Rural Urban Disparity in the Use of Preventive Care: What can we learn from Colorectal Cancer Screening?

Thesis (Ph.D.)--University of Rochester. School of Medicine & Dentistry. Dept. of Community and Preventive Medicine, 2012.There is evidence of rural urban disparity in the use of preventive care including colorectal cancer (CRC) screening. In this study, we try to understand the reasons behind the rural urban disparity in CRC screenin, and the trend for the screening and rural-urban disparity in the screening before and after Medicare expansion of colonoscopy coverage in 2001. We use Medicare Current Beneficiary Survey (MCBS), Area Resource File (ARF), Rural –Urban Commuting Area Codes (RUCAs) and American Hospital Association Annual Survey Database. We use weighted logistic regression to explore the explanations of rural urban disparity in CRC screening. We use bivariate probit model and propensity score to control for sample selection. Logistic regression analysis is used to explore the screening and disparity trend over time. We found that people with higher education, greater income, better supplemental insurance coverage, shorter distance, and living in an area with greater provider supply are more likely to receive CRC screening. Education, income, supplemental insurance coverage explains disparities between urban and large, small and isolated rural areas. Distance seems to explain disparities between urban and small rural, and urban and isolated rural areas. The possible provider supplies that explain the rural-urban disparity are primary care physician, specialist and preventive medicine physician supply. Our study has found an increasing trend for CRC screening and evidence for reduced disparity between urban and small rural areas in 2005, but not for other areas nor for other year. The rural-urban disparities are persistent across three years even after control for individual characteristics and area provider supply. People in rural areas should be targeted for interventions to increase CRC screening. Possible interventions to improve CRC screening, particularly in rural areas, should consider the following strategies: 1. Increasing CRC screening by FOBT use; 2. Use educational effort that has been proven to be effective, such as patient reminders, decision aid and one-on-one education; 3. Remove provider supply barrier to screening in rural areas including: (1) exploring the possibility of establishing mobile CRC screening facility, (2) motivating specialists to practice periodically in rural areas, and (3) exploring the impact of preventive medicine physicians