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Purpose: The objective was to examine the impact of regular primary care encounters (PCE) on early breast cancer detection in an Appalachian sample of Medicare beneficiaries diagnosed 2006-2008. Determinants of PCE were investigated and a mediation analysis was conducted where PCE was a mediator to cancer stage. Methods: A total of 3,589 cases were identified from Appalachian areas in Pennsylvania, Kentucky, Ohio, and North Carolina, and health care services were examined 2 months to 2 years prior to diagnosis. A regular care PCE variable was constructed with 4 ordinal levels: none, any, “annual,” and “semiannual.” Association of PCE with stage, mortality and covariables was conducted using ordinal logistic regressions and Cox Proportional Hazards survival models. Results: Sixty-eight percent of the cases had semi-annual PCE. Regular PCE was strongly associated with late-stage cancer rates (39%-13% by increasing PCE level, P < .0001) and 5-year all-cause mortality (42%-24%, P < .0001). Subgroup analysis revealed variations by hypertension and urban status, with nonhypertensives with no PCE being at particularly increased risk. Significant determinants of PCE included age, rural/urban status, comorbidity, dual Medicaid insurance, Appalachian region economic classification, state, select comorbidities, hypertension, and minimum distance to provider. Mediation analysis results were consistent with lower number of comorbidities leading to increased late cancer detection due to patients having a decreased PCE. Conclusion: PCE is an important determinant of cancer detection, with a dose-response relationship. Variations exist by geography and hypertension. Comorbidity may influence both PCE and late-stage rates with partial mediation through PCE. [ABSTRACT FROM AUTHOR]

Background Colorectal cancer represents a significant cause of morbidity and mortality, particularly in Appalachia where high mortality from colorectal cancer is more prevalent. Adherence to treatment guidelines leads to improved survival. This paper examines determinants of guideline concordance for colorectal cancer. Methods Colorectal cancer patients diagnosed in 2006-2008 from 4 cancer registries (Kentucky, Ohio, Pennsylvania, and North Carolina) were linked to Medicare claims (2005-2009). Final sample size after exclusions was 2,932 stage I-III colon, and 184 stage III rectal cancer patients. The 3 measures of guideline concordance include adjuvant chemotherapy (stage III colon cancer, <80 years), ≥12 lymph nodes assessed (resected stage I-III colon cancer), and radiation therapy (stage III rectal cancer, <80 years). Bivariate and multivariate analyses with clinical, sociodemographic, and service provider covariates were estimated for each of the measures. Results Rates of chemotherapy, lymph node assessment, and radiation were 62.9%, 66.3%, and 56.0%, respectively. Older patients had lower rates of chemotherapy and radiation. Five comorbidities were significantly associated with lower concordance in the bivariate analyses: myocardial infarction, congestive heart failure, respiratory diseases, dementia with chemotherapy, and diabetes with adequate lymph node assessment. Patients treated by hospitals with no Commission on Cancer (COC) designation or lower surgical volumes had lower odds of adequate lymph node assessment. Conclusions Clinical, sociodemographic, and service provider characteristics are significant determinants of the variation in guideline concordance rates of 3 colorectal cancer measures. [ABSTRACT FROM AUTHOR]

Background: The Affordable Care Act gives states the option to expand state Medicaid programs to cover many who are currently uninsured. The potential financial impact has not been thoroughly examined. We characterized the health risk of uninsured adults in Buncombe County, North Carolina, relative to that of local Medicaid recipients, to estimate the cost of expanding Medicaid coverage to include the uninsured., Methods: We obtained de-identified patient enrollment and claims data for 2008 from the Division of Medical Assistance, North Carolina Department of Health and Human Services and from the 3 safety-net providers who care for most of the county's low-income uninsured adults. We used the Chronic Illness and Disability Payment System (CDPS) risk-adjustment tool to measure the relative health risk of the two populations. Based on actual spending in the Medicaid group and its health risk relative to that of the uninsured, we then projected how much it would have cost to provide Medicaid coverage for these uninsured in 2008., Results: We estimated, based on CDPS adjustment for demographics and diagnoses, that these uninsured adults would have incurred costs 13% greater than those of the actual nondisabled adult Medicaid population. The projected cost of providing Medicaid coverage to these uninsured would have been $4,320 per person., Limitations: Data were drawn from only the 3 major safety-net organizations and therefore excluded care obtained from other safety-net providers. Also, this sample of uninsured people included some who are ineligible for Medicaid because of their citizenship status. Furthermore, Medicaid enrollment might lead to increased utilization, revealing a greater burden of illness than we detected., Conclusion: In Buncombe County, uninsured adults who enroll in expanded Medicaid are likely to have somewhat more costly health problems than do currently enrolled nondisabled adults.