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Up-to-Date Breast, Cervical, and Colorectal Cancer Screening Test Use in the United States, 2021

Susan A. Sabatino, MD1; Trevor D. Thompson, BS1; Mary C. White, ScD1; Maria A. Villarroel, PhD2; Jean A. Shapiro, PhD1; Jennifer M. Croswell, MD3; Lisa C. Richardson, MD1 (View author affiliations)

Suggested citation for this article: Sabatino SA, Thompson TD, White MC, Villarroel MA, Shapiro JA, Croswell JM, et al. Up-to-Date Breast, Cervical, and Colorectal Cancer Screening Test Use in the United States, 2021. Prev Chronic Dis 2023;20:230071. DOI: http://dx.doi.org/10.5888/pcd20.230071.

PEER REVIEWED

Summary

What is already known on this topic?

Breast, cervical, and colorectal cancer screening has been below the national 2020 Healthy People targets.

What is added by this report?

We used 2021 National Health Interview Survey data to examine the most recent national estimates of screening test use, disparities, and comparisons with 2030 Healthy People targets. Estimates were compared with 2019 estimates to examine differences during the COVID-19 pandemic.

What are the implications for public health practice?

Approximately 1 in 4 adults of screening age were not up to date with breast, cervical, and colorectal cancer screening in 2021. Estimates were below current national targets and disparities existed. Test use within recommended intervals may approximate prepandemic levels; fecal occult blood test and fecal immunochemical test use may have increased modestly.

Abstract

Introduction

We examined national estimates of breast, cervical, and colorectal cancer (CRC) screening test use and compared them with Healthy People 2030 national targets. Test use in 2021 was compared with prepandemic estimates.

Methods

In 2022, we used 2021 National Health Interview Survey (NHIS) data to estimate proportions of adults up to date with US Preventive Services Task Force recommendations for breast (women aged 50–74 y), cervical (women aged 21–65 y), and CRC screening (adults aged 50–75 y) across sociodemographic and health care access variables. We compared age-standardized estimates from the 2021 and 2019 NHIS.

Results

Percentages of adults up to date in 2021 were 75.7% (95% CI, 74.4%–76.9%), 75.2% (95% CI, 73.9%–76.4%), and 72.2% (95% CI, 71.2%–73.2%) for breast, cervical, and CRC screening, respectively. Estimates were below 50% among those without a wellness check in 3 years (all screening types), among those without a usual source of care or insurance (aged <65 y) (breast and CRC screening), and among those residing in the US for less than 10 years (CRC screening). Percentages of adults who were up to date with breast and cervical cancer screening and colonoscopy were similar in 2019 and 2021. Fecal occult blood/fecal immunochemical test (FOBT/FIT) use was modestly higher in 2021 (P < .001).

Conclusions

In 2021, approximately 1 in 4 adults of screening age were not up to date with breast, cervical, and CRC screening recommendations, and Healthy People 2030 national targets were not met. Disparities existed across several characteristics, particularly those related to health care access. Breast, cervical, and colonoscopy test use within recommended screening intervals approximated prepandemic levels. FOBT/FIT estimates were modestly higher in 2021.

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Introduction

The US Preventive Services Task Force (USPSTF) recommends breast, cervical, and colorectal cancer (CRC) screening to reduce cancer mortality rates (1). Use of these services did not reach national targets for 2020 (2,3). We used 2021 National Health Interview Survey (NHIS) data to examine the most recent national estimates of screening test use, disparities, and comparisons to national targets set by Healthy People (HP) 2030 (4). We compared estimates from 2021 with 2019 estimates to examine differences before and during the COVID-19 pandemic.

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Methods

We used data from the 2021 and 2019 NHIS, an in-person survey of nationally representative samples of the civilian, noninstitutionalized US population (5). One sample adult was randomly selected from each household to self-report information about health and health services use (final sample adult response rates were 50.9% for 2021 and 59.1% for 2019) (5). Because of the COVID-19 pandemic, telephone interviews were attempted first in early 2021. In May 2021, in-person interviews resumed as local conditions allowed (5). Interviews conducted at least partially by telephone were higher in 2021 than in 2019 (62.8% vs 34.3%), and survey weighting methods were modified between these years (5).

We included women aged 50 to 74 years (n = 6,851), women aged 21 to 65 years (n = 10,909), and adults aged 50 to 75 years (n = 12,938) in breast, cervical, and CRC screening analyses, respectively. Exclusions (in order) included prior or unknown hysterectomy (cervical only, n = 1,591), personal or unknown history of the cancer screened for (breast, n = 394; cervical, n = 71; CRC, n = 138), and insufficient information to determine screening status (breast, n = 130; cervical, n = 531; CRC, n = 280). USPSTF updated CRC screening recommendations to include adults aged 45 to 49 years (B recommendation) in May 2021 (6). Because this occurred mid-2021, CRC screening analyses include adults aged 50 to 75 years.

We defined being up to date with screening as reporting having received a USPSTF-recommended test for any reason within recommended screening intervals (Table 1) (1). Each year since the survey redesign in 2019 (www.cdc.gov/nchs/nhis/2019_quest_redesign.htm), NHIS has included a set of cancer control questions sponsored by the Centers for Disease Control and Prevention and the National Cancer Institute. The content of these questions varies from year to year on a rotating basis. In 2019 and 2021, this content included additional questions about breast, cervical, and CRC screening tests to complement rotating core questions in those years about whether respondents ever received these tests and the time since the most recent test. These screening tests included mammography (breast cancer); Papanicolaou (Pap) and human papillomavirus (HPV) tests (cervical cancer); and colonoscopy, sigmoidoscopy, computed tomography (CT) colonography, home fecal occult blood test (FOBT) or fecal immunochemical (FIT) test, and FIT-DNA test (CRC). For blood stool tests, separate questions were not asked about FIT and guaiac tests. Rather, they were asked about in combination (“The following questions are about the blood stool or fecal occult blood test, fecal immunochemical or FIT test. These are tests to determine whether you have blood in your stool or bowel movement and can be done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab. Have you ever had a blood stool or FIT test, using a HOME test kit? When was your most recent blood stool or FIT test, using a home test kit?”). In 2019, questions about nonendoscopic CRC screening tests were asked of respondents who answered yes when asked if they had received a CRC test other than colonoscopy or sigmoidoscopy. In 2021, questions about nonendoscopic tests were asked of all respondents aged 40 years or older. NHIS responses regarding time since FIT-DNA test were not released in 2019 but were available for 2021. Because of this, CRC screening comparisons between years do not examine FIT-DNA use or overall CRC estimates (which include FIT-DNA).

Findings are national estimates of screening test use, reported as weighted percentages with 95% CIs. Survey design variables and survey weights were used in all analyses to account for the complex sample design and produce national estimates. We examined the percentage of US adults of screening age who were up to date with screenings for 2021 overall, and by sociodemographic and health care access characteristics, using Wald F-tests (significance set at P < .05). Overall estimates were also age-standardized to the projected 2000 US standard population (7). We compared age-standardized estimates of being up to date for 2021 and 2019. Estimates not meeting NCHS reliability standards were suppressed (8). We conducted analyses by using SAS version 9.4 (SAS Institute, Inc) and SUDAAN version 11.0.1 (RTI International).

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Results

In 2021, an estimated 75.7% (95% CI, 74.4%–76.9%) of US women were up to date with breast cancer screening, 75.2% (95% CI, 73.9%–76.4%) were up to date with cervical cancer screening, and 72.2% (95% CI, 71.2%–73.2%) of US adults were up to date with CRC screening (Tables 2 and 3). Colonoscopy was the most commonly used CRC screening test, with an estimated 63.1% (95% CI, 62.1%–64.2%) up to date, compared with 10.1% (95% CI, 9.4%–10.8%) for FOBT/FIT and 8.3% (95% CI, 7.7%–8.9%) for FIT-DNA (age-standardized, not mutually exclusive, not shown in tables). An estimated 15.5% (95% CI, 14.7%–16.3%) were up to date with any blood stool test (FOBT/FIT or FIT-DNA). Age-standardized breast and cervical screening estimates (Table 2) were below HP 2030 targets (80.5% and 84.3%, respectively) and below HP 2020 targets (81.1% and 93.0%, respectively). Assuming that all women aged 30 to 65 years with unknown HPV test use did or did not have an HPV test did not yield large differences in cervical cancer screening estimates (75.7% [95% CI, 74.4%–76.9%] vs 74.1% [95% CI, 72.8%–75.4%], data not shown). Age-standardized estimates of CRC screening test use (Table 3) exceeded the HP 2020 target (70.5%) and approached the HP 2030 target (74.4%).

Estimates were below 50% among those without a wellness check in 3 years across all screening types, among those without a usual source of care or insurance (aged <65 years) for breast and CRC screening, and among those residing in the US for less than 10 years for CRC screening. American Indian or Alaska Native (AIAN) and Asian adults tended to have lower estimates by race across screening types. Hispanic adults were less likely than non-Hispanic adults to be up to date with cervical and CRC screening. Significant differences existed across all screening types by urbanization level, education, and income (Tables 2 and 3).

Age-standardized estimates of being up to date with breast and cervical cancer screening were similar in 2021 and 2019 (75.6% [95% CI, 74.4%–76.8%] vs 76.2% [95% CI, 74.9%–77.5%], P = .51 for breast cancer screening and 75.5% [95% CI, 74.2%–76.7%] vs 76.8% [95% CI, 75.6%–77.9%], P = .09 for cervical cancer screening). Colonoscopy estimates were also similar (63.1% [95% CI, 62.1%–64.2%] in 2021 vs 62.4% [95% CI, 61.3%–63.4%] in 2019, P = .28). Estimated FOBT/FIT use was somewhat higher in 2021 (10.1% [95% CI, 9.4%–10.8%] in 2021 vs 6.6% [95% CI, 6.1%–7.1%] in 2019, P < .001).

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Discussion

Estimates suggest that approximately one-quarter of US adults of screening age were not up to date with breast, cervical, and CRC screening in 2021, and screening test use was below HP 2030 targets (4); CRC test use neared the target and exceeded the HP 2020 target (11). Colonoscopy was the most common CRC test, although 15% of adults were estimated to have received a stool blood test. Adults who were uninsured, without a usual source of care, or with shorter residence in the US had low screening uptake, consistent with previous evidence (2,12,13). By race, estimates for Asian and AIAN adults tended to be lowest across screening types. Hispanic adults were less likely to be up to date than non-Hispanic adults for cervical and CRC screening. Differences were also observed by education, income, and urbanization level.

The similarity in most up to date test estimates for 2021 and 2019 could reflect recommended screening intervals longer than 1 year, as well as recovery from reported declines in screening use during the COVID-19 pandemic (14–19). Higher FOBT/FIT estimates for 2021 may suggest a shift toward increased home stool testing for CRC screening during the pandemic, consistent with other studies (20,21). Home-based testing has been identified as a screening facilitator during the pandemic (22). However, differences in survey methods and questions for nonendoscopic screening tests could have affected estimates.

Findings are subject to limitations. Data were self-reported, which could result in reporting bias (eg, recall bias). Limited evidence exists about self-reported HPV test accuracy (23,24). Assuming that all women aged 30 to 65 years with unknown HPV test use either did or did not have an HPV test did not yield large differences in cervical cancer screening estimates. Weights were adjusted for nonresponse, although nonresponse bias may be possible. Consistent with previous studies and HP targets (2–4,12,13,25), tests performed for any reason were included. Caution may be warranted in interpreting findings for small subgroups given missing information for some variables.

Approximately 1 in 4 adults of screening age were not up to date with breast, cervical, and CRC screening recommendations in 2021. Estimates were below current national targets and disparities persisted across sociodemographic and health care access groups, with particularly low use among those with less health care access. Use of these tests within recommended screening intervals may approximate prepandemic levels. FOBT/FIT use may have increased modestly. Survey changes could have affected estimates although findings are consistent with previous evidence (20,21).

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Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the National Cancer Institute. The NHIS was funded by the US government. All authors are federal government employees. No copyrighted materials or tools were used in this research.

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Author Information

Corresponding Author: Susan Sabatino, MD, MPH, 4770 Buford Hwy, Mailstop S107-4, Atlanta, GA 30341-3717 (SSabatino@cdc.gov).

Author Affiliations: 1Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. 2Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland. 3Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland.

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References

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Tables

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Table 1. Definitions of Being Up to Date With Breast, Cervical, and Colorectal Cancer Screening
Screening type Definition of up to date
Breast cancer Mammogram within prior 2 years
Cervical cancer Pap within prior 3 years (aged 21–65 y), or HPV test alone in prior 5 years (aged 30–65 y), or Pap + HPV co-test in prior 5 years (aged 30–65 y)
Colorectal cancer Colonoscopy within 10 years, or flexible sigmoidoscopy within 5 years, or FOBT/FIT within 1 year, or CT colonography within 5 years, or FIT-DNA within 3 years

Abbreviations: CT, computed tomography; FIT-DNA, fecal immunochemical DNA test; FOBT, fecal occult blood test; HPV, human papillomavirus; Pap, Papanicolaou test.

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Table 2. Percentage of Women Up to Date With Breast and Cervical Cancer Screening, United States, 2021
Characteristic Breast cancer screening Cervical cancer screening
No. Weighted % (95% CI) P valuea No. Weighted % (95% CI) P valuea
Overall, unadjusted 6,327 75.7 (74.4–76.9) NA 8,716 75.2 (73.9–76.4) NA
Overall, age-standardizedb 6,327 75.6 (74.4–76.8) NA 8,716 75.5 (74.2–76.7) NA
Age, y
21–30 NA NA NA 1,759 67.8 (64.8–70.7) <.001
31–40 NA NA 2,308 82.3 (80.3–84.1)
41–50 NA NA 1,848 78.0 (75.5–80.3)
51–65 NA NA 2,801 73.5 (71.3–75.5)
50–64 3,850 75.3 (73.8–76.8) .44 NA NA NA
65–74 2,477 76.3 (74.3–78.2) NA NA
Race
AIAN 104 52.8 (42.5–63.0) <.001 172 64.0 (51.3–75.4) <.001
Asian 326 66.6 (60.2–72.5) 705 63.6 (59.1–68.0)
Black/African American 766 81.6 (78.0–84.8) 1,106 73.3 (69.4–77.0)
White 4,861 75.7 (74.3–77.1) 6,026 78.1 (76.6–79.6)
Other, single and multiple race 55 73.4 (57.7–85.7) 166 72.5 (62.3–81.2)
Missing/unknown 215 79.4 (72.7–85.1) 541 65.4 (60.4–70.1)
Ethnicityc
Non-Hispanic 5,694 75.9 (74.7–77.2) .29 7,203 76.7 (75.3–78.1) <.001
Hispanic 633 73.8 (69.8–77.5) 1,513 68.7 (65.6–71.6)
  Mexican/Mexican American 341 72.9 (67.3–78.1) 823 68.0 (64.4–71.4)
  Other Hispanic groupd 282 74.3 (68.0–79.9) 673 69.7 (64.8–74.3)
Education
Less than high school 532 63.6 (58.3–68.7) <.001 592 57.7 (52.6–62.8) <.001
High school/GED 1,517 72.6 (70.0–75.1) 1,736 66.4 (63.4–69.3)
Some college 1,916 76.5 (74.2–78.7) 2,356 74.2 (72.1–76.3)
College degree 2,335 80.7 (78.8–82.4) 3,999 83.8 (82.4–85.1)
Missing/unknown 27 e 33 e
Income, %f
≤138 1,060 64.8 (61.0–68.5) <.001 1,558 67.4 (64.4–70.4) <.001
>138–250 1,154 69.5 (65.9–72.9) 1,639 66.1 (63.1–69.0)
>250–400 1,217 76.4 (73.4–79.3) 1,720 73.8 (70.9–76.6)
>400 2,896 81.4 (79.7–83.0) 3,799 83.4 (81.8–84.9)
Duration of US residence, y
<10 53 61.3 (45.7–75.5) .09 358 55.9 (49.3–62.3) <.001
≥10 897 73.9 (70.4–77.2) 1,349 69.6 (66.7–72.4)
Born in the US 5,260 76.5 (75.1–77.8) 6,797 77.7 (76.3–79.0)
Missing/unknown 117 67.0 (55.2–77.4) 212 68.6 (60.3–76.1)
County urbanization levelg
Large central metro 1,678 75.5 (72.9–77.9) .02 2,903 73.1 (71.0–75.2) .002
Large fringe metro 1,544 77.2 (74.7–79.6) 2,130 78.5 (76.0–80.7)
Medium/small metro 2,097 76.3 (74.0–78.5) 2,568 76.1 (73.6–78.5)
Nonmetropolitan 1,008 72.2 (69.3–74.9) 1,115 72.0 (68.2–75.6)
Sexual orientation
Lesbian or gay 97 78.8 (68.7–86.8) .19 163 71.4 (62.8–78.9) .03
Straight 5,976 76.0 (74.7–77.2) 7,867 76.0 (74.7–77.3)
Bisexual 46 60.6 (45.1–74.6) 328 69.4 (62.4–75.9)
Other 23 e 73 59.6 (44.2–73.7)
Missing/unknown 185 66.7 (57.3–75.2) 285 65.7 (58.7–72.3)
Usual source of care
Yes 5,774 78.6 (77.3–79.9) <.001 7,222 78.3 (77.0–79.6) <.001
No 547 44.1 (39.2–49.0) 1,490 61.1 (58.0–64.2)
Missing/unknown 6 e 4 e
Insurance
Aged <65 y
   Private 2,807 80.1 (78.4–81.7) <.001 5,999 79.8 (78.4–81.2) <.001
   Medicaid/other public 519 68.4 (63.4–73.1) 1,361 70.6 (67.3–73.8)
   Other coverage 233 76.8 (69.7–82.9) 341 70.1 (62.9–76.5)
   Uninsured 283 42.3 (35.3–49.6) 828 56.6 (52.4–60.8)
   Missing/unknown 8 e 15 e
Aged ≥65 yh
   Private 968 78.9 (75.9–81.7) <.001 85 70.1 (57.9–80.5) .21
   Medicare + Medicaid 191 74.7 (67.0–81.4) 10 e
   Medicare Advantage 887 80.2 (76.9–83.2) 45 e
   Medicare only 300 58.8 (51.6–65.7) 21 e
   Other coverage 113 79.7 (70.4–87.2) 7 e
   Uninsured 14 e 4 e
   Missing/unknown 4 e 0 NA
Disability
Yes 782 65.8 (61.8–69.7) <.001 513 64.0 (58.6–69.1) <.001
No 5,545 77.0 (75.7–78.3) 8,203 75.8 (74.5–77.1)
Doing errands alone
At least some difficulty 591 65.0 (60.2–69.6) <.001 492 60.5 (54.3–66.4) <.001
No difficulty 5,735 76.8 (75.5–78.0) 8,224 76.1 (74.8–77.4)
Missing/unknown 1 e 0 NA
Wellness check within 3 years
Yes 6,066 78.1 (76.9–79.3) <.001 8,180 77.8 (76.5–79.0) <.001
No 249 13.8 (9.6–19.0) 511 36.5 (31.6–41.5)
Missing/unknown 12 e 25 e

Abbreviations: AIAN, American Indian or Alaska Native and includes AIAN only or in combination with another race; GED, general educational development; NA, not applicable; NCHS, National Center for Health Statistics; NHIS, National Health Interview Survey; USPSTF, US Preventive Services Task Force.
a P value from Wald F tests, testing for any differences across groups excluding missing or unknown.
b Overall percentages are presented unadjusted and age-standardized to the 2000 US standard population. Percentages were age-standardized using the following age groups: 50–64, 65–74 (breast); and 21–34, 35–44, 45–65 (cervical). Percentages by sociodemographic and other variables are unadjusted.
c P value reflects differences between Hispanic and non-Hispanic groups.
d Information about adults from other Hispanic origin or ethnicity groups is not available in the NHIS public-use file.
e Estimates suppressed because they did not meet NCHS reliability standards (8).
f Family income as a percentage of the federal poverty threshold, and multiply imputed by NCHS when missing (5,9).
g Includes 4 groups based on the 2013 NCHS Urban–Rural Classification Scheme for Counties (5,10).
h For cervical screening, includes only age 65 years because USPSTF does not recommend routine screening beyond this age.

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Table 3. Percentage of Adults Up to Date With Colorectal Cancer Screening, United States, 2021
Characteristic Colorectal cancer screening
No. Weighted % (95% CI) P valuea
Overall (unadjusted) 12,520 72.2 (71.2–73.2) NA
Overall (age-standardized)b 12,520 71.6 (70.6–72.6) NA
Age, y
50–64 7,338 66.1 (64.8–67.4) <.001
65–75 5,182 83.0 (81.7–84.3)
Sex
Male 5,689 71.1 (69.6–72.5) .03
Female 6,830 73.3 (72.0–74.6)
Unknown 1 c
Race
AIAN 208 62.6 (55.0–69.8) <.001
Asian 611 60.9 (55.7–65.8)
Black/African American 1,399 71.3 (68.2–74.2)
White 9,776 74.0 (72.9–75.1)
Other single and multiple race 109 64.2 (52.9–74.5)
Missing/unknown 417 63.0 (57.0–68.6)
Ethnicityd
Non-Hispanic 11,304 73.6 (72.6–74.6) <.001
Hispanic 1,216 62.1 (58.7–65.4)
  Mexican/Mexican American 662 58.8 (54.2–63.3)
  Other Hispanic groupe 536 66.0 (61.1–70.6)
Education
Less than high school 1,071 59.2 (55.7–62.7) <.001
High school/GED 3,120 67.5 (65.6–69.5)
Some college 3,611 73.5 (71.7–75.3)
College degree 4,663 78.4 (77.0–79.8)
Missing/unknown 55 76.2 (60.6–87.9)
Income, %f
≤138 1,913 60.3 (57.5–63.1) <.001
>138–250 2,176 65.2 (62.7–67.8)
>250–400 2,420 71.3 (68.9–73.5)
>400 6,012 78.6 (77.4–79.8)
Duration of US residence
<10 y 83 37.6 (26.2–50.1) <.001
≥10 y 1,705 64.9 (62.0–67.7)
Born in US 10,467 74.5 (73.5–75.5)
Missing/unknown 265 60.1 (52.2–67.7)
County urbanization levelg
Large central metro 3,355 71.7 (69.7–73.6) .02
Large fringe metro 3,027 74.2 (72.4–76.0)
Medium and small metro 4,121 72.6 (70.6–74.5)
Nonmetropolitan 2,017 69.3 (66.7–71.9)
Sexual orientation
Lesbian or gay 250 76.1 (69.1–82.3) .65
Straight 11,744 72.4 (71.4–73.5)
Bisexual 90 70.0 (58.4–80.0)
Other 41 c
Missing/unknown 395 65.1 (58.7–71.1)
Usual source of care
Yes 11,240 75.5 (74.5–76.5) <.001
No 1,274 42.9 (39.7–46.1)
Missing/Unknown 6 c
Insurance
Age <65 y
   Private 5,265 71.0 (69.5–72.4) <.001
   Medicaid/other public 911 57.4 (53.8–61.0)
   Other coverage 535 75.2 (70.6–79.4)
   Uninsured 607 29.8 (25.3–34.6)
   Missing/unknown 20 c
Age ≥65 y
   Private 2,067 86.3 (84.4–88.0) <.001
   Medicare + Medicaid 337 71.1 (63.7–77.7)
   Medicare Advantage 1,720 85.4 (83.4–87.3)
   Medicare only 619 74.1 (69.8–78.0)
   Other coverage 399 84.8 (80.4–88.6)
   Uninsured 30 c
   Missing/unknown 10 c
Disability
Yes 1,452 71.6 (68.8–74.3) .63
No 11,068 72.3 (71.3–73.4)
Doing errands alone
At least some difficulty 1,015 68.5 (65.1–71.8) .02
No difficulty 11,502 72.6 (71.5–73.6)
Missing/unknown 3 c
Wellness check within 3 years
Yes 11,884 75.1 (74.1–76.1) <.001
No 603 17.3 (14.0–20.9)
Missing/unknown 33 c

Abbreviations: AIAN, American Indian/Alaska Native and includes AIAN only or in combination; GED, general educational development; NA, not applicable; NCHS, National Center for Health Statistics; NHIS, National Health Interview Survey; USPSTF, US Preventive Services Task Force.
a P value from Wald F tests testing for any differences across groups excluding missing/unknown.
b Overall percentages are presented as unadjusted and age-standardized to the 2000 US standard population. Percentages were age-standardized using the following age groups: 50–64, 65–75. Percentages by sociodemographic and other variables are unadjusted.
c Estimates suppressed because they did not meet NCHS standards for reliability (8).
d P value reflects differences between Hispanic and non-Hispanic groups.
e Information about adults from other Hispanic origin or ethnicity groups is not available in the NHIS public-use file.
f Family income as a percentage of the federal poverty threshold, and multiply imputed by NCHS when missing (5,9).
g Includes 4 groups based on the 2013 NCHS Urban–Rural Classification Scheme for Counties (5,10).

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