The median length of contact with all study clinics was 9.6 years for females and 10.3 years for males (inter-quartile range 3–20 years for females and 4–19 years for males). The median number of patient visits in the past 10 years was 10 for males and 11 for females (data not shown). Two percent of patients received care from multiple clinics. Most patients were female, aged 55–70, employed or retired, had private health insurance (), and had an average of 2.5 co-morbid conditions, including digestive disorders, chronic pain, and arthritis (range=0–10). The number of health maintenance visits in the previous two years ranged from 0 to 7 in both men and women. Sixty-two percent of men and 52% of women had no record of health maintenance visits within the last 2 years.
Patient Demographic Characteristics
represents the proportion of patients up-to-date for breast cancer screening overall and the odds of being up-to-date using clinical breast exam only, mammography screening only and both clinical breast exam and mammography screening, according to receipt of any health maintenance visit and insurance type at last healthcare visit. Overall 27% were up-to-date for clinical breast exam, 35% for mammography only and 19% for both mammography and clinical breast exam, which were ACS recommendations during the study period. The likelihood of receiving at least one health maintenance visit was strongly associated with insurance status (OR for any health maintenance visits for uninsured relative to private insurance was 0.57, 95% CI: 0.38–0.87, p=0.01, results not shown), and up-to-date breast cancer screening was higher among women who had at least one health maintenance visit compared to those with none for all 3 breast cancer screening outcomes.
Association of Up-to-date Breast Cancer Screening Status with Insurance Coverage in Women in Rural Oregon
The adjusted analysis indicated that, relative to women with private health insurance, women with private insurance and Medicare or Medicare were more likely to be up-to-date for clinical breast exam, (overall OR =1.63, 95% CI: 1.04–2.56, p=0.03). Examination of the interaction of health maintenance visit history and insurance status indicated that this overall difference was due to a significant association of up-to-date status for CBE with Medicare status in women with no health maintenance visits (OR 1.63, 95% CI: 1.04–4.72, p=0.0.03). The women with unknown health insurance status with at least one health maintenance visit were more likely to be up-to-date for clinical breast exam relative to those with private health insurance who also had at least one health care visit (OR 2.29, 95% CI 1.11–4.72, p=0.03), but the association was not significant in women with no health maintenance visits (OR=1.12, 95% CI 0.73–1.74). A similar association of decreased likelihood of up-to-date mammography screening or mammography with clinical breast exam in women with unknown or uninsured insurance status was observed in women who had no health maintenance visits, but there was no significant difference in likelihood of mammography status associated with uninsured or unknown insurance status in women who had at least one health maintenance visit. Using the USPSTF recommendations for mammography resulted in more women being up-to-date overall (50% versus 37%), but the relative differences associated with insurance coverage were unchanged.
presents the proportion of women eligible for cervical cancer screening who were up-to-date for a Pap test and the adjusted relative odds of being up-to-date according to last recorded insurance type. The results are presented according to the receipt of any health maintenance visit. Overall, 30% of women were up-to-date for Pap testing. As with breast cancer screening, the proportion up-to-date was higher among women who had at least one health maintenance visit compared with those who had none. Being uninsured relative to having private insurance represented the group least likely to be up-to-date, except among women with at least one preventive healthcare visit, where this was lowest among those with Medicare or Medicare plus private insurance. The odds ratio for up-to-date Pap test screening in women with any health maintenance visit versus none was 23.1 (95% CI: 10.6 – 50.6, p<0.0001, results not shown). As with mammography screening, the proportion of women up to date for cervical cancer screening increased when applying USPSTF recommendations from 30% to 52%. This difference is affected especially by dropping women aged 65 and older as the USPSTF recommends.
Association of Up-to-date Cervical Cancer Screening Status with Insurance Coverage in Rural Oregon Women
presents the proportion of patients who were up-to-date for colorectal cancer screening (using any of four different tests at the appropriate recommended screening interval) and the adjusted relative odds of being up-to-date according to last recorded insurance type. These results are also presented by subgroup according to the receipt of any health maintenance visit. Thirty-seven percent of men and 38% of women were up-to-date for colorectal cancer screening. Of patients with any record of colorectal cancer screening, the most recent screening method used was FOBT for 25% of men and 20% of women, colonoscopy for 64% of men and 74% of women, flexible sigmoidoscopy for 10% of men and 3% of women, and double contrast barium enema for 1% of men and 3% of women. The odds ratio for up-to-date colorectal cancer screening in women with any health maintenance visit versus none was 3.02 (95% CI: 2.13–4.27, p=<0.0001) and for men it was 2.30 (95% CI: 1.50–3.55, p<0.0001). A secondary analysis of female patients which added Mammography status to the analysis described in indicated that women who were up to date for Mammography were much more likely to be up-to-date for colorectal cancer screening (OR 1.74, CI 1.38–2.20, p<0.0001, results not shown).
Association of Up-to-date Colorectal Cancer Screening Status with Insurance Coverage in Rural Oregon
We found very small differences in our results for colorectal cancer screening with the USPSTF guidelines versus ACS guidelines, as the increase in the number of low risk patients who were up to date according to the more lenient USPSTF FOBT guideline (biennial rather than annual) was offset by a decrease in the number of high risk patients that were up to date according to the more restrictive USPSTF colonoscopy guideline (every 5 years rather than every 10 years). The association of USPSTF up to date status with insurance coverage (uninsured compared to private) was slightly increased relative to that of ACS up to date status (OR 0.41, CI 0.18–0.95 compared to OR 0.43, CI 0.19–1.00 for USPSTF and ACS overall up to date in males, respectively and OR 0.44, CI 0.25–0.77 compared to OR 0.45, CI 0.25–0.79 for USPSTF and ACS overall up to date in females, respectively.