Mammography use, breast cancer stage at diagnosis, and survival among older women.

BACKGROUND: Women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Yet, older women are least likely to undergo mammography, perhaps because mammography's value is less well demonstrated in older women. OBJECTIVE: To investigate the relationship between prior mammography use, cancer stage at diagnosis, and breast cancer mortality among older women with breast cancer. DESIGN: Retrospective cohort study using the Linked Medicare-Tumor Registry Database. SETTING: Population-based data from three geographic areas included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. PARTICIPANTS: Women aged 67 and older diagnosed with a first primary breast cancer, from 1987 to 1993, residing in Connecticut, metropolitan Atlanta, Georgia, or Seattle-Puget Sound, Washington. MEASUREMENTS: Medicare claims were reviewed and women were classified according to their mammography use during the 2 years before diagnosis: nonusers (no prior mammograms), regular users (at least two mammograms at least 10 months apart), or peri-diagnosis users (only mammogram(s) within 3 months before diagnosis). Mammography utilization was linked with SEER data to determine stage at diagnosis and cause of death. Our main outcome variables were (1) stage at diagnosis, classified as early (in situ/Stage I) or late (Stage II or greater), and (2) breast cancer mortality, measured from diagnosis until death from breast cancer or end of the follow-up period (December 31, 1994). RESULTS: Older women who were nonusers of mammography were diagnosed with breast cancer at Stage II or greater more often than regular users (adjusted odds ratio (OR), 3.12; 95% confidence interval (CI), 2.74-3.58). This association was present within each age group studied. Nonusers of mammography were at significantly greater risk of dying from their breast cancer than regular users for all women (adjusted hazard ratio (HR), 3.38; 95% CI, 2.65-4.32) and for women within each age group. Even assuming a lead time of 1.25 years, nonusers of mammography continued to be at increased risk of dying from breast cancer. Our findings remained significant for all women and for the two youngest age groups (67-74 years, 75-85 years), although the benefit was no longer statistically significant for the oldest women (85 years and older). CONCLUSIONS: Older women who undergo regular mammography are diagnosed with an earlier stage of disease and are less likely to die from their disease. These data support the use of regular mammography in older women and suggest that mammography can reduce breast cancer mortality in older women, even for women age 85 and older.

Validation of high-performance liquid chromatographic assay methods for the analysis of carboplatin in plasma ultrafiltrate.

Validation of two HPLC assays for the quantitation of carboplatin in human plasma ultrafiltrate is described. Both assay methods employed a YMC ODS-AQ 3.9 x 150 mm (3 microm) column for the chromatographic separation. The first method utilized direct UV detection, the second method utilized UV detection following post-column derivatization with sodium bisulfite. Structural analogues of carboplatin were synthesized and used as internal standards for the assays. With direct UV detection, sample clean-up using solid-phase extraction on amino cartridges was required prior to injection, with extraction recoveries ranging from 80 to 90%. This extraction procedure was not necessary with the post-column reaction method, which employed a more selective analytical wavelength. Unfortunately, instability of the post-column reagent was a problem and led to greater variability in predicted concentration values. For standard curves, a weighted (1/y2) regression approach was used for plots of peak area or peak height ratio (carboplatin/internal standard) vs. carboplatin concentration. The limit of detection of both assays was 0.025 microg/ml and both were validated for carboplatin concentrations from 0.05 to 40 microg/ml. Accuracy and precision data were generated using three batches of validation samples, each batch consisting of a standard curve and five sets of quality control samples. Stability of carboplatin in blood, plasma, plasma ultrafiltrate, and reconstituted extracts was evaluated. The assay methods were employed for the pharmacokinetic analysis of blood samples drawn from a pediatric patient that received a 400 mg/m2 dose of carboplatin.

Patient assertiveness and physician decision-making among older breast cancer patients.

The objective of this study was to determine whether assertive patient behavior influences physician decision-making in the treatment of older breast cancer patients. One hundred and twenty-eight physicians saw videotapes depicting women seeking care for breast cancer and then recommended evaluation and treatment plans. Identical scripts were used, but the age, race, socioeconomic status, mobility, general health, and assertive behavior of the patients were experimentally varied along with the physician's specialty and length of practice. No direct effects of assertive patient behavior were seen. However, black, comorbid, and lower SES women were more likely to have full staging of their tumors ordered when they made an assertive request. Treatment recommendations also showed an interaction of assertiveness with patient's age and social class as well as physicians' specialty. The results indicate that a moderately assertive patient request may change provider behavior, although the effects of assertiveness vary most by what type of patient demonstrates this behavior. In particular, assertiveness led to more careful diagnostic testing for patients who came from groups that are "disadvantaged."

Do hip replacements improve outcomes for hip fracture patients?

BACKGROUND: Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority. OBJECTIVES: To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation). DESIGN: Prospective cohort study. PARTICIPANTS: We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive. MEASUREMENTS: We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year). RESULTS: Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02). CONCLUSIONS: Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes.

Prevalence of domestic violence in an inpatient female population.

Studies have evaluated the prevalence of domestic violence in populations of patients in emergency and primary care settings, but there are little data on patients admitted to hospitals. We undertook a study to evaluate the prevalence of domestic violence among female inpatients. Of 131 consecutive female patients between the ages of 18 and 60 admitted to a nontrauma urban teaching hospital asked to complete a self-administered survey about domestic violence, 101 completed the questionnaire. Twenty-six percent of the respondents reported being in an abusive relationship at one time. Two patients felt that domestic violence contributed to their current reason for admission. No respondents were asked about domestic violence by health care providers. Domestic violence is an uncommon but important precipitant to nontrauma hospital admissions. Physicians should query all female inpatients about domestic assault.

Mammography use helps to explain differences in breast cancer stage at diagnosis between older black and white women.

BACKGROUND: Older black women are less likely to undergo mammography and are more often given a diagnosis of advanced-stage breast cancer than older white women. OBJECTIVE: To investigate the extent to which previous mammography explains observed differences in cancer stage at diagnosis between older black and white women with breast cancer. DESIGN: Retrospective cohort study using the Linked Medicare-Tumor Registry Database. SETTING: Population-based data from three geographic areas of the United States included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program (Connecticut; metropolitan Atlanta, Georgia; and Seattle-Puget Sound, Washington). PARTICIPANTS: Black and white women 67 years of age and older in whom breast cancer was diagnosed between 1987 and 1989. MEASUREMENTS: Medicare claims were used to classify women according to mammography use in the 2 years before diagnosis as nonusers (no previous mammography), regular users (> or =2 mammographies done at least 10 months apart), or peri-diagnosis users (mammography done only within 3 months before diagnosis). Information on mammography use was linked with SEER data to determine cancer stage at diagnosis. Stage was classified as early (in situ or local) or late (regional or distant). RESULTS: Black women were more likely to not undergo mammography (odds ratio [OR], 3.00 [95% CI, 2.41 to 3.75]) and to be given a diagnosis of late-stage disease (OR, 2.49 [CI, 1.59 to 3.92]) than white women. When women were stratified by previous mammography use, the black-white difference in cancer stage occurred only among nonusers (adjusted OR, 2.54 [CI, 1.37 to 4.71]). Among regular users, cancer was diagnosed in black and white women at similar stages (adjusted OR, 1.34 [CI, 0.40 to 4.51]). In logistic modeling, previous mammography alone explained about 30% of the excess late-stage disease in black women. In a separate model, previous mammography explained 12% of the excess late-stage disease among black women after adjustment for sociodemographic and comorbidity information. CONCLUSION: Differences in breast cancer stage at diagnosis between older black and white women are related to previous mammography use. Increased regular use of mammography may result in a shift toward earlier-stage disease at diagnosis and narrow the observed differences in stage at diagnosis between older black and white women.

Isolation of a hepadnavirus from the woolly monkey, a New World primate.

Hepatitis B virus (HBV) infections are a major worldwide health problem with chronic infections leading to cirrhosis and liver cancer. Viruses related to human HBV have been isolated from birds and rodents, but despite efforts to find hepadnaviruses that infect species intermediate in evolution between rodents and humans, none have been described. We recently isolated a hepadnavirus from a woolly monkey (Lagothrix lagotricha) that was suffering from fulminant hepatitis. Phylogenetic analysis of the nucleotide sequences of the core and surface genes indicated that the virus was distinct from the human HBV family, and because it is basal (ancestral) to the human monophyletic group, it probably represents a progenitor of the human viruses. This virus was designated woolly monkey hepatitis B virus (WMHBV). Analysis of woolly monkey colonies at five zoos indicated that WMHBV infections occurred in most of the animals at the Louisville zoo but not at four other zoos in the United States. The host range of WMHBV was examined by inoculation of one chimpanzee and two black-handed spider monkeys (Ateles geoffroyi), the closest nonendangered relative of the woolly monkey. The data suggest that spider monkeys are susceptible to infection with WMHBV and that minimal replication was observed in a chimpanzee. Thus, we have isolated a hepadnavirus with a host intermediate between humans and rodents and establishes a new animal model for evaluation of antiviral therapies for treating HBV chronic infections.

Improving residents' performances of clinical breast examination.

BACKGROUND: Clinical breast examination and mammography are recommended as combined modalities for breast cancer screening. Rates of mammography are increasing; however, clinical breast examination rates are decreasing. Specific training in breast examination may be warranted. METHODS: The authors developed an ambulatory rotation to teach breast cancer screening to medical residents. To assess whether this training improved screening performance, they compared clinical breast examination and mammography rates in residents' continuity clinics before and after training among residents who were assigned to the training program and residents who were not. RESULTS: 314 women patients were seen by 28 residents. The rates for annual clinical breast examination and mammography were 39% and 71%, respectively. Clinical breast examination rates increased by 18% among the residents assigned to the training program, whereas they dropped by 13% over than same period among the residents who had not received the training (p < 0.005). Female residents performed more clinical breast examinations than did their male counterparts (50% vs 34% p < 0.01). Mammography rates did not change with training, and were not associated with resident gender or career plans. CONCLUSION: Although the residents performed mammography at high rates, clinical breast examination rates were low. Short-term directed teaching about clinical breast examination increased the performance of this screening test, and is important to incorporate into teaching programs.

Physician variability and uncertainty in the management of breast cancer. Results from a factorial experiment.

OBJECTIVES: The purpose of this research was to determine the influence of patient and physician characteristics on physicians' level of variability and certainty in breast cancer care. METHODS: One hundred twenty-eight physicians viewed a videotape of a simulated physician-patient interaction in which the patient has an "atypical" breast lump. Six patient characteristics (age, race, socioeconomic status, physical mobility, comorbidity, presentation style) were manipulated experimentally, resulting in a balanced set of 32 different "patients." Physician subjects were recruited to fill four equal strata defined by specialty (surgeons versus nonsurgeons) and experience (< or = 15 or > 15 years since graduation from medical school). RESULTS: More than half of the physicians offered a diagnosis of benign breast disease, a third offered a diagnosis of breast cancer, and the rest believed that the patient had a normal breast or something "other." Results also indicated that physicians' level of certainty and test ordering behavior varied with the diagnosis that was offered. Of the six patient characteristics, only socioeconomic status influenced physician certainty; physicians were more certain of their diagnosis when the patient was of a higher socioeconomic status. Surgeons were found to be more certain of their diagnosis compared with nonsurgeons. However, surgeons were less likely to order radiologic tests or a tissue sample for metastatic evaluation than were nonsurgeons. CONCLUSIONS: Overall, physicians displayed considerable variability and uncertainty when diagnosing and managing possible breast cancer.

Using telerehabilitation to support assistive technology.

Telerehabilitation--the use of telecommunications technology to provide rehabilitation and long-term support to people with disabilities--offers exciting possibilities for the delivery and support of assistive technology services. This article describes the experiences of a specialty hospital serving persons with disabilities in exploring telerehabilitation to support assistive technology use in the home. Four case studies are presented to illustrate how telerehabilitation may be used in relation to seating evaluation, evaluation of home accessibility, setup of computer access systems, and training in use of augmentative communication devices.

Physician characteristics: do they influence the evaluation and treatment of breast cancer in older women?

BACKGROUND: To determine if physician specialty, length of time in practice, and fear of malpractice influence the diagnosis and management of breast cancer in older women. METHODS: We used a fractional factorial design that controlled for patient age (65 or 80 years), race, socioeconomic status, mobility, comorbidity, and assertive behavior through 2 videotaped scenarios (a potential breast cancer [no. 1] and a known stage IIA breast cancer [no. 2]). One hundred twenty-eight white male physicians equally divided by specialty (surgeon versus nonsurgeon) and time in practice (< or = 15 or >15 years) viewed the videotapes and made recommendations. RESULTS: The physician subjects saw 46 patients per week, 59% female, and 47% age > or = 65. Their concern over malpractice was 4.7 (on a 10-point Likert scale with a higher score indicating more concern) and did not differ by specialty or time in practice (P values > 0.7). After viewing scenario no. 1, surgeons were less likely than nonsurgeons to consider breast cancer as the principal diagnosis (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2 to 0.9) and to obtain a tissue diagnosis (OR = 0.3, 95% CI = 0.1 to 0.9). However, in scenario no. 2, surgeons were more likely to offer reconstruction (OR = 3.8, 95% CI = 1.4 to 10.4). Physicians in practice < or = 15 years were more likely than those in practice <15 years to obtain a tissue diagnosis in scenario no. 1 (OR = 6.1, 95% CI = 1.9 to 19.2) and to perform full primary therapy in scenario no. 2 (OR = 2.8, 95% CI = 1.2 to 6.9). Physicians who performed an extensive metastatic evaluation (bone or computer tomography [CT] scan) had greater concern over malpractice than those who did not, as did physicians who performed an axillary node dissection (OR = 2.1, 95% CI 1.3 to 3.4 and OR = 1.8, 95% CI = 1.1 to 3.0). CONCLUSIONS: With the uncertainty of how to diagnose and treat older women with breast cancer, physician specialty, length of time in practice, and concern over malpractice do influence clinical decisions.

Nonmedical influences on medical decision making: an experimental technique using videotapes, factorial design, and survey sampling.

OBJECTIVE: To study nonmedical influences on the doctor-patient interaction. A technique using simulated patients and "real" doctors is described. DATA SOURCES: A random sample of physicians, stratified on such characteristics as demographics, specialty, or experience, and selected from commercial and professional listings. STUDY DESIGN: A medical appointment is depicted on videotape by professional actors. The patient's presenting complaint (e.g., chest pain) allows a range of valid interpretation. Several alternative versions are taped, featuring the same script with patient-actors of different age, sex, race, or other characteristics. Fractional factorial design is used to select a balanced subset of patient characteristics, reducing costs without biasing the outcome. DATA COLLECTION: Each physician is shown one version of the videotape appointment and is asked to describe how he or she would diagnose or treat such a patient. PRINCIPAL FINDINGS: Two studies using this technique have been completed to date, one involving chest pain and dyspnea and the other involving breast cancer. The factorial design provided sufficient power, despite limited sample size, to demonstrate with statistical significance various influences of the experimental and stratification variables, including the patient's gender and age and the physician's experience. Persistent recruitment produced a high response rate, minimizing selection bias and enhancing validity. CONCLUSION: These techniques permit us to determine, with a degree of control unattainable in observational studies, whether medical decisions as described by actual physicians and drawn from a demographic or professional group of interest, are influenced by a prescribed set of nonmedical factors.

Validation of a high-performance liquid chromatographic assay method for pharmacokinetic evaluation of busulfan.

The development and validation of a high-performance liquid chromatographic (HPLC) assay for determination of busulfan concentrations in human plasma for pharmacokinetic studies is described. Plasma samples containing busulfan and 1,6-bis(methanesulfonyloxy)hexane, and internal standard, were prepared by derivatization with sodium diethyldithiocarbamate (DDTC) followed by addition of methanol and extraction with ethyl acetate. The extract was dried under nitrogen and the samples reconstituted with 100 microl of methanol prior to HPLC determination. Chromatography was accomplished using a Waters NovaPak octadecylsilyl (ODS) (150 x 3.9 mm I.D.) analytical column, NovaPak ODS guard column, and mobile phase of methanol-water (80:20, v/v) at a flow-rate of 0.8 ml/min with UV detection at 251 nm. The limit of detection was 0.0200 microg/ml (signal-to-noise ratio of 6) with a limit of quantitation (LOQ) of 0.0600 microg/ml for busulfan in plasma. Calibration curves were linear from 0.0600 to 3.00 microg/ml in plasma (500 microl) using a 1/y weighting scheme. Precision of the assay, as represented by C.V. of the observed peak area ratio values, ranged from 4.41 to 13.5% (13.5% at LOQ). No day-to-day variability was observed in predicted concentration values and the bias was low for all concentrations evaluated (bias: 0 to 4.76%; LOQ: 2.91%). The mean derivatization and extraction yield observed for busulfan in plasma at 0.200, 1.20 and 2.00 microg/ml was 98.5% (range 93.4 to 107%). Plasma samples containing potential busulfan metabolites and co-administered drugs, which may be present in clinical samples, provided no response indicating this assay procedure is selective for busulfan. This method was used to analyze plasma concentrations following administration of a 1 mg/kg oral busulfan dose.

Outcomes for older men and women with congestive heart failure.

OBJECTIVES: To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF). DESIGN: Prospective cohort study. PARTICIPANTS: A total of 519 patients, aged > or = 65, who were discharged alive after a hospitalization for CHF (DRG = 127). MEASUREMENTS: Outcomes (Activities of Daily Living (ADLs), shortness of breath when walking, perceived health, living situation, rehospitalization, and mortality) were measured at 3 times (6 weeks, 6 months, and 1 year) post-discharge. RESULTS: The 205 men were, on average, younger (77 +/- 7 vs 80 +/- 8, P < .001), wealthier (46% vs 21% earned > or = $10,000, P < .001), and more often married (50% vs 19%, P < .001). Men were more likely than women to have a previous history of CHF (71% vs 63%, P = .052). Men also had higher 1-year mortality than women (48% vs 35%, P = .009), even after adjusting for age, comorbidity, physiological severity (APACHE II APS and RAND discharge instability), radiological evidence of CHF, prior ADLs, walking ability, living situation, and perceived health. Men and women survivors at 1-year had similar and substantial impairment for all non-fatal outcomes considered (all P values > or = .489). Their adjusted mean ADL scores were consistent with complete dependence on one essential activity (range 0-6 dependencies); 35% were short of breath walking less than 1 block; 62% had fair or poor perceived health; 32% received some formal care; and 46% were rehospitalized within 1 year of discharge. CONCLUSIONS: Men with CHF have a higher mortality than women with CHF. Men and women who survive have similar and substantial impairment for all non-fatal outcomes (ADLs, shortness of breath upon walking, perceived health, living situation, and rehospitalization).

Variations in the performance of hip fracture procedures.

OBJECTIVES: Hip replacement is the preferred treatment for displaced femoral neck fractures, whereas other less expensive procedures are preferred for nondisplaced fractures. The authors determined whether there was geographic variation in the use of hip replacement to treat displaced and nondisplaced fractures. METHODS: The authors studied 332 patients, age 65 years or older, hospitalized with a femoral neck fracture in three cities. RESULTS: The population was 55% over age 80, 80% female, and lived in Houston (17%), Pittsburgh (29%), and Minneapolis (54%). Rates of hip replacement varied by city (Houston-84%, Pittsburgh-77%, Minneapolis-63%; P = 0.002), with great variability among patients with nondisplaced fractures (Houston-88%, Pittsburgh-77%, and Minneapolis-56%; P = 0.0001), and no variation among those with displaced fractures (P = 0.72). Other factors associated with hip replacement are history of hip fracture (P = 0.003) and cerebrovascular disease (P < or = 0.10), APACHE II-APS score (P = 0.09), and impacted fracture (P = 0.001). Sociodemographic and functional status (perceived health; activities of daily living and instrumental activities of daily living dependencies) were not associated with hip replacement (P > 0.10). In a logistic model controlling for prior history, APACHE II-APS, and fracture characteristics, city remained a significant predictor of hip replacement (P < 0.001). CONCLUSIONS: Despite an absence of evidence supporting its appropriateness and a much higher cost, hip replacement is used to treat nondisplaced fractures much more frequently in Houston and Pittsburgh than in Minneapolis.

Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment.

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbidities, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.

Black women receive less mammography even with similar use of primary care.

BACKGROUND: Black women with breast cancer have a decreased 5-year survival rate in comparison with white women, possibly because of less frequent use of mammography. Having a regular provider or source of health care is the most important determinant of mammography use. OBJECTIVE: To examine whether the difference in mammography use between elderly black women and elderly white women is related to the number of visits made to a primary care physician. DESIGN: Retrospective review of 1990 Health Care Financing Administration billing files (Medicare part B) from 10 states. SETTING: Outpatient mammography services in 10 states. PARTICIPANTS: Black women and white women, 65 years of age and older, residing in one of the 10 states. MEASUREMENTS: Any mammogram. Predictors included race, number of visits to a primary care physician (0, 1, 2, or 3 or more), median income of ZIP code of residence (a surrogate measure of income), and state. RESULTS: The following are findings from Georgia; similar results were found in each state studied. The mean age of the 335,680 women was 75 years; 20% were black. Sixty-eight percent of the black women and 69% of the white women made at least one visit to a primary care physician. Overall, 14% of the women had had mammography; black women had mammography less often than white women (9% compared with 15%). At each primary care visit level (1, 2, or 3 or more visits), black women had mammography less often than white women (1 visit, 7% compared with 15%; 2 visits, 12% compared with 21%; and 3 or more visits, 12% compared with 20%). Even among women who had made at least one visit to a primary care physician, a deficit for blacks occurred in each income quintile (lowest quintile, 13% compared with 20%; low, 10% compared with 18%; middle, 12% compared with 18%; high, 10% compared with 19%; and highest, 12% compared with 22%) and in each state (in Georgia, for example, the percentages were 14% compared with 21%). An age-, income-, and state-adjusted logistic model predicting mammography use for 2.9 million white women in all 10 states shows the powerful effect of primary care use on mammography (odds ratios for 1, 2, and 3 or more visits were, respectively, 2.73 [95% CI, 2.70 to 2.77]; 3.98 [CI, 3.93 to 4.03]; and 4.62 [CI, 4.58 to 4.67]). The same model fit to 250 000 black women shows a lesser effect (analogous odds ratios were 1.77 [CI, 1.67 to 1.87]; 2.49 [CI, 2.36 to 2.63]; and 3.15 [CI, 3.04 to 3.25]). CONCLUSION: Among older women, mammography is used less often for blacks than for whites. More frequent use of mammography is associated with more visits to a primary care physician in both groups, but the deficit for black women persists at each income level and in each state, even after primary care use is considered. Primary care visits are less likely to "boost" mammography use for black women than for white women.

Variability in mammography use among older women.

OBJECTIVE: To determine rates of and explore factors associated with mammography use among older women. DESIGN: Retrospective review of part B (physician) bills submitted to Medicare during 1990. SETTING: Health Care Financing Administration (HCFA) data, including sociodemographic information and part B physician bills for all services delivered to Medicare-eligible women in 1990. PATIENTS/PARTICIPANTS: Women age 65 or older as of January 1, 1990, residing in one of 10 states with part B coverage through December 31, 1990. MEASUREMENTS AND MAIN RESULTS: The outcome was receipt of a mammogram (yes/no). We explored factors associated with mammography use within three age groups: 65 to 74, 75 to 84, and 85+. The factors considered were race, state, median income of ZIP Code of residence (from the 1990 US Census, and used to divide the population into quintiles within each state), and number of primary care visits (0, 1, 2, and 3+). Overall, 15% of women had a mammogram: 20% of women age 65 to 74, 12% of women age 75 to 84, and 4% of women age 85 and older. Mammography use was lowest in Oklahoma and highest in Washington. However, in each state the older the age category, the less the mammography use (e.g., 9% vs 5% vs 2% in Oklahoma and 25% vs 16% vs 5% in Washington for women 65-74, 75-84, and 85+, respectively). Mammography use was lower for black than for white women age 65 to 74 (14% vs 21%, P < .001) and 75 to 84 (9% vs 12%, P < .001). Women in each of these two age groups had lower mammography use if they resided in the lowest income quintile and highest if they resided in the highest income quintile (17% vs 23% 65-74, and 10% vs 13% 75-84, P values < .001). Among the oldest women (those 85+), mammography use was low (4%) and varied minimally by race and income (P = .907 and .003, respectively). In all age groups, mammography use was lowest among women who did not have a primary care visit, was greater among women who had at least one visit, and continued to rise with increasing numbers of visits (all P values < .001). For example, among women age 75 to 84, mammography use increased from 5% to 10%, 14%, and 17% for those with 0, 1, 2, and 3+ visits. CONCLUSIONS: We found that mammography use was less for women who were older, of black race, who did not visit a primary care provider, and who lived in areas with lower median income and certain geographic locations (states). Similar factors influenced mammography use in women age 65 to 74, where there is greater consensus as to who should receive a mammogram, and women age 75 to 84, where there is neither consensus nor data. Surprisingly, neither race nor income had much influence on mammography use among women age 85 or older.

As mammography use increases, are some providers omitting clinical breast examination?

OBJECTIVE: To explore use of clinical breast examination (CBE) among women receiving mammography. METHODS: A retrospective cohort analysis of 100 women aged 50 years or older with at least one bilateral mammogram. Chart review documented demographic information, severity of illness, and performance of CBE (from 1 year prior to 18 months after the mammogram). RESULTS: The mean age of the 100 women was 63 years. They were predominantly unmarried (60%), nonwhite (58%), and not currently employed (57%). Three quarters (76%) had mammography and CBE (comprehensive screening), while the remaining 24% had mammography only. Sociodemographic factors did not differ for women with and without comprehensive screening (P>.1). However, patients of female providers were more likely to receive comprehensive screening than patients of male providers. Specifically, 95% of women seen by female attending physicians or fellows had comprehensive screening vs 67% for male attending physicians or fellows and 61% for residents (P=.008). CONCLUSIONS: Mammography may be replacing CBE especially among patients of male providers. Interventions targeted to these providers could help improve the use of CBE and mammography.