Cancer Screening Among U.S. Medicaid Enrollees with Chronic Comorbidities or Residing in Long-Term Care Facilities

Abstract

Background: Ensuring appropriate cancer screenings among low-income persons with chronic conditions and persons residing in long-term care (LTC) facilities presents special challenges. This study examines the impact of having chronic diseases and of LTC residency status on cancer screening among adults enrolled in Medicaid, a joint state-federal government program providing health insurance for certain low-income individuals in the U.S.

Methods: We used 2000-2003 Medicaid data for Medicaid-only beneficiaries and merged 2003 Medicare-Medicaid data for dually-eligible beneficiaries from four states to estimate the likelihood of cancer screening tests during a 12-month period. Multivariate regression models assessed the association of chronic conditions and LTC residency status with each type of cancer screening.

Results: LTC residency was associated with significant reductions in screening tests for both Medicaid-only and Medicare-Medicaid enrollees; particularly large reductions were observed for receipt of mammograms. Enrollees with multiple chronic comorbidities were more likely to receive colorectal and prostate cancer screenings and less likely to receive Papanicolaou (Pap) tests than were those without chronic conditions.

Conclusions: LTC residents have substantial risks of not receiving cancer screening tests. Not performing appropriate screenings may increase the risk of delayed/missed diagnoses and could increase disparities; however, it is also important to consider recommendations to appropriately discontinue screening and decrease the risk of overdiagnosis. Although anecdotal reports suggest that patients with serious comorbidities may not receive regular cancer screening, we found that having chronic conditions increases the likelihood of certain screening tests. More work is needed to better understand these issues and to facilitate referrals for appropriate cancer screenings.

Keywords: Healthcare Disparities; Mass Screening; Medicaid; Neoplasms; Nursing Homes.

Figure 1. Logistic Regression Analysis of Rates of Cancer Screening Tests for Medicaid Only (Non-Dual) Enrollees (Odds Ratios and Upper 95% Confidence Intervals)

Regression analyses controlled for age, age squared, sex, race/ethnicity, urban-rural residence status, state, number of chronic conditions (LTC study regressions only) and number of outpatient physician visits (chronic condition study regressions only). LTC regressions utilized non-LTC residents as the reference group; chronic condition regressions utilized individuals with zero chronic conditions as the reference group. All odds ratios are statistically significant at p<0.0001 except for CRC screening among LTC residents (not significant), Pap test among LTC residents (p=0.0006), prostate cancer screening among LTC residents (not significant) and mammography among enrollees with four or more chronic conditions (p=0.01).

Figure 2. Logistic Regression Analysis of Rates of Cancer Screening Tests for Dual Medicare-Medicaid Enrollees (Odds Ratios and Upper 95% Confidence Intervals)

Regression analyses controlled for age, age squared, sex, race/ethnicity, urban-rural residence status, state, number of chronic conditions (LTC study regressions only) and number of outpatient physician visits (chronic condition study regressions only). LTC regressions utilized non-LTC residents as the reference group; chronic condition regressions utilized individuals with zero chronic conditions as the reference group. All odds ratios are statistically significant at p<0.0001 except for mammography among enrollees with 2–3 chronic conditions (p=0.03) and Pap test among enrollees with 2–3 chronic conditions (not significant).