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Pancreatic cancer (PC) is highly fatal, and its incidence is increasing in the United States. Population‐based registry studies suggest associations between a few autoimmune conditions and PC risk, albeit based on a relatively small number of cases. We conducted a population‐based, nested case‐control study to examine the associations between autoimmune conditions and PC risk within the Surveillance, Epidemiology, and End Results Program (SEER)‐Medicare population. Incident primary malignant PC cases (n = 80 074) were adults ≥66 years and diagnosed between 1992 and 2015. Controls (n = 320 296) were alive at the time cases were diagnosed and frequency‐matched to cases (4:1 ratio) by age, sex, and year of diagnosis. We used multivariable‐adjusted, unconditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for 45 autoimmune conditions identified from Medicare claims. Eight autoimmune conditions including ankylosing spondylitis (OR = 1.45; 95% CI: 1.14‐1.84), Graves' disease (OR = 1.18; 95% CI: 1.03‐1.34), localized scleroderma (OR = 1.27; 95% CI: 1.06‐1.52), pernicious anemia (OR = 1.08; 95% CI: 1.02‐1.14), primary sclerosing cholangitis (OR = 1.37; 95% CI: 1.18‐1.59), pure red cell aplasia (OR = 1.31; 95% CI: 1.16‐1.47), type 1 diabetes (OR = 1.11; 95% CI: 1.07‐1.15), and ulcerative colitis (OR = 1.18; 95% CI: 1.07‐1.31) were associated with increased PC risk (false discovery rate‐adjusted P values <.10). In subtype analyses, these conditions were associated with pancreatic ductal adenocarcinoma, whereas only ulcerative colitis was associated with pancreatic neuroendocrine tumors. Our results support the hypothesis that autoimmune conditions may play a role in PC development. [ABSTRACT FROM AUTHOR]

PURPOSE: End-of-life (EOL) cancer care is costly, with challenges regarding intensity and place of care. We described EOL care and costs for patients with colorectal cancer (CRC) in the United States and the province of Ontario, Canada, to inform better care delivery. METHODS: Patients diagnosed with CRC from 2007 to 2013, who died of any cancer from 2007 to 2013 at age ≥ 66 years, were selected from the US SEER cancer registries linked to Medicare claims (n = 16,565) and the Ontario Cancer Registry linked to administrative health data (n = 6,587). We estimated total and resource-specific costs (2015 US dollars) from public payer perspectives over the last 360 days of life by 30-day periods, by stage at diagnosis (0-II, III, IV). RESULTS: In all months, especially 30 days before death, higher percentages of SEER-Medicare than Ontario patients received chemotherapy (15.7% v 8.0%), and imaging tests (39.4% v 31.1%). A higher percentage of Ontario patients were hospitalized (62.5% v 51.0%), but 43.2% of hospitalized SEER-Medicare patients had intensive care unit (ICU) admissions versus 17.9% of hospitalized Ontario patients. Cost differences between cohorts were greater for patients with stage IV disease. In the last 30 days, mean total costs for patients with stage IV disease were $15,881 (SEER-Medicare) and $12,034 (Ontario) versus $19,354 and $17,312 for stage 0-II. Hospitalization costs were higher for SEER-Medicare patients ($11,180 v $9,434), with lower daily hospital costs in Ontario ($1,067 v $2,004). CONCLUSION: These findings suggest opportunities for reducing chemotherapy and ICU use in the United States and hospitalizations in Ontario. [ABSTRACT FROM AUTHOR]

The article focuses on the 2019 National Conference hosted by the organization American Choral Directors Association (ACDA) in Missiouri with the theme Legacy and Community. Topics discussed include honoring and welcoming of conducting fellows from South Africa as part of the initiative International Conductors Exchange Program (ICEP), details of various events such as An die Muzik and Kuesta, and profile of conducting fellows from South Africa and United States.

Case-control studies evaluating a screening test's efficacy in reducing cancer mortality require accurate classification of test indication to obtain a valid result. However, for analogous studies of cancer incidence, determination of test indication is not as critical because, to define exposure, we need consider only tests that can identify precursor lesions whose treatment might prevent cancer, not tests leading to cancer diagnosis. This study utilizes US Surveillance, Epidemiology, and End Results (SEER)-Medicare data, which do not include information about colonoscopy indication, to evaluate the efficacy of colonoscopy in preventing colorectal cancer (CRC) incidence. Cases were Medicare enrollees diagnosed with CRC between 1996 and 2013; up to 3 controls were matched to each case. Colonoscopy receipt prior to presumed onset of occult cancer was associated with an approximately 60% reduction in CRC incidence (odds ratio = 0.41, 95% confidence interval: 0.40, 0.42). The association was robust to differing exposure windows and estimates of occult cancer duration and is similar to those from CRC incidence studies in which exam indication was available. Our results suggest that, when it is impractical/impossible to determine whether tests were conducted for screening, the efficacy of a test in preventing cancer incidence can still be estimated using a case-control study design. [ABSTRACT FROM AUTHOR]

Background: Patterns of end-of-life cancer care differ in Canada and the United States; yet little is known about differences in service-specific and overall costs. Aim: The aim of this study was to compare end-of-life costs in Ontario, Canada, and the United States, using administrative health data. Design: Advanced-stage nonsmall cell lung cancer patients who died from cancer at age ⩾65.5 years in 2001–2005 were selected from the US Surveillance, Epidemiology, and End Results–Medicare database (N = 16,858) and the Ontario Cancer Registry (N = 8643). We estimated total and service-specific costs (2009 US dollars) in each of the last 6 months of life from the public payer perspectives for short-term and long-term survivors (lived <180 and ⩾180 days post-diagnosis, respectively). Services were defined for comparisons between systems. Results: Mean monthly costs increased as death approached, were higher in short-term than long-term survivors, and were generally higher in the United States than in Ontario until the month before death, when they were similar (long-term survivors: US$10,464 and US$10,094 (p = 0.53), short-term survivors US$14,455 and US$12,836 (p = 0.11), in Surveillance, Epidemiology, and End Results–Medicare and Ontario, respectively). Costs for Medicare hospice and Ontario’s palliative care components were similar and increased closer to death. Inpatient hospitalization was the main cost driver with similar costs in both cohorts, despite lower utilization in the United States. The compositions of many services and costs differed. Conclusion: Costs for nonsmall cell lung cancer patients were slightly higher in the United States than Ontario until 1 month before death. Administrative data allow exploration and international comparisons of reimbursement policies, health-care delivery, and costs at the end of life. [ABSTRACT FROM AUTHOR]

Background Both the United States and Canada offer government-financed health insurance for the elderly, but few studies have compared care at the end of life for cancer patients between the two systems. Methods We identified care for non–small cell lung cancer (NSCLC) patients who died of cancer at age 65 years and older during 1999–2003. Patients were identified from US Surveillance, Epidemiology, and End Results (SEER)–Medicare data (N = 13 533) and the Ontario Cancer Registry (N = 8100). Health claims during the last 5 months of life identified chemotherapy and emergency room use, hospitalizations, and supportive care. We estimated rates per person-months (PM) for short-term survivors (died <6 months after diagnosis) and longer-term survivors (died ≥6 months after diagnosis), adjusting for demographic differences. To test whether monthly rates in Ontario were statistically significantly different from the United States, standardized differences were computed, and a 99% confidence interval (CI) was constructed to account for the multiple tests performed. All statistical tests were two-sided. Results Rates of chemotherapy use were statistically significantly higher for SEER–Medicare patients than Ontario patients in every month before death (short-term survivors at 5 months before death: SEER–Medicare, 33.2 patients per 100 PM vs Ontario, 9.5 per 100 PM, rate difference = 23.7 per 100 PM, 99% CI = 18.3 to 29.1 per 100 PM, P < .001; longer-term survivors at 5 months before death: SEER–Medicare, 24.4 patients per 100 PM vs Ontario, 14.5 per 100 PM, rate difference = 9.9 per 100 PM, 99% CI = 7.7 to 12.1 per 100 PM, P <. 001). During the last 30 days of life, fewer SEER–Medicare than Ontario patients were hospitalized (short-term survivors, 49.9 vs 78.6 patients per 100 PM, rate difference = 28.6 per 100 PM, 95% CI = 22.9 to 34.4 per 100 PM, P <. 001; longer-term survivors, 44.1 vs 67.1 patients per 100 PM, rate difference = 23.0 per 100 PM, 95% CI = 18.5 to 27.5 per 100 PM, P < .001). Conclusions NSCLC patients in both Ontario and the United States used extensive end-of-life care. Limited availability of hospice care in Ontario and differing attitudes between the United States and Ontario regarding end-of-life care may explain the differences in practice patterns. [ABSTRACT FROM PUBLISHER]

Background: Experimental studies suggest that iron overload might increase pancreatic cancer risk. We evaluated whether prediagnostic hemochromatosis and iron-overload diseases, including sideroblastic and congenital dyserythropoietic anemias, and non-alcoholic-related chronic liver disease (NACLD) were associated with pancreatic cancer risk in older adults., Methods: We conducted a population-based, case-control study within the U.S. Surveillance, Epidemiology, and End Results Program (SEER)-Medicare linked data. Incident primary pancreatic cancer cases were adults > 66 years. Controls were alive at the time cases were diagnosed and matched to cases (4:1 ratio) by age, sex, and calendar year. Hemochromatosis, iron-overload anemias, and NACLD were reported 12 or more months before pancreatic cancer diagnosis or control selection using Medicare claims data. Adjusted unconditional logistic regression models were used to calculate ORs and 95% confidence intervals (CI) between hemochromatosis, sideroblastic and congenital dyserythropoietic anemias, NACLD, and pancreatic cancer., Results: Between 1992 and 2015, 80,074 pancreatic cancer cases and 320,296 controls were identified. Overall, we did not observe statistically significant associations between hemochromatosis, sideroblastic anemia, or congenital dyserythropoietic anemia and pancreatic cancer; however, sideroblastic anemia was associated with later primary pancreatic cancer (OR, 1.30; 95% CI, 1.03-1.64). NACLD was associated with first (OR, 1.10; 95% CI, 1.01-1.19), later (OR, 1.17; 95% CI, 1.02-1.35), and all (OR, 1.12; 95% CI, 1.04-1.20) pancreatic cancer., Conclusions: Overall hemochromatosis and iron-overload anemias were not associated with pancreatic cancer, whereas NACLD was associated with increased risk in this large study of older adults., Impact: These results partly support the hypothesis that iron-overload diseases increase pancreatic cancer risk., (©2021 The Authors; Published by the American Association for Cancer Research.)

BACKGROUND: Following approval of imatinib, a breakthrough tyrosine kinase inhibitor (TKI), survival significantly improved by more than 20% since 2001 among treated chronic myelogenous leukemia (CML) patients. Subsequently, more expensive second-generation TKIs with varying selectivity profiles have been approved. Population-based studies are needed to evaluate the real-world utilization of TKI therapies, particularly given their escalating costs and recommendations for maintenance therapy. OBJECTIVE: To assess the utilization patterns of first-line TKIs, overall and by specific agent, among elderly CML patients in the United States, and the cost implications. METHODS: CML patients aged 65 years and older at diagnosis between 2007 and 2015 were identified from population-based cancer registries in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The percentage of CML patients receiving imatinib, dasatinib, or nilotinib within the first year of diagnosis was calculated along with time to first-line treatment initiation. Bivariate comparisons and Cox proportional hazards models were used to identify factors associated with TKI initiation. Average monthly patient responsibility, including patient out-of-pocket (OOP) costs, stratified by Part D low-income subsidy (LIS) status were also calculated. RESULTS: Among the 1,589 CML patients included, receipt of any TKI within 1 year of diagnosis increased from 66.2% to 78.9%. In 2015, the distribution of first-line TKI therapies was 41.3% imatinib, 28.3% dasatinib, and 9.3% nilotinib. Almost 60% of patients initiated TKI treatment within 3 months of diagnosis. Multivariable analysis indicated that TKI use in the first year was lower among the very elderly (aged > 75 years vs. 65-69 years: HR = 0.72; 95% CI = 0.63-0.83), patients with more comorbidities (Hierarchical Condition Category risk score > 2 vs. HR = 0.74, 95% CI = 0.62-0.88), and patients ineligible for LIS (HR = 0.75; 95% CI = 0.65-0.87). Average monthly patient OOP cost was significantly lower for LIS-eligible versus LIS-ineligible patients: imatinib (2016: $12 vs. $487), dasatinib (2016: $34 vs. $557), and nilotinib (2016: $1 vs. $526). CONCLUSIONS: TKI use has increased significantly since 2007. While imatinib remained the most frequently prescribed first-line agent, by 2015 newer TKIs represented one third of the market share. Utilization patterns indicated persistent age, comorbidity, and financial barriers. TKI use is indicated for long-term therapy, and increased adoption of newer, more expensive agents raises concerns about the sustained affordability of CML treatment, particularly among unsubsidized patients. DISCLOSURES: No outside funding supported this study. There are no reported conflicts of interest.

Oral anticancer medications (OAMs) are increasingly utilized. We evaluated the representativeness and completeness of IQVIA, a large aggregator of pharmacy data, for breast cancer, colon cancer, chronic myeloid leukemia, and myeloma cases diagnosed in six Surveillance, Epidemiology, and End Results Program (SEER) registries between 2007 and 2011. Patient's SEER and SEER-Medicare data were linked and compared with IQVIA pharmacy data from 2006 to 2012 for specific OAMs. Overall, 67.6% of SEER cases had a pharmacy claim in IQVIA during the treatment assessment window. This varied by location, race and ethnicity, and insurance status. IQVIA consistently identified fewer cases who received an OAM of interest than SEER-Medicare. The difference was least pronounced for breast cancer agents and most pronounced for myeloma agents. The IQVIA pharmacy database included a large portion of persons in the SEER areas. Future studies should assess receipt of OAMs for other cancer sites and in different SEER registries., (Published by Oxford University Press 2020. This work is written by US Government employees and is in the public domain in the US.)

The growing use of oral systemic therapies and transition of some cancer treatments to the outpatient setting makes capturing all cancer case patients more difficult. We aim to develop algorithms to identify potentially missed incident case patients and estimate impact on incidence rates. We reviewed claims from SEER-Medicare 5% noncancer control patient sample to identify potentially missed chronic myeloid leukemia (CML) and bladder case patients based on diagnosis codes, cancer-related treatments, and oncology consultations. Observed rates of definite missed CML and definite and probable missed bladder case patients were calculated and the impact of missed case patients of these two cancers on SEER 65+ incidence rates were estimated. From 2008 to 2015, the algorithm estimated 781 definite CML case patients missed, increasing the number by 10.7%. From 2007 to 2015, the algorithm estimated 4629 definite and 5772 probable bladder case patients missed, increasing the number by 3.8% to 8.1%. Our algorithms offer potential methods for identifying missed case patients and validating the completeness of cancer registries., (Published by Oxford University Press 2020. This work is written by US Government employees and is in the public domain in the US.)

Background: This article describes characteristics of patients receiving home health following an initial cancer diagnosis, comparing those enrolled in Medicare Advantage (MA) and Traditional Medicare (TM), using the newly linked 2010-2014 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare and home health Outcome and Assessment Information Set (OASIS) data., Methods: We identified SEER-Medicare beneficiaries with at least one OASIS assessment within 3 months of cancer diagnosis in 2010-2014, and summarized their demographic and clinical characteristics. Demographic and diagnostic data were obtained from the SEER-Medicare data, while further details about cognitive status, mood, function, and medical history were obtained from OASIS. We assessed differences between MA and TM beneficiaries using chi-square tests for independence, t-tests, and Kruskal-Wallis tests., Resutls: We identified 104 023 patients who received home health within 3 months of cancer diagnosis: 81 587 enrolled in TM and 22 436 enrolled in MA. TM cancer patients had higher unadjusted rates of home health use than MA patients (16.3% vs 10.3%, P < .001). TM cancer patients receiving home health had more limitations in their cognitive function than their MA counterparts and longer lengths of service (mean = 42.2 days vs 39.4 days, P < .001; median = 27 vs 26 days, interquartile range = 42)., Conclusion: This study demonstrates the large number of cancer patients in the SEER-Medicare-OASIS data and describes characteristics for TM and MA patients. These newly linked data can be used to assess home health care among older patients with cancer., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Health services researchers have studied how care from oncologists impacts treatment and outcomes for cancer patients. These studies frequently identify physician specialty using files from the Center for Medicare and Medicaid Services (CMS) or the American Medical Association (AMA). The completeness of the CMS data resources, individually or combined, to identify oncologists is unknown. This study assessed the sensitivity of CMS data to capture oncologists included in the AMA Physician Masterfile., Methods: Oncologists were identified from three CMS data resources: physician claims, the National Plan and Provider Enumeration System Registry, and the Medicare Data on Provider Practice and Specialty file. CMS files and AMA data were linked using a unique physician identifier. Sensitivity to identify any oncologists, radiation oncologists (ROs), surgical oncologists (SOs), and medical oncologists (MOs) was calculated for individual and combined CMS files. For oncologists in the AMA data not identified as oncologists in the CMS data, their CMS specialty was assessed., Results: Individual CMS files each captured approximately 83% of the 17 934 oncologists in the AMA Masterfile; combined CMS files captured 90.4%. By specialty, combined CMS data captured 98.2% of ROs, 89.3% of MOs, and 70.1% of SOs. For ROs and SOs in the AMA data not identified as oncologists in the CMS data, their CMS specialty was usually similar to the AMA subspecialty; ROs were radiologists and SOs were surgeons., Conclusion: Using combined files from CMS identified most ROs and MOs found in the AMA, but not most SOs. Determining whether to use the AMA data or CMS files for a particular research project will depend on the specific research question and the type of oncologist included in the study., (Published by Oxford University Press 2020. This work is written by US Government employees and is in the public domain in the US.)

Medical care costing studies have excluded patients with a prior cancer history. This study aims to update methods for estimating medical care costs attributable to cancer and to evaluate the effect of a prior history of cancer on costs for colorectal cancer (CRC) patients. We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data and matched cancer patients to controls without cancer to estimate cancer-attributable costs by phases of care using Medicare 2007-2013 claims. CRC annualized average cancer-attributable costs were $56.0 K, $5.3 K, $92.5 K, and $24.3 K in the initial, continuing, and end-of-life cancer and noncancer death phases, respectively, in 2014 dollars. Costs were higher for patients diagnosed with more advanced stage, younger ages, and nonwhite races. Costs for patients with prior cancers were consistently higher than patients without prior cancers, especially in the continuing (4.9 K vs 7.2 K) and end-of-life noncancer death (22.7 K vs 30.0 K). Our CRC costs improve previous estimates by using more recent data and updated methods., (Published by Oxford University Press 2020. This work is written by US Government employees and is in the public domain in the US.)

Background: The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was first created almost 30 years ago. Over time, additional data have been added to the SEER-Medicare database, allowing for expanded insights into the delivery of health care across the cancer continuum from screening to end of life., Methods: This article includes an overview of the current SEER-Medicare database, presenting potential users with an introduction to how the data can facilitate innovative epidemiologic and health services research studies. With a focus on the population 65 years and older, this article presents descriptive data on beneficiary demographics, cancer characteristics, service settings, Medicare coverage (eg, Parts A, B, C, and D), and use (number of services or bills) from 2011 to 2015., Results: From 2011 to 2015, 857 056 cancer patients and 601 470 population-based noncancer controls were added to the database. The database includes detailed tumor characteristics and clinical assessments for cancer cases, and demographics and health-care use (eg, hospitals, outpatient facilities, individual providers, hospice, home health-care providers, and pharmacies) for both cases and controls. Although characteristics varied overall between cases and controls, sufficient cancer-specific matched controls are available. Roughly 60% of cases were enrolled in fee for service at cancer diagnosis. The annual average number of claims per case was 60.7 and 92.3 during the year before and after cancer diagnosis, respectively, and 127.5 during the year before death., Conclusions: The large sample size and diverse array of data on cancer patients and noncancer controls in the SEER-Medicare database make it a unique resource for conducting cancer health services research., (Published by Oxford University Press 2020. This work is written by US Government employees and is in the public domain in the US.)

Purpose: Colonoscopy and flexible sigmoidoscopy are both recommended colorectal cancer (CRC) screening strategies, but their relative effectiveness is unclear. We sought to evaluate the ability of each of these two modalities to reduce CRC mortality., Methods: We conducted a case-control study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Cases were persons aged 70-85 years who died of CRC and were matched to up to three non-CRC controls. Receipt of endoscopy was ascertained from Medicare claims and endoscopy indication assigned using a validated algorithm. Conditional logistic regression models were developed to estimate the association between screening colonoscopy or sigmoidoscopy and CRC mortality. We conducted secondary analyses by race, sex, and endoscopist characteristics, and with varying duration of the look-back period., Results: In the initial analysis using all available look-back years, screening flexible sigmoidoscopy was associated with a 35% reduction in CRC mortality (OR 0.65, 95% CI 0.48, 0.89), while screening colonoscopy was associated with a 74% reduction (OR 0.26, 95% CI 0.23, 0.30). Sigmoidoscopy was not associated with any reduction in proximal CRC mortality. The association between colonoscopy and reduced CRC mortality was stronger in the distal than the proximal colon. Results were similar in analyses using a 5-year look-back period., Conclusions: Screening colonoscopy was associated with greater reductions in CRC mortality than screening sigmoidoscopy, and with a greater reduction in the distal than the proximal colon. These results provide additional information on the relative benefits of screening for CRC with sigmoidoscopy and colonoscopy.

Background: The Surveillance, Epidemiology and End Results (SEER)-Medicare data combine clinical information from population-based cancer registries with Medicare claims. These data have been used in many studies to understand cancer screening, treatment, outcomes, and costs. However, until recently, these data included limited information related to the characteristics and outcomes of cancer patients residing in or admitted to nursing homes., Objectives: To provide an overview of the new linkage between SEER-Medicare data and the Minimum Data Set (MDS), a nursing home resident assessment instrument detailing residents' physical, psychological, and psychosocial functioning as well as any therapies or treatments received., Research Design: This is a descriptive, retrospective cohort study., Subjects: Persons in SEER-Medicare diagnosed with cancer from 2004 to 2013 were linked to the 2011-2014 MDS, with 17% of SEER-Medicare patients linked to the MDS data. During 2011-2014, we identified 318,617 cancer patients receiving care in a nursing home and 256,947 cancer patients newly admitted to a total of 10,953 nursing homes. Of these patients, approximately two thirds were Medicare fee-for-service beneficiaries., Results: The timing from cancer diagnoses to nursing home admission varied by cancer. In total, 93% of all patients were admitted directly to a nursing home from an acute care hospital. The majority of patients were cognitively intact, 21% reported some level of depression, and 9% had severe functional limitations., Conclusions: The new SEER-Medicare-MDS dataset provides a valuable resource for understanding the postacute and long-term care experiences of cancer patients receiving care in United States' nursing homes.

Segmented line regression models, which are composed of continuous linear phases, have been applied to describe changes in rate trend patterns. In this article, we propose a procedure to compare two segmented line regression functions, specifically to test (i) whether the two segmented line regression functions are identical or (ii) whether the two mean functions are parallel allowing different intercepts. A general form of the test statistic is described and then the permutation procedure is proposed to estimate the p-value of the test. The permutation test is compared to an approximate F-test in terms of the p-value estimation and the performance of the permutation test is studied via simulations. The tests are applied to compare female lung cancer mortality rates between two registry areas and also to compare female breast cancer mortality rates between two states.

Background: The ability of medical students to recognize heart murmurs is poor (20%), and does not improve with subsequent years of training. A teaching method to improve this skill would be useful., Study Objectives: To determine whether intensive repetition of four basic cardiac murmurs improves auscultatory proficiency in medical students., Design: Controlled intervention study., Subjects: Fifty-one second-year medical students in an east coast medical school., Interventions: Subjects were classified into three groups: (1) a monitored group, who listened to 500 repetitions of each murmur in a monitored setting, (2) an unmonitored group, who listened to 500 repetitions of each murmur in an unmonitored setting, and (3) a control group. All three groups were tested using a pretest and posttest methodology., Measurements and Results: The 20 subjects in the monitored group improved from 13.5 +/- 9.8 to 85 +/- 17.6% following the intervention (mean +/- SD). Similarly, 21 students in the unmonitored group improved from 20.9 +/- 10.9 to 86.1 +/- 15.6%. Ten control students showed no significant improvement (24 +/- 21.7 to 32 +/- 22.5%). The differences between the two intervention groups and the control subjects was significant at p < 0.001 by analysis of variance., Conclusion: Five hundred repetitions of four basic cardiac murmurs significantly improved auscultatory proficiency in recognizing basic cardiac murmurs by medical students. These results suggest that cardiac auscultation is, in part, a technical skill.