Self-Reported Use of Mammography and Insurance Status Among Women Aged greater than or equal to 40 Years -- United States, 1991-1992 and 1996-1997

In the United States, breast cancer is the most commonly diagnosed malignancy among women and the second leading cause of cancer death (1). Lack of health insurance coverage often is an important financial barrier to seeking preventive health care such as mammography screenings (2,3). To assess mammography use and the impact of insurance status on mammography use, state-specific proportions of women aged greater than or equal to 40 years who reported receiving a mammogram during the preceding 2 years by insurance status were derived using data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1991-1992 and 1996-1997. This report describes the results of this analysis, which indicate that the percentage of women reporting having had a screening mammogram during the previous 2 years increased, but women with insurance were substantially more likely than women without insurance to have had a mammogram.

Forty-six states and the District of Columbia (DC) participated in BRFSS surveys during 1991-1992 and 1996-1997. * Using a multistage sampling design and random-digit dialing, each state conducted monthly telephone interviews sampling noninstitutionalized adults (aged greater than or equal to 18 years) (3,4). Annual data were weighted to the age, sex, and race distribution of each state's adult population using 1994 census or intercensal estimates. Female respondents aged greater than or equal to 40 years were asked, "Have you ever had a mammogram?" If the respondent answered "yes," she was asked, "How long has it been since your last mammogram?" and "Was it part of a routine checkup, or was it because of a breast problem other than cancer, or was it because you had already had breast cancer?" Respondents also were asked, "Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?" In the 1996 and 1997 surveys, respondents who answered "no" were asked to reconsider the question. For consistency between the surveys, this analysis categorized respondents in 1996 and 1997 who first answered "no" to the insurance question as uninsured, even if they answered "yes" when asked again; the increase in the percentage of persons insured based on "yes" responses on reconsideration of the question was less than 2%.

Almost all women aged greater than or equal to 65 years have Medicare coverage (3). However, the aggregated results for all women aged greater than or equal to 40 years are presented because this format is consistent with prior analyses of trends in mammography coverage using data from the BRFSS and national objectives for breast cancer screening (5,6). To compensate for the potential affects of the resulting differences in age distributions between insured and uninsured women, estimates were age-adjusted to the age distribution of women in the 1994 BRFSS sample for participating states.

The overall pooled age-adjusted proportion of women with insurance who reported having had a mammogram was 65.2% in 1991-1992 and 70.9% in 1996-1997; the proportion of women without insurance who reported having had a mammogram was 39.6% in 1991-1992 and 46.2% in 1996-1997. In each of the 46 states and DC in both 1991-1992 and 1996-1997, the prevalence of self-reported screening mammography use within the previous 2 years was higher among insured women than among uninsured women; uninsured women represented approximately 9% of the sample in 1996-1997 (Table_1).

Among insured women, from 1991-1992 to 1996-1997, the age-adjusted proportion aged greater than or equal to 40 years who reported having had a mammogram during the preceding 2 years increased in 43 states. Increases in 26 states were statistically significant; the largest absolute increases in mammography use were in Mississippi (from 51.4% to 65.3%) and Alaska (from 63.9% to 76.4%). Mammography use decreased in three states (Minnesota, Vermont, and Washington), and DC, but the changes were not statistically significant.

Among uninsured women, mammography use increased in 33 states; the increase was significant in six. The largest absolute increases were 31.0% in Alaska (from 33.8% to 64.8%) and 23.9% in New Jersey (from 23.7% to 47.6%). Although there were decreases in 14 states, the only statistically significant decrease was in New Hampshire (from 51.1% to 32.4%; p=0.047).

Reported by the following BRFSS coordinators: J Cook, MBA, Alabama; P Owen, Alaska; B Bender, MBA, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; S Hoecherl, Florida; L Martin, MS, Georgia; A Onaka, PhD, Hawaii; J Aydelotte, Idaho; B Steiner, MS, Illinois; K Horvath, Indiana; A Wineski, Iowa; M Perry, Kansas; K Asher, Kentucky; R Jiles, PhD, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks, MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson, Mississippi; T Murayi, PhD, Missouri; P Feigley, PhD, Montana; M Metroka, Nebraska; E DeJan, MPH, Nevada; L Powers, MA, New Hampshire; G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; T Melnik, DrPH, New York; K Passaro, PhD, North Carolina; J Kaske, MPH, North Dakota; P Pullen, Ohio; N Hann, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania; J Hesser, PhD, Rhode Island; D Shepard, South Carolina; M Gildemaster, South Dakota; D Ridings, Tennessee; K Condon, Texas; R Giles, Utah; C Roe, MS, Vermont; L Redman, MPH, Virginia; K Wynkoop-Simmons, PhD, Washington; F King, West Virginia; P Imm, MS, Wisconsin; M Futa, MA, Wyoming. Epidemiology and Health Svcs Research Br, Div of Cancer Prevention and Control, and Health Care and Aging Studies Br, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that the percentage of women reporting having had a screening mammogram in the previous 2 years has increased over time, and this increase has been observed among both insured and uninsured women. However, women without insurance continue to be substantially less likely than women with insurance to have this procedure. These results underscore the importance of public health activities to increase access to breast and cervical cancer screening services for women who are medically underserved (7). If breast cancer mortality is to continue to decrease, then access to mammography for all women, particularly the uninsured, must be enhanced (8).

The findings in this report are subject to at least three limitations. First, because the BRFSS is a telephone survey, women living in a household without a telephone (5% of U.S. households) are excluded (9). Second, the survey's self-reported data may not be consistent with reports of mammography use from medical records. However, studies comparing self-reports with medical records found that the error in self-reporting mammography use is not substantial enough to explain the differences seen in the analyses described in this report (10). Finally, the response rates within the BRFSS have dropped from 84.1% and 82.9% in 1991 and 1992, respectively, to 77.9% and 76.8% in 1996 and 1997, respectively. Because respondents may differ from nonrespondents, this increase in nonresponse could portend greater bias in later samples.

This study indicates that lack of health insurance decreases the likelihood that a woman will receive a mammogram. This is an important finding given the efforts being made to reduce breast cancer mortality in this country, where a substantial proportion of women lack health insurance. The demonstrated efficacy of regular breast cancer screening with mammography suggests that efforts such as CDC's National Breast and Cervical Cancer Early Detection Program, a comprehensive nationwide program administered through state health departments and American Indian/ Alaskan Native tribal organizations, could facilitate the early detection of breast cancer in underserved women.

References

1. Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics 1998. Ca: a Cancer Journal for Clinicians 1998;48;6-29.

2. CDC. Health insurance coverage and receipt of preventive health services -- United States, 1993. MMWR 1995;44:219-25.

3. Makuc DM, Freid VM, Parsons PE. Health insurance and cancer screening among women. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, National Center for Health Statistics, 1994. (Advance data series 16, no. 254).

4. Frazier EL, Franks AI, Sanderson LM. Using behavioral risk factor surveillance data. In: Using chronic disease data: a handbook for public health practitioners. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1992.

5. CDC. Self-reported use of mammography among women aged greater than or equal to 40 years -- United States, 1989 and 1995. MMWR 1997;46:937-41.

6. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

7. Henson RM, Wyatt SW, Lee NC. The National Breast and Cervical Cancer Early Detection Program: a comprehensive public health response to two major health issues for women. Public Health Management Practice 1996; 2;36-47.

8. Wingo PA, Ries LA, Rosenberg HM, Miller DS, Edwards BK. Cancer incidence and mortality, 1973-1995: a report card for the U.S. Cancer 1998;82;1197-207.

9. Lavrakas PJ. Telephone survey methods: sampling, selection, and supervision. 2nd ed. Newbury Park, California: Sage Publications, 1993.

10. Etzi S, Lane DS, Grimson R. The use of mammography vans by low-income women: the accuracy of self-reports. Am J Public Health 1994;84;107-9.

Arkansas, Kansas, Nevada, and Wyoming did not participate.

TABLE 1. Percentage of women aged >=40 years who reported having had a mammogram during the previous 2 years, by
insurance status -- United States, Behavioral Risk Factor Surveillance System (BRFSS), 1991-1992 and 1996-1997 *
==============================================================================================================================
                                         Insured                                               Uninsured
                   ------------------------------------------------      ---------------------------------------------------
                      Sample size       Percentage      Percentage          Sample size       Percentage        Percentage
                   -----------------     1991-1992       1996-1997       ----------------      1991-1992        1996-1997
                   1991-      1996-    -------------    -----------      1991-     1996-     -------------    --------------
State               1992       1997     %      (SE+)     %     (SE)       1992      1997       %     (SE)       %      (SE)
----------------------------------------------------------------------------------------------------------------------------
Alabama             1,225      1,424   68.3    (1.5)    70.7   (1.4)        190       200    41.5   ( 4.3)    43.0    ( 5.1)
Alaska                641        754   63.9    (2.8)     6.4&  (2.4)         83       162    33.8   ( 8.1)     4.8&   ( 5.2)
Arizona               977      1,231   63.6    (2.2)     3.2&  (2.2)        133       119    47.2   ( 4.5)    41.8    ( 7.0)
California          1,764      2,370   72.0    (1.3)    74.1   (1.1)        185       263    43.1   ( 6.7)    45.9    ( 6.0)
Colorado              997      1,128   68.7    (1.6)    71.7   (1.6)         85        80    42.9   ( 6.6)    30.5    ( 5.9)
Connecticut         1,144      1,375   69.5    (1.6)     4.1&  (1.4)         64        83    50.3   ( 7.3)    36.4    ( 7.4)
Delaware              973      1,636   69.2    (1.7)     7.2&  (1.3)         83       106    36.3   ( 6.8)    41.8    ( 5.4)
District
  of Columbia         853        822   80.7    (1.7)    76.9   (1.7)        114        83    54.9   ( 5.2)    63.4    ( 6.7)
Florida             1,581      2,356   65.4    (1.6)     7.3&  (1.1)        207       294    39.0   ( 4.4)    43.6    ( 4.2)
Georgia             1,017      1,383   64.0    (1.7)     0.9&  (1.4)        139       105    44.7   ( 5.8)     0.2&   ( 4.6)
Hawaii              1,076      1,418   66.8    (1.8)     4.2&  (1.4)         67        74    32.0   ( 5.8)    48.6    (10.7)
Idaho               1,055      2,430   56.0    (1.8)    59.5   (1.3)        112       245    26.0   ( 4.0)    24.6    ( 4.3)
Illinois            1,244      1,828   66.1    (1.7)    68.7   (1.3)        112       143    40.6   ( 5.7)    54.3    ( 5.1)
Indiana             1,422      1,458   61.5    (1.5)     5.9&  (1.5)        103       127    25.7   ( 4.6)    33.8    ( 6.7)
Iowa                1,046      2,627   60.0    (1.9)    64.1   (1.2)         57       125    45.2   (10.2)    40.3    ( 8.0)
Kentucky            1,264      2,695   55.8    (1.7)     8.0&  (1.2)        183       223    31.8   ( 4.0)    33.3    ( 6.3)
Louisiana             926        974   56.8    (1.9)     5.1&  (1.8)        175       186    29.0   ( 5.3)    49.9&   ( 5.6)
Maine                 744      1,132   68.1    (2.0)    72.5   (1.7)         52       106    42.8   ( 8.2)    39.4    ( 7.0)
Maryland            1,172      2,899   75.0    (1.5)    78.5   (1.0)         88       195    42.9   ( 6.1)    56.8    ( 5.5)
Massachusetts         781      1,081   71.8    (1.8)    76.1   (1.6)         43        66    39.8   ( 9.7)    62.6    ( 8.4)
Michigan            1,440      1,605   68.5    (1.4)     5.1&  (1.3)         89        98    45.2   ( 7.3)    50.1    ( 6.2)
Minnesota           2,007      2,908   69.4    (1.2)    68.7   (1.0)         89       137    42.7   ( 6.8)    35.3    ( 4.8)
Mississippi         1,013      1,114   51.4    (1.9)     5.3&  (1.8)        148       128    35.6   ( 4.9)    39.8    ( 7.0)
Missouri              938      1,172   63.7    (1.9)    66.4   (1.6)        115       110    35.1   ( 5.2)    43.2    ( 8.3)
Montana               725      1,195   62.5    (2.1)     9.2&  (1.5)         75       135    23.7   ( 5.1)    37.8&   ( 4.6)
Nebraska              993      1,755   55.7    (2.0)     4.5&  (1.6)         48        94    36.6   ( 8.0)    45.2    (11.6)
New Hampshire         845        982   70.6    (1.8)    73.5   (1.5)         54        64    51.1   ( 8.1)    32.4&   ( 4.8)
New Jersey          1,036      1,881   60.6    (1.8)     8.9&  (1.3)         48       136    23.7   ( 7.9)    47.6&   ( 5.9)
New Mexico            587        902   64.0    (2.4)    69.1   (1.9)        128       164    34.1   ( 5.1)    41.1    ( 6.4)
New York            1,221      2,448   64.4    (1.7)     3.9&  (1.1)         98       184    35.2   ( 6.8)    45.0    ( 5.4)
North Carolina      1,256      2,133   64.2    (1.7)     1.0&  (1.2)        127       192    35.2   ( 5.0)    42.6    ( 4.6)
North Dakota        1,105      1,222   65.6    (1.7)     1.1&  (1.6)         60        88    29.2   ( 7.6)    27.5    ( 6.0)
Ohio                  790      1,715   60.4    (2.1)    69.8   (1.6)         56       120    46.9   ( 7.1)    56.4    ( 5.9)
Oklahoma              931      1,235   57.9    (1.9)     4.8&  (1.7)        157       147    29.2   ( 4.2)    26.7    ( 5.3)
Oregon              2,094      2,084   70.3    (1.1)    73.3   (1.1)        183       160    42.0   ( 5.1)    37.6    ( 5.0)
Pennsylvania        1,521      2,472   62.1    (1.5)     8.5&  (1.1)         73       159    46.4   ( 7.7)    53.8    ( 5.5)
Rhode Island        1,093      1,220   69.5    (1.6)     7.0&  (1.5)         48        63    37.1   ( 7.7)    48.3    ( 8.8)
South Carolina      1,258      1,352   64.2    (1.7)     1.5&  (1.6)        177       155    43.2   ( 4.6)    54.4    ( 6.6)
South Dakota        1,113      1,439   59.7    (1.7)     7.3&  (1.5)         68       107    24.4   ( 5.4)    37.4    ( 7.6)
Tennessee           1,588      2,167   60.4    (1.4)     6.5&  (1.3)        174       179    36.9   ( 4.7)    45.8    ( 5.0)
Texas               1,033      1,167   62.7    (1.8)    66.3   (1.7)        196       222    40.6   ( 5.0)    47.3    ( 4.9)
Utah                  944      1,606   62.9    (1.8)    64.6   (1.6)         71       150    35.8   ( 9.6)    21.8    ( 5.6)
Vermont             1,038      1,813   69.6    (1.6)    69.2   (1.3)         96       168    35.1   ( 6.0)    50.0    ( 5.1)
Virginia              931      1,752   65.6    (1.8)     0.5&  (1.5)        101       206    48.7   ( 6.0)    47.0    ( 5.4)
Washington          1,319      2,289   69.9    (1.5)    68.7   (1.1)         99       133    39.1   ( 6.7)    49.9    ( 7.4)
West Virginia       1,664      1,783   60.1    (1.4)     9.1&  (1.3)        232       196    31.2   ( 3.8)    43.4    ( 6.0)
Wisconsin             803      1,402   64.7    (1.9)    67.4   (1.8)         31        84    60.8   ( 8.7)    50.3    ( 8.1)

Pooled             53,188     77,834   65.2    (0.3)     0.9&  (0.3)      5,116     6,764    39.6   ( 1.3)    46.2&   ( 1.3)
----------------------------------------------------------------------------------------------------------------------------
* Percentages are age-adjusted to the distribution of the 1994 BRFSS sample.
+ Standard error.
& Difference within insurance group between 1991-1992 and 1996-1997 is significant (p<0.05). 

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