Czwikla Jonas, Urbschat Iris, Kieschke Joachim, Schüssler Frank, Langner Ingo, Hoffmann Falk
Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
Department of Health, Long-Term Care and Pensions, SOCIUM Research Center on Inequality and Social Policy, University of Bremen, Bremen, Germany.
Front Oncol. 2019 Sep 18;9:909. doi: 10.3389/fonc.2019.00909. eCollection 2019.
Investigating geographic variations in mammography screening participation and breast cancer incidence help improve prevention strategies to reduce the burden of breast cancer. This study examined the suitability of health insurance claims data for assessing and explaining geographic variations in mammography screening participation and breast cancer incidence at the district level. Based on screening unit data (1,181,212 mammography screening events), cancer registry data (13,241 incident breast cancer cases) and claims data (147,325 mammography screening events; 1,778 incident breast cancer cases), screening unit and claims-based standardized participation ratios (SPR) of mammography screening as well as cancer registry and claims-based standardized incidence ratios (SIR) of breast cancer between 2011 and 2014 were estimated for the 46 districts of the German federal state of Lower Saxony. Bland-Altman analyses were performed to benchmark claims-based SPR and SIR against screening unit and cancer registry data. Determinants of district-level variations were investigated at the individual and contextual level using claims-based multilevel logistic regression analysis. In claims and benchmark data, SPR showed considerable variations and SIR hardly any. Claims-based estimates were between 0.13 below and 0.14 above (SPR), and between 0.36 below and 0.36 above (SIR) the benchmark. Given the limited suitability of health insurance claims data for assessing geographic variations in breast cancer incidence, only mammography screening participation was investigated in the multilevel analysis. At the individual level, 10 of 31 Elixhauser comorbidities were negatively and 11 positively associated with mammography screening participation. Age and comorbidities did not contribute to the explanation of geographic variations. At the contextual level, unemployment rate was negatively and the proportion of employees with an academic degree positively associated with mammography screening participation. Unemployment, income, education, foreign population and type of district explained 58.5% of geographic variations. Future studies should combine health insurance claims data with individual data on socioeconomic characteristics, lifestyle factors, psychological factors, quality of life and health literacy as well as contextual data on socioeconomic characteristics and accessibility of mammography screening. This would allow a comprehensive investigation of geographic variations in mammography screening participation and help to further improve prevention strategies for reducing the burden of breast cancer.
调查乳房X光检查筛查参与率和乳腺癌发病率的地理差异有助于改进预防策略，以减轻乳腺癌负担。本研究检验了医疗保险理赔数据在评估和解释地区层面乳房X光检查筛查参与率和乳腺癌发病率地理差异方面的适用性。基于筛查单位数据（1,181,212次乳房X光检查筛查事件）、癌症登记数据（13,241例乳腺癌确诊病例）和理赔数据（147,325次乳房X光检查筛查事件；1,778例乳腺癌确诊病例），估算了德国下萨克森州46个地区在2011年至2014年期间基于筛查单位和理赔数据的乳房X光检查标准化参与率（SPR）以及基于癌症登记和理赔数据的乳腺癌标准化发病率（SIR）。进行了Bland-Altman分析，以将基于理赔数据的SPR和SIR与筛查单位及癌症登记数据进行对比。使用基于理赔数据的多水平逻辑回归分析，在个体和背景层面调查地区层面差异的决定因素。在理赔数据和基准数据中，SPR显示出相当大的差异，而SIR几乎没有差异。基于理赔数据的估计值比基准值低0.13至高0.14（SPR），以及低0.36至高0.36（SIR）。鉴于医疗保险理赔数据在评估乳腺癌发病率地理差异方面的适用性有限，在多水平分析中仅对乳房X光检查筛查参与情况进行了调查。在个体层面，31种埃利克斯豪泽合并症中有10种与乳房X光检查筛查参与呈负相关，11种呈正相关。年龄和合并症对地理差异的解释没有作用。在背景层面，失业率与乳房X光检查筛查参与呈负相关，拥有学术学位的员工比例与乳房X光检查筛查参与呈正相关。失业率、收入、教育程度、外国人口和地区类型解释了58.5%的地理差异。未来的研究应将医疗保险理赔数据与关于社会经济特征、生活方式因素、心理因素、生活质量和健康素养的个体数据以及关于社会经济特征和乳房X光检查筛查可及性的背景数据相结合。这将有助于全面调查乳房X光检查筛查参与的地理差异，并有助于进一步改进减轻乳腺癌负担的预防策略。
