Colorectal cancer screening participation: comparisons with mammography and prostate-specific antigen screening.

OBJECTIVES: The relation of personal characteristics, health and lifestyle behaviors, and cancer screening practices to current colorectal cancer (CRC) screening was assessed and compared with those factors' relation to current mammography screening in women and prostate-specific antigen (PSA) screening in men. METHODS: A cross-sectional random-digit-dialed telephone survey of 954 Massachusetts residents aged 50 and older was conducted. RESULTS: The overall prevalence of current CRC screening was 55.3%. Logistic regression results indicated that family history of CRC (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.02, 3.86), receiving a regular medical checkup (OR = 3.07; 95% CI = 2.00, 4.71), current screening by mammography in women and PSA in men (OR = 4.40; 95% CI = 2.94, 6.58), and vitamin supplement use (OR = 1.87; 95% CI = 1.27, 2.77) were significant predictors of CRC screening. CONCLUSIONS: Health and lifestyle behaviors were related to increased current CRC, mammography, and PSA screening. Personal factors independently related to CRC screening were not consistent with those related to mammography and PSA screening. This lack of consistency may reflect different stages of adoption of each type of screening by clinicians and the public.

Underutilizers of mammography screening today: characteristics of women planning, undecided about, and not planning a mammogram.

Using concepts from the Precaution Adoption Process Model, we identified behavioral factors, sociodemographic and psychosocial variables, and beliefs about breast cancer that discriminated among women at different stages with regard to their intention to obtain mammography screening. An independent survey company conducted telephone interviews with 2,507 women aged 50 to 80 who were identified as underutilizers of mammography screening. Each underutilizer was assigned to one of three stages with regard to intention to get a mammogram: (a) definitely planning, (b) thinking about, and (c) not planning. Estimated actual risk of breast cancer, perceived risk to breast cancer, worry about breast cancer, and fear of learning from a mammogram that one has breast cancer were variables found to be significantly associated with intention to obtain a mammogram for several subgroups of underutilizing women. There are significant behavioral and psychosocial variables, beliefs and feelings about breast cancer, and demographic characteristics that distinguish underutilizing women at various stages with regard to intention to obtain mammography screening. Our findings provide new information that could help the health care professional motivate women who are not planning to utilize this preventive health measure to become regular utilizers.

Cancer control knowledge, attitudes, and perceived skills among medical students.

BACKGROUND: The Cancer Prevention and Control Education (CPACE) program aims to strengthen and coordinate curriculum offerings in cancer prevention and control for medical, graduate nursing and public health students. METHODS: Students were surveyed on cancer-related knowledge and confidence as part of needs assessment and evaluation efforts. The students completed self-administered surveys (response rate 78%). Descriptive and stratified analysis and ANOVA were conducted. RESULTS: Knowledge and confidence generally increased with each successive class year, but confidence varied markedly across specific counseling scenarios and by gender. While the students overall reported greater confidence in performing an examination than in interpreting the results, confidence varied significantly across specific types of examinations. CONCLUSIONS: Understanding of basic information about common cancers was disappointing. Confidence to perform and interpret examinations could be higher, especially for opposite-gender screening examinations. Implications of the findings for CPACE curriculum development are discussed.

Promoting mammography: results of a randomized trial of telephone counseling and a medical practice intervention.

BACKGROUND: Despite widespread promotion of mammography screening, a distinct minority of women have remained underusers of this effective preventive measure. We sought to measure the effects of barrier-specific telephone counseling (BSTC) and a physician-based educational intervention (MD-ED) on mammography utilization among underusers of mammography screening. DESIGN: This was a randomized controlled trial. Women meeting criteria for mammography underuse at baseline (grouped by practice affiliation) were randomized to a reminder control condition (RC group received annual mailed reminders), BSTC or MD-ED interventions and followed for 3 years. Underuse was defined by failure to get two annual or biannual mammograms over a 2- to 4-year period prior to a baseline survey. PARTICIPANTS AND SETTING: The study included 1655 female underusers of mammography aged 50-80 years who were members of two health maintenance organizations (HMO) in central Massachusetts. INTERVENTIONS: BSTC consisted of periodic brief, scripted calls from trained counselors to women who had not had a mammogram in the preceding 15 months. Women could receive up to three annual calls during the study. MD-ED consisted of physician and office staff trainings aimed at improving counseling skills and office reminder systems. MAIN OUTCOME MEASURE: Self-report of mammography use during the study period was the main outcome measure. Regular use was defined as > or =1 mammogram every 24 months. RESULTS: Forty-four percent in each intervention group became regular users compared to 42% in the RC group. Among subjects who had prior but not recent mammograms at baseline, BSTC was effective (OR=1.48; 95% CI=1.04; 2. 10), and MD-ED marginally effective (OR=1.28; 95% CI=0.88, 1.85). Most recent users at baseline and few never users became regular users (61% and 17%, respectively) regardless of intervention status. CONCLUSIONS: Among mammography underusers BSTC modestly increases utilization for former users at a reasonable cost ($726 per additional regular user).

The effectiveness of using standardized patients to improve community physician skills in mammography counseling and clinical breast exam.

BACKGROUND: Traditional didactic continuing education is relatively ineffective in improving physicians' clinical skills. We hypothesized that a centralized course including small group workshops utilizing standardized patients could improve clinical skills for a reasonable cost. METHODS: We designed a 5-h course aimed at improving physicians' counseling skills (re: screening mammography) and clinical breast exam (CBE) skills. The course included lectures, demonstrations, and small group skills sessions utilizing standardized patients and was offered to 156 typical community-based primary care physicians. Pre- and postcourse evaluation included in-office assessments of physician CBE and counseling performance by standardized patients and a written test of knowledge and attitudes. RESULTS: A total of 54.5% of eligible physicians participated. They improved modestly in only one of three areas of counseling skills measured (providing counseling appropriate to the patient's readiness to accept mammography, P = 0.01). The overall CBE score increased substantially from 24.8 to 34.7 (P < 0.0001). Knowledge in all areas measured and confidence in counseling patients also increased. The basic course cost $202 per physician trained. CONCLUSIONS: Most community-based primary care physicians may find small group training and in-office evaluation involving standardized patients acceptable. Such training may be more effective in improving physical exam skills than complex communication skills.

Underusers of mammogram screening: stage of adoption in five U.S. subpopulations. The NCI Breast Cancer Screening Consortium.

BACKGROUND: The purpose of this report is to describe the characteristics of women ages 50 to 80 who do not follow commonly accepted mammography screening guidelines. It provides unique understanding of the robustness of characteristics of underusers across five different U.S. subpopulations. METHODS: The data are from the baseline surveys of the five studies of the NCI Breast Cancer Screening Consortium. Stage of adoption of mammography screening and other characteristics of underusers are presented. Polytomous logistic regression analysis was used to explore multivariable associations with stage of adoption in each study site. RESULTS: The five samples studied by the Consortium range in size from 259 to 4,477 women (n = 11,292). The relationship of the perceptions of the pros and cons of mammography with stage of adoption was strikingly similar across the five samples. Other variables consistently associated with stage were a recent receipt of a breast physical examination and recommendation for mammography by a physician. CONCLUSIONS: The findings suggest a need to encourage regular screening through effective communication from a health care provider. Intervention messages should be designed to increase the pros of mammography, decrease the cons, and highlight these differentially according to the woman's stage of adoption.

Periodic health evaluation of adults: a survey of family physicians.

BACKGROUND: The routine periodic health evaluation (PHE) is a popular format in primary care practice for the delivery of clinical preventive services to adults, but knowledge of the current pattern of use and of the content of the PHE is limited. METHODS: We surveyed a random sample of 567 family physicians (response rate, 60.1%) in New England regarding their approach to and attitudes about the PHE of adults. RESULTS: Family physicians reported spending a mean of 35.2% (11.6 hours per week) of their total ambulatory care time on adult PHEs, which were usually scheduled for 20 to 30 minutes each. All respondents recommended a PHE to men > or = 50 years old and to women > or = 40 years old, and more than 90% recommended a PHE to younger patients. Most physicians (80.7%) reported that the PHE is their primary mechanism for delivering preventive services, and 90.6% believed that the PHE should include a comprehensive physical examination. The mean number of physical examination items performed during the PHE was 11.6 to 13.9, depending on patient age and sex. As part of the PHE, most physicians (71.6% to 90.7%, depending on patient age and sex) ordered one or more screening laboratory tests not recommended by the US Preventive Services Task Force. Utilization of fewer laboratory tests was associated with residency training, employment in a health maintenance organization (HMO), and limited concern about malpractice suits. CONCLUSIONS: Family physicians reported spending a substantial amount of time on the PHE of adults, performing extensive screening physical examinations and many screening laboratory tests of unknown effectiveness. Among family physicians, there is considerable unexplained variation in the form and content of the PHE.

Office systems for promoting screening mammography. A survey of primary care practices.

BACKGROUND: Office tracking, scheduling, and reminder systems have been shown to improve utilization of screening mammography, but little is known about the use of these systems by primary care physicians. METHODS: We surveyed 132 primary care and obstetrics and gynecology practices affiliated with an independent practice association model health maintenance organization in central Massachusetts to determine their use of reminder, scheduling, and follow-up systems, and education and counseling services aimed at increasing screening mammography rates. RESULTS: The use of chart flags to remind physicians of a patient's need for mammography screening was reported by 30% of practices. Thirty-one percent reported the use of flow sheets, and 27% reported the use of mail or telephone patient reminders. At least one of these three systems was used by 57% of the practices, whereas 43% reported having none of these three systems. Variations in the use of these office systems were related to specialty type, physician number, and clinical staffing. The majority of practices (77%) reported using written educational materials, and 42% offered prevention counseling with nonphysician staff. Very few offices (8%) reported using mail or telephone reminders for previously scheduled appointments. CONCLUSIONS: Despite the proven effectiveness of reminder systems for screening mammography, many practices do not have a system in place. Promotion of reminder systems in primary care practices could have a substantial impact on mammography utilization.

Characteristics of primary care office systems as predictors of mammography utilization.

OBJECTIVE: To evaluate the association between primary care office systems and mammography utilization by women older than 50 years. DESIGN: Cross-sectional. SETTING: An independent-practice association health maintenance organization (HMO) in Massachusetts. PARTICIPANTS: One hundred thirty-two primary care practices, representing 321 physicians and 4378 women with at least 12 months of recent, continuous assignment to a practice participating in the HMO. MEASUREMENTS: Practice characteristics and procedures for mammography referral and follow-up were ascertained by interviews of office managers. For each practice, the proportion of women older than 50 years who received a mammogram during their most recent 12-month period of assignment to the practice was calculated. MAIN RESULTS: Forty-five percent of eligible women received a mammogram during their most recent year of assignment to an HMO practice. In a regression model, use of one particular urban mammography center, group practice, and low percentage of Medicaid patients in the practice were each associated with 9% to 12% higher mammography utilization; use of flowsheets and the scheduling of mammograms by the patients themselves were associated with 7% to 9% higher utilization. Smaller, nonsignificant increases were associated with the use of reminders to patients (5%) and the presence of only internists on staff (5%). The model accounted for 51% of the variation in mammography utilization among practices. CONCLUSIONS: Mammography utilization among women older than 50 years, in a population in which cost was not a barrier, was related to specific office characteristics. Features of the mammography center, the process for scheduling mammograms, the use of flowsheets to prompt physicians, and the use of reminders to patients are important.

A survey of formal training in the care of children in family practice residency programs.

BACKGROUND: Declining hospitalization rates for children and an increased emphasis on ambulatory care may be affecting the way family practice residency programs train their residents in the care of children. METHODS: We surveyed all US family practice residency program directors to determine the nature of the child care training that programs currently provide to residents. RESULTS: Responses were received from 78% of the programs. Residencies required a mean of 5.2 months of formal pediatric training (range: 1 to 11 months). Thirty percent of programs noted a declining inpatient census on inpatient pediatric teaching services, but since 1978, the mean duration of inpatient pediatric training increased by 0.4 months to a required mean of 2.7 months of general pediatric inpatient training (range: 0 to 6 months). The mean time devoted to structured outpatient pediatric training was only 1.6 months (range: 0 to 6 months). Nine percent of responding programs required no formal pediatric outpatient training other than family health center experience. CONCLUSIONS: Despite declining inpatient census and increased emphasis on comprehensive ambulatory care, family practice residencies require more formal inpatient pediatric training than formal outpatient training.

The epidemiology of acute appendicitis in California: racial, gender, and seasonal variation.

The incidence of acute appendicitis has been reported to vary substantially by country, geographic region, race, sex, season, and occupation, but the reasons for this variation are unknown. We evaluated several risk factors for appendicitis by analyzing data from hospital discharge abstracts on all cases of acute appendicitis treated surgically in nonfederal hospitals in California from 1983 to 1986 (N = 102,546). Comparison of age and sex-specific incidence rates for four racial/ethnic groups (white, Hispanic, black, and Asian/other) revealed rates in blacks and the Asian/other group one-half or less of the rates for whites and Hispanics between the ages of 5 and 29 years. Incidence rates in males were higher than rates in females in all racial/ethnic groups for most ages (RR = 1.1-1.7). Seasonal variation in incidence was modest. Peak rates occurred in July, August, and September, and the lowest rates occurred in December. Hypotheses about the etiology of appendicitis must account for substantial racial/ethnic, gender, age variation, and modest seasonal variation in the incidence.

Quantitative ultraviolet skin exposure in children during selected outdoor activities.

We determined the cumulative exposure of 3 body sites to ultraviolet radiation from sunlight for 126 children observed from 1-3 d during a variety of common recreational activities at a girl scout camp, baseball camp and community baseball field. Median arm exposure to children playing baseball at a camp ranged from 27.6% to 33.2% of the possible ambient exposure. These exposures are similar to adult exposures reported for comparable activities. Median exposure to the arm at the girl scout camp during mixed activities ranged from 9.0% to 26.5% of possible ambient exposure. At the girl scout camp, exposure both within and between activity groups varied substantially and were more variable than the baseball players' exposure. Arm exposure was greater than cheek and forehead exposure for all subject groups, with an arm-to-cheek exposure ratio ranging from 1.7 to 2.3. For organized sports, such as baseball, it may be possible to assign a single exposure estimate for use in epidemiologic studies or risk estimates. However, for less uniform outdoor activities, wide variability in exposure makes it more difficult to predict an individual's exposure.

The natural history of HIV-1 infection: staging classifications of disease.

We evaluated and compared four staging classification systems for HIV infection in a population-based cohort: (1) a staging based on prodromal clinical criteria; (2) the Walter Reed Staging Classification (WRSC); (3) the immunologic staging system (ISS), and (4) a simple staging based on oral disease and CD4+ T-cell depletion. The staging systems were applied to 386 HIV-infected men in the San Francisco Men's Health Study cohort who did not have AIDS at the baseline examination. After 48-56 months of follow-up the cumulative incidence of AIDS and the cumulative mortality by stage was determined for each staging. Unlike the other systems, the WRSC could not classify a substantial proportion of HIV-infected men (51.9%). The WRSC and ISS include one or more stages which did not appear to be associated with a prognosis substantially different from that of adjacent stages. The simplified staging system based on CD4+ T-cell depletion and oral disease may be the most effective of the systems studied. A more complete understanding of the pathophysiology during the evolution of HIV infection will be required to define a more detailed staging of this disease.

Incidence and case fatality rates for acute appendicitis in California. A population-based study of the effects of age.

In 1984, 24,794 appendectomies and abscess drainage procedures were performed for acute appendicitis in California hospitals. Analysis of hospital discharge abstracts revealed age- and sex-specific incidence rates and in-hospital case fatality rates for acute appendicitis lower than previously reported. In persons aged 60 years and older, the case fatality rate for nonperforating appendicitis with appendectomy was 0.7% and for perforating appendicitis and abscess 2.4%. Surgery was delayed beyond the day of admission in 21% of persons aged 40-59 years, 29% of persons aged 60-79 years, and 47% of persons aged 80 years and over. The proportion of cases with perforation increased from 22% to 75% between ages 20 and 80 years. The population incidence of perforating appendicitis changed little after age 20 years, while the incidence of nonperforating cases declined sharply. The high proportion of appendicitis cases with perforation among the elderly may be due to the decreased incidence of nonperforating appendicitis in the elderly and not to a greater propensity for perforation, as previously proposed. Most elderly in California receive timely surgery for appendicitis and tolerate it better than previously reported. Diminished tolerance for intra-abdominal infection may be the primary determinant of the increase in case fatality with age.