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Importance of primary care for underserved cancer patients with multiple chronic conditions

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Abstract

Purpose

To understand the impact of pre-existing conditions on healthcare utilization among under- and uninsured patients in the transition from cancer treatment to post-treatment survivorship.

Methods

Using electronic health record data, we constructed a cohort of patients seen in an integrated county health system between 1/1/2010 and 12/31/2016. Six hundred thirty-one adult patients diagnosed with non-metastatic breast or colorectal cancer during this period (cases) were matched 1:1 on sex and Charlson comorbidity index to non-cancer patients who had at least two chronic conditions and with at least one visit to the health system during the study period (controls). Conditional fixed effects Poisson regression models compared number of primary care and emergency department (ED) visits and completed [vs. no show or missed] appointments between cancer and non-cancer patients.

Results

Cancer patients had significantly lower number of visits compared with non-cancer patients (N = 46,965 vs. 85,038). Cancer patients were less likely to have primary care (IRR = 0.25; 95% CI: 0.24, 0.27) and ED visits (IRR = 0.57; 95% CI: 0.50, 0.64) but more likely to complete a scheduled appointment (AOR = 4.83; 95% CI: 4.32, 5.39) compared with non-cancer patients. Cancer patients seen in primary care at a higher rate were more likely to visit the ED (IRR = 2.06; 95% CI: 1.52, 2.80) than those seen in primary care at a lower rate.

Conclusion

Health systems need to find innovative, effective solutions to increase primary care utilization among cancer patients with chronic care conditions to ensure optimal management of both chronic conditions and cancer.

Implications for Cancer Survivors

Maintaining regular connections with primary care providers during active cancer treatment should be promoted.

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Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Cho H, et al. Assessing non-cancer-related health status of us cancer patients: other-cause survival and comorbidity prevalence. Am J Epidemiol. 2013;178(3):339–49.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Parry C, et al. Cancer survivors: a booming population. Cancer Epidemiol Biomarkers Prev. 2011;20(10):1996–2005.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Miller KD, et al. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin. 2019;69(5):363–85.

    Article  PubMed  Google Scholar 

  4. Hoopes M, et al. Identifying and characterizing cancer survivors in the US primary care safety net. Cancer. 2019;125(19):3448–56.

    Article  PubMed  Google Scholar 

  5. Williams MS et al. The association between hypertension and race/ethnicity among breast cancer survivors. J Racial Ethn Health Disparities. 2020;7(6):1172–1177

  6. Tammemagi CM, et al. Comorbidity and survival disparities among black and white patients with breast cancer. JAMA. 2005;294(14):1765–72.

    Article  CAS  PubMed  Google Scholar 

  7. Villarreal-Garza C, et al. Impact of diabetes and hyperglycemia on survival in advanced breast cancer patients. Exp Diabetes Res. 2012;2012:732027.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Sarfati D, Koczwara B, Jackson C. The impact of comorbidity on cancer and its treatment. CA Cancer J Clin. 2016;66(4):337–50.

    Article  PubMed  Google Scholar 

  9. SpringerLink (Online service) and Patricia A. Ganz. Improving Outcomes for Breast Cancer Survivors: Perspectives on Research Challenges and Opportunities. Cham: Springer International Publishing : Imprint: Springer, 2015.

  10. Hong C-C, Ambrosone CB, Goodwin PJ. Comorbidities and their management: potential impact on breast cancer outcomes. In: Improving Outcomes for Breast Cancer Survivors. Springer; 2015. p. 155–75.

    Chapter  Google Scholar 

  11. Pettit S, et al. Glycaemic control in people with type 2 diabetes mellitus during and after cancer treatment: A systematic review and meta-analysis. PLoS One. 2017;12(5):e0176941.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Yuan C, et al. Preexisting type 2 diabetes and survival among patients with colorectal cancer. Cancer Epidemiol Biomark Prev. 2021;30(4):757.

    Article  Google Scholar 

  13. Starfield B. Primary care: Concept, evaluation, and policy. New York: Oxford University Press; 1992.

    Google Scholar 

  14. National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/25983.

  15. Lafata JE, et al. Preventive care receipt and office visit use among breast and colorectal cancer survivors relative to age- and gender-matched cancer-free controls. J Cancer Surviv. 2015;9(2):201–7.

    Article  PubMed  Google Scholar 

  16. Martin JY, et al. Racial disparities in the utilization of preventive health services among older women with early-stage endometrial cancer enrolled in Medicare. Cancer Med. 2017;6(9):2153–63.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Wallner LP, et al. Ten-year trends in preventive service use before and after prostate cancer diagnosis: a comparison with noncancer controls. Perm J. 2017;21:16–184.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Earle CC, Neville BA. Under use of necessary care among cancer survivors. Cancer. 2004;101(8):1712–9.

    Article  PubMed  Google Scholar 

  19. Finley CR, et al. What are the most common conditions in primary care? Systematic review. 2018;64(11):832–40.

    Google Scholar 

  20. Roy S et al. Comparison of comorbid conditions between cancer survivors and age-matched patients without cancer. J Clin Med Res. 2018;10(12):911–919. https://doi.org/10.14740/jocmr3617w

  21. Akinyemiju T, et al. Disparities in the prevalence of comorbidities among US adults by state Medicaid expansion status. Prev Med. 2016;88:196–202.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Dallas County Medical District dba Parkland Health & Hospital System, Dallas County Health Needs Assessment. 2019. https://www.parklandhospital.com/Uploads/public/documents/PDFs/Health-Dashboard/CHNA%202019.pdf

  23. Charlson ME, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.

    Article  CAS  PubMed  Google Scholar 

  24. Pruitt SL, et al. Cervical cancer burden and opportunities for prevention in a safety-net healthcare system. Cancer Epidemiol Biomarkers Prev. 2018;27(12):1398–406.

  25. Nutting PA, et al. Continuity of primary care: to whom does it matter and when? Ann Fam Med. 2003;1(3):149–55.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Craddock Lee SJ, et al. Achieving coordinated care for patients with complex cases of cancer: a multiteam system approach. J Oncol Pract. 2016;12(11):1029–38.

    Article  Google Scholar 

  27. Balasubramanian BA et al. Surveillance for colorectal cancer survivors in an integrated safety-net health system in the United States. Int J Care Coord. 2018;21(1-2):26–35.

  28. Balsubramanian BA et al. Thematic analyses of challenges of care coordination for underinsured and uninsured cancer survivors with chronic conditions. JAMA Netw Open. 2021;4(8):e2119080.

  29. George A, Rubin G. Non-attendance in general practice: a systematic review and its implications for access to primary health care. Fam Pract. 2003;20(2):178–84.

    Article  PubMed  Google Scholar 

  30. Kaplan-Lewis E, Percac-Lima S. No-show to primary care appointments: why patients do not come. J Prim Care Community Health. 2013;4(4):251–5.

    Article  PubMed  Google Scholar 

  31. Shimotsu S, et al. Increased likelihood of missed appointments (“no shows”) for racial/ethnic minorities in a safety net health system. J Prim Care Community Health. 2016;7(1):38–40.

    Article  PubMed  Google Scholar 

  32. Weaver SJ, Jacobsen PB. Cancer care coordination: opportunities for healthcare delivery research. Transl Behav Med. 2018;8(3):503–8.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Nekhlyudov L, O’Malley DM, Hudson SV. Integrating primary care providers in the care of cancer survivors: gaps in evidence and future opportunities. Lancet Oncol. 2017;18(1):e30–8.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Taplin SH, et al. Reviewing cancer care team effectiveness. J Oncol Pract. 2015;11(3):239–46.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Doose M, et al. Comorbidity management in black women diagnosed with breast cancer: the role of primary care in shared care. J Gen Intern Med. 2021;36(1):138–46.

    Article  PubMed  Google Scholar 

  36. Clauser SB, et al. Multilevel intervention research: lessons learned and pathways forward. J Natl Cancer Inst Monogr. 2012;2012(44):127–33.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Lee SJ, et al. Achieving coordinated care for patients with complex cases of cancer: a multiteam system approach. J Oncol Pract. 2016;12(11):1029–38.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Lee SJC, et al. Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol. BMC Cancer. 2018;18(1):1204.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Lemieux-Charles L, McGuire WL. What do we know about health care team effectiveness? A review of the literature. Med Care Res Rev. 2006;63(3):263–300.

    Article  PubMed  Google Scholar 

  40. National Cancer Institute. Optimizing the management and outcomes for cancer survivors transitioning to follow-up care (RFA-CA-19–035). 2019 4/30/2019]; Available from: https://grants.nih.gov/grants/guide/rfa-files/RFA-CA-19-035.html.

  41. National Cancer Institute. Research Answers to National Cancer Institute's (NCI) Provocative Questions (RFA-CA-20–004). 2020 2/1/2020]; Available from: https://grants.nih.gov/grants/guide/rfa-files/rfa-ca-20-004.html.

  42. Nekhlyudov L, et al. Going beyond being lost in transition: a decade of progress in cancer survivorship. J Clin Oncol. 2017;35(18):1978–81.

    Article  PubMed  PubMed Central  Google Scholar 

  43. O’Malley D, et al. Learning the landscape: implementation challenges of primary care innovators around cancer survivorship care. J Cancer Surviv. 2017;11(1):13–23.

    Article  PubMed  Google Scholar 

  44. Parsons SK, et al. Promoting high-quality cancer care and equity through disciplinary diversity in team composition. J Oncol Pract. 2016;12(11):1141–7.

    Article  PubMed  Google Scholar 

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Funding

Support for this project came from the National Cancer Institute (R01-CA203856).

Author information

Authors and Affiliations

  1. Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Dallas, TX, USA

    Katelyn K. Jetelina, Quiera S. Booker-Nubie & Bijal A. Balasubramanian

  2. Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA

    Katelyn K. Jetelina, Simon Craddock Lee, Hong Zhu, Navid Sadeghi & Bijal A. Balasubramanian

  3. Department of Population and Data Sciences, UT Southwestern Medical Center, 5323 Harry Hines Blvd, MSC 9066, Dallas, TX, 75390-9066, USA

    Simon Craddock Lee, Hong Zhu & Michael E. Miller

  4. Dallas Department of Health and Human Services, Dallas, TX, USA

    Udoka C. Obinwa

  5. Department of Internal Medicine, Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA

    Navid Sadeghi

  6. Parkland Health & Hospital System, Dallas, TX, USA

    Navid Sadeghi & Umber Dickerson

Authors
  1. Katelyn K. Jetelina
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  2. Simon Craddock Lee
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  4. Udoka C. Obinwa
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  5. Hong Zhu
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  9. Bijal A. Balasubramanian
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Contributions

Conceptualization: BAB, SCL; methodology: BAB KKJ; formal analysis: KKJ, QSB-N, UCO, HZ; writing—original draft preparation: KKJ; writing—review and editing: all authors; funding acquisition: BAB, SCL, NS; data acquisition: MEM.

Corresponding author

Correspondence to Simon Craddock Lee.

Ethics declarations

Ethics approval

The study was approved by the Institutional Review Board at the University of Texas Southwestern Medical Center and University of Texas Health Science Center at Houston, with additional site approval by Parkland Health & Hospital System.

Consent to participate

A waiver of informed consent was granted for this study.

Conflict of interest

The authors declare no competing interests.

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Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Katelyn K. Jetelina and Simon Craddock Lee are joint first authors.

Appendix

Appendix

Table

Table 6 ICD-10 codes for case and control definition
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6

Table

Table 7 Conditional fixed incidence rate ratio of count of emergency care visits among matched cancer and non-cancer patients with interaction
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7

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Jetelina, K.K., Lee, S.C., Booker-Nubie, Q.S. et al. Importance of primary care for underserved cancer patients with multiple chronic conditions. J Cancer Surviv 17, 1276–1285 (2023). https://doi.org/10.1007/s11764-021-01159-8

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  • DOI: https://doi.org/10.1007/s11764-021-01159-8

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