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Original Research |

IMPROVING PATIENT CARE

Primary Care Utilization and Colorectal Cancer Incidence and Mortality Among Medicare Beneficiaries: A Population-Based, Case–Control Study

Jeanne M. Ferrante, MD, MPH; Ji-Hyun Lee, DrPH; Ellen P. McCarthy, PhD, MPH; Kate J. Fisher, MA; Ren Chen, MD, MPH; Eduardo C. Gonzalez, MD; Kymia Love-Jackson, MBA; and Richard G. Roetzheim, MD, MSPH
[+] Article and Author Information

From Rutgers–Robert Wood Johnson Medical School and Cancer Institute of New Jersey, New Brunswick, New Jersey; Moffitt Cancer Center and University of South Florida, Tampa, Florida; and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

An earlier version of this paper was presented at the Cancer and Primary Care Research International Network 5th International Annual Meeting, Cleveland, Ohio, 6 June 2012.

Note: Dr. Roetzheim has full access to all study data and takes responsibility for their integrity and the accuracy of the data analysis and interpretation.

Disclaimer: The ideas and opinions expressed herein are those of the authors, and endorsement by the State of California, Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their contractors and subcontractors is not intended or inferred.

Acknowledgment: The authors thank the Applied Research Program, National Cancer Institute; the Office of Research, Development and Information, Centers for Medicare & Medicaid Services; Information Management Services; and the SEER program tumor registries in the creation of the SEER–Medicare database.

Grant Support: By the American Cancer Society (grant RSGHP-08-141-01-CPHPS). This study used the linked SEER–Medicare database. The collection of the California cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code, section 103885; the National Cancer Institute's SEER program under contract N01-PC-35136 awarded to the Northern California Cancer Center, contract N01-PC-35139 awarded to the University of Southern California, and contract N02-PC-15105 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention's National Program of Cancer Registries, under agreement U55/CCR921930-02 awarded to the Public Health Institute.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0347.

Reproducible Research Statement: Study protocol, statistical code, and data set: Not available.

Corresponding Author Address: Jeanne M. Ferrante, MD, MPH, Department of Family Medicine and Community Health, Rutgers–Robert Wood Johnson Medical School, 1 World's Fair Drive, Suite 1500, Somerset, NJ 08873; e-mail, jeanne.ferrante@rutgers.edu.

Current Author Addresses: Dr. Ferrante: Department of Family Medicine and Community Health, Rutgers–Robert Wood Johnson Medical School, 1 World's Fair Drive, Suite 1500, Somerset, NJ 08873.

Dr. Lee and Ms. Fisher: Moffitt Cancer Center, Biostatistics and Bioinformatics Department, 12902 Magnolia Drive, Tampa, FL 33612.

Dr. McCarthy: Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA 02446.

Dr. Chen: University of South Florida, 3515 East Fletcher Avenue, MDT 1200, Tampa, FL 33612.

Drs. Gonzalez and Roetzheim and Ms. Love-Jackson: University of South Florida, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612.

Author Contributions: Conception and design: J. Ferrante, J.H. Lee, E.P. McCarthy, K.J. Fisher, E.C. Gonzalez, R.G. Roetzheim.

Analysis and interpretation of the data: J. Ferrante, J.H. Lee, E.P. McCarthy, K.J. Fisher, R. Chen, R.G. Roetzheim.

Drafting of the article: J. Ferrante, K.J. Fisher, E.C. Gonzalez, K. Love-Jackson, R.G. Roetzheim.

Critical revision of the article for important intellectual content: J. Ferrante, E.P. McCarthy, K.J. Fisher, E.C. Gonzalez, R.G. Roetzheim.

Final approval of the article: J. Ferrante, J.H. Lee, E.P. McCarthy, K.J. Fisher, R. Chen, E.C. Gonzalez, K. Love-Jackson, R.G. Roetzheim.

Provision of study materials or patients: R.G. Roetzheim.

Statistical expertise: J.H. Lee, E.P. McCarthy, K.J. Fisher, R. Chen.

Obtaining of funding: J.H. Lee, R.G. Roetzheim.

Administrative, technical, or logistic support: J. Ferrante, E.P. McCarthy, K. Love-Jackson, R.G. Roetzheim.

Collection and assembly of data: J.H. Lee, E.P. McCarthy, K.J. Fisher, R. Chen, R.G. Roetzheim.


Ann Intern Med. 2013;159(7):437-446. doi:10.7326/0003-4819-159-7-201310010-00003
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Chinese translation

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.

Figures

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Appendix Figure.

Study flow diagram.

CRC = colorectal cancer.

* Includes unmatched cases.

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Grahic Jump Location
Figure 1.

Association between number of PCP visits and CRC incidence, stratified by early- versus late-stage CRC, proximal versus distal CRC, year of CRC diagnosis, and number of non-PCP visits.

CRC = colorectal cancer; OR = odds ratio; PCP = primary care physician.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Association between number of PCP visits and CRC mortality, stratified by early- versus late-stage CRC, proximal versus distal CRC, year of CRC diagnosis, and number of non-PCP visits.

CRC = colorectal cancer; OR = odds ratio; PCP = primary care physician.

Grahic Jump Location

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Summary for Patients

Using Primary Care Services Can Help Reduce the Burden of Colorectal Cancer

The full report is titled “Primary Care Utilization and Colorectal Cancer Incidence and Mortality Among Medicare Beneficiaries. A Population-Based, Case–Control Study.” It is in the 1 October 2013 issue of Annals of Internal Medicine (volume 159, pages 437-446). The authors are J.M. Ferrante, J.H. Lee, E.P. McCarthy, K.J. Fisher, R. Chen, E.C. Gonzalez, K. Love-Jackson, and R.G. Roetzheim.

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