Disparities/Minority Health

Studies show lower colorectal cancer screening rates and access to surgery among the poor, minority, and uninsured

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. It is curable, if detected at an early stage through colonoscopy or other screening methods. Early detection and treatment can also prevent potentially fatal complications of CRC, including bowel perforation and obstruction and peritonitis (inflammation of the stomach lining). Yet use of CRC screening remains low, with only half of those 50 years and older obtaining recommended screening. Three studies supported by the Agency for Healthcare Research and Quality examined trends in CRC screening as well as access to CRC surgery.

The first study (HS10771 and HS10856) reveals that CRC screening increased a modest 3 percent from 2000 to 2003, but primarily among high- and middle-income groups. The second study (T32 HS00059) shows that poor, minority, and uninsured patients are more likely than others to need emergency surgery for CRC-related problems such as bowel obstruction. According to the third study (HS09869), improving access of sicker, poorer, and minority patients to high-quality hospitals for CRC surgery may improve their outcomes. The studies are briefly discussed here.

Phillips, K.A., Liang, S-Y., Ladabaum, U., and others (2007, February). "Trends in colonoscopy for colorectal cancer screening." Medical Care 45(2), pp. 160-167.

CRC screening increased a modest 3 percent from 2000 to 2003, primarily due to increases in use of colonoscopy. However, increased use of colonoscopy was primarily among high- and middle-income groups. Among Medicare enrollees with high and middle incomes, colonoscopy use increased 14 percent from 2000 to 2003 compared with an increase of only 7 percent among low-income groups, a significant difference. Similarly, among insured, non-Medicare enrollees with high and middle incomes, colonoscopy use increased 11 percent compared with 4 percent among low-income groups, also a significant difference.

Nevertheless, screening rates remained modest, and lower income individuals continued to be screened less, even after Medicare coverage for screening began in 2001. Low-income individuals had both lower rates of all types of CRC screening initially and lower rates of increase in screening. Many low-income individuals may not have access to colonoscopy. For example, publicly funded clinics may only offer fecal occult blood testing (testing of a stool sample for traces of blood).

Thus, study results should not be construed to imply that colonoscopy is the only preferred screening method and should be offered to all individuals, note the researchers. They recommend making efforts to facilitate CRC screening among low-income individuals a major priority. Their findings were based on data analysis of the 2000 and 2003 National Health Interview Surveys.

Diggs, J.C., Xu, F., Diaz, M., and others (2007, March). "Failure to screen: Predictors and burden of emergency colorectal cancer resection." The American Journal of Managed Care 13(3), pp. 157-164.

Poor, uninsured, and minority patients are less likely to be screened for CRC. Thus, they are more likely to end up needing emergency CRC-related surgery for such problems as bowel perforation, peritonitis, or bowel obstruction. Patients undergoing CRC-related emergency surgery had a threefold greater risk of dying in the hospital, hospital stays that were 4 days longer, and over $19,000 in excess hospital charges when compared with nonemergency patients, even after adjusting for other factors such as cancer stage and demographics.

Among younger patients, Medicaid-insured persons were twice as likely and the uninsured were nearly three times as likely to undergo emergency CRC surgery. Among older patients, those dually eligible for Medicare and Medicaid had 37 percent higher risk for emergency CRC surgery. In 2002, the mean excess length of stay and hospital charges associated with emergency compared with nonemergency CRC surgery amounted to 54,979 excess hospital days and more than $250 million in hospital charges.

Increased CRC screening among these vulnerable subgroups would reduce the substantial patient and societal burden associated with failure to screen, conclude the researchers. Their findings were based on analysis of the 2002 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project.

Zhang, W., Ayanian, J.Z., and Zaslavsky, A.M. (2007, February). "Patient characteristics and hospital quality for colorectal cancer surgery." International Journal for Quality in Health Care 19(1), pp. 11-20.

Improving access of sicker, poorer, and minority patients to high-quality hospitals for CRC surgery may improve their outcomes, concludes this study. The researchers examined characteristics of California hospitals where CRC patients underwent CRC-related surgery. CRC patients who were Hispanic or Asian, less affluent, or with more advanced cancer were less likely to undergo CRC surgery at hospitals that conducted a high volume of CRC surgeries. They were also treated at hospitals with above average mortality rates (30 days after surgery) than hospitals that treated the less severely ill, white, or more affluent. Black patients also underwent CRC surgery at hospitals with above average mortality rates.

Among elderly Medicare beneficiaries, managed care members were more likely than fee-for-service beneficiaries to enter hospitals with high patient volume. However, adjusted mortality rates were similar for hospitals used by the two groups. Most of the racial variation in outcomes within individual hospitals stemmed from patients' clinical status, yet racial differences in hospital selection were substantial. There are still racial barriers to high-quality surgical care for CRC patients, independent of other patient characteristics, conclude the researchers.

Their study demonstrated disparities in hospital selection across racial groups and across clinical and socioeconomic strata. Their findings were based on analysis of a population-based cancer registry in California for a total of 38,237 patients diagnosed with stage I-III (nonmetastatic) colorectal cancer between 1994 and 1998. The researchers linked registry data to hospital discharge abstracts, U.S. Census data, and Medicare enrollment data.

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