The history and the effect of the mammography quality assurance legislation in Michigan.

This paper describes the history of mammography quality assurance legislation in Michigan, the first of its kind in the nation. It discusses the collaboration of multiple organizations in the legislative process as well as in the implementation of it. It describes the effect of the legislation on the quality of mammography throughout the state and summarizes the lessons learned from the process, especially as they apply to the implementation of the Mammography Quality Standards Act at the national level.

Mammography use and outcomes in a community. The Greater Lansing Area Mammography Study.

BACKGROUND: Mammography is widely known to reduce morbidity and mortality from breast cancer, but a population-based assessment of mammography use and follow-up of mammography findings has not been reported previously. METHODS: An observational, population-based, follow-up study was conducted of all women having mammograms in the Greater Lansing, Michigan, metropolitan area, between June 1987 and June 1988. A total of 17,811 Greater Lansing women participated. The adherence of women to mammography screening guidelines was estimated, and mammography's utility to detect breast cancer was assessed through follow-up review of breast biopsy results. RESULTS: Thirty-seven percent of the expected number of women 35 years of age and older had mammograms. Adherence to screening guidelines declined with age, and less than 5% (302 of 6700) of women 55 years of age and older reporting having annual mammograms. Seventy-six percent of women reported that their physicians prompted the examination. The predictive value of a positive mammogram was 21.9% for women without symptoms and 32.4% for women with symptoms. Mammography's sensitivity and specificity for breast cancer detection were 71% and 98%, respectively. CONCLUSIONS: The study highlights the need to target mammography to women 50 years of age and older, underscores the importance of physicians in promoting mammography, and demonstrates the analytic value and limitation of mammography in clinical decision-making.

Physicians' attitudes toward mandatory workplace urine drug testing.

BACKGROUND: Workplace drug testing programs are being increasingly implemented in both the public and private sectors, and health care workers are unlikely to be excluded from such testing. METHODS: A survey of attending physicians' attitudes toward mandatory hospital-based urine drug testing was undertaken in a medium-sized, midwestern county. RESULTS: Seventy-four percent (272/368) of the sample responded. Seventy-two percent of the subjects believed physician drug use to be a minor or nonexistent problem, 38% lacked confidence in the testing procedure, and 60% believed that testing infringed on the physician's right to privacy; yet 87% would submit to testing if required by a hospital. Forty-five percent of respondents agreed with the policy of mandatory testing for physicians with hospital privileges, 34% disagreed, and 21% were uncertain. Respondents were more supportive of mandatory testing of other health care and non-health care occupations than for themselves. Support for testing was greatest for illicit drugs. If implemented, physicians preferred mandatory testing to be performed by hospital medical staff independent of hospital administration. CONCLUSIONS: Further education and discussion within the physician community appears to be necessary before widespread mandatory workplace urine drug testing of physicians is implemented.

Clostridium perfringens outbreak associated with minestrone soup.

Clostridium perfringens food poisoning usually occurs after animal protein foods such as meat or poultry are consumed. In November 1990, an outbreak of gastrointestinal illness occurred among attendees at a conference of cake decorators held in Michigan. All 42 conference attendees were surveyed. Thirty-two of 42 (76%) attendees reported gastrointestinal symptoms. The median incubation period was 6.5 hours (range, 1.5-15 hours). Ill persons were almost five times more likely to have consumed minestrone soup than were those who were not ill (relative risk = 4.92, 95% confidence interval 1.23-infinity). Bacteriologic analysis identified C. perfringens in the soup and in 11 of 12 stool specimens from ill persons. The soup was cooked 2 days prior to serving and was slowly cooled before refrigeration; it was briefly reheated on the day served. Failure to monitor time and temperature controls during the cooling and reheating of the soup probably allowed for C. perfringens proliferation in the minestrone soup. This investigation demonstrated that nonanimal protein sources, such as legumes, can support substantial C. perfringens growth and should be regarded as potential vehicles in C. perfringens outbreaks.

The design and implementation of a community breast cancer screening project.

A breast cancer screening program offers a community the opportunity to highlight and address an important health issue. This article has described the important elements of any such screening effort. To be successful, the program will require a multidisciplinary cadre of health care professionals working collaboratively throughout all phases of the planning, screening, and follow-up process. An agency should be identified to lead these professionals and monitor the progress of the screening effort. These screening programs can have direct and indirect benefits in the community. The direct benefits include improved access and delivery of health services, particularly those that meet state-of-the-art quality standards. The indirect benefits involve the promotion of breast cancer screening through education of women and providers about good breast health practices. As our experience in Michigan has shown, efforts featuring a broad coalition of forces can foster debate and discussion throughout the community and ultimately lead to improvements in the delivery of breast cancer screening services.

Disease prevention strategies for Army aviators: clues from a descriptive analysis of the flying duty medical examination.

The U.S. government spends approximately $300,000 to train an Army aviator. Maintaining a healthy aviator population is important not only to the completion of the aviation mission, but also for budgetary reasons. We reviewed Army aviator physical examinations and self-reported risk behavior questionnaires from the Aeromedical Epidemiological Data Repository at Fort Rucker, Alabama, to assess aviator health. Overall, aviators are healthy adults; however, the health status of aviators can be improved by reducing tobacco use, limiting cholesterol and fat intake, and wearing hearing protection devices both during and off duty.

Sentinel surveillance of HIV infection among new inmates and implications for policies of corrections facilities.

Seroprevalence surveys of incoming inmates provide useful sentinel information on human immunodeficiency virus (HIV) infection rates among groups that practice HIV-associated high-risk behaviors. In addition, such data are beneficial to corrections officials in the formulation of institutional policies to prevent HIV infection. Inmates entering the Michigan corrections system from December 1987 to March 1988 participated in blind, anonymous serosurveys for HIV infection. Eight of 802 entering inmates (1.0 percent) were seropositive; most seropositive persons reported intravenous drug use. The most common risk behaviors reported by study participants were intravenous drug use (20.0 percent), multiple sexual partners (37.1 percent), and infrequent (that is, never or seldom) use of condoms (82.6 percent). Women reported the highest rates of intravenous drug use (35.1 percent) and needle-sharing (19.4 percent). Results from this study indicate that in spite of wide-spread HIV-associated risk behaviors, the extent of HIV-seropositivity among incoming inmates in Michigan is relatively low. Such data suggest that there is still time to impact the course of the AIDS epidemic among high-risk groups in States where the prevalence of HIV infection is relatively low. The data also indicate that the potential for HIV spread in correctional facilities is noteworthy and that HIV prevention education and substance abuse treatment services are needed in corrections facilities.

Screening mammography for women 50 years of age and older: practices and trends, 1987.

Recently, public and private efforts have been mounted to promote screening mammography. To assess recent trends in the percentage of women 50 years of age and older who have had a screening mammogram, we analyzed data from interviews from women from 33 states who participated in the 1987 Behavioral Risk Factor Surveillance System. Our study group included 8,402 women 50 years of age and older who had visited a physician for a routine checkup in the last year; among these 8,402 women, only 29% reported having had a screening mammogram in the past year. However, of the women in the study group, the percentage who had a screening mammogram in the last year showed a relative increase of 38% during 1987, from 24% for women interviewed in the first quarter of 1987 to 33% for women interviewed in the fourth quarter. However, not all groups of patients benefited equally from the observed trend--the absolute and relative increases in the percentage of women screened were lowest for women who were older, less educated, in low-income groups, and who had poor personal health practices. Although the percentage of women 50 years of age and older who reported being screened increased dramatically during 1987, special efforts are needed to reach the patient groups that are being left behind in the trend toward increased use of screening mammograms.

Amyotrophic lateral sclerosis. A case-control study following detection of a cluster in a small Wisconsin community.

From 1975 to 1983, six cases of amyotrophic lateral sclerosis (ALS) were diagnosed in long-term residents of Two Rivers, Wis; the probability that this occurred due to chance was less than .05. To investigate potential risk factors for ALS, we conducted a case-control study using two control subjects matched to each case patient for age, gender, and duration of residence in Two Rivers. Physical trauma, the frequent consumption of freshly caught Lake Michigan fish, and a family history of cancer were reported more often by case patients than control subjects. These findings support previous studies proposing a role for trauma in ALS pathogenesis and suggest that the causative role of diet should be further explored. Continued surveillance for and epidemiologic investigation of ALS clusters with subsequent retrospective analysis may provide clues concerning the cause of ALS.

Hepatitis B vaccination programs for hospital workers: results of a statewide survey.

To assess the implementation of hepatitis B virus (HBV) vaccination programs for hospital workers, we mailed questionnaires to all 229 licensed Michigan hospitals. The response rate was 96% (221/229); of these, 68% (150/221) had vaccination programs. Although multiple hospital characteristics were associated with the presence of a vaccination program, characteristics that independently predicted the presence of a program were medical school affiliation, nonpsychiatric specialty, and the existence of a hepatitis B immune globulin protocol. The most common reason given (56%, 40/71) for the absence of a program was insufficient worker risk of hepatitis B infection; this response was frequent in psychiatric (91%, 10/11) and rural hospitals (61%, 11/18). Among high-risk workers, attending physicians were less likely than other high-risk workers to be included in vaccination programs (68% vs. 95%, respectively). Fear of vaccine-associated acquired immunodeficiency syndrome was most frequently cited as the primary reason for vaccine refusal. We conclude that unwarranted fears about the vaccine's safety need to be dispelled, that high-risk physicians should be included in vaccination programs, and that rural and psychiatric hospital policies reflect their perceived risk of occupational HBV infection.

Q fever. A call to heighten our index of suspicion.

The prevalence of Q fever infection is probably underestimated. In Michigan, the first two reported human cases of Q fever occurred in 1984. The case-patients lived in adjacent, rural counties and had multiple exposures to goats. We conducted a serosurvey of goat owners and a reference population to compare the prevalence of Q fever antibodies in the two-county area. Goat owners were almost three times more likely to be seropositive with Q fever antibodies than the reference population (43% vs 15%). Among goat owners, individual and household seropositivity prevalences were positively correlated with the number of goats, the number of positive goats, and the number of goat births on the farm. Q fever should be considered more often in the differential diagnosis of patients with compatible illness, especially those with frequent animal contact.

A measles outbreak at university medical settings involving health care providers.

In 1985, a measles outbreak involved 14 students and non-student contacts in Michigan. Eight transmissions occurred at university medical facilities; five of these were likely airborne transmissions. Medical students and a medical resident were involved in the outbreak's propagation. Health care providers need to be immune to measles. Measles should be suspected in young adults with compatible illnesses; persons suspected to have measles should be placed in stringent respiratory isolation to preclude airborne transmission.

Are physicians advising smokers to quit? The patient's perspective.

Physicians can play an important role in smoking cessation because they have frequent contact with smokers and because most smokers believe that a physician's advice is important in the decision to quit. Therefore, to determine smokers' perceptions of physician involvement in smoking cessation, we analyzed aggregate data from two random statewide surveys of 5875 Michigan adults. Of smokers who had seen a physician in the previous year, only 44% reported that they had ever been told to quit smoking by a physician. Young male smokers were the least likely (30%) to have been told to quit. Smokers who were hypertensive, obese, diabetic, sedentary, or users of oral contraceptives were no more likely to have been told to quit than smokers without these additional cardiovascular risks. Conversely, smokers who had survived a myocardial infarction or stroke were more likely to have been told to quit than smokers who had not suffered these events (73% vs 43%). Most smokers do not perceive physicians to be even minimally involved in their efforts to quit. Physicians need to increase their efforts in counseling smokers to quit before smoking-related diseases result, especially for smokers with additional risk factors for cardiovascular disease.