Patient Knowledge of and Barriers to Breast, Colon, and Cervical Cancer Screenings: A Cross-Sectional Survey of TRICARE Beneficiaries

The National Defense Appropriations Act for fiscal year 2009, Subtitle B, waived copayments for preventive cancer screening services for all TRICARE beneficiaries, excluding Medicare-eligible beneficiaries.¹ These preventive services include screening for colorectal cancer (CRC), breast cancer, and cervical cancer based on current guidelines (eAppendix1).

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TRICARE Prime is a health care option available to active-duty service members (ADSMs), military retirees, and their families, providing no-fee, routine cancer screening through a primary care manager (PCM) or any network (commercial) provider.

Despite having unrestricted access to these cancer screenings, TRICARE Prime beneficiaries report overall screening completion rates that are below the national commercial benchmarks established by the Healthcare Effectiveness Data and Information Set (HEDIS) for all 3 cancer types.² Specifically, among TRICARE Prime beneficiaries enrolled in the western region of the U.S. in October 2013, the reported breast cancer screening rate was 61.6% (43,138/69,976) for women aged 42 to 69 years, which is well below the HEDIS 75th percentile of 76%. Similarly, the reported rate of cervical cancer screening among women aged 24 to 64 years was 68.3% (63,523/92,946), well below the HEDIS 75th percentile of 79%. Last, the reported rate of CRC screening among male and female TRICARE Prime members aged 51 to 75 years was 61.6% (52,860/85,827), also below the 2013 HEDIS 75th percentile of 63% based on internal review of TRICARE data used for HEDIS reporting.

Given the reported low screening rates, the Defense Health Agency (DHA) performed a cross-sectional survey to assess TRICARE Prime West region beneficiaries’ knowledge and understanding of preventive health screening, specifically for breast cancer, cervical cancer, and CRC, and to identify any potential barriers to access for these screenings.

Methods

A mostly closed-ended, 42-item telephone survey was designed and conducted (eAppendix2)

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. The survey was fielded from October to November 2013 among TRICARE Prime beneficiaries enrolled in the western U.S. (New Mexico, Arizona, Nevada, southwest corner of Texas, Colorado, Utah, Wyoming, Montana, Idaho, North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Hawaii, California, Washington, Oregon, and Alaska). Data were analyzed from 2014 to 2015. The target sample included women aged 21 to 64 years and men aged 51 to 64 years to capture the appropriate age and gender populations for which screening for breast cancer, cervical cancer, and CRC apply. Because the focus was on TRICARE Prime members, the upper age limit was set at 64 years to exclude members aged ≥ 65 years, as this is the age when Medicare becomes the primary health plan among retirees. The sampled TRICARE Prime population comprised active-duty and retired service members and their family members who were enrolled in the TRICARE West region at the time of the survey.

All women participating in the survey, regardless of age, were asked questions regarding cervical cancer screening. Women aged ≥ 42 years additionally were asked a second set of survey questions specific to breast cancer screening, and women aged between 51 and 64 years were asked a third set of questions related to CRC screening. The ages selected were 1 to 2 years after the recommended age for the respective screening to ensure adequate follow-up time for the member to obtain the screening. Men included in the survey were asked questions related only to CRC screening.

The target survey sample was 3,500 beneficiaries, separated into the following 4 strata: women aged 21 to 64 years of age enrolled in the direct care system (n = 1,250); women aged 21 to 64 years enrolled in the purchased (commercial) care network (n = 1,250); men aged 51 to 64 years enrolled in the direct care system (n = 500); and men aged 51 to 64 years enrolled in the purchased care network (n = 500). The random sample was drawn from an overall population of about 35,000 members. Sampling was performed without replacement until the target number of surveys was achieved. Survey completion was defined as the respondent having reached the end of the survey questionnaire but not necessarily having answered every question.

Data Elements

The preventive health survey collected information on beneficiaries’ knowledge of and satisfaction with their PCM, the primary location where they sought health care in the previous 12 months, preference for scheduling cancer screening tests, and general knowledge about the frequency and type of screening for breast, cervical, and colorectal cancers. Responses were scored based on guidelines effective as of 2009. In addition, the survey collected information on the beneficiary’s overall health status, current age, highest level of education achieved, current employment status, place of residence (on or off a military installation), race, and whether the beneficiary carried other health insurance aside from TRICARE.