Cervical Cancer Screening
g among
g
Medicaid Managed Care Members:
The Roles of Substance Use
Disorders, Mental Illness and
y Status
Disability
Sharada Weir,
Weir DPhil
Coverage and Care for Vulnerable Populations
Under Medicaid and CHIP
June 27, 2010
Study Coauthors and Collaborators
- Center for Health Policy and Research, UMMS:
-
-
Sharada Weir, DPhil
Heather Posner,
Posner MSPH
Jianying Zhang, MPH
Whitney Jones, PhD Candidate
Georgianna Willis,
Willis PhD
Jeffrey Baxter, MD
Robin Clark, PhD
CHPR Office of Clinical Affairs
MassHealth Office of Acute and Ambulatory Care
MassHealth Behavioral Health Program
MassHealth Information Analysis
Importance of Cervical Cancer
Screening
g
- Cervical cancer is the second leading cause of death
from cancer (after breast cancer) in women ages 20-39.
- Cervical
C
cancer is treatable, but evidence ffrom the
SEER database showed that five year survival drops
from 92% if diagnosed early to 17% if diagnosed late.
- As early stage cervical cancers are typically
asymptomatic, Papanicolaou (Pap) smear tests are key
to early detection.
- According to the American Cancer Society, between
60 80% of women with newly diagnosed advanced
60-80%
cervical cancer did not have a Pap test in the past 5
years.
Ratee (%
Use of Pap smears among US women 18 years of age and over,
by selected years
90.0
88.0
86.0
84.0
82.0
80.0
78.0
76.0
740
74.0
72.0
70.0
≥18 years
18-24 yyears
25-44 years
45-54 years
55-64 years
2000
2003
Year (NHIS)
2005
Medicaid Population
- Medicaid women eligible for the cervical cancer
screening measure are insured but vulnerable
- 26%: Disability basis for Medicaid eligibility
- Different types of disability associated with
various barriers to care
- 74%: Low income basis for Medicaid eligibility
- Food/housing insecurity
- Low levels of educational attainment
- Racial/ethnic minority status
- Behaviors such as drug/alcohol abuse and
smoking and comorbidities including mental
illness
HEDIS Cervical Cancer Screening
Measure
- National Committee for Quality Assurance’s
(NCQAs) Healthcare Effectiveness Data and
Information Set (HEDIS) is the standard by which
plans are compared
p
on q
quality
y
health p
- Roughly compatible with clinical guidelines
- ACS & USPSTF recommend screening every 11
2 years for women ages 21-29 and every 2-3
years thereafter if 3 consecutive normal tests
y
recorded; screening may be discontinued
beyond ages 65-70
HEDIS Cervical Cancer Screening
Measure
Component
Criteria
Denominator
Being female, aged between 21 and 64 at the end of
the 2006, and being continuously enrolled in a
MassHealth managed care plan during 2004, 2005
and 2006 with at most one gap in enrollment of no
more than 45 days during each calendar year.
Numerator
The numerator event was having at least one
Papanicolaou (Pap) smear test in the past three
years, 2004-2006.
Data collection
Hybrid: numerator status determined from a
methodology
combination of insurance claims and medical records
Massachusetts and National
Medicaid Managed Care 2007
Reported Rates
HEDIS Cervical Cancer
Screening Measure
R t
Rate
Plan† Rate
Range
MassHealth Mean
79%
74 - 85%
National Medicaid Mean
66%
National Medicaid 90th
percentile
77%
† Five
health plans serve Massachusetts Medicaid Managed Care Members
Conceptual (Andersen) Model
Predisposing
Characteristics
• Age cohort
• Race/ethnicity
• Primary
language
• Disability
status
• Neighborhood
educational
attainment
Enabling
Resources
Community
y
• Residential county
• Neighborhood
income
Insurance
• Health plan
Provider
• Provider type
• Setting (ED vs.
office)
Need for Care
• CDPS illness
burden score†;
• Diagnoses†:
substance abuse,,
mental health
disorders
• Domestic violence
• Tobacco use
Cervical
Cancer
Screening
† Andersen considered past medical history to be a ‘predisposing’ factor and current symptoms and
diagnoses as ‘need’. Our data on illness burden and specific (generally, chronic) diagnoses were collected
within the two-year HEDIS data collection period and may be expected to affect contemporaneous
perceived need for screening.
Data
- W
Working
ki with
ith th
the MassHealth
M
H lth plans,
l
CHPR
was able to access member-level HEDIS data
- Dependent variable: numerator hit status
- Indicates whether the member met the
measure’s requirements
- Independent variables:
- Individual, family and neighborhood
characteristics; diagnoses; disability
status; health care utilization; region;
provider type; and health plan
Analysis
- M
Multivariate
lti i t llogistic
i ti regression
i using
i STATA
version 9.2
- Adjusted odds ratios presented
j
with robust
- Standard errors adjusted
Huber-White Sandwich variance estimator
- Significance evaluated at alpha≤0.05
- Model passed the Hosmer-Lemshow
goodness-of-fit test
- 83% of cases were correctly classified
Sample Description
- 12% of women sampled for the measure had a
substance use disorder (SUD)
- 25% were diagnosed with severe mental illness (SMI;
mostly major depression)
- 26% qualified for Medicaid because of a work-limiting
disability
- Among women with disabilities, 50% had an SMI and
21% had an SUD
- A majority
j it off women with
ith an SUD h
had
d att lleastt one
co-occurring SMI diagnosis
Adjusted Odds Ratios (OR) for Cervical Cancer Screening
Adjusted OR
Predisposing
Individual Characteristics
21 <= Age <= 30
1.62 ***
50 <= Age <= 65
0.61 ***
Black race
1.57
Hispanic ethnicity
1.62
Other race/ethnicity
1 36
1.36
Unknown race/ethnicity
1.26
Spanish primary language
1.65
Other primary language
1.21
Has a work-limiting disability
0.65 *
Neighborhood Characteristics
High school graduate, percent
1.43
College graduates
graduates, percent
2 69
2.69
Continued…
Continued from previous slide…
Adjusted OR
Enabling
Health Care Utilization
≥ 1 ED visit
0.96
1-29 Ambulatory
y Office Visits
7.77 ***
30+ Ambulatory Office Visits
17.30 ***
Provider: Community Health Center
1.14
Provider: Single-practice
0.98
Provider: Other type
0.98
N i hb h d Ch
Neighborhood
Characteristics
t i ti
Household income, mean ($000)
1.01
Percent minority
y race/ethnicityy
1.46
6
Continued…
Continued from previous slide…
Adjusted OR
Need
Overall Illness Burden
CDPS Illness Burden Score
Diagnoses
Alcohol/drug abuse
Tobacco use
Severe mental illnessa
Other mental illnessb
Domestic violence
Hosmer-Lemeshow goodness of fit (p-value)
Percent of cases correctly classified
Number
u be o
of obse
observations
a o s
1 19
1.19
0.54 ***
1.27
1.21
1.24
0.43 *
0.07
82.7%
1,868
,868
Note. Reference groups for odds ratios in the table are: age cohort,31-49 years old; race/ethnicity,
white; primary language
language, English;provider type,
type group practice.
practice All equations are also adjusted for
county of residence and health plan.
a Major depression, schizophrenia, and bipolar disorder
b Other depression, anxiety disorder and other mental illness
*<0.05; **<0.01; ***<0.001
Key Findings
- Some vulnerable groups less likely to be screened
work limiting disabilities (OR=0.65)
(OR 0.65)
- Women with work-limiting
- Women with an SUD, particularly drug abuse or
dependence (OR=0
(OR 0.54)
54)
- Women with evidence of domestic violence in
claims data (OR=0
(OR 0.43)
43)
- However, we found no evidence of an association
between mental illness and screening and no
evidence of racial/ethnic disparities
- Provider contacts are important
important, but the type of PCP
is not
Comparison with Prior Studies
-
-
-
Some prior
S
i research
hh
has shown
h
that
h women with
i h di
disabilities
bili i
less likely to be screened, while other studies find no significant
association after controlling for socio-demographic variables
- We found that substantially lower odds of screening
(adjusted for individual demographics and area
socioeconomic variables) for women with disabilities
Studies show that women who abuse drugs or alcohol more
likely to be diagnosed with cervical cancer, yet there are few
studies
t di on th
the iimpactt off substance
b t
use disorders
di d
on screening
i
- We found substantial negative effects of drug
abuse/dependence
p
on regular
g
Pap
p testing
g
Literature on mental illness mixed
- We found no significant effects of mental health conditions
as a group or individually
i di id ll
Study Limitations
- Findings may not be generalizable to other
states with different Medicaid benefit
structures or population characteristics
- Use of administrative data
- Some member characteristics unobserved
or poorly observed (e
(e.g.,
g substance use
use,
race, domestic violence)
- No data on individual circumstances and
type of disability to better understand our
findings for women with a disability
Data Strengths
- Administrative claims data offer an advantage
over survey data by eliminating recall and
social desirability biases, allowing for
relatively long, accurate look back periods
- Self-reported Pap screening data have
been found to overstate screening rates
- Claims data contain rich information on
comorbid diagnoses
diagnoses, usual source of care
care,
and other variables that may drive results
Discussion
- Healthy People 2010 set a goal of 90% of
women ages 18 and older receiving a
Papanicolaou (Pap) smear test within the prior
three years
- Massachusetts Medicaid Managed Care
Organizations had not reached this goal by 2007,
though MA Medicaid on average exceeded National
Medicaid 90th percentile
- Vulnerable groups less likely to be screened
Implications
- Women with SUDs or disabilities face
barriers to cervical cancer screening
- Physician contacts may be key to
i
increasing
i routine
ti screening
i and
d
reducing preventable cervical cancer
morbidity and mortality
- Better integration of drug abuse
treatment with preventive health care is
needed