Abstract
Investigating geographic variations in mammography screening participation and breast cancer incidence help improve prevention strategies to reduce the burden of breast cancer. This study examined the suitability of health insurance claims data for assessing and explaining geographic variations in mammography screening participation and breast cancer incidence at the district level. Based on screening unit data (1,181,212 mammography screening events), cancer registry data (13,241 incident breast cancer cases) and claims data (147,325 mammography screening events; 1,778 incident breast cancer cases), screening unit and claims-based standardized participation ratios (SPR) of mammography screening as well as cancer registry and claims-based standardized incidence ratios (SIR) of breast cancer between 2011 and 2014 were estimated for the 46 districts of the German federal state of Lower Saxony. Bland-Altman analyses were performed to benchmark claims-based SPR and SIR against screening unit and cancer registry data. Determinants of district-level variations were investigated at the individual and contextual level using claims-based multilevel logistic regression analysis. In claims and benchmark data, SPR showed considerable variations and SIR hardly any. Claims-based estimates were between 0.13 below and 0.14 above (SPR), and between 0.36 below and 0.36 above (SIR) the benchmark. Given the limited suitability of health insurance claims data for assessing geographic variations in breast cancer incidence, only mammography screening participation was investigated in the multilevel analysis. At the individual level, 10 of 31 Elixhauser comorbidities were negatively and 11 positively associated with mammography screening participation. Age and comorbidities did not contribute to the explanation of geographic variations. At the contextual level, unemployment rate was negatively and the proportion of employees with an academic degree positively associated with mammography screening participation. Unemployment, income, education, foreign population and type of district explained 58.5% of geographic variations. Future studies should combine health insurance claims data with individual data on socioeconomic characteristics, lifestyle factors, psychological factors, quality of life and health literacy as well as contextual data on socioeconomic characteristics and accessibility of mammography screening. This would allow a comprehensive investigation of geographic variations in mammography screening participation and help to further improve prevention strategies for reducing the burden of breast cancer.
Highlights
Organized population-based mammography screening programs aim to reduce the mortality of breast cancer [1, 2], which is accountable for most cancer related deaths among women [3]
This study aimed to examine the suitability of health insurance claims data for assessing and explaining geographic variations in mammography screening participation and breast cancer incidence at the district level
We systematically examined the suitability of German health insurance claims data for assessing and explaining district-level variations in mammography screening participation and breast cancer incidence using screening unit, cancer registry and health insurance claims data
Summary
Organized population-based mammography screening programs aim to reduce the mortality of breast cancer [1, 2], which is accountable for most cancer related deaths among women [3]. In Germany, the implementation of an organized population-based mammography screening program started in 2005 and was completed nationwide in 2009 [18,19,20]. More than 95% of women aged 50–69 years are invited biennially to participate [21]. In 2016, the German participation rate of 51% [21] was lower than the acceptable level of 70% defined in the European Guidelines [14] and lower than the European average of 60% [22]
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