help with the references. Finally, we would like to acknowledge Drs Martin L. Brown and Rachel Ballard-Barbash for their thoughtful reviews.

Author Affiliations: From Cancer Prevention Institute of California (SSM), Freemont, CA; Division of Cancer Control and Population Sciences (NB, CNK), National Cancer Institute, Rockville, MD; Westat, Inc (DOS), Rockville, MD.

Funding Source: All authors were employed at the National Cancer Institute.

Author Disclosures: The authors (SS-M, NB, DGS, CNK) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SS-M, NB, DGS, CNK); acquisition of data (SS-M); analysis and interpretation of data (SS-M, NB, DGS, CNK); drafting of the manuscript (SS-M, NB, DGS, CNK); critical revision of the manuscript for important intellectual content (SS-M, NB, DGS, CNK); statistical analysis (SS-M, DGS); obtaining funding (SS-M); administrative, technical, or logistic support (SS-M, NB); and supervision (SS-M, NB).

Address correspondence to: Salma Shariff-Marco, PhD, MPH, Cancer Prevention Institute of California, 2201 Walnut Ave, Ste 300, Fremont, CA 94538. E-mail:
1. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010 [published correction appears in CA Cancer J Clin. 2011;61(2):133-134]. CA Cancer J Clin. 2010;60(5):277-300.

2. American Cancer Society. Colorectal Cancer Facts & Figures, 2008-2010. Atlanta GA: American Cancer Society; 2008. Accessed February 5, 2013.

3. Levin B, Lieberman DA, McFarland B, et al; American Cancer Society Colorectal Cancer Advisory Group; US Multi-Society Task Force; American College of Radiology Colon Cancer Committee. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008;134(5):1570-1595.

4. Agency for Healthcare Research and Quality. Prevention and Chronic Care Program. U.S. Preventive Services Task Force. Published 2009. Accessed October 13, 2009.

5. Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects. CA Cancer J Clin. 2007;57(2):90-104.

6. Rakowski W, Breslau ES. Perspectives on behavioral and social science research on cancer screening. Cancer. 2004;101(5)(suppl):1118-1130.

7. Ananthakrishnan AN, Schellhase KG, Sparapani RA, Laud PW, Neuner JM. Disparities in colon cancer screening in the Medicare population. Arch Intern Med. 2007;167(3):258-264.

8. van Jaarsveld CH, Miles A, Edwards R, Wardle J. Marriage and cancer prevention: does marital status and inviting both spouses together influence colorectal cancer screening participation? J Med Screen. 2006;13(4):172-176.

9. Link BG, Northridge ME, Phelan JC, Ganz ML. Social epidemiology and the fundamental cause concept: on the structuring of effective cancer screens by socioeconomic status. Milbank Q. 1998;76(3):375-402.

10. Etzioni DA, Ponce NA, Babey SH, et al. A population-based study of colorectal cancer test use: results from the 2001 California Health Interview Survey. Cancer. 2004;101(11):2523-2532.

11. Jerant AF, Fenton JJ, Franks P. Determinants of racial/ethnic colorectal cancer screening disparities. Arch Intern Med. 2008;168(12):1317-1324.

12. Shapiro JA, Seeff LC, Thompson TD, Nadel MR, Klabunde CN, Vernon SW. Colorectal cancer test use from the 2005 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev. 2008;17(7):1623-1630.

13. Trivers KF, Shaw KM, Sabatino SA, Shapiro JA, Coates RJ. Trends in colorectal cancer screening disparities. Am J Prev Med. 2008;35(3):185-193.

14. Hiatt RA, Klabunde C, Breen N, Swan J, Ballard-Barbash R. Cancer screening practices from National Health Interview Surveys: past, present and future. J Natl Cancer Inst. 2002;94(24):1837-1846.

15. Meissner HI, Breen N, Klabunde CN, Vernon SW. Patterns of colorectal cancer screening uptake among men and women in the United States. Cancer Epidemiol Biomarkers Prev. 2006;15(2):389-394.

16. Holden DJ, Jonas DE, Porterfield DS, Reuland D, Harris R. Systematic review: enhancing the use and quality of colorectal cancer screening. Ann Intern Med. 2010;152(10):668-676.

17. Crawley LM, Ahn DK, Winkleby MA. Perceived medical discrimination and cancer screening behaviors of racial and ethnic minority adults. Cancer Epidemiol Biomarkers Prev. 2008;17(8):1937-1944.

18. O’Malley AS, Forrest CB, Feng S, Mandelblatt J. Disparities despite coverage: gaps in colorectal cancer screening among Medicare beneficiaries. Arch Intern Med. 2005;165(18):2129-2135.

19. Zapka JG, Puleo E, Vickers-Lahti M, Luckmann R. Healthcare system factors and colorectal cancer screening. Am J Prev Med. 2002;23(1):28-35.

20. Weitzman ER, Zapka J, Estabrook B, Goins KV. Risk and reluctance: understanding impediments to colorectal cancer screening. Prev Med. 2001;32(6):502-513.

21. Farmer MM, Bastani R, Kwan L, Belman M, Ganz PA. Predictors of colorectal cancer screening from patients enrolled in a managed care health plan. Cancer. 2008;112(6):1230-1238.

22. Giorgi Rossi P, Federici A, Bartolozzi F, Farchi S, Borgia P, Guasticchi G. Understanding non-compliance to colorectal cancer screening: a case control study, nested in a randomised trial [ISRCTN83029072]. BMC Public Health. 2005;5:139.

23. Ponce NA, Huh S, Bastani R. Do HMO market level factors lead to racial/ethnic disparities in colorectal cancer screening? a comparison between high-risk Asian and Pacific Islander Americans and high-risk whites. Med Care. 2005;43(11):1101-1108.

24. Koka VK, Potti A, Fraiman GN, Hanekom D, Hanley JF. An epidemiological study evaluating the relationship of distance from a tertiary care cancer center to early detection of colorectal carcinoma. Anticancer Res. 2002;22(4):2481-2483.

25. Haas JS, Fitzmaurice G, Brawarsky P, et al. Association of regional variation in primary care physicians’ colorectal cancer screening recommendations with individual use of colorectal cancer screening. Prev Chronic Dis. 2007;4(4):A90.

26. Fukuda Y, Nakamura K, Takano T. Reduced likelihood of cancer screening among women in urban areas with low socioeconomic status: a multilevel analysis in Japan. Public Health. 2005;119(10):875-884.

27. Schootman M, Jeffe DB, Baker EA, Walker MS. Effect of area poverty rate on cancer screening across US communities. J Epidemiol Community Health. 2006;60(3):202-207.

28. Lian M, Schootman M, Yun S. Geographic variation and effect of area-level poverty rate on colorectal cancer screening. BMC Public Health. 2008;8:358.

29. James TM, Greiner KA, Ellerbeck EF, Feng C, Ahluwalia JS. Disparities in colorectal cancer screening: a guideline-based analysis of adherence. Ethn Dis. 2006;16(1):228-233.

30. Coughlin SS, Thompson TD. Colorectal cancer screening practices among men and women in rural and nonrural areas of the United States, 1999. J Rural Health. 2004;20(2):118-124.

31. Pornet C, Dejardin O, Morlais F, Bouvier V, Launoy G. Socioeconomic determinants for compliance to colorectal cancer screening: a multilevel analysis. J Epidemiol Community Health. 2010;64(4):318-324.

32. Commission on the Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report. Geneva, Switzerland: World Health Organization; 2008. finalreport/en/index.html. Accessed February 5, 2013.

33. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80-94.

34. Palitz AM, Selby JV, Grossman S, et al. The Colon Cancer Prevention Program (CoCaP): rationale, implementation, and preliminary results. HMO Pract. 1997;11(1):5-12.

35. Levin TR, Jamieson L, Burley DA, Reyes J, Oehrli M, Caldwell C. Organized colorectal cancer screening in integrated health care systems. Epidemiol Rev. 2011;33(1):101-110.

36. Ganz PA, Farmer MM, Belman M, et al. Improving colorectal cancer screening rates in a managed care health plan: recruitment of provider organizations for a randomized effectiveness trial. Cancer Epidemiol Biomarkers Prev. 2003;12(9):824-829.

37. Ganz PA, Farmer MM, Belman MJ, et al. Results of a randomized controlled trial to increase colorectal cancer screening in a managed care health plan. Cancer. 2005;104(10):2072-2083.

38. California Office of Statewide Health Planning and Development. Medical service study areas. Published 2005. Accessed October 13, 2009.

39. California Health Interview Survey. CHIS 2005 Methodology Series. Report 1— Sample Design. Los Angeles, CA: UCLA Center for Health Policy Research; April 2007.

40. Mobley LR. RTI Spatial Impact Factor Database. Version 1. Developed for the National Cancer Institute under the R21 grant Spatial Impact Factors and Mammography Use, Principal Investigator Lee Mobley. Research Triangle Park, NC: RTI International. 2006.

41. California Health Interview Survey. CHIS 2005 Adult Survey. Los Angeles, CA: UCLA Center for Health Policy Research; 2006.

42. National Center for Health Workforce Analysis. Area Resource File (ARF). Rockville, MD: Bureau of Health Professions, Health Resources and Services Administration; 2004.

43. National Center for Health Workforce Analysis. User Documentation for the Area Resource File (ARF) 2004 Release. Rockville, MD: Bureau of Health Professions, Health Resources and Services Administration; 2004.

44. Maly MT. The neighborhood diversity index: a complementary measure of racial residential settlement. J Urban Aff. 2000;22(1):37-47.

45. California Health Interview Survey. CHIS 2005 Methodology Series. Report 5—Weighting and Variance Estimation. Los Angeles, CA: UCLA Center for Health Policy Research; April 2007.

46. Rabe-Hesketh S, Skrondal A. Multilevel and Longitudinal Modeling Using Stata. College Station, TX: Stata Press; 2005.

47. Pfeffermann D, Skinner CJ, Holmes DJ, Goldstein H, Rasbash J. Weighting for unequal selection probabilities in multilevel models. J R Stat Soc Series B Stat Methodol. 1998;60:23-40.

48. Chantala K, Blanchette D, Suchindran CM. Software to compute sampling weights for multilevel analysis. Published April 28, 2011. Accessed September 15, 2011.

49. Merlo J, Chaix B, Ohlsson H, et al. A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. J Epidemiol Community Health. 2006;60(4):290-297.

50. Larsen K, Merlo J. Appropriate assessment of neighborhood effects on individual health: integrating random and fixed effects in multilevel logistic regression. Am J Epidemiol. 2005;161(1):81-88.

51. Larsen K, Petersen JH, Budtz-Jørgensen E, Endahl L. Interpreting parameters in the logistic regression model with random effects. Biometrics. 2000;56(3):909-914.

52. Merlo J, Yang M, Chaix B, Lynch J, Råstam L. A brief conceptual tutorial on multilevel analysis in social epidemiology: investigating contextual phenomena in different groups of people. J Epidemiol Community Health. 2005;59(9):729-736.

53. Litaker D, Tomolo A. Association of contextual factors and breast cancer screening: finding new targets to promote early detection. J Womens Health (Larchmt). 2007;16(1):36-45.

54. Wholey DR, Burns LR, Lavizzo-Mourey R. Managed care and the delivery of primary care to the elderly and the chronically ill. Health Serv Res. 1998;33(2, pt 2):322-353.

55. Morrisey MA. Competition in hospital and health insurance markets: a review and research agenda. Health Serv Res. 2001;36 (1, pt 2):191-221.

56. Baker LC, Phillips KA, Haas JS, Liang SY, Sonneborn D. The effect of area HMO market share on cancer screening. Health Serv Res. 2004;39(6, pt 1):1751-1772.

57. Phillips KA, Fernyak S, Potosky AL, Schauffler HH, Egorin M. Use of preventive services by managed care enrollees: an updated perspective. Health Aff (Millwood). 2000;19(1):102-116.

58. Massey DS, Denton NA. The dimensions of residential segregation. Soc Forces. 1988;67(2):281-315.

59. Iceland J, Weinberg DH, Steinmetz E. Racial and Ethnic Residential Segregation in the United States: 1980-2000. Washington, DC: US Government Printing Office; 2002.

60. Krieger N, Chen JT, Waterman PD, Soobader MJ, Subramanian SV, Carson R. Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measure and geographic level matter? the Public Health Disparities Geocoding Project. Am J Epidemiol. 2002;156(5):471-482.

61. Zimmerman RK, Norwalk MP, Tabbara M, Grufferman S. Predictors of colorectal cancer screening in diverse primary care practices. BMC Health Serv Res. 2006;6:116.

62. Peterson NB, Murff HJ, Ness RM, Dittus RS. Colorectal cancer screening among men and women in the United States. J Womens Health (Larchmt). 2007;16(1):57-65.

63. Schenck AP, Klabunde CN, Davis WW. Racial differences in colorectal cancer test use by Medicare consumers. Am J Prev Med. 2006; 30(4):320-326.

64. Bastani R, Glenn BA, Maxwell AE, Ganz PA, Mojica CM, Chang LC. Validation of self-reported colorectal cancer (CRC) screening in a study of ethnically diverse first-degree relatives of CRC cases. Cancer Epidemiol Biomarkers Prev. 2008;17(4):791-798.

65. Palaniappan LP, Maxwell AE, Crespi CM, Wong EC, Shin J, Wang EJ. Population colorectal cancer screening estimates: comparing selfreport to electronic health record data in California. Int J Canc Prev. 2011;4(1).

66. Partin MR, Grill J, Noorbaloochi S, et al. Validation of self-reported colorectal cancer screening behavior from a mixed-mode survey of veterans. Cancer Epidemiol Biomarkers Prev. 2008;17(4):768-776.
Copyright AJMC 2006-2019 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up