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Cancer Epidemiology, Biomarkers & Prevention
Cancer Epidemiology, Biomarkers & Prevention
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Insurance-Based Differences in Time to Diagnostic Follow-up after Positive Screening Mammography

Danielle D. Durham, Whitney R. Robinson, Sheila S. Lee, Stephanie B. Wheeler, Katherine E. Reeder-Hayes, J. Michael Bowling, Andrew F. Olshan and Louise M. Henderson
Danielle D. Durham
1Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina.
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Whitney R. Robinson
1Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina.
2Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.
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Sheila S. Lee
3Department of Radiology, UNC School of Medicine, Chapel Hill, North Carolina.
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Stephanie B. Wheeler
2Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.
4Department of Health Policy and Management, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Katherine E. Reeder-Hayes
2Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.
5Division of Hematology/Oncology, UNC School of Medicine, Chapel Hill, North Carolina.
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J. Michael Bowling
6Department of Health Behavior, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Andrew F. Olshan
1Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina.
2Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.
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Louise M. Henderson
1Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina.
2Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.
3Department of Radiology, UNC School of Medicine, Chapel Hill, North Carolina.
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  • For correspondence: louise_henderson@med.unc.edu
DOI: 10.1158/1055-9965.EPI-16-0148 Published November 2016
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  • Figure 1.
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    Figure 1.

    Comparison of the Kaplan–Meier estimates of the time-to-event curve stratified by insurance status for women less than 65 years old receiving a positive screening mammogram between 1995–2010. Tick marks represent observations in time as each woman experiences the follow-up event.

  • Figure 2.
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    Figure 2.

    Comparison of the Kaplan–Meier estimates of the time-to-event curve stratified by insurance status for women 65 years and older receiving a positive screening mammogram between 1995–2010. Tick marks represent observations in time as each woman experiences the follow-up event.

Tables

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  • Table 1.

    Demographic distribution of women ages 40 years and older receiving a positive screening mammogram between 1995–2010 by insurance status stratifying by women younger than 65 years and women 65 years and older

    Insurance status
    AllNo insuranceaMedicaid onlyMedicare onlyMedicare & MedicaidMedicare & privatePrivate only
    n (%)n (%)n (%)n (%)n (%)n (%)n (%)
    Age <65 y
     Total31,194916 (3)934 (3)634 (2)475 (1)592 (2)27,643 (89)
    Race/Ethnicity
     Black, non-Hispanic3,916 (13)144 (16)374 (40)165 (26)178 (37)108 (18)2,947 (11)
     White, non-Hispanic24,969 (80)665 (73)458 (49)423 (67)269 (57)444 (75)22,710 (82)
     Other859 (3)82 (9)40 (4)bb15 (3)703 (3)
     Unknown1,450 (5)25 (3)62 (7)bb25 (4)1,283 (5)
    Age, y
     40–447,307 (23)212 (23)276 (30)64 (10)62 (13)35 (6)6,658 (24)
     45–497,040 (22)220 (24)204 (22)98 (15)97 (20)72 (12)6,349 (23)
     50–546,648 (21)184 (20)184 (20)121 (19)105 (22)109 (18)5,945 (22)
     55–595,590 (18)144 (16)159 (17)165 (26)109 (23)162 (27)4,851 (18)
     60–644,609 (15)156 (17)111 (12)186 (29)102 (21)214 (36)3,840 (14)
    Education
     <High school1,580 (5)140 (15)227 (24)107 (17)141 (30)59 (10)906 (3)
     High school/GED6,692 (21)295 (32)273 (29)204 (32)142 (30)183 (31)5,595 (20)
     Some college7,286 (23)206 (22)167 (18)130 (21)64 (13)140 (24)6,579 (24)
     College graduate8,372 (27)103 (11)59 (6)48 (8)25 (5)103 (17)8,034 (29)
     Unknown7,264 (23)172 (19)208 (22)145 (23)103 (22)107 (18)6,529 (24)
    Age 65+ y
     Total11,832—192 (2)2,617 (22)753 (6)7,087 (60)1,183 (10)
    Race/Ethnicity
     Black, non-Hispanic1,226 (10)—46 (24)363 (14)285 (38)422 (6)110 (9)
     White, non-Hispanic9,883 (83)—132 (69)2,115 (81)408 (54)6,245 (88)983 (83)
     Other134 (1)—b27 (1)b71 (1)19 (2)
     Unknown589 (5)—b112 (4)b349 (5)71 (6)
    Age, y
     65–694,342 (37)—80 (42)920 (35)222 (29)2,354 (33)766 (65)
     70–743,320 (28)—49 (26)753 (29)204 (27)2,086 (29)228 (19)
     75+4,170 (35)—63 (33)944 (36)327 (43)2,647 (37)189 (16)
    Education
     <High school1,632 (14)—62 (32)457 (17)297 (39)705 (10)111 (9)
     High school/GED3,767 (32)—58 (30)892 (34)195 (26)2,277 (32)345 (29)
     Some college2,291 (19)—20 (10)403 (15)65 (9)1,564 (22)239 (20)
     College graduate1,579 (13)—17 (9)267 (10)25 (3)1,106 (16)164 (14)
     Unknown2,563 (22)—35 (18)598 (23)171 (23)1,435 (20)324 (27)
    • ↵aWomen reporting no insurance 65 years and older were removed from the models due to small sample size (n = 24).

    • ↵bCell counts < 11 have been suppressed.

  • Table 2.

    Median and mean time to initial diagnostic follow-up in days, proportion with follow-up greater than 60 days, and proportion with no follow-up for women ages 40 years and older receiving a positive screening mammogram between 1995–2010 by insurance status, stratified at 65 years of age

    Insurance statusMedian (IQR)aMean (SD)Percentage with follow-up > 60 dPercentage with no follow-up within 365 d
    All12 (7–22)43 (116)11.910.1
    Age <65 y
     No insurance16 (8–37)62 (166)17.513.8
     Medicaid only14 (7–27)47 (121)12.98.5
     Medicare only15 (8–28)53 (159)15.59.6
     Medicare & Medicaid14 (8–29)60 (220)14.09.5
     Medicare & private13 (7–24)42 (80)13.08.2
     Private only12 (7–21)40 (108)11.010.9
     All, <6512 (7–22)41 (114)11.410.8
    Age 65+ y
     Medicare only13 (7–26)54 (135)14.58.8
     Medicare & Medicaid14 (8–29)55 (142)15.98.8
     Medicare & private12 (7–21)44 (118)12.57.7
     Private only12 (7–21)40 (87)11.510.6
     All, 65+13 (7–22)46 (121)13.28.3
    • ↵aIQR reported as a range; from the 25th percentile to the 75th percentile.

  • Table 3.

    Unadjusted and adjusted HR estimates and 95% CIs of the association between insurance status and time to initial diagnostic follow-up after a positive screening mammogram for women younger than 65 years and women 65 years and older between 1995–2010

    UnadjustedAdjustedb
    Insurance statusHR (95% CI)PaHR (95% CI)Pa
    Age <65 y
     No insurance0.59 (0.33–1.06)0.080.47 (0.25–0.89)0.02
     Medicaid only0.75 (0.44–1.28)0.280.81 (0.46–1.42)0.46
     Medicare only0.86 (0.44–1.67)0.650.95 (0.47–1.91)0.88
     Medicare & Medicaid0.63 (0.32–1.24)0.180.50 (0.24–1.02)0.06
     Medicare & private2.16 (1.07–4.38)0.031.81 (0.86–3.83)0.12
     Private only (referent)1.00 (—)—1.00 (—)—
    Age 65+ y
     Medicare only0.89 (0.66–1.20)0.440.97 (0.70–1.34)0.83
     Medicare & Medicaid0.79 (0.49–1.27)0.330.99 (0.57–1.74)0.99
     Medicare & private (referent)1.00 (—)—1.00 (—)—
     Private only1.92 (1.22–3.03)0.0052.09 (1.27–3.44)<0.01
    • ↵aAll P values are 2-sided, and α < 0.05 was considered statistically significant.

    • ↵bThe adjusted model includes race, education, breast density, categorical age, history of breast biopsy, family history of breast cancer, and facility type.

  • Table 4.

    Unadjusted and adjusted OR estimates and 95% CIs of the association between insurance status and time to initial diagnostic follow-up of more than 60 days after a positive screening mammogram for women younger than 65 years and women 65 years and older between 1995–2010

    UnadjustedAdjustedb
    Insurance statusOR (95% CI)PaOR (95% CI)Pa
    Age <65 y
     No insurance1.61 (1.38–1.89)<0.00011.59 (1.31–1.94)<0.0001
     Medicaid only0.97 (0.82–1.14)0.701.00 (0.82–1.21)0.96
     Medicare only1.19 (0.98–1.43)0.081.21 (0.97–1.52)0.09
     Medicare & Medicaid1.09 (0.88–1.36)0.431.09 (0.85–1.42)0.49
     Medicare & private0.95 (0.77–1.17)0.621.10 (0.87–1.40)0.43
     Private only (referent)1.00 (—)—1.00 (—)—
    Age 65+ y
     Medicare only1.21 (1.08–1.35)0.0011.14 (0.99–1.30)0.06
     Medicare & Medicaid1.29 (1.08–1.56)0.0060.96 (0.76–1.20)0.73
     Medicare & private (referent)1.00 (—)—1.00 (—)—
     Private only1.12 (0.96–1.31)0.161.14 (0.95–1.36)0.16
    • ↵aAll P values are 2-sided, and α < 0.05 was considered statistically significant.

    • ↵bThe adjusted model includes race, education, breast density, categorical age, history of breast biopsy, family history of breast cancer, and facility type.

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Cancer Epidemiology Biomarkers & Prevention: 25 (11)
November 2016
Volume 25, Issue 11
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Insurance-Based Differences in Time to Diagnostic Follow-up after Positive Screening Mammography
Danielle D. Durham, Whitney R. Robinson, Sheila S. Lee, Stephanie B. Wheeler, Katherine E. Reeder-Hayes, J. Michael Bowling, Andrew F. Olshan and Louise M. Henderson
Cancer Epidemiol Biomarkers Prev November 1 2016 (25) (11) 1474-1482; DOI: 10.1158/1055-9965.EPI-16-0148

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Insurance-Based Differences in Time to Diagnostic Follow-up after Positive Screening Mammography
Danielle D. Durham, Whitney R. Robinson, Sheila S. Lee, Stephanie B. Wheeler, Katherine E. Reeder-Hayes, J. Michael Bowling, Andrew F. Olshan and Louise M. Henderson
Cancer Epidemiol Biomarkers Prev November 1 2016 (25) (11) 1474-1482; DOI: 10.1158/1055-9965.EPI-16-0148
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