The use of preventive health services among elderly uterine cancer survivors

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NCOLOGY

he use of preventive health services among elderlyterine cancer survivors

. Marshall McBean, MD; Xinhua Yu, MB, PhD; Beth A. Virnig, PhD, MPH

BJECTIVE: The purpose of the study was to determine whetheromen who survived uterine cancer received 4 recommended preven-

ive services (mammography, colorectal cancer screening, influenzammunization, and bone density testing) at the same rates as womenith no history of cancer.

TUDY DESIGN: We used the Surveillance, Epidemiology, and Endesults–Medicare database to compare the rates among survivorsged 67 years or older with a matched group of women with no historyf cancer.

ESULTS: Survivors were significantly more likely to have a mammo-

dressed this issue in sur

6.e1 American Journal of Obstetrics & Gynecology JANUARY 2008

.30-1.50) or a colorectal cancer screening examination (adjusted OR,

.11; 95% CI, 1.05-1.18). Influenza immunization and bone densityesting rates were similar. The 28% of survivors seen by an obstetri-ian-gynecologist or gynecologic oncologist had the highest rates ofse.

ONCLUSION: Efforts need to be made to increase the use of servicesy all women to achieve the target rates established by Healthy People010.

ey words: cancer screening, cancer survival, preventive services,
ram (adjusted odds ratio [OR], 1.40; 95% confidence interval [CI],
ite this article as: McBean AM, Yu X, Virnig BA. The use of preventive health services among elderly uterine cancer survivors. Am J Obstet Gynecol 2008;198;6.e1-86.e8.

terine cancer is the fourth most com-monly occurring cancer among

merican women, with an annual inci-ence of 23.3/100,000 in 2000-2003.1 Theighest incidence occurs in women 65ears of age and older, 84.5/100,000.1 For-unately, 5-year relative survival rates are

high: 87.8% among those younger than 65years of age and 77.3% among olderwomen.1 Thus, it is important to knowwhether the level of medical care to diag-nose and prevent other diseases amongcancer survivors is similar to that amongwomen with no history of cancer. Con-flicting theories and empirical evidencesuggest that those with chronic diseases,including cancer, could be either more orless likely to receive recommended care.Feinstein2 suggested that persons withchronic diseases would be more likely to bescreened or provided care for other dis-eases. On the other hand, the competingdemands model argued that the many de-mandsonthephysicianandpatient, aswellas practice constraints, would result in de-creased use of recommended services.3

Whereas some have found that personswith chronic diseases were more likely tobe screened than those who were diseasefree,4,5 others have reported the oppo-site.6,7 None of these studies includedenough persons to comment on cancersurvivors.

Recent studies using the linked Surveil-lance, Epidemiology, and End Results(SEER)–Medicare database have ad-

colorectal cancer with somewhat conflict-ing results.8,9 Breast cancer survivors werefound more likely to receive influenza vac-cine, mammography, bone density testing,either sigmoidoscopy or fecal occultblood testing, and other screening ser-vices than other women.8 Subse-quently, colorectal cancer survivorswere found less likely to receive influ-enza vaccine and bone density testing,as well as scoring lower on a compositeendpoint of 19 necessary care servicesthan women with no history of can-cer.9 Mammography rates in this studywere higher among cancer survivors.

The purpose of this study was to extendour knowledge to women who have sur-vived uterine cancer. We compared the useof 2 cancer screening services (mammog-raphy and colon cancer screening), as wellan influenza immunization and bone den-sity testing, among Medicare beneficiarieswho survived 5 years or longer after the di-agnosis of uterine cancer with the use ofthese services among women with no his-tory of cancer.

MATERIALS AND METHODSWe used SEER-Medicare data files from

rom the Division of Health Policy andanagement, School of Public Health,niversity of Minnesota, Minneapolis, MN.

resentations of preliminary findings made athe 12th Hong Kong International Cancerongress, Hong Kong, People’s Republic ofhina, Dec. 8-10, 2005, and as abstract045, 42nd Annual Meeting of the Americanociety of Clinical Oncology, June 2-6, 2006,tlanta, GA.

eceived Nov. 3, 2006; revised March 19,007; accepted May 22, 2007.

his work was supported by grants from theational Institute of Aging (R01 AG 025079) and

he National Cancer Institute (R01 CA 098974).eprints: A. Marshall McBean, MD, MSc,ivision of Health Policy and Management,niversity of Minnesota School of Publicealth, MMC 97, 420 Delaware St., S.E.,inneapolis, MN 55455; [email protected]

002-9378/$34.002008 Mosby, Inc. All rights reserved.

oi: 10.1016/j.ajog.2007.05.036

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vivors of breast and t
he 2003 merge, in which 97% of the

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EER subjects 65 years of age or olderere linked to Medicare data.10 Theseles contain information on cancer casesiagnosed from 1973-1999 and Medi-are data through 2002. Uterine canceratients were identified using the SEERite recode variable for uterine cancercorpus and not otherwise specified; n �3,613). Of the women diagnosed from973-1993 (n � 44,981), we accepted8,231 women: those who had in situ (n

2167; 4.8%), local (n � 32,132;1.4%), and regional (n � 3932; 8.7%)isease. We excluded those who werenstaged (n � 1963; 4.4%), had distantisease (n � 2126; 4.7%), or had missingtaging information (n � 2661; 5.9%).

To be considered a survivor, theoman had to live for at least 5 years af-

er the diagnosis and until Jan. 1, 1999,hich resulted in a sample of 24,789omen. Medicare claims from 1997 and998 were used to identify comorbiditiesnd information on other covariates in-icated below. Thus, the results are foromen 67 years of age or older (n �1,461).Consistent with other studies using

he linked SEER-Medicare database, wexcluded those beneficiaries who did notave both Medicare Part A and Part B (n

572), were enrolled in managed caren � 5375), had end-stage renal diseasen � 7), or enrolled in a hospice programn � 932), resulting in 14,575 women inhe final survivor cohort.

The Medicare National Claims His-ory (NCH) and outpatient files for dif-erent years were used to determine thetudy outcomes: 1999 for influenza im-

unization; 1999 and 2000 for mam-ography and bone density testing; and

999-2002 for colorectal cancer screen-ng. These periods were based on Medi-are reimbursement policy: 12 monthsor influenza vaccination; 24 months forone density testing; and 48 months forolorectal cancer screening; or the com-only used period in the literature for

valuating mammography use, 24onths.Mammograms were identified using

he following Health Care Financing Ad-inistration’s common procedure cod-

ng system (HCPCS) and Current Proce-
ural Terminology (CPT) codes, 76090- w
6092, G0202-G0207, and G0236 andhe International Classification of Dis-ases, Ninth Revision, Clinical Modifica-ions (ICD-9-CM) code V76.12. HCPCSnd CPT codes G0105, G0121, 44388,4389, 44392, 44393, 44394, 45378,5380, and 45383-45385 identifiedolonoscopies; G0104, 45300, 45305,5308, 45309, 45315, 45320, 45330,5331, 45333, 45338, and 45339 identi-ed sigmoidoscopies; and G0106,0120, G0122, 74270, and 74280 identi-ed double-contrast barium enemas.These colon-related procedure codes

ad to be accompanied by ICD-9-CModes V76.41 and V76.51 used to iden-ify colorectal cancer screening. Further-

ore, the colon-related procedure codesere accepted as screening only if the pa-

ient was not seen in the previous 3onths for the following ICD-9-CM di-

gnosis codes: abdominal pain (787.3,89.0x. 789.6x); altered bowel habits564.0, 787.x); gastrointestinal bleeding587.x); positive fecal occult blood test792.1); weight loss (783.2); iron defi-iency anemia (280.x); or anemia, un-pecified (285.9). Bone density testingas identified using HCPCS and CPT

odes G0130-G0133, 76070, 76071,6075, 76076, 76078, 76977, 78350,8351, and ICD-9-CM procedure code8.98. HCPCS and CPT codes 90724,0657-90659, G0008, and ICD-9-CMode V04.81 were used to identify influ-nza vaccinations.

In addition to age and race, 2 other co-ariates were obtained directly from theerged data files: median household in-

ome for each beneficiary’s ZIP code ofesidence in 2000 and rural residence.

edicare claims data from 1997-1998ere used to determine whether a personad been hospitalized and, if hospital-

zed, whether in a teaching or a non-eaching hospital; the specialties of phy-icians providing care to the beneficiary;omorbidities; and the average annualumber of physician visits.Using the specialty identification

odes available in the NCH file, physi-ians were grouped into primary care;ncology specialists, except gynecologicncology; obstetrics-gynecology or gy-ecologic oncology; and other. If a
oman was seen by an obstetrician-gy- t
JANUARY 2008 Americ

ecologist or gynecologic oncologist, sheas put in that group. Women not seeny a obstetrician-gynecologist or gyne-ologic oncologist but seen by anotherype of oncologist were put into the on-ology group. Persons not in the previ-us 2 groups were put into the primaryare group if they visited a primary carehysician. Those who were not seen byny of the above specialists were put intohe category “other,” which also in-luded women who had no physicianisit in 1997 or 1998 (� 1%).Consistent with the recommendation

f Klabunde et al,11 we used the Charlsonndex to categorize and weight comor-idities. Because all persons with a diag-osis of cancer would have a Charlsoncore 1 or greater, cancer was excludedhen calculating the Charlson scores.We used the propensity score match-

ng method to create an appropriateomparison population of women witho history of cancer.12 These latteromen were found in the SEER-Medi-

are Sumdenom file, a random sample of% of women living in the SEER areasho had no history of cancer through999 (n � 61,964). Before calculating theropensity scores, we used the Medicareles to exclude women who developedancer after 1999 (n � 3564). This re-ulted in 58,420 available women, whiche called the total available comparisonopulation pool.The propensity score matching in-

olved 2 additional steps. We first usedogistic regression to estimate the pro-ensity score (the predicted probability

rom the model of having had uterineancer or not) for each survivor andoman in the comparison populationool. The model predictors included allhe variables mentioned above (age,ace, rural residence, median householdncome of the ZIP code of residence,ospitalization history, Charlson score,ype of physician visited in 1997-1998,nd average annual number of physicianisits in 1997-1998 as well as a state indi-ator). Each cancer survivor wasatched with a woman with no history

f any type of cancer living in the sameEER area whose propensity score wasearest to that of the cancer survivor (1-

o-1 nearest neighbor method). The ps-

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atch2 module in Stata 9.1 (Stata Corp,ollege Station, TX) was used for thisatching procedure.13

Analyses were performed on theatched cohorts. Univariate and bivari-

te analysis were performed to describend compare the populations and theirse of services. Because the age distribu-

ions of the survivor and the comparisonroups were different (Table 1), weresent overall crude rates and age-ad-

usted rates. Differences between cohortsere tested using the Z-test. Multivariate

ogistic regression analyses were carriedut on the cohort of cancer survivors forach preventive service to examine thempact of the covariates described earliern the receipt of each service while si-ultaneously adjusting for the others.o adjust for possible geographical dif-

erence between SEER areas, we used theeneralized estimate equation modelith geographic areas as the cluster vari-

ble. Differences were judged statisticallyignificant if the 95% confidence intervalCI) did not include 1.00. All statisticalnalyses used the Statistical Analysisoftware (SAS GENMOD, v 9.1 for Win-ows; SAS Institute Inc, Cary, NC).This study was approved by the Hu-an Subjects Committee of the Univer-

ity of Minnesota (study number312M55082).

ESULTShe distributions of the characteristics of

he cancer survivors, and those with noistory of cancer, shown in Table 1, dem-nstrate the improved balance in the in-ependent variables obtained throughhe propensity score matching. Approx-mately 28% of women had seen an ob-tetrician-gynecologist or gynecologicncologist.The age-adjusted rates (Table 2)

howed that women who survived uter-ne cancer were more likely than womenith no history of cancer to have mam-ography or colorectal cancer screen-

ng. The age-adjusted relative risks were.11 (56.1 per 100 vs 49.9 per 100; P �

0001) and 1.07 (21.3% vs 19.8%; P �0018), respectively. Multivariate analy-is, which included all women in the
tudy and adjusted for all of the covari- s
6.e3 American Journal of Obstetrics & Gynecolog

tes in Table 2, confirmed these findingsith significantly different adjusted odds

atios of 1.40 (95% CI, 1.30-1.50) forammography and 1.11 (95% CI, 1.05-

.18) for colorectal screening (data nothown). No differences in influenza vac-ination rates or bone density testingere found using either method.The age-adjusted rates of mammogra-

hy among cancer survivors were signif-cantly higher than among women witho history of cancer for all of the sub-roups of the sociodemographic, healthare, and clinical variables, except forlack women (Table 2). Among survi-ors, age-adjusted mammography ratesere over 50% greater among womenho had seen an obstetrician-gynecolo-ist or gynecologic oncologist thanmong women who had seen primaryare physicians only, 76.2 per 100 vs 49.7er 100. Similarly, large differences wereeen between survivors who saw obste-rician-gynecologist or gynecologic on-ologists, compared with those who sawrimary care physicians for bone densitynd colorectal cancer testing (71.8% and9.7%, respectively; P � .0001). Amaller but still significant differenceas seen for influenza vaccination:

8.9%; P � .0001).Among cancer survivors, the multi-

ariate model results, which adjustedimultaneously for all variables, con-rmed that visiting an obstetrician-gy-ecologist or gynecologic oncologist wastrongly and significantly associated witheceiving each of the preventive servicesTable 3). Characteristics that predictedigher rates of use of all 4 preventive ser-ices were younger age, not having beenospitalized, and having 5 or more phy-ician visits per year. Black women hadpproximately half of the relative odds ofaving bone density testing or influenzaaccination. Women with the highestharlson comorbidity score had a much

ower relative probability of receivingny of the services.

OMMENThe good news is that women who sur-ived 5 years or longer after the diagnosisf uterine cancer had preventive health
ervice utilization rates that were signif- c
y JANUARY 2008

cantly greater than the rates amongomen with no history of cancer for 2 of

he services we measured and equal ratesor 2. Unfortunately, the rates among theurvivors for mammography (56.0%),olon cancer screening (21.2%), and in-uenza vaccination (52.7%) were wellelow the national targets set in Healthyeople 2010 of 70%, 50%, and 90%, re-pectively. The rates were even lower inhe total pool of available controls:4.5%, 17.5%, and 47.0%, respectivelydata not shown.).

These rates are similar to those re-orted by others who have used Medi-are data.14,15 However, it should beoted that influenza vaccination isnown to be underreported in studiessing Medicare data. The most commoneasons given are the administration ofaccine by providers that choose not toill Medicare (grocery stores and otheretail outlets, community clinics, etc) orhat are not allowed to bill Medicare (theepartment of Veterans Affairs). How-

ver, there is no reason to believe that theroviders of influenza vaccine to theancer survivors and the women with noistory of cancer would have differentilling practices, and few elderly womeneceive care at the Department of Veter-ns Affairs.

The most striking and consistent find-ng was the association of receiving carerom an obstetrician-gynecologist or gy-ecologic oncologist with the highestates: multivariate odds ratios for theomparison with primary care physi-ians among survivors of 1.09-1.65. Oth-rs have recently reported higher rates ofammography screening among elderlyomen who visited obstetrician-gyne-

ologists than among those seen by otherypes of primary care physicians or byther physicians.16 Also, preventiveealth visits to obstetrician-gynecolo-ists are significantly more likely to bessociated with breast examination andrescription for a mammogram (53%nd 87%, respectively) than preventiveealth visits to either internists (33% and3%) or family/general practitioners45% and 22%).17

These authors suggested that primaryare physicians may defer to obstetri-
ian-gynecologists for female-specific


TABLE 1Study subject characteristics

No history of cancer

P valuea

Cancer survivorsTotal pool ofavailable controls

After propensityscore matching

Characteristic Number Percent Number Percent Number Percent

Total 14,575 100.0 58,420 100.0 14,575 100.0................................................................................................................................................................................................................................................................................................................................................................................

Age group, y.......................................................................................................................................................................................................................................................................................................................................................................

67-74 4647 31.9 24,803 42.5 5071 34.8 �.0001.......................................................................................................................................................................................................................................................................................................................................................................

75-84 7501 51.5 24,031 41.1 6748 46.3.......................................................................................................................................................................................................................................................................................................................................................................

85 or older 2427 16.7 9586 16.4 2756 18.9................................................................................................................................................................................................................................................................................................................................................................................

Race.......................................................................................................................................................................................................................................................................................................................................................................

White 13,739 94.3 48,360 82.8 13,795 94.6 .3844.......................................................................................................................................................................................................................................................................................................................................................................

Black 307 2.1 4205 7.2 299 2.1.......................................................................................................................................................................................................................................................................................................................................................................

Other 529 3.6 5855 10.0 481 3.3................................................................................................................................................................................................................................................................................................................................................................................

Rural residence.......................................................................................................................................................................................................................................................................................................................................................................

No 12959 88.9 51478 88.1 12960 88.9 .8522.......................................................................................................................................................................................................................................................................................................................................................................

Yes 1616 11.1 6942 11.9 1615 11.1................................................................................................................................................................................................................................................................................................................................................................................

Median household income ofZIP code

.......................................................................................................................................................................................................................................................................................................................................................................

� $40,000 4051 27.8 19262 33.0 3978 27.3 .0288.......................................................................................................................................................................................................................................................................................................................................................................

$40,000-$51,999 5058 34.7 19632 33.6 4944 33.9.......................................................................................................................................................................................................................................................................................................................................................................

� $52,000 5466 37.5 19526 33.4 5653 38.8................................................................................................................................................................................................................................................................................................................................................................................

Hospitalization history.......................................................................................................................................................................................................................................................................................................................................................................

Not hospitalized 10408 71.4 43115 73.8 10489 72.0 .0577.......................................................................................................................................................................................................................................................................................................................................................................

Hospitalized, nonteaching 1928 13.2 7517 12.9 1880 12.9.......................................................................................................................................................................................................................................................................................................................................................................

Hospitalized, teaching 2239 15.4 7788 13.3 2206 15.1................................................................................................................................................................................................................................................................................................................................................................................

Charlson score.......................................................................................................................................................................................................................................................................................................................................................................

0 6433 44.1 26688 45.7 6497 44.6 .0356.......................................................................................................................................................................................................................................................................................................................................................................

1 3962 27.2 15043 25.7 3972 27.3.......................................................................................................................................................................................................................................................................................................................................................................

� 2 4180 28.7 16689 28.6 4106 28.2................................................................................................................................................................................................................................................................................................................................................................................

Medical specialty.......................................................................................................................................................................................................................................................................................................................................................................

Primary care 8856 60.8 41088 70.3 9043 62.0 .1417.......................................................................................................................................................................................................................................................................................................................................................................

Oncologist 675 4.6 1078 1.8 633 4.3.......................................................................................................................................................................................................................................................................................................................................................................

Obstetrician-gynecologist orgynecologic oncologist

4133 28.4 9526 16.3 4021 27.6

.......................................................................................................................................................................................................................................................................................................................................................................

Other 911 6.3 6728 11.5 878 6.0................................................................................................................................................................................................................................................................................................................................................................................

Average number of physicianvisits per year

.......................................................................................................................................................................................................................................................................................................................................................................

0-4 6060 41.6 28190 48.3 6141 42.1 .4442.......................................................................................................................................................................................................................................................................................................................................................................

5-9 5105 35.0 17791 30.5 5159 35.4.......................................................................................................................................................................................................................................................................................................................................................................

10-14 2108 14.5 7543 12.9 1988 13.6.......................................................................................................................................................................................................................................................................................................................................................................

� 15 1302 8.9 4896 8.4 1287 8.8................................................................................................................................................................................................................................................................................................................................................................................a P values are for the differences between the cancer survivors and those women with no history of cancer after propensity score matching.

McBean. The use of preventive health services. Am J Obstet Gynecol 2008.

JANUARY 2008 American Journal of Obstetrics & Gynecology 86.e4


8

TABLE 2Crude, age-specific, and age-adjusted rates of preventive service useamong uterine cancer survivors and comparison group

MammogramColorectal cancerscreening

Influenzavaccination Bone density testing

CharacteristicCancersurvivors

Nohistoryofcancer

Cancersurvivors

Nohistoryofcancer

Cancersurvivors

Nohistoryofcancer

Cancersurvivors

Nohistoryofcancer

Crude rate 56.0 50.0a 21.2 20.0b 52.7 52.7 19.4 20.2b

................................................................................................................................................................................................................................................................................................................................................................................

Age-specific rates, y.......................................................................................................................................................................................................................................................................................................................................................................

67-74, reference 71.3 66.3a 29.0 28.5 54.3 55.3 25.4 26.8.......................................................................................................................................................................................................................................................................................................................................................................

75-84 56.2 51.0a 20.4 19.2 54.8 54.8 19.4 20.4.......................................................................................................................................................................................................................................................................................................................................................................

� 85 25.8 16.8a 8.6 5.8a 43.4 42.5 7.9 7.3................................................................................................................................................................................................................................................................................................................................................................................

Age-adjusted rates................................................................................................................................................................................................................................................................................................................................................................................

Total 56.1 49.9a 21.3 19.8c 52.7 52.7 19.5 20.1................................................................................................................................................................................................................................................................................................................................................................................

Race.......................................................................................................................................................................................................................................................................................................................................................................

White 56.4 50.2a 21.3 20.0c 53.3 53.3 19.7 20.0.......................................................................................................................................................................................................................................................................................................................................................................

Black 47.3 42.5 20.4 16.6 33.2 31.5 11.3 9.2.......................................................................................................................................................................................................................................................................................................................................................................

Other 52.1 43.7a 22.2 16.3b 49.2 46.5 19.0 19.2................................................................................................................................................................................................................................................................................................................................................................................

Rural residence.......................................................................................................................................................................................................................................................................................................................................................................

No 56.8 50.5a 21.7 20.1c 52.0 52.1 20.5 21.2.......................................................................................................................................................................................................................................................................................................................................................................

Yes 50.3 45.2a 18.5 17.5 58.8 57.4 11.7 10.9................................................................................................................................................................................................................................................................................................................................................................................


.......................................................................................................................................................................................................................................................................................................................................................................

� $40,000 52.5 45.5a 19.7 17.5b 53.5 52.9 15.4 15.0.......................................................................................................................................................................................................................................................................................................................................................................

$40,000-$51,999 56.2 49.5a 20.5 18.9b 53.8 53.0 19.5 20.0.......................................................................................................................................................................................................................................................................................................................................................................

� $52,000 58.5 53.2a 23.3 22.2 51.1 52.2 22.7 23.6................................................................................................................................................................................................................................................................................................................................................................................

Hospitalization history.......................................................................................................................................................................................................................................................................................................................................................................

Not hospitalized 58.3 52.3a 22.1 20.7c 53.3 53.1 20.4 21.0.......................................................................................................................................................................................................................................................................................................................................................................

Hospitalized, nonteaching 49.8 42.6a 17.8 16.2 51.3 50.8 15.4 15.5.......................................................................................................................................................................................................................................................................................................................................................................

Hospitalized, teaching 50.9 43.9a 20.0 18.3 51.2 52.0 18.5 19.1................................................................................................................................................................................................................................................................................................................................................................................

Charlson score.......................................................................................................................................................................................................................................................................................................................................................................

0 60.5 52.8a 22.9 21.2b 51.2 51.0 20.6 20.8.......................................................................................................................................................................................................................................................................................................................................................................

1 58.4 52.6a 22.5 20.5b 56.9 56.2 21.5 21.9.......................................................................................................................................................................................................................................................................................................................................................................

� 2 47.0 42.2a 17.3 16.4 51.0 51.9 15.8 16.9................................................................................................................................................................................................................................................................................................................................................................................

Medical specialty.......................................................................................................................................................................................................................................................................................................................................................................

Primary care 49.7 44.3a 19.4 17.1a 53.0 52.8 16.3 16.1.......................................................................................................................................................................................................................................................................................................................................................................

Oncologist 59.8 44.2a 20.9 19.8 53.1 51.4 17.7 16.6.......................................................................................................................................................................................................................................................................................................................................................................


76.2 70.3a 27.1 27.8 57.7 58.8 28.0 31.6a

.......................................................................................................................................................................................................................................................................................................................................................................

Other 27.5 19.3a 11.7 8.2b 27.2 23.9 10.0 7.0b

................................................................................................................................................................................................................................................................................................................................................................................


.......................................................................................................................................................................................................................................................................................................................................................................

0-4 45.6 38.5a 17.3 14.5a 42.9 42.4 14.2 14.2.......................................................................................................................................................................................................................................................................................................................................................................

5-9 62.5 57.3a 23.3 24.1 59.0 59.3 21.7 22.1.......................................................................................................................................................................................................................................................................................................................................................................

10-14 64.2 58.6a 25.2 23.0 59.8 61.9 24.5 27.6b

.......................................................................................................................................................................................................................................................................................................................................................................

� 15 64.7 58.5c 26.3 22.8b 62.3 60.2 28.2 28.1................................................................................................................................................................................................................................................................................................................................................................................a P � .001 for comparison between uterine cancer survivors and comparison group.b P � .05 for comparison between uterine cancer survivors and comparison group.c P � .01 for comparison between uterine cancer survivors and comparison group.

McBean. The use of preventive health services. Am J Obstet Gynecol 2008.

6.e5 American Journal of Obstetrics & Gynecology JANUARY 2008

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creening. Although this might explainifferences found for mammographynd bone density testing, it would notpply to colorectal cancer screening ornfluenza immunization. Also, deferringhis care to obstetrician-gynecologistsould not be good policy or practice for

he elderly because we found that only

TABLE 3Odds ratios and 95% CI by patientamong uterine cancer survivors an

Characteristic

Mammography

OR (95% CI)

Race..........................................................................................................

White Referent group..........................................................................................................

Black 0.84 (0.70 to 0...........................................................................................................

Other 0.79 (0.60 to 1....................................................................................................................

Age (per 10 y) 0.34 (0.33 to 0....................................................................................................................

Rural residence..........................................................................................................

No Referent group..........................................................................................................

Yes 0.97 (0.88 to 1....................................................................................................................


..........................................................................................................

� $40,000 Referent group..........................................................................................................

$40,000-$51,999 1.04 (0.91 to 1...........................................................................................................

� $52,000 1.10 (0.91 to 1....................................................................................................................

Hospitalization history..........................................................................................................

Not hospitalized Referent group..........................................................................................................

Hospitalized, nonteaching 0.69 (0.61 to 0...........................................................................................................

Hospitalized, teaching 0.68 (0.65 to 0....................................................................................................................

Charlson score..........................................................................................................

0 Referent group..........................................................................................................

1 0.74 (0.69-0...........................................................................................................

� 2 0.43 (0.39-0....................................................................................................................

Medical specialty..........................................................................................................

Primary care Referent group..........................................................................................................

Oncologist 1.51 (1.19-1...........................................................................................................


3.25 (2.68-3.

..........................................................................................................

Other 0.35 (0.28 to 0....................................................................................................................


..........................................................................................................

0-4 Referent group..........................................................................................................

5-9 2.10 (1.87 to 2...........................................................................................................

10-14 2.45 (2.07 to 2...........................................................................................................

15 or more 2.77 (2.50 to 3....................................................................................................................

OR, odds ratio.a P values are for a linear trend test of odds ratios.

McBean. The use of preventive health services. Am J Obste

ne-quarter of elderly survivors visited a

n obstetrician-gynecologist or gyneco-ogic oncologist over a 2-year period.mong the 58,420 women without can-er available in the comparison popula-ion pool, only 16.2% did (Table 1). If were to achieve the targets of Healthy Peo-le 2010, the use of these services willave to be promoted more effectively by

d health service characteristicscomparison group

Colorectal cancerscreening Influenz

Pa OR (95% CI) P OR (95%

.........................................................................................................................

Referent group Referen.........................................................................................................................

1.06 (0.97 to 1.17) 0.52 (0..........................................................................................................................

1.04 (0.87 to 1.24) 0.87 (0..........................................................................................................................

0.50 (0.46 to 0.54) 0.85 (0..........................................................................................................................

.........................................................................................................................


0.96 (0.88 to 1.06) 1.08 (0..........................................................................................................................

.........................................................................................................................

.304 Referent group .084 Referen.........................................................................................................................

0.98 (0.84 to 1.14) 1.03 (0..........................................................................................................................

1.13 (0.98 to 1.31) 1.04 (0..........................................................................................................................

.........................................................................................................................


0.77 (0.65 to 0.93) 0.81 (0..........................................................................................................................

0.86 (0.79 to 0.95) 0.75 (0..........................................................................................................................

.........................................................................................................................

�.001 Referent group �.001 Referen.........................................................................................................................

0.87 (0.79 to 0.94) 1.05 (0..........................................................................................................................

0.60 (0.55 to 0.66) 0.80 (0..........................................................................................................................

.........................................................................................................................


1.03 (0.89 to 1.20) 0.91 (0..........................................................................................................................

1.38 (1.16 to 1.63) 1.09 (1.

.........................................................................................................................

0.55 (0.42 to 0.73) 0.41 (0..........................................................................................................................

.........................................................................................................................

�.001 Referent group �.001 Referen.........................................................................................................................

1.44 (1.32 to 1.56) 1.91 (1..........................................................................................................................

1.71 (1.44 to 2.03) 2.15 (1..........................................................................................................................

1.91 (1.44 to 2.54) 2.62 (2..........................................................................................................................

necol 2008.

ll physicians. Although we found these v

JANUARY 2008 Americ

trong associations with visiting an ob-tetrician-gynecologist or gynecologicncologist, we cannot exclude the possi-ility that the women who see, or seek,hese physicians may be more preven-ion oriented.

The large differences found betweenlack and white women for influenza

accination Bone density testing

I) P OR (95% CI) P

..................................................................................................................

up Referent group..................................................................................................................

o 0.64) 0.54 (0.35 to 0.84)..................................................................................................................

o 1.24) 0.88 (0.67 to 1.16)..................................................................................................................

o 0.89) 0.55 (0.51 to 0.59)..................................................................................................................

..................................................................................................................


o 1.21) 0.79 (0.67 to 0.93)..................................................................................................................

..................................................................................................................

up .615 Referent group .009..................................................................................................................

o 1.09) 1.08 (1.00 to 1.18)..................................................................................................................

o 1.22) 1.25 (1.06 to 1.48)..................................................................................................................

..................................................................................................................


o 0.90) 0.73 (0.60 to 0.88)..................................................................................................................

o 0.83) 0.82 (0.75 to 0.90)..................................................................................................................

..................................................................................................................

up �.001 Referent group �.001..................................................................................................................

o 1.15) 0.93 (0.88 to 0.98)..................................................................................................................

o 0.85) 0.61 (0.54 to 0.69)..................................................................................................................

..................................................................................................................


o 1.05) 0.99 (0.78 to 1.25)..................................................................................................................

o 1.14) 1.65 (1.48 to 1.84)

..................................................................................................................

o 0.47) 0.62 (0.48 to 0.80)..................................................................................................................

..................................................................................................................

up �.001 Referent group �.001..................................................................................................................

o 2.13) 1.56 (1.42 to 1.73)..................................................................................................................

o 2.49) 1.93 (1.73 to 2.17)..................................................................................................................

o 2.92) 2.48 (2.23 to 2.76)..................................................................................................................

and

a v

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......... .........

t gro......... .........

99) 42 t......... .........

06) 61 t......... .........

36) 80 t......... .........

......... .........

t gro......... .........

06) 96 t......... .........

......... .........

t gro......... .........

18) 97 t......... .........

33) 89 t......... .........

......... .........

t gro......... .........

78) 73 t......... .........

72) 68 t......... .........

......... .........

t gro......... .........

80) 96 t......... .........

46) 74 t......... .........

......... .........

t gro......... .........

92) 80 t......... .........

93) 04 t

......... .........

44) 36 t......... .........

......... .........

t gro......... .........

36) 72 t......... .........

89) 86 t......... .........

06) 35 t......... .........

accination and bone density testing are


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8

onsistent with other reports.18,19 Blackurvivors were only half as likely to re-eive these services (P � .0001; Tables 2nd 3). Among postmenopausal women,one mineral density is highest amonglacks, and osteoporotic fracture rates,

ncluding hip fracture, are highestmong whites,20,21 which may explainhe differences in the bone density mea-urement rates. In addition, postmeno-ausal black women do not perceive os-eoporosis as a health risk.22 On thether hand, uterine cancer survivors ofll races will almost certainly have un-ergone bilateral salpingo-oophorec-omy and may also have undergone ra-iation therapy, increasing their risk ofsteoporosis and bone fracture. De-reased bone density has been reportedmong breast cancer survivors largelyecause of lower rates of the use of hor-one therapy among survivors23 as well

s an increased risk of bone fracture inlderly women with histories of pelvic ir-adiation for cervical, rectal, or anal can-er.24 Thus, rates of bone density testingn elderly uterine cancer survivors needo be improved and be equal among allacial groups.

It is not surprising that the use of pre-entive services declined with age amonglderly Medicare cancer survivors. This haseen reported for mammography25 andone density testing,19 although self-re-orted influenza vaccination rates haveeen reported to be highest among those5 years old or older.18,26 Bynum et al25

lso reported that health status, as mea-ured by the propensity to die, was inde-endently associated with screening mam-ography use in the elderly Medicare

opulation. We found that those with theighest Charlson scores, developed as aredictor of mortality, had the lowest ratesf use for all of the preventive services.The strengths of this paper include the

arge size of the population studied, itsational scope, the accuracy of the SEERiagnoses and staging, and the consis-ency of the results with recently pub-ished information on mammographynd the use of other services.14,5 In addi-ion, because the distribution of patientharacteristics were different betweenancer survivors and the total pool of
vailable controls, we used the propen- 1
6.e7 American Journal of Obstetrics & Gynecolog

ity score matching to make them moreomparable in terms of the observableharacteristics. Thus, the differences weound between these 2 groups in the uti-ization of preventive services was moreikely due to being a cancer survivor andess likely due to potential confounders.

We may have misclassified and under-ounted the number of women whoere treated by oncologists. The Medi-

are data system permits a physician toist only 1 specialty, and they may chooseo list the specialization that was earnedrst. This would not have an impact on

he overall results of the study but mayave reduced the validity of the inferenceith regard to the impact of seeing anncologist. Such a problem would notxist for obstetrician-gynecologists andynecologic oncologists in this study be-ause we grouped them together. Finally,he number of women we reported re-eiving colorectal cancer screening mayave included both, some whose exami-ations were not actually for screening.herefore, we performed a separatenalysis that used only the followingcreening codes: HCPCS codes G0104-0106 and G0120-G0122. Although the

ates were much lower, 4.5 per 100mong the survivors and 3.7 per 100 inhe comparison group, the difference be-ween the groups was greater, 20.4%,nd still significant (P � .01.)

In summary, women who survived 5ears or longer after the diagnosis of uter-ne cancer had preventive health servicetilization rates that were significantlyreater or equal to the rates among womenith no history of cancer. However, effortseed to be made to increase the use of allervices to achieve more acceptable rates.f

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. Chao A, Paganini-Hill A, Ross RK, Hender-on BE. Use of preventive care by the elderly.rev Med 1987;16:710-22.. Bostick RM, Sprafka JM, Virnig BA, PotterD. Predictors of cancer prevention attitudesnd participation in cancer screening examina-ions. Prev Med 1994; 23:816-26.. Fontana SA, Baumann LC, Helberg C, LoveR. The delivery of preventive services in pri-ary care practices according to chronic sta-

us. Am J Public Health 1997;87:1190-6.. Kiefe CI, Funkhouser E, Fouad MN, May DS.hronic disease as a barrier to breast and cer-ical cancer screening. J Gen Intern Med998;13:357-65.. Earle CC, Burstein HJ, Winer EP, Weeks JP.uality of non-breast cancer health mainte-ance among elderly breast cancer survivors.Clin Oncol 2003;21:1447-51.. Earle CC, Neville BA. Under use of necessaryare among cancer survivors. Cancer 2004;01:1712-9.0. Potosky AL, Riley GF, Lubitz JD, MentnechM, Kessler LG. Potential for cancer relatedealth services research using a linked Medi-are-tumor registry database. Medical Care993;31:732-48.1. Klabunde CN, Potosky AL, Legler JM, War-en JL. Development of a comorbidity index us-ng physician claims data. J Clin Epidemiol000;53:1258-67.2. Little RJ, Rubin DB. Causal effects in clinicalnd epidemiological studies via potential out-omes: concepts and analytical approaches.nnu Rev Public Health 2000;21:121-45.3. Leuven E, Sianesi B. PSMATCH2: Stataodule to perform full Mahalanobis and pro-ensity score matching, common supportraphing, and covariate imbalance testing.003 (this version 3.0.0.). Available at: http://

deas.repec.org/c/boc/bocode/s432001.html.4. Pham HH, Schrag D, Hargraves JL, BachB. Delivery of preventive services to olderdults by primary care physicians. JAMA005;294:473-81.5. Ananthakrishnan AN, Schelhase KG,arapani RA, Laud PW, Neuner JM. Disparities

n colon cancer screening in the Medicare pop-lation. Arch Intern Med 2007;167:258-64.6. Harrison RV, Janz NK, Wolfe RA, TedeschiJ, Huang X, McMahon LF Jr. Five-year mam-ography rates and associated factors forlder women. Cancer 2003;97:1147-55.7. Wallace AE, MacKenzie TA, Weeks WB.omen’s primary care providers and breast

ancer screening: who’s following the guide-ines? Am J Obstet Gynecol 2006;194:744-8.8. Centers for Disease Control and Preventionehavioral Risk Factor Surveillance System.vailable at: http://www.cdc.gov/brfss/. Ac-essed March 16, 2007.9. Neuner JM, Binkley N, Sparapani RA, LaudW, Nattinger AB. Bone density testing in olderomen and its association with patient age.Am Geriatr Soc 2006;54:485-9.0. Barrett-Connor E, Siris ES, Wehren LE, et
l. Osteoporosis and fracture risk in women of
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http://ideas.repec.org/c/boc/bocode/s432001.html

http://ideas.repec.org/c/boc/bocode/s432001.html

http://www.cdc.gov/brfss/

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2Hti22nn


ifferent ethnic groups. J Bone Miner Res005;20:185-94.1. Fang J, Freeman R, Jeganathan R, Alder-an MH. Variations in hip fracture hospital-

zation rates among different race/ethnicityroups in New York City. Ethn Dis 2004;4:280-4.2. Kidambi S, Partington S, Binkley N. Low
one mass prevalence and osteoporosis risk i
actor assessment in African Americanisconsin women. WMJ 2005;104:59-65.

3. Chen Z, Maricic M, Pettinger M, et al. Os-eoporosis and rate of bone loss among post-enopausal survivors of breast cancer. Cancer005;104:1520-30.4. Baxter NN, Habermann EB, Durham SB,irnig BA. Pelvic fractures in older women follow-

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5. Bynum JP, Braunstein JB, Sharkey P,addad K, Wu AW. The influence of health sta-

us, age, and race on screening mammographyn elderly women. Arch Intern Med005;165:2083-8.6. Bonito AJ, Lenfestey NF, Eicheldinger C, Ian-acchione VG, Campbell L. Disparities in immu-izations among elderly Medicare beneficiaries,
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The use of preventive health services among elderly uterine cancer survivors