Incident depression in patients diagnosed with multiple sclerosis: a multi-database study.

BACKGROUND AND PURPOSE: Data on rates of newly diagnosed depression after multiple sclerosis (MS) diagnosis are sparse. Here, incident, treated depression in MS patients after diagnosis compared with matched non-MS patients is described. METHODS: A matched cohort study was conducted in two separate electronic medical databases: the US Department of Defense (US-DOD) military healthcare system and the UK's Clinical Practice Research Datalink GOLD (UK-CPRD). The study population included all patients with a first recorded diagnosis of MS and matched non-MS patients. Patients with a history of treated depression were excluded. Incidence rates and incidence rate ratios with 95% confidence intervals for treated depression after MS diagnosis/matched date were estimated. RESULTS: Incidence rate ratios of treated depression amongst MS patients compared with non-MS patients were 3.20 (95% confidence interval 3.05-3.35) in the US-DOD and 1.90 (95% confidence interval 1.74-2.06) in the UK-CPRD. Incidence rate ratios were elevated across age and sex. Rates were higher in females than males but, compared to non-MS patients, males with MS had a higher relative risk than females with MS. CONCLUSIONS: Multiple sclerosis patients in the UK and the USA have a two- to three-fold increased risk of new, treated depression compared to matched non-MS patients.

Race and differences in breast cancer survival in a managed care population.

BACKGROUND: African-American women with breast cancer have poorer survival than European-American women. After adjustment for socioeconomic variables, survival differences diminish but do not disappear, possibly because of residual differences in health care access, biology, or behavior. This study compared breast cancer survival in African-American and European-American women with similar health care access. METHODS: We measured survival in women with breast cancer who are served by a large medical group and a metropolitan Detroit health maintenance organization where screening, diagnosis, treatment, and follow-up are based on standard practices and mammography is a covered benefit. We abstracted data on African-American and European-American women who had been diagnosed with breast cancer from January 1986 through April 1996 (n = 886) and followed these women for survival through April 1997 (137 deaths). RESULTS: African-American women were diagnosed at a later stage than were European-American women. Median follow-up was 50 months. Five-year survival was 77% for African-American and 84% for European-American women. The crude hazard ratio for African-American women relative to European-American women was 1.6 (95% confidence interval [CI] = 1.1-2.2). Adjusting only for stage, the hazard ratio was 1.3 (95% CI = 0.9-1.9). Adjusting only for sociodemographic factors (age, marital status, and income), the hazard ratio was 1.2 (95% CI = 0.8-1.9). After adjusting for age, marital status, income, and stage, the hazard ratio was 1.0 (95% CI = 0.7-1.5). CONCLUSION: Among women with similar medical care access since before their diagnoses, we found ethnic differences in stage of breast cancer at diagnosis. Adjustment for this difference and for income, age, and marital status resulted in a negligible effect of race on survival.

Racial differences in the presentation and surgical management of breast cancer.

BACKGROUND: African American women are seen with more advanced breast cancers, are less likely to be treated with breast-conserving surgery, and generally have poorer prognoses than white women. There are a myriad of potential causes for these phenomena. The purpose of this study was to measure racial differences in the surgical treatment of breast cancer among women with comparable health care access and delivery. METHODS: The Breast Cancer Registry of the Department of Surgery at Henry Ford Hospital was accessed for all patients between January 1, 1990, and December 31, 1997 for whom data on race, tumor characteristics, stage, and treatment specifics were available. Socioeconomic information was collected with use of 1990 census block data. Proportions of women who received each treatment were compared for African Americans and whites with use of the relative risk (RR) and 95% confidence intervals (CI). We used multiple logistic regression to obtain estimates of the relative risk, controlling for potential confounding factors. RESULTS: Of the 1699 patients in the database, 1250 had sufficient information for analysis. A total of 8.7% of African American women were diagnosed with late-stage disease (i.e., stage III or IV) compared with 7.9% of whites. Nevertheless, African American women had a lower frequency of stage I disease (30.5% vs 36.2%) and a higher frequency of stage II disease (36.8% vs 31.4%). Overall and adjusted risk estimates for age, tumor stage, marital status, median income, and type of insurance revealed no substantive or statistically significant differences between African American and white patients. The adjusted RR for local excision was 1.39 (95% CI 0.78 to 2.49), for lumpectomy and axillary dissection RR 0.92 (95% CI 0.66 to 1.29), for simple mastectomy RR 0.84 (95% CI 0.41 to 1.72), and for modified radical mastectomy RR 1.00 (95% CI 0.73 to 1.36). CONCLUSIONS: In this setting of equal access to health care, African American women still have higher frequencies of stage II disease, although the frequencies for late-stage disease are similar. Nevertheless, no surgical differences were found in this population, even after the effects of socioeconomic indicators and stage at diagnosis were controlled for Survival differences between African American and white women are unlikely to be explained by differences in treatment.

Influenza immunization in a managed care organization.

OBJECTIVE: To compare the effects of different types of computer-generated, mailed reminders on the rate of influenza immunization and to analyze the relative cost-effectiveness of the reminders. DESIGN: Randomized controlled trial. SETTING: Multispecialty group practice. PATIENTS: We studied 24,743 high-risk adult patients aligned with a primary care physician. INTERVENTION: Patients were randomized to one of four interventions: (1) no reminder, which served as control; (2) a generic postcard; (3) a personalized postcard from their physician; and (4) a personalized letter from their physician, tailored to their health risk. MEASUREMENTS: The immunization rate was measured using billing data. A telephone survey was conducted in a subgroup of patients to measure reactions to the mailed reminders. To evaluate the cost-effectiveness, a model was constructed that integrated the observed effect of the interventions with published data on the effect of immunization on future inpatient health care costs. MAIN RESULTS: All three of the reminders studied increased the influenza vaccination rate when compared with the control group. The vaccination rate was 40.6% in the control group, 43.5% in the generic postcard group, 44.7% in the personalized postcard group, and 45.2% in the tailored letter group. The rates of immunization increased as the intensity of the intervention increased (p < .0001). Seventy-eight percent of patients in the letter group deemed the intervention useful, and 86% reported that they would like to get reminders in the future. The cost-effectiveness analysis estimated that in a nonepidemic year, the net savings per 100 reminders sent would be $659 for the personalized postcard intervention and $735 for the tailored letter intervention. When these net cost-savings rates were each applied to the entire high-risk cohort of 24,743 patients, the estimated total net savings was $162,940 for the postcard and $181,858 for the tailored letter. CONCLUSIONS: Although the absolute increase in immunization rates with the use of reminders appeared small, the increases translated into substantial cost savings when applied to a large high-risk population. Personalized reminders were somewhat more effective in increasing immunization, and personalized letters tailored to the patients' condition were deemed useful and important by the individuals who received them and had a beneficial indirect effect on patient satisfaction.

Redesigning primary care processes to improve the offering of mammography. The use of clinic protocols by nonphysicians.

OBJECTIVE: To develop, within the framework of continuous quality improvement, new processes for offering mammography and determine whether protocols executed completely by nonphysicians would increase mammography utilization. DESIGN: A prospective follow-up study with patients from an intervention clinic and two control clinics. SETTING: Three general internal medicine clinics in a large, urban teaching hospital in Detroit, Michigan. PATIENTS/PARTICIPANTS: A total of 5,934 women, aged 40 through 75 years, making 16,546 visits to one of the clinics during the study period (September 1, 1992, through November 31, 1993). INTERVENTION: Medical assistants and licensed practical nurses in the intervention clinic were trained to identify women due for screening mammography, and to directly offer and order a mammogram if patients agreed. MEASUREMENTS AND MAIN RESULTS: Patients were considered up-to-date with screening if they had a mammogram within 1 year (if age 50-75) or 2 years (if age 40-49) prior to the visit or a mammogram within 60 days after the visit. The proportion of visits each month in which a woman was up-to-date with mammography was calculated using computerized billing records. Prior to the intervention, the proportion of visits in which women were up-to-date was 68% (95% confidence interval [CI] 63%, 73%) in the intervention clinic and 66% (95% CI 61%, 71%) in each of the control clinics. At the end of the evaluation, there was an absolute increase of 9% (95% CI 2%, 16%) in the intervention clinic, and a difference of 1% (95% CI -5%, 7%) in one of the control clinics and -2% (95% CI -3%, 5%) in the other. In the intervention clinic, the proportion of visits in which women were up-to-date with mammography increased over time and was consistent with a linear trend (p = .004). CONCLUSIONS: Redesigning clinic processes to make offering of mammography by medical assistants and licensed practical nurses a routine part of the clinic encounter can lead to mammography rates that are superior to those seen in physicians' usual practice, even when screening levels are already fairly high. Physicians need not be considered the sole, or even the primary, member of the health care team who can effectively deliver some preventive health measures.

Patient-related risk factors that predict poor outcome after total hip replacement.

OBJECTIVE: To identify factors associated with poor outcome after total hip replacement (THR) surgery. DATA SOURCES: This article is the first to present results from the American Medical Group Association (AMGA) THR consortium. STUDY DESIGN: The outcomes evaluated were pain and physical function. Eight patient risk factors were evaluated. These included the age, sex, race, marital status, and education of the patient; whether the patient had polyarticular disease or other comorbid conditions; and the patient's preoperative pain and physical function score. DATA COLLECTION: Data were collected from patients using AMGA-approved, self-administered questionnaires preoperatively and at six weeks, three months, six months, one year, and two years postoperatively. PRINCIPAL FINDINGS: Of the patient risk factors studied, race, education, number of comorbid conditions, and preoperative Health Status Questionnaire (HSQ) score were found to be associated with poor outcome. These risk factors were found to have an effect on both pain and physical function at six months postoperatively. Patients with higher preoperative scores were found to have higher postoperative scores, but substantially fewer of these patients received any benefit from their surgery. For each 10-point increase in preoperative score, patients could expect at least a 6-point decrease in postoperative improvement. CONCLUSIONS: Our study indicates that preoperative status is an important predictor of outcome for THR.

Inadequate follow-up of abnormal mammograms.

Routine mammographic screening increases detection of nonpalpable breast cancer. Timely follow-up of abnormalities is essential because delays may lead to postponement of treatment and decreased survival for women who have cancer. The purpose of this study was to determine the percentage of women with an abnormal mammogram who do not have adequate follow-up and to determine factors associated with inadequate follow-up. The study was conducted in a metropolitan health system that includes a large urban teaching hospital in Detroit and 26 ambulatory care centers. From the radiology database, all women with an abnormal screening mammogram performed between January 1, 1992, and July 31, 1992 were identified. We defined adequate follow-up as follow-up within three months of due date. Follow-up status was determined using medical records and telephone interviews. The percentage of women with inadequate follow-up was calculated. Relative risks compared percentages of women with inadequate follow-up according to demographic and screening-related variables. We calculated adjusted relative risks using multivariate binomial regression. We identified 1,249 women with abnormal screening mammograms. Inadequate follow-up occurred for 226 (18.1%) of the women. Among women with follow-up recommended in 4-6 months, 36.8% had inadequate follow-up. Among women with immediate follow-up recommended (obtain additional views or outside films for comparison, ultrasound, biopsy, or surgical referral), 7.2% had inadequate follow-up. Inadequate follow-up was associated with lower estimated household income and no history of previous mammogram. Among women with inadequate follow-up who were interviewed, 87% reported that they had been notified of their results. We found that the percentage of women with inadequate follow-up of abnormal mammograms is high, especially among women who require six-month follow-up. Women with low income and no history of a previous mammogram were at greatest risk for inadequate follow-up. These results document a previously unrecognized problem with mammography screening and suggest that the implementation of tracking systems to ensure timely follow-up of abnormal screening mammograms is essential. Medical Subject Headings (MeSH): mammography, follow-up, screening.

Evaluation of factors potentially associated with inadequate follow-up of mammographic abnormalities.

BACKGROUND: To increase the proportion of women who receive the recommended follow-up for mammographic abnormalities, factors which inhibit follow-up must be identified. Patient and health care delivery related factors were evaluated, stratified by type of follow-up recommendation, to determine reasons for inadequate follow-up. METHODS: All Caucasian and African American women at the Henry Ford Medical Group, in southeastern Michigan, with an abnormal screening mammogram result between January 1, 1992 and July 31, 1992 were identified. All women with inadequate follow-up, and a random sample of women with adequate follow-up, were invited to participate in a telephone interview that assessed three major dimensions of the Health Belief Model (susceptibility, benefits, and barriers), general health and health behaviors, and related characteristics. The relationship between these factors and inadequate follow-up was evaluated separately for women with immediate and 6-month follow-up recommendations, using univariate and multivariate analyses. RESULTS: A total of 555 women were invited to participate in the study (219 with inadequate follow-up and 336 with adequate follow-up). Interviews were completed for 418 women (75.3%). Women who were not notified of their mammographic abnormality were excluded from this study, leaving 399 women available for analysis. Among the women who had the recommended immediate follow-up, those who reported difficulty in obtaining medical appointments were 4 times more likely to have inadequate follow-up (95% confidence interval [CI] 1.5, 11.3), after adjusting for other variables. Among the women with six-month follow-up recommended, those who received fewer mammograms in the past 5 years were more likely to have inadequate follow-up (odds ratio [OR] = 4.0; 95% CI 1.6, 10.4). In this group, sociodemographic characteristics were not associated with inadequate follow-up, although women with transportation problems were at a higher risk (crude OR = 5.2; 95% CI 1.6, 16.7; adjusted OR = 3. 1; 95% CI 0.5, 18.3). Among women with 6-month follow-up recommended, those who perceived their health as poor or fair (crude OR = 2.4; 95% CI 1.2, 5.1; adjusted OR = 2.3; 95% CI 0.8, 6.8) and those who did not examine their own breasts frequently (crude OR = 2.3; 95% CI 1.0, 5.4; adjusted OR = 2.7; 95% CI 0.5, 18.3) were also more likely to have inadequate follow-up. CONCLUSIONS: Results from this study demonstrate that the relative importance of factors associated with inadequate follow-up of abnormal mammograms differs according to the type of follow-up recommended. For both types of recommendations, the factors identified are noteworthy because they are amenable to intervention. Efforts should be made to facilitate appointment scheduling for follow-up of abnormal mammograms, and information about previous mammography screening should be obtained to identify women who are at a high risk for inadequate follow-up.

Screening mammography use: the importance of a population perspective.

Mammography has been shown to be effective in decreasing breast cancer mortality. However, not all women receive recommended screening. The purpose of this study was to measure the effect of systemic health care delivery factors and patient demographic factors on the use of mammography among a population of women with insurance coverage for screening mammography. We studied 8,805 women, 50 to 74 years of age, who were members of a health maintenance organization in Michigan during 1992. Data were obtained from computerized patient registration and billing systems. Estimated household income was based on zip code and 1990 U.S. Census information. During the study period, 47% of the entire study population received a mammogram. Among the 4,628 women who did not receive a mammogram, 2,358 (51%) did not have any primary care visits in 1992, or did not have a visit at a time when they were due for mammography. Among women with at least one visit during 1992, 60% received a mammogram. Analysis of this group revealed that Caucasian race, married status, and higher estimated household income were associated with 3%-5% higher mammography rates (in absolute terms); seeing a gynecologist and attending a primary care clinic where mammography was available on site were associated with 10%-11% higher rates; and not having at least one of their primary care visits at a time when due for screening was associated with a 33.5% lower mammography rate. These differences persisted after adjusting for other variables. In this population, factors surrounding health care delivery, such as having an office visit when due for screening, the number of office visits, and having been seen by a gynecologist, had a greater association with mammography use than did demographic factors. A population-based perspective that includes developing outreach strategies for women overdue for screening, who have not visited their health care provider, is as important as further improvements in office-based strategies to increase breast cancer screening.