Assessing Colorectal Cancer Screening Adherence of Medicare Fee-for-Service Beneficiaries Age 76 to 95 Years

Abstract

PROBLEM FACED: There is a growing concern about potential overuse of colorectal cancer (CRC) screening services in part because the U.S. Preventive Services Task Force (USPSTF) recommends against routine CRC screening of average-risk individuals over age 75 years. This study examined rates of CRC screening adherence, defined by Medicare coverage policy, among average-risk Medicare fee-for-service (FFS) beneficiaries age 76 to 95 years.WHAT WE DID: Using a 2002-2010 5% random non-cancer sample of Medicare beneficiaries residing in the SEER areas, we constructed a 9-year cohort that included average-risk beneficiaries age 76 to 95. Two outcomes of interest were (1) up-to-date status of overall CRC screening adherence and (2) up-to-date status of adherence to colonoscopy versus other screening modalities (i.e., fecal occult blood test, flexible sigmoidoscopy, and double-contrast barium enema), conditional on patient adherence. Because of our claims-data-based method used for determining the up-to-date adherence status, we further focused on a subsample of averagerisk beneficiaries age 86 to 95, for whom any screening services used may be considered potential overuse by USPSTF recommendations. WHAT WE FOUND:Overall CRC screening adherence rates of Medicare beneficiaries age 76 to 95 increased from 13.0% to 21.4% from 2002 to 2010. In 2002, 2.2% were adherent to colonoscopy and 10.7% by the other modalities, and the corresponding rates were 19.5% and 1.9% in 2010. In addition, the rates of adherence to colonoscopy were 1.1% for those age 86 to 90 and almost nil for those age 91 to 95 in 2002, but became 13.5% and 8.2% in 2010, respectively. The Figure shows the rates of CRC screening adherence by modality among those age 86 to 90 and 91 to 95 combined. In contrast to whites, blacks age 76 to 95 had 7-percentage-point lower adherence rates. However, overall adherence rates among blacks increased by 168.6% from 2002 to 2010, while rates among whites increased by 63.0%. INTERPRETATION:The rapid rise in overall adherence rates may be linked to Medicare coverage policy of screening colonoscopy for average-risk beneficiaries starting in 2001, and to colonoscopy's 10-year screening interval. Our subsample analysis of those age 86 to 95 showed that the overall adherence rates almost doubled, rising from 6.7% to 12.5% from 2002 to 2010.These increases, largely driven by colonoscopy use, may represent at least some overuse of CRC screening services. However, this study could not fully evaluate appropriateness of CRC screening services because the USPSTF recommends case-by-case consideration of screening for average-risk individuals age 75 to 84. REAL-LIFE IMPLICATIONS:To our knowledge, this is the first study evaluating rates of CRC screening adherence among average-risk, Medicare FFS beneficiaries since Medicare began to reimburse for average-risk screening colonoscopy in 2001.We observed that high proportions of very elderly average-risk Medicare FFS beneficiaries received colonoscopies in spite of USPSTF recommendations for...

Decreasing Black-White Disparities in Colorectal Cancer Incidence and Stage at Presentation in the United States

“…More specifically, rates of FOBT use have declined in blacks while rates of endoscopic screening have increased (56). Thus, increasing use of endoscopic screening methods among blacks and public health attention towards black-white CRC screening disparities may have resulted in a shift towards CRC diagnoses in earlier stages in blacks (35,57,58). While it is essential to see how stage trends continue in the next several years, the implication for stage at diagnosis is that blacks may have benefited disproportionately from collective CRC early detection efforts in recent years.…”

Assessing the impact of colonoscopy complications on use of colonoscopy among primary care physicians and other connected physicians: an observational study of older Americans

“…Prior work suggests substantial overuse of colonoscopies in patients over the ages of 75 and 85 years. 15 16 Nevertheless, fewer colonoscopies were performed overall among the older versus younger patients, which may reflect physicians' appreciation of the lower benefit of screening in this group. The decline in colonoscopy rates was observed for younger but not older physicians.…”

Overuse of colorectal cancer screening services in the United States and its implications

“…An article entitled “Assessing Colorectal Cancer Screening Adherence of Medicare Fee-For-Service Beneficiaries Age 76 to 95 Years” recently published at the Journal of Oncology Practice ( JOP ) by Bian et al [1] highlighted the trends in the overuse of CRC screening services among average-risk elderly populations at the age of 76–95 years from 2002 to 2010. CRC screening is an effective and a cost-effective way for reducing CRC-related death.…”

“…This JOP article [1] reports an observational study designed for addressing this concern. This study used a 5% random non-cancer sample of Medicare fee-for-service (FFS) enrollees during 2002–2010 residing in the Surveillance, Epidemiology, and End Results (SEER) areas to construct a 9-year study cohort that included average-risk enrollees at the age of 76–95 years.…”

“…Finally, this JOP article [1] may offer some insights of using observational data for cancer health services/outcomes research in China. The dataset used in this study was longitudinal non-cancer data, paralleled to the SEER data (the cancer registry data covering a quarter of the US populations).…”