Beyond the mammography quality standards act: measuring the quality of breast cancer screening programs.

OBJECTIVE: A high-quality screening mammography program should find breast cancer when it exists and when the lesion is small and ensure that suspicious findings receive prompt follow-up. The Mammography Quality Standards Act (MQSA) guidelines related to tracking outcomes are insufficient for assessing quality of care. We used data from a quality improvement project to determine whether screening mammography facilities could show that they met certain quality benchmarks beyond those required by MQSA. MATERIALS AND METHODS: Participating facilities provided aggregate data on screening mammography examinations performed in calendar year 2009 and corresponding diagnostic follow-up, including patients lost to follow-up, timing of diagnostic imaging and biopsy, cancer detection rates, and the proportion of cases of cancer detected as minimal and early-stage tumors. RESULTS: Among the 52 participating institutions, the percentage of institutions meeting each benchmark varied from 27% to 83%. Facilities with American College of Surgeons or National Consortium of Breast Centers designation were more likely to meet benchmarks pertaining to cancer detection and early detection, and disproportionate share facilities were less likely to meet benchmarks pertaining to timeliness of care. CONCLUSION: The results suggest a combination of quality of care issues and incomplete tracking of patients. To accurately measure the quality of the breast cancer screening process, it is critical that there be complete tracking of patients with abnormal screening mammography findings so that results can be interpreted solely in terms of quality of care. The MQSA guidelines for tracking outcomes and measuring quality indicators should be strengthened for better assessment of quality of care.

Vitamin D and insulin resistance in non-diabetic women's interagency HIV study participants.

We explored the relationship between vitamin D levels and insulin resistance (IR) among 1082 nondiabetic (754 HIV-infected) women enrolled in the Women's Interagency HIV study (WIHS), a large and well-established cohort of HIV infected and uninfected women in the US. Vitamin D levels 20-29 ng/mL were considered insufficient and <20 ng/mL deficient. IR was estimated using the homeostasis model assessment (HOMA) and a clinically significant cut-off ≥2.6 was used for HOMA-IR. In the unadjusted analysis, women who were vitamin D insufficient or deficient were 1.62 (95% CI: 1.01-2.61, p=0.05) and 1.70 (95% CI: 1.11-2.60, p=0.02) times more likely to have HOMA values≥2.6 compared to women with sufficient vitamin D. The association did not remain significant after adjustment for factors associated with IR. Among the 754 HIV-infected women, current PI use (OR 1.61, 95% CI: 1.13-2.28, p=0.008) remained independently associated with HOMA ≥2.6 while vitamin D insufficiency (OR 1.80, 95% CI: 0.99-3.27, p=0.05) was marginally associated with HOMA ≥2.6 after adjustment. Ethnicity, body mass index, smoking status, and hepatitis C status were independently associated with insulin resistance in HIV-infected and uninfected women. We found a marginally significant association between vitamin D insufficiency and insulin resistance among nondiabetic HIV-infected WIHS women.

Describing the appearance and flavor profiles of fresh fig (Ficus carica L.) cultivars.

Twelve fig cultivars, including cultivars destined for the fresh and dried markets, were harvested from 6 locations and evaluated by a trained panel using descriptive sensory analysis. Instrumental measurements were taken at harvest and also during sensory analysis. Each fresh fig cultivar had a characteristic appearance and flavor sensory profile regardless of the source. The primary flavor attributes used to describe the fig cultivars were "fruity,""melon,""stone fruit,""berry,""citrus,""honey,""green," and "cucumber." Maturity levels significantly affected the chemical composition and sensory profiles of the fig cultivars. Less mature figs had a higher compression force, a thicker outer skin, and higher ratings for "green" and "latex" flavors, firmness, graininess, bitterness, tingling, and seed adhesiveness. Meanwhile, more mature figs had higher soluble solids concentration, and were perceptibly higher in "fruit" flavors, juiciness, stickiness, sliminess, and sweetness. The specific sensory terminology used for fig appearance and flavor profiles will assist with communication between marketers and consumers, which can increase fresh fig consumption.

The racial disparity in breast cancer mortality in the 25 largest cities in the United States.

INTRODUCTION: Although the racial disparity in breast cancer mortality is widely discussed there are no studies that analyze this phenomenon at the city level. METHODS: We used national death files, abstracting those cases for which the cause was malignant neoplasm of the breast (ICD-10=C50) for the numerators and American Community Survey data for the denominators. The 25 largest cities in the US were the units of analysis. Non-Hispanic Black:non-Hispanic White rate ratios (RRs) were calculated, along with their confidence intervals, as measures of the racial disparity. Seven ecological (city-level) variables were examined as possible correlates. RESULTS: Almost all the NHB rates were greater than almost all the NHW rates. All but 3 of the RRs (range 0.78-2.09; median=1.44) were >1, 13 of them significantly so. None of the RRs<1 were significant. From among the 7 potential correlates, only median household income (r=-0.43, p=0.037) and a measure of segregation (r=0.42, r=0.039) were significantly related to the RR. CONCLUSION: This is the first study that we have been able to locate which examines city-level racial disparities in breast cancer mortality. The results are of concern for several cities and for the field in general. A strategy for reducing this disparity in Chicago is in place and may serve as a model for other cities wanting to initiate a similar process. Clearly it is time to take action.

The racial disparity in breast cancer mortality.

Black women die of breast cancer at a much higher rate than white women. Recent studies have suggested that this racial disparity might be even greater in Chicago than the country as a whole. When data describing this racial disparity are presented they are sometimes attributed in part to racial differences in tumor biology. Vital records data were employed to calculate age-adjusted breast cancer mortality rates for women in Chicago, New York City and the United States from 1980-2005. Race-specific rate ratios were used to measure the disparity in breast cancer mortality. Breast cancer mortality rates by race are the main outcome. In all three geographies the rate ratios were approximately equal in 1980 and stayed that way until the early 1990s, when the white rates started to decline while the black rates remained rather constant. By 2005 the black:white rate ratio was 1.36 in NYC, 1.38 in the US, and 1.98 in Chicago. In any number of ways these data are inconsistent with the notion that the disparity in black:white breast cancer mortality rates is a function of differential biology. Three societal hypotheses are posited that may explain this disparity. All three are actionable, beginning today.

Smoking cessation among women with and at risk for HIV: are they quitting?

BACKGROUND: Cigarette smoking is an important risk factor for adverse health events in HIV-infected populations. While recent US population-wide surveys report annual sustained smoking cessation rates of 3.4-8.5%, prospective data are lacking on cessation rates for HIV-infected smokers. OBJECTIVE: To determine the sustained tobacco cessation rate and predictors of cessation among women with or at risk for HIV infection. DESIGN: Prospective cohort study. PARTICIPANTS: A total of 747 women (537 HIV-infected and 210 HIV-uninfected) who reported smoking at enrollment (1994-1995) in the Women's Interagency HIV Study (WIHS) and remained in follow-up after 10 years. The participants were mostly minority (61% non-Hispanic Blacks and 22% Hispanics) and low income (68% with reported annual incomes of less than or equal to $12,000). MEASUREMENTS AND MAIN RESULTS: The primary outcome was defined as greater than 12 months continuous cessation at year 10. Multivariate logistic regression was used to identify independent baseline predictors of subsequent tobacco cessation. A total of 121 (16%) women reported tobacco cessation at year 10 (annual sustained cessation rate of 1.8%, 95% CI 1.6-2.1%). Annual sustained cessation rates were 1.8% among both HIV-positive and HIV-negative women (p = 0.82). In multivariate analysis, the odds of tobacco cessation were significantly higher in women with more years of education (p trend = 0.02) and of Hispanic origin (OR = 1.87, 95% CI = 1.4-2.9) compared to Black women. Cessation was significantly lower in current or former illicit drug users (OR = 0.42 95% CI = 0.24-0.74 and OR = 0.65, 95% CI = 0.49-0.86, respectively, p trend = 0.03) and women reporting a higher number of cigarettes per day at baseline (p trend < 0.001). CONCLUSIONS: HIV-infected and at-risk women in this cohort have lower smoking cessation rates than the general population. Given the high prevalence of smoking, the high risk of adverse health events from smoking, and low rates of cessation, it is imperative that we increase efforts and overcome barriers to help these women quit smoking.

Black-White health disparities in the United States and Chicago: a 15-year progress analysis.

OBJECTIVES: In an effort to examine national and Chicago, Illinois, progress in meeting the Healthy People 2010 goal of eliminating health disparities, we examined whether disparities between non-Hispanic Black and non-Hispanic White persons widened, narrowed, or stayed the same between 1990 and 2005. METHODS: We examined 15 health status indicators. We determined whether a disparity widened, narrowed, or remained unchanged between 1990 and 2005 by examining the percentage difference in rates between non-Hispanic Black and non-Hispanic White populations at both time points and at each location. We calculated P values to determine whether changes in percentage difference over time were statistically significant. RESULTS: Disparities between non-Hispanic Black and non-Hispanic White populations widened for 6 of 15 health status indicators examined for the United States (5 significantly), whereas in Chicago the majority of disparities widened (11 of 15, 5 significantly). CONCLUSIONS: Overall, progress toward meeting the Healthy People 2010 goal of eliminating health disparities in the United States and in Chicago remains bleak. With more than 15 years of time and effort spent at the national and local level to reduce disparities, the impact remains negligible.

Cancer screening knowledge, attitudes, and behaviors among culturally Deaf adults: implications for informed decision making.

BACKGROUND: Previous studies show that Deaf persons tend to have lower health status, lack health knowledge, have differing health attitudes, and decreased health care utilization when compared to the general population. The authors sought to examine knowledge, attitudes, and behaviors surrounding age- and gender-specific cancer screening tests amongst a sample of Deaf adults who were patients of Deaf-friendly medical organizations. The authors also sought to compare age- and gender-specific cancer screening rates amongst this sample to that of the general US population. METHODS: A sample of 203 adult Deaf patients participated in a comprehensive, face-to-face health survey conducted between November 2002 and March 2003. The survey was administered in American Sign Language by Deaf interviewers and included age- and gender-specific cancer knowledge, attitude, and behavior questions. RESULTS: Knowledge pertaining to Pap smear among females was low, while the proportion having ever had a Pap smear was comparable to the general population. Mammography knowledge amongst females age 50 and older was comparatively higher, although it remained lower than the proportion of females in this age group who reported ever receiving a mammogram. Overall, screening rates for breast, cervical, and colorectal cancer were similar to rates in the general US population. Attitudes toward specific cancer screening tests were also favorable. CONCLUSIONS: Persons within the Deaf community can have cancer screening rates similar to those of the general US population. However, utilization in the absence of knowledge regarding these tests is worrisome and brings about ethical, health care quality and health education concerns.