The influence of dermatologist and primary care physician visits on melanoma outcomes among Medicare beneficiaries.

BACKGROUND: Ambulatory visits to dermatologists and primary care physicians (PCPs) may improve melanoma outcomes through early detection. We sought to measure the effect of dermatologist and PCP visits on melanoma stage at diagnosis and mortality. METHODS: We used data from the database linking Surveillance Epidemiology and End Results (SEER) and Medicare data (1994 to 2005) to examine patterns of dermatologist and PCP ambulatory visits before diagnosis for 18,884 Medicare beneficiaries with invasive melanoma or unknown stage at diagnosis. Visits were assessed during the 2-year time interval before the month of diagnosis. We examined whether dermatologist and PCP visits were associated with diagnosis of thinner melanomas (defined as local stage tumors having Breslow thickness <1 mm) and lower melanoma mortality. RESULTS: Medicare beneficiaries visiting both a dermatologist and PCP before diagnosis had greater odds of diagnosis of a thin melanoma (adjusted odds ratio, 1.26; 95% confidence interval, 1.12-1.41) and lower melanoma mortality (adjusted hazard ratio 0.66, 95% confidence interval, 0.57-0.76) compared with those without such visits. The mortality findings were attenuated once stage at diagnosis was adjusted for in the multivariable model. CONCLUSION: Improved melanoma outcomes among Medicare beneficiaries may depend on adequate access and use of dermatologist and PCP services.

Primary care utilization and colorectal cancer incidence and mortality among Medicare beneficiaries: a population-based, case-control study.

BACKGROUND: Utilization of primary care may decrease colorectal cancer (CRC) incidence and death through greater receipt of CRC screening tests. OBJECTIVE: To examine the association of primary care utilization with CRC incidence, CRC deaths, and all-cause mortality. DESIGN: Population-based, case-control study. SETTING: Medicare program. PARTICIPANTS: Persons aged 67 to 85 years diagnosed with CRC between 1994 and 2005 in U.S. Surveillance, Epidemiology, and End Results (SEER) regions matched with control patients (n = 205,804 for CRC incidence, 54,160 for CRC mortality, and 121,070 for all-cause mortality). MEASUREMENTS: Primary care visits in the 4- to 27-month period before CRC diagnosis, CRC incidence, CRC mortality, and all-cause mortality. RESULTS: Compared with persons having 0 or 1 primary care visit, persons with 5 to 10 visits had lower CRC incidence (adjusted odds ratio [OR], 0.94 [95% CI, 0.91 to 0.96]) and mortality (adjusted OR, 0.78 [CI, 0.75 to 0.82]) and lower all-cause mortality (adjusted OR, 0.79 [CI, 0.76 to 0.82]). Associations were stronger in patients with late-stage CRC diagnosis, distal lesions, and diagnosis in more recent years when there was greater Medicare screening coverage. Ever receipt of CRC screening and polypectomy mediated the association of primary care utilization with CRC incidence. LIMITATION: This study used administrative data, which made it difficult to identify potential confounders and prevented examination of the content of primary care visits. CONCLUSION: Medicare beneficiaries with higher utilization of primary care have lower CRC incidence and mortality and lower overall mortality. Increasing and promoting access to primary care in the United States for Medicare beneficiaries may help decrease the national burden of CRC. PRIMARY FUNDING SOURCE: American Cancer Society.

The effects of primary care on breast cancer mortality and incidence among Medicare beneficiaries.

BACKGROUND: Primary care physician (PCP) services may have an impact on breast cancer mortality and incidence, possibly through greater use of screening mammography. METHODS: The authors conducted a retrospective, 1:1 matching case-control study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database to examine use of PCP services and their association with breast cancer mortality and incidence. SEER cases representing the 3 outcomes of interest (breast cancer mortality, all-cause mortality among women diagnosed with breast cancer, and breast cancer incidence) were matched to unaffected controls from the 5% Medicare random sample. Conditional logistic regression was used to examine associations between physician visits and breast cancer outcomes while controlling for other covariates. RESULTS: Women who had 2 or more PCP visits during the 24-month assessment interval had lower odds of breast cancer mortality, all-cause mortality, and late-stage breast cancer diagnosis compared with women who had no PCP visits or 1 PCP visit while adjusting for other covariates, including mammography and non-PCP visits. Women who had 5 to 10 PCP visits had 0.69 times the odds of breast cancer mortality (95% confidence interval, 0.63-0.75), 0.83 times the odds of death from any cause having been diagnosed with breast cancer (95% confidence interval, 0.79-0.87), and 0.67 times the odds of a late-stage breast cancer diagnosis (95% confidence interval, 0.61-0.73) compared with those who had no PCP visits or 1 PCP visit. CONCLUSIONS: The current findings suggest that PCPs play an important role in reducing breast cancer mortality among the Medicare population. Further research is needed to better understand the impact of primary care on breast cancer and other cancers that are amendable to prevention or early detection.

Influence of primary care on breast cancer outcomes among Medicare beneficiaries.

PURPOSE: We used the Surveillance Epidemiology and End Results (SEER)-Medicare database to explore the association between primary care and breast cancer outcomes. METHODS: Using a retrospective cohort study of 105,105 female Medicare beneficiaries with a diagnosis of breast cancer in SEER registries during the years 1994-2005, we examined the total number of office visits to primary care physicians and non-primary care physicians in a 24-month period before cancer diagnosis. For women with invasive cancers, we examined the odds of diagnosis of late-stage disease, according to the American Joint Commission on Cancer (AJCC) (stages III and IV vs stages I and II), and survival (breast cancer specific and all cause) using logistic regression and proportional hazards models, respectively. We also explored whether including noninvasive cancers, such as ductal carcinoma in situ (DCIS), would alter results and whether prior mammography was a potential mediator of associations. RESULTS: Primary care physician visits were associated with improved breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower breast cancer and overall mortality. Prior mammography (and resultant earlier stage diagnosis) mediated these associations in part, but not completely. Similar results were seen for non-primary care physician visits. Results were similar when women with DCIS were included in the analysis. CONCLUSIONS: Medicare beneficiaries with breast cancer had better outcomes if they made greater use of a primary care physician's ambulatory services. These findings suggest adequate primary medical care may be an important factor in achieving optimal breast cancer outcomes.

Primary care utilization and colorectal cancer outcomes among Medicare beneficiaries.

BACKGROUND: Primary medical care may improve colorectal cancer (CRC) outcomes through increased use of CRC screening tests and earlier diagnosis. We examined the association between primary care utilization and CRC screening, stage at diagnosis, CRC mortality, and all-cause mortality. METHODS: We conducted a retrospective cohort study of patients, aged 67 to 85 years, diagnosed as having CRC between 1994 and 2005 in the Surveillance, Epidemiology, and End Results-Medicare-linked database. Association of the number of visits to primary care physicians (PCPs) in the 3- to 27-month period before the CRC diagnosis and CRC screening, early-stage diagnosis, CRC mortality, and all-cause mortality were examined using multivariable logistic regression and Cox proportional hazards models. RESULTS: The odds of CRC screening and early-stage diagnosis increased with increasing number of PCP visits (P < .001 for trend). Compared with persons having 0 or 1 PCP visit, patients with 5 to 10 visits had increased odds of ever receiving CRC screening at least 3 months before diagnosis (adjusted odds ratio, 2.60; 95% CI, 2.48-2.72) and early-stage diagnosis (1.35; 1.29-1.42). Persons with 5 to 10 visits had 16% lower CRC mortality (adjusted hazard ratio [AHR], 0.84; 95% CI, 0.80-0.88) and 6% lower all-cause mortality (0.94; 0.91-0.97) compared with persons with 0 or 1 visit. CONCLUSIONS: Medicare beneficiaries with CRC have better outcomes if they have greater utilization of primary care before diagnosis. Revitalization of primary care in the United States may help strengthen the national efforts to reduce the burden of CRC.

Assessment of elementary school students' sun protection behaviors.

BACKGROUND/OBJECTIVES: Studies suggest that excessive sun exposure in childhood contributes to the development of skin cancer later in life. METHODS: This study explores 4th grade student assessment of their sun protection behaviors. This study used baseline data collected in the Fall of 2006 for the Sun Protection for Florida's Children (SPF) project. In brief, the SPF project is a group randomized trial to test the effectiveness of a school based intervention promoting sun protection in general, and hat use in particular, in Hillsborough County Schools, Florida. The data reported in this study were collected at baseline before any intervention activities was initiated. RESULTS: The self-reported use of various methods of sun protection was low. Only a small percentage of students wore long sleeves or a hat with a brim before leaving for school. In addition, few students wore a hat with a wide brim when outside but not at school. Students spent an average of 59.1 minutes per week outdoors while attending school and 35.5 minutes during peak sun exposure. CONCLUSION: Sun exposure at school poses a significant risk to student health and more needs to be carried out to promote the use of a wide-brimmed hat and limiting student sun exposure.