Breast Cancer Screening Among Women with Medicaid, 2006–2008: a Multilevel Analysis
- 266 Downloads
Nationally, about one third of women with breast cancer (BC) are diagnosed at late stage, which might be reduced with greater utilization of BC screening. The purpose of this paper is to examine the predictors of BC mammography use among women with Medicaid, and differences among Medicaid beneficiaries in their propensity to use mammography.
The sample included 2,450,527 women drawn from both fee-for-service and managed care Medicaid claims from 25 states, during 2006–2008. The authors used multilevel modeling of predictors at person, county, and state levels of influence and examined traditional factors affecting access and the expanded scope of practice allowed for the nurse practitioner (NP) in some states to provide primary care independent of physician oversight.
Black [OR = 0.87; 95 % CI (0.87–0.88)] and American Indian women [OR = 0.74; 95 % CI (0.71–0.76)] had lower odds ratio of mammography use than white women, while Hispanic [OR = 1.06; 95 % CI (1.05–1.07)] had higher odds ratio of mammography use than white women. Living in counties with higher Hispanic residential segregation [OR = 1.16; 95 % CI (1.10–1.23)] was associated with a higher odds ratio of mammography use compared to areas with low Hispanic residential segregation, whereas living among more segregated black [OR = 0.78; 95 % CI (0.75–0.81)] or Asian [OR = 0.19; 95 % CI (0.17–0.21)] communities had lower odds ratio compared to areas with low segregation. Holding constant statistically the perceived shortage of MDs, which was associated with significantly lower mammography use, the NP regulatory variable [OR = 1.03; 95 % CI (1.01–1.07)] enhanced the odds ratio of mammography use among women in the six states with expanded scope of practice, compared with women residing in 19 more restrictive states.
Racial and ethnic disparities exist in the use of mammography among Medicaid-insured women. More expansive NP practice privileges in states are associated with higher utilization, and may help reduce rural disparities.
KeywordsBreast cancer screening Medicaid Multilevel analysis Racial or ethnic disparities Racial or ethnic residential segregation Nurse practitioner regulation
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. Funding support for Lee Mobley, Sujha Subramanian, Sonja Hoover, and Jiantong Wang was provided by the Centers for Disease Control and Prevention (Contract No. 200-2008-27958, Task order 35, to RTI International).
Compliance with Ethical Standards
The authors have no potential conflicts of interest to disclose. The research does not involve human participants or animals and did not require informed consent. This manuscript has not been submitted to more than one journal for simultaneous consideration. This manuscript has not been published previously (partly or in full). This study has not been split up into several parts to increase the quantity of submissions and submitted to various journals or to one journal over time. No data have been fabricated or manipulated (including images) to support our conclusions. No data, text, or theories by others are presented as if they were the author’s own. Proper acknowledgements to other works have been given. Consent to submit has been received explicitly from all co-authors, as well as from the responsible authorities—tacitly or explicitly—at the institute/organization where the work has been carried out. Authors whose names appear on this manuscript have contributed sufficiently to the scientific work and therefore share collective responsibility and accountability for the results.
- 7.Lian M, Schootman M, Doubeni CA, Park Y, Major JM, Stone RA, et al. Geographic variation in colorectal cancer survival and the role of small-area socioeconomic deprivation: a multilevel survival analysis of the NIH-AARP Diet and Health Study Cohort. Am J Epidemiol. 2011;174(7):828–38.CrossRefPubMedPubMedCentralGoogle Scholar
- 13.National Conference of State Legislatures (NCSL). Scope of Practice Legislative Database, 2011–2013. 2013. http://www.ncsl.org/issues-research/health/scope-of-practice-legislation-tracking-database.aspx. Accessed Feb 2015.
- 14.Centers for Medicare & Medicaid Services, Research Data Assistance Center. Medicaid data 2006–2008. 2013. Minneapolis, MN: Research Data Assistance Center. Available from: http://www.resdac.org/cms-data/search?f=im_field_program_type%3A2
- 15.Byrd V, Dodd AH. Assessing the usability of encounter data for enrollees in comprehensive managed care across MAX 2007–2009, Medicaid Policy Brief, Brief 15. 2012 Princeton, NJ: Mathematica Policy Research, Inc.Google Scholar
- 16.U.S. Preventive Task Force. Screening for breast cancer. 2002. cited 2014 August 25. Available from: http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca2002.htm
- 17.Research Triangle Institute (RTI). Spatial impact factor database. 2014. Research Triangle Park, NC: RTI International. Available from: https://rtispatialdata.rti.org
- 18.Massey DS, Denton NA. The dimensions of residential segregation. Sociol Forum. 1988;67:281–315.Google Scholar
- 22.Cassidy A. Health policy brief: nurse practitioners and primary care. Health Aff (Millwood). 2012.Google Scholar
- 23.Yee T, Boukus E, Cross D, Samuel D. Primary care workforce shortages: nurse practitioner scope-of-practices laws and payment policies. National Institute for Health Care Reform, Research Brief No. 13. 2013. 2013 [cited 2014 June]. Available from: http://www.nihcr.org/PCP-Workforce-NPs
- 25.Hansen-Turton T. Nurse practitioners as leaders in primary care: current challenges and future opportunities. National Conference of State Legislatures: Louisville, KY; 2010 .Available from: http://www.ncsl.org/documents/health/hansenturtonpp.pdf Google Scholar
- 26.Ewing J, Hinkley K. Meeting the primary care needs of rural America: examining the role of non-physician providers. The Rural Health Connection. 2013.Google Scholar
- 27.American Association of Retired Persons (AARP). State profiles: reforming the health care system, 12th edition. 2003. [cited 2015 February 17]. Available from: http://assets.aarp.org/rgcenter/health/d17984_reform_2003.pdf
- 28.Gelman A, Hill J. Data analysis using regression and multilevel/hierarchical models. Cambridge, UK: Cambridge University Press; 2007.Google Scholar
- 31.Schulz AJ, Williams DR, Israel BA, Lempert LB. Racial and spatial relations as fundamental determinants of health in Detroit. Milt Q. 2002;80(4):677–707 .ivGoogle Scholar
- 39.LaVeist TA. The political empowerment and health-status of African-Americans—mapping a new territory. AJS. 1992;97(4):1080–95.Google Scholar