Metabolic phenotypes of obesity: frequency, correlates and change over time in a cohort of postmenopausal women.

OBJECTIVE: The possibility that a subset of persons who are obese may be metabolically healthy-referred to as the 'metabolically healthy obese' (MHO) phenotype-has attracted attention recently. However, few studies have followed individuals with MHO or other obesity phenotypes over time to assess change in their metabolic profiles. The aim of the present study was to examine transitions over a 6-year period among different states defined simultaneously by body mass index (BMI) and the presence/absence of the metabolic syndrome (MetS). METHODS: We used repeated measurements available for a subcohort of participants enrolled in the Women's Health Initiative (N=3512) and followed for an average of 6 years to examine the frequency of different metabolic obesity phenotypes at baseline, the 6-year transition probabilities to other states and predictors of the risk of different transitions. Six phenotypes were defined by cross-tabulating BMI (18.5-<25.0, 25.0-<30.0, ⩾30.0 kg m-2) by MetS (yes, no). A continuous-time Markov model was used to estimate 6-year transition probabilities from one state to another. RESULTS: Over the 6 years of follow-up, one-third of women with the healthy obese phenotype transitioned to the metabolically unhealthy obese (MUO) phenotype. Overall, there was a marked tendency toward increased metabolic deterioration with increasing BMI and toward metabolic improvement with lower BMI. Among MHO women, the 6-year probability of becoming MUO was 34%, whereas among unhealthy normal-weight women, the probability of 'regressing' to the metabolically healthy normal-weight phenotype was 52%. CONCLUSIONS: The present study demonstrated substantial change in metabolic obesity phenotypes over a 6-year period. There was a marked tendency toward metabolic deterioration with greater BMI and toward metabolic improvement with lower BMI.

Multivitamin and mineral use and breast cancer mortality in older women with invasive breast cancer in the women's health initiative.

Multivitamin use is common in the United States. It is not known whether multivitamins with minerals supplements (MVM) used by women already diagnosed with invasive breast cancer would affect their breast cancer mortality risk. To determine prospectively the effects of MVM use on breast cancer mortality in postmenopausal women diagnosed with invasive breast cancer, a prospective cohort study was conducted of 7,728 women aged 50-79 at enrollment in the women's health initiative (WHI) in 40 clinical sites across the United States diagnosed with incident invasive breast cancer during WHI and followed for a mean of 7.1 years after breast cancer diagnosis. Use of MVM supplements was assessed at WHI baseline visit and at visit closest to breast cancer diagnosis, obtained from vitamin pill bottles brought to clinic visit. Outcome was breast cancer mortality. Hazard ratios and 95 % confidence intervals (CIs) for breast cancer mortality comparing MVM users to non-users were estimated using Cox proportional hazard regression models. Analyses using propensity to take MVM were done to adjust for potential differences in characteristics of MVM users versus non-users. At baseline, 37.8 % of women reported MVM use. After mean post-diagnosis follow-up of 7.1 ± 4.1 (SD) years, there were 518 (6.7 %) deaths from breast cancer. In adjusted analyses, breast cancer mortality was 30 % lower in MVM users as compared to non-users (HR = 0.70; 95 % CI 0.55, 0.91). This association was highly robust and persisted after multiple adjustments for potential confounding variables and in propensity score matched analysis (HR = 0.76; 95 % CI 0.60-0.96). Postmenopausal women with invasive breast cancer using MVM had lower breast cancer mortality than non-users. The results suggest a possible role for daily MVM use in attenuating breast cancer mortality in women with invasive breast cancer but the findings require confirmation.

Analysis of a hepatitis C screening programme for US veterans.

This study analyses a screening programme for hepatitis C virus (HCV) infection among US veterans in a suburban Veterans Affairs Medical Center, in New York. This is the first study examining all 11 potential risk factors listed in the 2001 National U.S. Veterans Health Administration Screening Guidelines. A retrospective study was conducted of 5400 veterans 'at risk' of HCV, identified through a questionnaire in this institution's primary-care outpatient departments between 1 October 2001 and 31 December 2003. Multivariate logistic regression models were built to identify independent predictors of infection. Of 2282 veterans tested for HCV, 4.6% were confirmed by HCV PCR to be HCV infected. In the multivariate model developed, injection drug use, blood transfusion before 1992, service during the Vietnam era, tattoo, and a history of abnormal liver function tests were independent predictors of HCV infection. Our data support considering a more targeted screening approach that includes five of the 11 risk factors.

An educational approach to improving physician breast cancer screening practices and counseling skills.

A multifaceted, individualized, physician education program designed to increase the breast cancer screening practices of community-based primary care physicians is described and the results are evaluated. Community-based surveys identified primary care providers with breast cancer screening educational needs who were assigned, using a factorial design, to an intervention or control condition. The sample included 154 control and 128 intervention physicians. The intervention consisted of a 1-2h in-office training program and/or self-study workbook. Self-reported overall breast cancer screening need scores improved for a greater proportion of intervention than control physicians, particularly those receiving the in-office intervention (P=0.03). Clinical breast examination (CBE) need declined (P=0.01); use of provider reminder systems increased (P=0.02); preparedness to counsel about CBE (P=0.04) and recognition that age is an important risk factor for breast cancer (P=0.02) improved in more intervention compared to control physicians.

A systems model of clinical preventive care: the case of breast cancer screening among older women. For the NCI Breast Cancer Screening Consortium.

BACKGROUND: In older women covered by Medicare, relationships among physician recommendation, mammography in the past 2 years, and clinical breast examination (CBE) in the past year were systematically explored with a variety of predisposing, enabling, and situational factors identified in the Systems Model of Clinical Preventive Care. METHODS: A population-based survey of women age 65 years and older was conducted in five National Cancer Institute's Breast Cancer Screening Consortium geographic areas. Analyses focused on women with a regular physician and site of care (n = 5318). RESULTS: Physician recommendation and mammography use declined with women's increasing age and increased with income, education, and insurance. CBE and mammography increased with number of physicians and breast cancer family history; mammography use decreased with worsening health status. Recommendations were higher among physicians who were younger, female, and internists. Family practitioners were older and male; women who saw family practitioners reported characteristics associated with decreased screening-lower income, education, and insurance-and seeing only one physician. CONCLUSIONS: Public policy and health system changes that create a uniform system of finance and service performance expectations may reduce the persistent discrepancy in physician recommendation and mammography use due to sociodemographics and physician specialty.

A threat to the public health workforce: evidence from trends in preventive medicine certification and training.

Evidence of a growing need for preventive medicine specialists is the congruence between needed competencies for practice in the current health care environment, as identified by the Council on Graduate Medical Education (COGME) and in other national reports, and the core competencies of preventive medicine residents. The total number of certified specialists in preventive medicine is 6091. The proportion of self-designated preventive medicine specialists among all U.S. physicians is on the decline and the greatest decline has been among those in public health (PH) and general preventive medicine (GPM). In addition, the total number of preventive medicine residents is on the decline, and the decline has been greatest among those training in PH and combined PH/GPM. One of the reasons for this decline has been inadequate funding due to the absence of Medicare graduate medical education (GME) financing for population-based vs. individual patient care services and meager and diminishing Title VII support. A paucity of faculty is apparent in medical schools with residency training and board certification in preventive medicine. Several actions may help reverse this trend and assure adequate numbers of preventive medicine specialists: expansion of Title VII to increase the number of residents receiving stipends and tuition, adding infrastructure support for faculty development and funding of demonstration projects in distance learning and in joint generalist/ preventive medicine residency training. Medicare GME reform should include recognition of population-based services and inclusion of preventive medicine residencies in provisions for "nonhospital-based" training and in up-weighting methodologies for primary care training. Expansion of Veterans Affairs, National Institute for Occupational Safety and Health, and Department of Defense support is also needed as is attention to resident debt reduction.

Methodology for targeting physicians for interventions to improve breast cancer screening.

INTRODUCTION: Uneven increases in mammography utilization rates call for methods to efficiently target educational interventions to women who do not regularly use mammography and physicians who do not adhere to national guidelines for breast cancer screening. This paper discusses a method for identifying physicians who are nonadherers to breast cancer screening guidelines or in need of continuing medical education (CME) in this area. METHODS: A 1995 community-based telephone survey of randomly selected women aged 50-80, residing in four Long Island, NY, townships was used to identify women who underuse mammography and their regular physicians. Community-based surveys of physicians permitted identification of nonadherent providers. Nonadherence to breast cancer screening recommendations was the primary criterion, but because of anticipated physician reluctance to self report nonadherence with screening guidelines, additional criteria were developed to identify physicians with educational needs relating to breast cancer screening. These criteria included lack of office reminder systems and knowledge relating to breast cancer screening, and lack of confidence in patient counseling and clinical breast examination skills. RESULTS: Overall response rates were 77% for women's survey, and 66% for the physician survey. 3427 women were classified as underusers (38.5%) and 87% of underusers provided the name and address of their regular physicians. By physician self report, 45% of physicians were classified as nonadherers and 42% were identified as having related educational needs. CONCLUSION: A feasible method for identifying physicians who are nonadherers to breast cancer screening recommendations or in need of CME about this is described, permitting efficient targeting of educational interventions to those with patients who underuse mammography. The method is not dependent on access to a specific provider or patient population.

Core competencies for preventive medicine residents: Version 2.0.

During the early 1990s, the American College of Preventive Medicine (ACPM), with support from the Health Resources and Services Administration (HRSA), identified core competencies and performance indicators (measures to assess their achievement) for all preventive medicine residents. After the competencies were approved, distributed by the ACPM and HRSA, and published in the American Journal of Preventive Medicine, they were integrated in various ways into the operation of individual residency programs. Changes in the health care system during the decade, however, necessitated an update of the original competencies to better equip preventive medicine educators to prepare residents for new roles those in preventive medicine can play in a restructured health care system. HRSA funded an effort to produce Version 2.0 of the preventive medicine competencies based on review and refinement of the original competencies through a consensus process. This article includes these revised core competencies and performance indicators.

Current perspectives on physician barriers to breast cancer screening.

BACKGROUND: Despite reports of rising mammography utilization, breast cancer screening rates still lag behind national recommendations and goals, particularly for older women. This study explores current modifiable physician barriers to screening. METHODS: Family physicians and internists on the staff of 10 Long Island community hospitals were surveyed during three successive waves (1988, 1990, 1995) about breast cancer screening behavior. The final survey also assessed current attitudes and level of confidence in screening abilities and beliefs relating to cancer risk and screening of the elderly. RESULTS: The proportion of physicians reporting regularly referring all women aged 50 to 75 years for mammography increased significantly from 37 percent (1988) to 64 percent (1995), while the proportion reporting regularly performing clinical breast examinations remained stable at 56 percent. More than 25 percent of respondents to the 1995 survey were not aware that breast cancer risk increases with aging, and more than one half did not recognize that breast cancer detection by mammography is enhanced in older postmenopausal women. Some physicians reported lack of confidence in aspects of patient counseling, examination, and use of office systems to promote screening. CONCLUSION: Continuing medical education programs addressing knowledge deficits and perceived physician needs for enhancement of clinical breast examination skills are needed to promote continued improvement in inadequate mammography screening rates.

Breast cancer screening knowledge and skills of students upon entering and exiting a medical school.

PURPOSE: To assess needs for breast cancer screening education by comparing medical students' training and knowledge of breast cancer screening upon their entry to and exit from medical school. METHOD: Seventy-seven medical students at one medical school completed questionnaires as first-year students (in 1992) and again as fourth-year students (in 1996) that assessed their breast cancer screening knowledge. The fourth-year questionnaire included additional questions about the students' clinical training in breast cancer screening skills and their perceptions of needs for further training. RESULTS: Although the students performed significantly better on the knowledge-based questions in their fourth year than they did in their first year, considerable room for improvement remained. The students reported learning the most from surgery rotations and more from standardized patients than from faculty. Women medical students performed significantly more clinical breast examinations than did men students. CONCLUSIONS: Most of the medical students reported needing additional training in clinical breast examination. More curricular time devoted to education about breast cancer screening is needed.

Defining competencies and performance indicators for physicians in medical management.

The recent and profound changes in the American health care delivery system have created a need for physicians who are trained and willing to assume a high level of responsibility for managing evolving health care organizations. Yet most physicians receive no formal training in medical administration and management because changes in medical school and residency education have lagged behind changes in clinical practice and reimbursement. To avoid haphazard approaches and unnecessary duplication of resources, it is important for physicians involved in managerial medicine to collectively identify competencies in this area needed in the marketplace. The American College of Preventive Medicine (ACPM), with funding from the Health Resources and Services Administration (HRSA), undertook an effort to identify competencies essential for physicians who will fill leadership roles in medical management. Like ACPM's earlier effort to develop core competencies in preventive medicine, this project drew upon the theoretical model of competency-based education. This article describes the strategy we followed in reaching consensus among a diverse group of physician executives and preventive medicine residency program directors, and includes the list of medical management competencies and performance indicators developed. Recurrent issues that can sidetrack competency development projects are also presented as well as suggestions for overcoming them. The competencies can serve as a framework for expanding current core preventive medicine training in management and administration and for developing new training programs to equip physicians with the special expertise they will need to provide management leadership within the changing landscape of health care delivery.

Outcomes of recommendations for breast biopsies in women receiving mammograms from a county health van.

OBJECTIVE: To describe the outcomes of breast biopsy recommendations for women screened through a mobile mammography van. METHODS: Data on all women screened through the Mobile Mammography Program in Suffolk County, Long Island, NY, from 1990 to 1994 were analyzed to determine biopsy recommendation rates, biopsy rates, positive biopsy rates, and cancer detection rates. Follow-up information was obtained from the women's physicians. RESULTS: The breast cancer detection rate for women screened through the Mobile Mammography Program averaged 0.33% over a five-year period. The biopsy recommendation rate based on abnormal mammograms remained stable, at about 1% to 2%, over a five-year period, as did the rate of positive biopsies among women having biopsies (36.8% to 44.4%). For women ages 50 and older, the cancer rate in 1994 was 0.36%, while for women younger than age 50, the cancer rate was 0.25% (0.32% for all ages). CONCLUSIONS: These findings show that a breast cancer screening program using a mobile van can have comparable cancer detection rates to national figures and a fairly stable biopsy recommendation rate from which follow-up resource needs can be estimated.

Confirmatory analysis of opinions regarding the pros and cons of mammography.

This investigation extends prior research to apply decision-making constructs from the transtheoretical model (TTM) of behavior change to mammography screening. Study subjects were 8,914 women ages 50-80, recruited from 40 primarily rural communities in Washington State. Structural equation modeling showed that favorable and unfavorable opinions about mammography (i.e., pros and cons) fit the observed data. Analysis of variance supported the associations between readiness to obtain screening (i.e., stage of adoption) and opinions about mammography (i.e., decisional balance) previously found in research using smaller samples from another geographic region. This report extends these earlier studies by using structural equation modeling, opinion scales based both on principal component analyses and on a priori definitions, a developmental sample and a confirmatory sample, and by sampling from a different geographic region. It is recommended that future research examine whether opinions regarding the cons of mammography are more individually specific than the pros.

Trends in mammography use and their relation to physician and other factors.

This study examines trends and factors (e.g., physician utilization) affecting mammography use from 1988 to 1990 among women residing in an area of high breast cancer incidence. Mail surveys of independent random samples of over 2000 women 50 to 75 years of age residing on Long Island were conducted each of the three study years, and responses were compared. Statistically significant increases in reported mammography use occurred over the 3-year period within all age, income, and educational subgroups. These were accompanied by a decline in reporting that the doctor did not recommend it, as a reason for not having a mammogram, and by a statistically significant increase in reported physician recommendation among those who visit a doctor annually, particularly those using a gynecologist. Clinical breast examination was the strongest predictor of mammography use, with knowledge of the recommended screening frequency also strong associated. Despite a regionally high incidence of breast cancer, screening mammography use corresponded to national rates. Access and visits to a regular physician were critical factors and substantiated the need for education of women, family practitioners, and internists about breast cancer screening guidelines.

The use of cohort vs repeated cross-sectional sample survey data in monitoring changing breast cancer screening practices.

BACKGROUND: The method used to select a study sample is a key element in designing a research protocol. This article explores two of the more common methods used, focusing on the relative advantages and disadvantages of each one. METHODS: Both cohort and repeated, independent cross-sectional surveys were conducted in each of 3 years (1988-1990) in the Awareness of Breast Cancer Screening Project to follow changing breast cancer screening rates among a population of women 50-75 years of age on Long Island, New York. RESULTS: Both survey methods revealed statistically significant increases in self-reports of mammography use. The cohort and repeated cross-sectional survey sample responses to questions concerning knowledge, attitudes, and behavior regarding breast cancer screening were comparable. An educational effect of the baseline survey itself on the cohort was not seen. CONCLUSIONS: Each of the two survey methods has advantages and disadvantages with respect to the other. The cohort method permits examination of changes in the same individual over time and is less costly and less time-consuming to perform. On the other hand, the cross-sectional method does not suffer from cumulative losses in respondents with repeated surveys and better reflects the changing community. The study findings can be used to guide the selection of an appropriate survey methodology for monitoring breast cancer screening practices in other settings.

Performance indicators for assessing competencies of preventive medicine residents.

Heightened national interest in population-based medicine, clinical preventive services, and health care management underscores the current need for definition and assessment of physician competency in these areas. This article describes a project sponsored by the Health Resources and Services Administration (HRSA) to develop competencies for each of the three specialty areas in preventive medicine and appropriate measures for the achievement of those competencies. We discuss fundamental issues surrounding assessment that helped guide the process, types of measurement strategies, and criteria for effective competencies and performance indicators. The article also explains the Work Group process used to reach consensus and identifies concerns and challenges raised during this process. We include the list of specialty competencies and performance indicators developed by the project. The project, entitled "Improving Training of Preventive Medicine Residents through the Development and Evaluation of Competencies," served as a model for interorganizational collaboration between the federal government (HRSA); a specialty society, the American College of Preventive Medicine (ACPM); and a preventive medicine residency program, State University of New York (SUNY) at Stony Brook. The commonality of competencies expected of residents in all three specialty areas of preventive medicine--occupational medicine, general preventive medicine and public health, and aerospace medicine--reaffirmed the rationale for including all of these areas within the single specialty of preventive medicine.

Consensus on core competencies for preventive medicine residents.

Of the currently available literature on assessment of physician competency, very little applies to the needs of preventive medicine specialists. Yet the diversity of the field and the confusion among other medical specialists about the particular expertise of preventive medicine physicians suggest a need for consensus on fundamental competencies expected of graduates of preventive medicine residency training programs. We apply theoretical material on competency-based education from teacher training and instructional development to professional training in preventive medicine. We describe the process by which the Graduate Medical Education Subcommittee of the American College of Preventive Medicine (ACPM), a working group of specialists, derived and refined core competencies in working sessions at professional meetings. The drafts produced at these sessions were circulated widely to residency directors and other individuals and groups in preventive medicine before being approved by the ACPM Board of Regents and included in the Residency Training Manual distributed by ACPM. This article includes this list of core competencies for preventive medicine residents. In addition, the article describes assumptions about competency development that guided the process and identifies recurrent problems in competency development. This information may be helpful to readers who wish to develop additional competencies or to tailor these competencies for their own preventive medicine residency programs.