Disparities in Utilization of Medical Specialists for Colonoscopy

Michele J. Josey,Jan M. Eberth,Mario Schootman,Whitney E. Zahnd,Cassie L. Odahowski

doi:10.1089/heq.2019.0052

Michele J. Josey, Jan M. Eberth + Show 3 more

Open Access

https://doi.org/10.1089/heq.2019.0052

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Journal: Health Equity	Publication Date: Sep 1, 2019
Citations: 5	License type: cc-by

Affiliation: University of South Carolina, SSM Health Care

Abstract

Purpose: Colonoscopy is the preferred screening modality for colorectal cancer (CRC) prevention. The quality of the procedure varies although medical specialists such as gastroenterologists and colorectal surgeons tend to have better outcomes. We aimed to determine whether there are demographic and clinical differences between those who received a colonoscopy from a specialist versus those who received a colonoscopy from a nonspecialist.Methods: Using the population-based South Carolina Outpatient Ambulatory Surgery Database, we looked retrospectively to obtain patient-level endoscopy records from 2010 to 2014. We used multilevel logistic regression to model whether patients saw a specialist for their colonoscopy. The primary variables were patient race and insurance type, and an interaction by rurality was tested.Results: Of the 392,285 patients included in the analysis, 81% saw a specialist for their colonoscopy. County of residence explained 30% of the variability in the outcome. Non-Hispanic black (OR=0.65; confidence interval [95% CI]: 0.64–0.67) and Hispanic patients (OR=0.75; 95% CI: 0.67–0.84) were significantly less likely than non-Hispanic white patients to see a specialist. Compared with commercial/HMO insurance, all other types were less likely to see a specialist, and even more so for rural patients. The interaction of race by rurality was not significant.Conclusions: Specialists play a key role in CRC screening and can affect later downstream outcomes. This study has shown that ethnic minorities and adults with public or other insurance, particularly in rural areas, are most likely not to see a specialist. These results are consistent with disparities in CRC incidence, mortality, and survival.

Highlights

Colorectal cancer (CRC) is the third most common cancer and the third leading cause of cancer-related death in the United States.[1]
Our findings coupled with previous research suggest that racial disparities in CRC outcomes may be due in large part to access and utilization of high-quality screening and treatment
Future studies should investigate whether this phenomenon is due to preference, lack of communication, or a byproduct of insurance coverage, as well as extend these findings to examine the effects of the receipt of colonoscopy from a specialist on long-term CRC outcomes

Summary

Introduction

Colorectal cancer (CRC) is the third most common cancer and the third leading cause of cancer-related death in the United States.[1] CRC can be both prevented and detected at an earlier more treatable stage with receipt of regular recommended screenings. The overall CRC incidence and mortality have declined by at least 30% over the past two decades, due in large part to increased screening.[2,3] the racial disparity between African Americans and white Americans in CRC mortality, and prevalence of adenomas and polyps (which are the precursors to CRC) have persisted.[4,5,6,7] In addition to race, physician-related factors (e.g., medical specialty) and insurance coverage have been associated with CRC screening and disease outcomes. Colonoscopy is the preferred cancer prevention modality and was estimated to have contributed to a 77% and 65% reduction in CRC incidence and mortality,

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