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Objectives: Our goal was to determine if increasing primary care physician supply was associated with lower incidence and mortality rates for colorectal cancer., Study Design: We performed an ecologic study of Florida's 67 counties, using data from the state tumor registry and the American Medical Association physician masterfile., Population: Florida residents were included., Outcomes Measured: We measured age-adjusted colorectal cancer incidence and mortality rates for Florida's 67 counties during the period 1993 to 1995., Results: Increasing primary care physician supply was negatively correlated with both colorectal cancer (CC) incidence (CC = -0.46; P < .0001) and mortality rates (CC = -0.29; P =.02). In linear regression that controlled for other county characteristics, each 1% increase in the proportion of county physicians who were in primary care specialties was associated with a corresponding reduction in colorectal cancer incidence of 0.25 cases per 100,000 (P < .0001) and a reduction in colorectal cancer mortality of 0.08 cases per 100,000 (P =.0008)., Conclusions: Incidence and mortality of colorectal cancer decreased in Florida counties that had an increased supply of primary care physicians. This suggests that a balanced work force may achieve better health outcomes.

Background: Comorbidity may be associated with later detection of cancer., Methods: Incident cases of colorectal, breast, and prostate cancer and melanoma were determined from the 1994 Florida state tumor registry (N = 32,074). The relationship between comorbidity and late stage at diagnosis was examined using multiple logistic regression., Results: Patients with comorbid conditions had greater odds of late stage diagnosis for each of the four cancers (colorectal, melanoma, breast, and prostate). Higher mortality rates were observed among patients with comorbid illness, not as a result of later stage at diagnosis, but rather due to their underlying disease., Conclusions: Comorbidity was associated with later stage diagnosis. Further research is needed to determine mechanisms by which comorbidity might influence stage at diagnosis.

Objectives: We hypothesized that health insurance payer and race might influence the care and outcomes of patients with colorectal cancer., Methods: We examined treatments received for all incident cases of colorectal cancer occurring in Florida in 1994 (n = 9551), using state tumor registry data. We also estimated the adjusted risk of death (through 1997), using proportional hazards regression analysis controlling for other predictors of mortality., Results: Treatments received by patients varied considerably according to their insurance payer. Among non-Medicare patients, those in the following groups had higher adjusted risks of death relative to commercial fee-for-service insurance: commercial HMO (risk ratio [RR] = 1.40; 95% confidence interval [CI] = 1.18, 1.67; P = .0001), Medicaid (RR = 1.44; 95% CI = 1.06, 1.97; P = .02), and uninsured (RR = 1.41; 95% CI = 1.12, 1.77; P = .003). Non-Hispanic African Americans had higher mortality rates (RR = 1.18; 95% CI = 1.01, 1.37; P = .04) than non-Hispanic Whites., Conclusions: Patients with colorectal cancer who were uninsured or insured by Medicaid or commercial HMOs had higher mortality rates than patients with commercial fee-for-service insurance. Mortality was also higher among non-Hispanic African American patients.

Background: Physicians are important in the early detection of melanoma. We investigated whether primary care physician supply and the supply of dermatologists were related to stage at diagnosis for malignant melanoma., Methods: From the state tumor registry in Florida in 1994, we identified incident cases of malignant melanoma for which stage at diagnosis was available (N = 1884). Data on physician supply was obtained from the 1994 American Medical Association Physician Masterfile. Logistic regression determined the effects of physician supply (at the ZIP code level) on the odds of early-stage diagnosis controlling for patients' age, gender, race/ethnicity, marital status, education level, income level, comorbidity, and type of health insurance., Results: Each additional dermatologist per 10,000 population was associated with a 39% increased odds of early diagnosis (odds ratio = 1.39, 95% confidence interval [CI] 1.09-1.70, P =.010). For each additional family physician per 10,000 population, the odds of early diagnosis increased 21% (odds ratio = 1.21, 95% CI 1.09-1.33, P <.001). Each additional general internist per 10,000 population was associated with a 10% decrease in the odds of early-stage diagnosis (odds ratio = 0.90, 95% CI 0.83-0.98, P =.009). The supplies of general practitioners, obstetrician/gynecologists, and other nonprimary care specialists were not associated with stage at diagnosis., Conclusions: Increasing supplies of dermatologists and family physicians were associated with earlier detection of melanoma. In contrast, increasing supplies of general internists were associated with reduced odds of early detection. Our findings suggest that the composition of the physician work force may affect important health outcomes and needs further study.

Background: Despite widespread use, the accuracy of community-based automated blood pressure machines has been questioned. We sought to determine if these machines are as accurate and reliable as those obtained by a clinician with a mercury manometer., Methods: We randomly selected 25 pharmacies and compared blood pressure readings obtained from their automated machines with from a mercury manometer. We used 3 volunteers with arm circumferences at the low, medium, and high ends of the acceptable range of a normal adult cuff size., Results: For the subject with the small arm size, store machines reported systolic pressure readings that were, on average, 10 mm Hg higher than those obtained by the clinician (P <.001) and diastolic pressures 9 mm Hg higher (P <.001). The mean systolic pressure readings for the subject with the medium arm size were not significantly different between the store machine and the mercury manometer, and the readings were only modestly different for diastolic pressure. For the subject with the large arm size, store machines reported diastolic pressure readings that were, on average, 8.3 mm Hg lower than those obtained using the mercury manometer (P <.001), but with no significant difference in the systolic pressure., Conclusions: We found that automated blood pressure machines from a representative community-based sample of pharmacies did not meet the accepted standards of accuracy and reliability. Accuracy of readings is especially uncertain for patients having arm sizes larger or smaller than average.

Background: Policymakers question whether there is a relationship between the number and distribution of physicians and the outcomes for important health conditions. We hypothesized that increasing primary care physician supply would be related to earlier detection of colorectal cancer., Methods: We identified incident cases of colorectal cancer occurring in Florida in 1994 (n = 8,933) from the state cancer registry. We then obtained measures of physician supply from the 1994 American Medical Association Physician Masterfile and examined the effects of physician supply (at the levels of county and ZIP code clusters) on the odds of late-stage diagnosis using multiple logistic regression., Results: For each 10-percentile increase in primary care physician supply at the county level, the odds of late-stage diagnosis decreased by 5% (adjusted odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.92 - 0.99; P = .007). For each 10-percentile increase in specialty physician supply, the odds of late-stage diagnosis increased by 5% (adjusted OR = 1.05; 95% CI, 1.02-1.09; P = .006). Within ZIP code clusters, each 10-percentile increase in the supply of general internists was associated with a 3% decrease in the odds of late-stage diagnosis (OR = 0.97; 95% CI, 0.95 - 0.99; P = .006), and among women, each 10-percentile increase in the supply of obstetrician/gynecologists was associated with a 5% increase in the odds of late-stage diagnosis (OR = 1.05; 95% CI, 1.01 - 1.08; P = .005)., Conclusions: If the relationships observed were causal, then as many as 874 of the 5463 (16%) late-stage colorectal cancer diagnoses are attributable to the physician specialty supply found in Florida. These findings suggest that an appropriate balance of primary care and specialty physicians may be important in achieving optimal health outcomes.

Background: Unavoidable exposure to disease and to patients susceptible and vulnerable to disease warrants that students entering medical school be immunized against many of the illnesses for which vaccines are available. The validity of immunization records presented at the time of registration, however, is largely dependent on the provision of accurate and reliable documentation by the student., Methods: We evaluated for authenticity the immunization and tuberculin testing records of 85 students entering medical school in 1990. Five levels of valid documentation were defined, and the information on each record was reviewed accordingly., Results: Only 43% of the records were original documents or laboratory reports of antibody titers, and 7.5% were not date-specific. We found that 8% to 20% of the forms were missing physician and/or student signatures, and 12% to 19% of the forms did not have health care provider addresses., Conclusions: Even though medical student preventive health programs may have strict requirements, there may be substantial deficiencies in the quality of the documentation provided by the students. Such deficiencies undermine the purpose of these programs.

Breast cancer detection and awareness projects have been implemented nationwide in an attempt to increase compliance with screening mammography. Previous studies, however, showed that the elderly, minorities, and women of lower socioeconomic status fail to respond in representative numbers. A cross-sectional analysis of 6640 participants of a Breast Cancer Detection and Awareness Project in Tampa, FL, was conducted to determine if barriers and motivations to screening differed among targeted (the elderly, minorities, women of lower socioeconomic status) and nontargeted groups. Targeted demographic groups reported far more barriers to screening and fewer motivating factors in their decision to participate in screening. This was true for the elderly, minorities, and women of lower socioeconomic status. Women in greater need of screening mammography report fewer motivations, and must overcome greater barriers to participate in media-promoted breast screening projects. Changes in the design and promotion of these screening projects must occur to prevent reverse targeting.

A survey of primary care physicians in the greater Tampa Bay metropolitan area was conducted to determine compliance with screening mammography and associated physician characteristics. Information requested included their age, sex, specialty, and board certification status, and the ages and frequencies that they recommend screening mammography for their patients. A total of 565 physicians responded. Even though 88% indicated they follow American Cancer Society recommendations when advising screening mammography, only 62% were actually in full compliance. A significantly greater percentage of obstetricians/gynecologists were compliant (74%) compared to other specialties (family practice, 57%, p = .006; internal medicine, 56%, p = .007; general practice, 53%, p = .003). Women physicians were more likely to be compliant than men (83% versus 58%, p less than .001), and younger physicians more likely than older physicians (72% versus 49%, p less than .001). There was no significant difference in compliance rates between board certified and noncertified physicians.