Delivery of preventive services for low-income persons over age 50: a comparison of community health clinics to private doctors' offices.

This study focused on the use of 14 evidence-based preventive services for the low-income population over age 50: colorectal, breast and cervical cancer screening, cholesterol screening, counseling around diet, exercise, tobacco, alcohol and illicit drugs, and immunizations for influenza, tetanus and pneumonia. Population characteristics and rates of delivery of these preventive services are compared for low-income users of community health clinics vs private doctors' offices/HMOs. Three nationally representative data-files from the National Health Interview Survey--the Person-Level File, Sample Adult File, and Sample Adult Prevention File--were linked to obtain the necessary data on preventive services use in the 12,024 persons over age 50.

Economic evaluation of breast cancer treatment: considering the value of patient choice.

Purpose: To use 5 years of primary data to compare the incremental cost-effectiveness of breast conservation and radiation versus mastectomy with the restriction of choice to a single therapy versus providing a choice of either therapy.

Patients And Methods: We evaluated a random retrospective cohort of 2,517 Medicare beneficiaries treated for newly diagnosed stage I or II breast cancer from 1992 through 1994. The outcome measures were quality-adjusted life-years (QALYs) and 5-year medical costs.

Predictors of long-term outcomes in older breast cancer survivors: perceptions versus patterns of care.

Purpose: There are few data on sequelae of breast cancer treatments in older women. We evaluated posttreatment quality of life and satisfaction in a national population.

Patients And Methods: Telephone surveys were conducted with a random cross-sectional sample of 1,812 Medicare beneficiaries 67 years of age and older who were 3, 4, and 5 years posttreatment for stage I and II breast cancer.

An exploratory instrumental variable analysis of the outcomes of localized breast cancer treatments in a medicare population.

This study is motivated by the potential problem of using observational data to draw inferences about treatment outcomes when experimental data are not available. We compare two statistical approaches, ordinary least-squares (OLS) and instrumental variables (IV) regression analysis, to estimate the outcomes (three-year post-treatment survival) of three treatments for early stage breast cancer in elderly women: mastectomy (MST), breast conserving surgery with radiation therapy (BCSRT), and breast conserving surgery only (BCSO). The primary data source was Medicare claims for a national random sample of 2907 women (age 67 or older) with localized breast cancer who were treated between 1992 and 1994.

Sequelae of axillary lymph node dissection in older women with stage 1 and 2 breast carcinoma.

Background: There are few data on the long-term sequelae of axillary dissection among older breast carcinoma patients. We describe the impact of axillary dissection in a cohort of older women.

Methods: A longitudinal cohort of 571 patients with Stage 1 and 2 breast carcinoma, 67 years and older, diagnosed between 1995 and 1997 from 29 hospitals in five regions, and followed for 2 years.

Costs and benefits of different strategies to screen for cervical cancer in less-developed countries.

Background: About 80% of cervical cancers occur in less-developed countries. This disproportionate burden of cervical cancer in such countries is due mainly to the lack of well-organized screening programs. Several cervical cancer screening strategies have been proposed as more cost-effective than cytology screening.

Variations in breast carcinoma treatment in older medicare beneficiaries: is it black or white.

Background: To evaluate associations between race and breast carcinoma treatment.

Methods: Data from 984 black and 849 white Medicare beneficiaries 67 years or older with local breast carcinoma and a subset of 732 surviving women interviewed 3-4 years posttreatment were used to calculate adjusted odds of treatment, controlling for age, comorbidity, attitudes, region, and area measures of socioeconomic and health care resources.

Results: Sixty-seven percent of women received a mastectomy and 33% received breast-conserving surgery.

Patient and provider characteristics that affect the use of axillary dissection in older women with stage I-II breast carcinoma.

Background: Axillary dissection for the evaluation and treatment of patients with breast carcinoma often is not performed in older women. The objective of this study was to examine patient, clinical, and surgeon characteristics associated with the use of axillary dissection after breast-conserving surgery (BCS).

Methods: A cohort of 464 women age > or = 67 years who were newly diagnosed with Stage I-II breast carcinoma and who underwent BCS were surveyed along with their 158 surgeons, and their medical records were reviewed.

Feasibility of mobile cancer screening and prevention.

Many areas have high cancer mortality rates and medically underserved populations. This study describes the feasibility (acceptability and costs) of an urban multiphasic (multiple cancers) screening van. Feasibility was evaluated by literature review and informant interviews.

Patient and provider priorities for cancer prevention and control: a qualitative study in Mid-Atlantic Latinos.

Objective: This study examines the cancer prevention and control priorities of uninsured Latin Americans and their primary care providers in metropolitan Washington, D.C. Patient and provider priorities are compared to identify common ground for future interventions in resource constrained primary care settings.

Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force.

Purpose: To perform a systematic review of the cost-effectiveness of colorectal cancer screening for the U.S. Preventive Services Task Force.

Benefits and costs of using HPV testing to screen for cervical cancer.

Context: Despite quality assurance standards, Papanicolaou (Pap) test characteristics remain less than optimal.

Objective: To compare the societal costs and benefits of human papillomavirus (HPV) testing, Pap testing, and their combination to screen for cervical cancer.

Design, Setting, And Population: A simulation model of neoplasia natural history was used to estimate the societal costs and quality-adjusted life expectancy associated with 18 different general population screening strategies: Pap plus HPV testing, Pap testing alone, and HPV testing alone every 2 or 3 years among hypothetical longitudinal cohorts of US women beginning at age 20 years and continuing to 65 years, 75 years, or death.

Advancing age and cervical cancer screening and prognosis.

Objectives: To determine associations between advancing age and screening behavior and prognosis in long-term members of a prepaid health plan diagnosed with invasive cervical cancer (ICC).

Design: Case series.

Setting: Prepaid health plan.

Communication between physicians and older women with localized breast cancer: implications for treatment and patient satisfaction.

Purpose: To identify factors associated with patient-physician communication and to examine the impact of communication on patients' perception of having a treatment choice, actual treatment received, and satisfaction with care among older breast cancer patients.

Materials And Methods: Data were collected from 613 pairs of surgeons and their older (greater-than-or-equal 67 years) patients diagnosed with localized breast cancer. Measures of patients' self-reported communication included physician- and patient-initiated communication and the number of treatment options discussed.

Adherence of low-income women to cancer screening recommendations.

Background: African-American and low-income women have lower rates of cancer screening and higher rates of late-stage disease than do their counterparts.

Objective: To examine the effects of primary care, health insurance, and HMO participation on adherence to regular breast, cervical, and colorectal cancer screening.

Design: Random-digit-dial and targeted household telephone survey of a population-based sample.

Constructs of burden of illness in older patients with breast cancer: a comparison of measurement methods.

Objective: The burden of illness can influence treatment decisions, but there are limited data comparing the performance of different illness burden measures. We assessed the correlations between five previously validated measures of illness burden and global health and physical function and evaluated how each measure correlates with breast cancer treatment patterns in older women.

Data Source: A cohort of 718 women > 67 years with early-stage breast cancer formed the study group.

Screening mammography and breast cancer treatment patterns in older women.

Objective: To examine the impact of mammography screening on treatment options received by a cohort of older breast cancer patients.

Setting And Population: We studied 718 newly diagnosed breast cancer patients, 67 years and over, diagnosed with TNM Stage I and II disease between 1995 and 1997 at 29 hospitals in five regions.

Methods: Data were collected from patients, surgeons, and medical records.

Inreach and outreach interventions to improve mammography use.

Objective: to assess the effectiveness of patient-targeted interventions in increasing mammography use when performed outside (outreach) or inside the primary care medical setting (inreach).

Methods: We performed a meta-analysis of controlled interventions to increase mammography use in patients in the United States published between 1980 and February 2001. Interventions were classified by setting (inreach or outreach), mechanism of action (behavioral, cognitive, sociologic, or a combination), type of control group (active or usual care), number of strategies, and mode of delivery (static or interactive).

If we gave away mammograms, who would get them? A neighborhood evaluation of a no-cost breast cancer screening program.

Background: Low- and no-cost mammography programs have become a widespread strategy to increase access to breast cancer screening in low-income populations. However, rigorous evaluations of who remains unscreened in communities with these programs are lacking. We conducted a case-control study of African American older women in East Baltimore, Maryland, comparing attendees at a no-cost program to friends and neighbors not using no-cost venues.

The emotional consequences of false positive mammography: African-American women's reactions in their own words.

High false positive rates associated with screening for breast cancer in the United States have an unintended psychological consequence for women (Lerman et al., 1991) that has raised concerns in recent years (Sox, 1998). This study uses inductive qualitative analysis of open-ended interviews with 45 African American women living in New York City who were part of a larger study of women and their experiences after receiving an abnormal mammogram.

Medicare fees and small area variations in breast-conserving surgery among elderly women.

This study used data from Medicare files, the American Hospital Association's Annual Survey of Hospitals, and the 1990 census to investigate whether Medicare fees for breast-conserving surgery (BCS) and mastectomy (MST) affected the rate of BCS across 799 3-digit ZIP code areas in 1994. The full model, which was based on the conceptual framework of the supply of and demand for different treatments, explained 51 percent of the variation in BCS rates. Medicare fees were statistically significant and had the hypothesized effects: a 10 percent higher BCS fee was associated with a 7 to 10 percent higher BCS rate, while a 10 percent higher MST fee was associated with a 2 to 3 percent lower proportion receiving BCS.

Cost of genetic counseling and testing for BRCA1 and BRCA2 breast cancer susceptibility mutations.

Counseling and predictive testing are now available for the recently isolated BRCA1 and BRCA2 breast cancer susceptibility genes. We examined the societal costs of providing this counseling and testing to women at risk of having a breast cancer susceptibility mutation. Genetic counselors in a research program prospectively monitored the time necessary to provide counseling and results disclosure.

The art and science of incorporating cost effectiveness into evidence-based recommendations for clinical preventive services.

As medical technology continues to expand and the cost of using all effective clinical services exceeds available resources, decisions about health care delivery may increasingly rely on assessing the cost-effectiveness of medical services. Cost-effectiveness is particularly relevant for decisions about how to implement preventive services, because these decisions typically represent major investments in the future health of large populations. As such, decisions regarding the implementation of preventive services frequently involve, implicitly if not explicitly, consideration of costs.

Measuring and predicting surgeons' practice styles for breast cancer treatment in older women.

Background: Few measures exist to assess physicians' practice style, and there are few data on physicians' practice styles and patterns of care.

Objectives: To use clinical vignettes to measure surgeons' "propensity" for local treatments for early-stage breast cancer and to describe factors associated with propensity.

Research Design And Subjects: A cross-sectional mailed survey with telephone follow-up of a random sample of 1,000 surgeons treating Medicare beneficiaries in fee-for-service settings.