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J Rural Health. 2016 Sep;32(4):363-373. doi: 10.1111/jrh.12159. Epub 2015 Nov 26.

Is Travel Time to Colonoscopy Associated With Late-Stage Colorectal Cancer Among Medicare Beneficiaries in Iowa?

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Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.
Department of Geography, University of Iowa, Iowa City, Iowa.
Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa.
Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.
Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa.
Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa.



Colorectal cancer (CRC) screening has been shown to decrease the incidence of late-stage colorectal cancer, yet a substantial proportion of Americans do not receive screening. Those in rural areas may face barriers to colonoscopy services based on travel time, and previous studies have demonstrated lower screening among rural residents. Our purpose was to assess factors associated with late-stage CRC, and specifically to determine if longer travel time to colonoscopy was associated with late-stage CRC among an insured population in Iowa.


SEER-Medicare data were used to identify individuals ages 65 to 84 years old diagnosed with CRC in Iowa from 2002 to 2009. The distance between the centroid of the ZIP code of residence and the ZIP code of colonoscopy was computed for each individual who had continuous Medicare fee-for-service coverage for a 3- to 4-month period prior to diagnosis, and a professional claim for colonoscopy within that time frame. Demographic characteristics and travel times were compared between those diagnosed with early- versus late-stage CRC. Also, demographic differences between those who had colonoscopy claims identified within 3-4 months prior to diagnosis (81%) were compared to patients with no colonoscopy claims identified (19%).


A total of 5,792 subjects met inclusion criteria; 31% were diagnosed with early-stage versus 69% with late-stage CRC. Those divorced or widowed (vs married) were more likely to be diagnosed with late-stage CRC (OR: 1.20, 95% CI: 1.06-1.37). Travel time was not associated with diagnosis of late-stage CRC.


Among a Medicare-insured population, there was no relationship between travel time to colonoscopy and disease stage at diagnosis. It is likely that factors other than distance to colonoscopy present more pertinent barriers to screening in this insured population. Additional research should be done to determine reasons for nonadherence to screening among those with access to CRC screening services, given that over two-thirds of these insured individuals were diagnosed with late-stage CRC.


Medicare; access to care; colorectal cancer; geography; health services research

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