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Racial Disparities in Colorectal Cancer Screening - More Equitable Outcomes in the Equal-Access Military Health System
Navin R. Changoor*1,2, Cheryl K. Zogg1, Anju Ranjit1, Gezzer Ortega2, Louis L. Nguyen1, Eric Schneider1, Ronald Bleday4, Quoc-Dien R. Trinh1, Peter A. Learn3, Adil H. Haider1, Joel E. Goldberg4
1Center for Surgery and Public Health, Brigham and Womens Hospital, Boston, MA; 2Surgery, Howard University Hospital, Washington, ; 3Surgical Oncology, Walter Reed National Military Medical Center, Bethesda, MD; 4Surgery, Brigham and Women's Hospital, Boston, MA

Introduction:
Rates of colorectal cancer (CRC) screening are low in the US, despite national recommendations from the US Preventive Services Task Force. Racial minorities and lower-income individuals are among the least likely to be screened. Lack of insurance is frequently blamed. The objective of this study was to ascertain whether universal insurance coverage within the Department of Defense (DoD) TRICARE system leads to more equitable access to care among patients recommended to begin screening at age 50y.
Methods:
Four years (2007-2010) of TRICARE (insurance coverage to active/reserve/retired members of the US Armed Services and their dependents) were queried for adults aged 50y in 2007 and followed forward in time for 3y(ages 50-53y) to identify their first screening colonoscopy, flexible sigmoidoscopy, and/or fecal occult blood test (FOBT). Patients with diverticulitis, IBD, benign/malignant lesions, missing information, or incomplete follow-up within TRICARE were excluded. Screening variations based on demographics, sponsor rank, and service branch were compared using descriptive statistics and multivariable logistic regression.
Results:
A total of 24,944 enrollees were included. Majority was White (69.1%; 20.3% Black, 5.0% Asian), retired (dependents) (79.4%), and enlisted service members (72.2%). Overall, 54.0% received any screening: 50.0% endoscopy (with/without FOBT) and 4.0% FOBT alone (Table). Black patients were most likely to be screened (56.5%): White (53.5%) and Asian (52.9%) (p<0.001). Relative to White patients, they had 20% higher risk-adjusted odds of being screened (95%CI:1.12-1.30), 19% higher odds of presenting for endoscopy (95%CI:1.10-1.28), and 22% higher odds of receiving FOBT (95%CI:1.07-1.40). Females were more likely to be screened (OR[95%CI]:1.12[1.06-1.18]), as were officers when compared to enlisted service members (1.30[1.21-1.40]). Enrollees in the Air Force (55.7%), Coast Guard (54.9%) and Marine Corps (54.1%) were among the most likely to be screened, followed by similar percentages in the Army (52.6%) and Navy (52.6%). Variations ranged from 52.2-54.9% among census regions and 53.5% in military-operated (direct) versus 55.0% in civilian (purchased) care.
Conclusion:
Our results indicate that racial disparities in CRC screening may be mitigated within an equal-access healthcare system. Despite comparable screening across the board, significant variations in access remain, including among officers versus enlisted-service members (an indicator of income in TRICARE). Whether the result of enhanced insurance coverage, military lifestyle and values, or variations in the promotion of screening practices within the DoD, these findings highlight the need for ongoing efforts to understand and develop meaningful approaches to promote more equitable access to preventative care - among both military and civilian populations.
Differences in type of CRC screening received, among patients (n=13,479) who were screened
 Endoscopy n=12,471 [n(%)]FOBT n=1,008 [n(%)]p-value
Mean Age in years (SD)51.1 (0.95)51.8 (0.55) 
Race  0.753
White8,533 (68.4)706 (70.0) 
Asian605 (4.9)48 (4.8) 
Black2,660 (21.3)202 (20.0) 
Mixed/Other673 (5.4)52 (5.2) 
Beneficiary category  < 0.001
Active duty and dependents2,588 (20.8)116 (11.8) 
Retired and dependents9,774 (78.4)884 (87.7) 
Other109 (0.9)8 (0.8) 
Rank  < 0.001
Enlisted8,714 (69.9)765 (75.9) 
Officer3,114 (25.0)184 (18.3) 
US census region  < 0.001
South7,946 (63.7)685 (68.0) 
Midwest1,171 (9.4)101 (10.0) 
Northeast452 (3.6)42 (4.2) 
West2,902 (23.3)180 (17.9) 
Female4,306 (34.5)384 (38.1)0.022
Married11,158 (89.5)875 (86.8)0.009
Healthcare system (hospital type)  <0.001
Direct care (military hospital)8,364 (67.1)259 (25.7) 
Purchase care (civilian hospital)4102 (32.9)749 (74.3) 
Service Branch  0.001
Air Force4,101 (32.9)278 (27.6) 
Army4,472 (35.9)349 (34.6) 
Navy2760 (22.1)262 (26.0) 
Coast Guard238 (1.9)30 (3.0) 
Marine Corps719 (5.8)73 (7.2) 

Two-sided p-values <0.05 considered significant. Taken from Chi-squared tests (Fisher’s exact tests in cell counts <5) for categorical variables and a one-way analysis of variance for continuous age.


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