Visit to Primary Care Soon After Cancer Surgery Associated with Reduced Mortality Risk in Older Adults

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Older adults who had a primary care visit within 90 days after cancer surgery exhibited significantly reduced mortality risk, according to a new retrospective cohort study published in JAMA Surgery.

Among the 2566 participants aged 65 years and older from the Duke University Health System (DUHS) who underwent cancer surgery, those without a primary care physician (PCP) at the time of surgery had a higher 90-day postoperative mortality rate compared to those with a PCP (3.6% vs 2.0%; adjusted P = .03).

Moreover, in a subanalysis of participants who had unfragmented care (ie, underwent surgery and had a PCP visit within the same study institution), those who had a postoperative primary care visit had a significantly lower 90-day postoperative mortality rate compared to those who did not (0.3% vs 3.3%; adjusted P = .001).

“These findings suggest that postoperative primary care use may substantially improve survivorship after cancer surgery among older patients,” wrote researchers in the study published online August 7, 2024.

Approximately 75% of cancer survivors in the US are 65 years and older, and many have comorbidities that necessitate both oncologic and nononcologic care, according to first author Hadiza Kazaure, MD, Division of Surgical Oncology, Department of Surgery, Duke University, and colleagues. Also, older adults who undergo surgery are more likely to have complications, such as a new diagnosis occurring postoperatively and clinical decompensation. Surgery may prompt changes in multimorbidity management, emphasizing the need for coordinated primary and surgical oncology care.

“Despite the clinical complexity and surgical vulnerability of older patients with cancer, there is a paucity of data on the association between primary care use and postoperative survivorship,” wrote investigators. “Considering the ramifications of an aging population on cancer care, this substantial knowledge gap is a barrier to the development of care models aimed at enhancing cancer survivorship of older patients.”

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Kazaure and colleagues examined the association between primary care use and mortality among older adults who underwent inpatient surgery for 1 of 12 cancer types at DUHS between January 1, 2017, and December 31, 2019. Participants were categorized into the following 3 tiers:

1. Patients with a PCP vs no PCP
2. Those who had a PCP and underwent surgery at DUHS (unfragmented care) vs not (fragmented care)
3. Those who had a primary care visit within 90 postoperative days vs not

The main outcome was postoperative 90-day mortality risk, “analyzed using inverse propensity weighted Kaplan-Meier curves, with log-rank tests adjusted for propensity scores,” researchers wrote.

The mean age of the cohort was 72.9 years, and 51.5% were men and 74.3% were White. Nearly all participants (93.7%) had medical insurance, but more than one-quarter (28.9%) had no PCP.

Additional findings. Researchers reported mortality rates of 1.1% at 30 days, 1.8% at 60 days, and 2.5% at 90 days. Overall, compared to participants in the PCP group, those in the no-PCP group had a higher inpatient mortality rate (0.5% vs 1.2%; P = .007) and 90-day postoperative mortality rate (3.6% vs 2.0%; P = .01).

In the subset of patients who had unfragmented care (n=823), 48.6% (n=400) had a primary care visit within 90 days after surgery. There were no differences in sex, race and ethnicity, health insurance coverage, or urgency of surgery between participants who had a primary care visit and those who did not. However, researchers reported individuals with a postoperative PCP visit were older, had higher comorbidity burden, visited the emergency department (ED) more frequently, and were readmitted more often than those who did not.

Kazaure and coauthors acknowledged several study limitations, including its retrospective and single-institution design. They also cited a lack of data on comorbidity severity, medication use, laboratory data, and reasons for PCP visits, ED visits, and hospital readmissions.

“In line with emerging literature suggesting that a team-based approach between PCPs and oncology teams may substantially improve survivorship, our results are foundational for further studies on surgery and primary care engagement, which may aid the development of postoperative oncology–primary care models to optimize survivorship of older adults after cancer surgery,” investigators concluded. “More studies are needed to delineate extant care coordination patterns by cancer type as well as barriers to having a PCP and a primary care visit among older patients with cancer.”

Reference: KazaureHS, Howard LE, Hyslop T, et al. Primary care use and 90-day mortality among older adults undergoing cancer surgery. JAMA Surg. Published online August 7, 2024. doi:10.1001/jamasurg.2024.2598