Rural Racial Disparities and Barriers in Mammography Utilization among Medicare Beneficiaries in Texas: A Longitudinal Study
Introduction
The disparities in screening mammography among rural racial/ethnic minority populations are not well understood. Therefore, this study aimed to investigate regular screening mammography patterns among Medicare beneficiaries in Texas to further assess the rural racial/ethnic disparities.
Methods
A retrospective longitudinal study design was used to examine the utilization of mammography among female Medicare beneficiaries aged 65-75 who initially enrolled in Medicare from 2010-2013 using Medicare claims data from 2010-2019. Utilization of mammography was assessed every two years from the time of enrolling in Medicare until the endpoint follow-up period for individuals, including outcomes such as death, breast cancer diagnosis, residential change between urban and rural areas, or the end of study (December 31, 2019), whichever occurred first. Regular users of mammography were defined as individuals who adhered to mammography screening guidelines and had at least one mammography every two years throughout the study period. To further examine the disparities in mammography utilization, stratification by urban-rural classification and race/ethnicity was performed. Descriptive and multinomial logistic regression analyses were conducted using SAS/STAT.
Results
Of the 114,939 eligible female Medicare beneficiaries, 60.59% of them had undergone screening mammography within the first two years when they reached the age of 67. This percentage gradually declined to 38.07% by the time they reached the age of 75, with a decrease rate of 5.63% every two years as they got older. At the endpoint follow-up, 21.2% of Hispanics, 33.3% of non-Hispanic Blacks (NHB), and 38.4% non-Hispanic Whites (NHW) in rural areas had regular screening mammography, compared to 33.5% of Hispanic, 44.9% of NHB, and 45.3% of NHW in urban areas. Stratification analyses showed that Hispanics and NHB from rural Texas were 33% (95% CI, 25% - 40%) and 22% (95% CI, 6% - 36%) less likely to have regular screening mammography compared to their urban counterparts. Overall, Hispanics were 46% (95% CI, 43%-50%) less likely to use screening mammography regularly compared to NHW after adjusting for covariates. Medicare beneficiaries who had established primary care providers (PCP) care were 3.31 (95% CI, 3.2-3.42) times more likely to undergo regular screening mammography compared to those without a PCP. Beneficiaries who were hospitalized more than twice a year or had a Charlson’s Comorbidity Index (CCI) score ≥3 were 45% (95% CI, 38%-51%) and 50% (95% CI, 46%-54%) less likely to use screening mammography regularly compared to those who were not hospitalized or had a CCI score of zero, respectively.
Conclusion
Our study revealed significant racial/ethnic disparities in screening mammography among rural Hispanic and NHB female Medicare Beneficiaries. Lack of a regular PCP, as well as overall health status indicated by hospitalization and comorbidity, were identified as major barriers to adhering to mammography screening guidelines. These findings highlight the importance of addressing rural racial/ethnic disparities and implementing targeted interventions to enhance screening mammography utilization and to achieve equitable screening practices for all populations.