Brenda E. Sirovich

Esophageal Adenocarcinoma Incidence: Are We Reaching the Peak?

Background: A steep increase in the incidence of esophageal adenocarcinoma has been observed between 1973 and 2001, but recent trends have not been reported. Our aim was to examine recent trends in esophageal adenocarcinoma incidence. Methods: We used the Surveillance Epidemiology and End Results database of the National Cancer Institute to identify all patients who were diagnosed with esophageal adenocarcinoma between 1973 and 2006. Incidence trends were analyzed for esophageal adenocarcinoma overall and by stage using joinpoint regression. Results: Overall esophageal adenocarcinoma incidence increased from 3.6 per million in 1973 to 25.6 per million in 2006. Incidence trend analysis, however, suggests that the increase has slowed, from an 8.2% annual increase prior to 1996 to 1.3% increase in subsequent years (P = 0.03). Stage-specific trend analyses suggest that the change in overall esophageal adenocarcinoma incidence largely reflects a plateau in the incidence of early stage disease. Its slope has changed direction, from a 10% annual increase prior to 1999 to a 1.6% decline in subsequent years (P = 0.01). Conclusions: The incidence of early stage esophageal adenocarcinoma seems to have plateaued. Impact: Although definitive conclusions will require additional years of data, the plateau in early stage disease might portend stabilization in the overall incidence of esophageal adenocarcinoma. Cancer Epidemiol Biomarkers Prev; 19(6); 1468–70. ©2010 AACR.

The Frequency of Pap Smear Screening in the United States

AbstractBACKGROUND: U.S. professional medical societies and the national health systems of all other industrialized nations recommend that most women need not undergo Papanicolaou (Pap) smear screening annually. There are no data, however, regarding the frequency at which women actually undergo screening. OBJECTIVE: To describe the frequency of cervical cancer screening in the United States. DESIGN: National Health Interview Survey, a cross-sectional population-based telephone survey conducted by the National Center for Health Statistics. PARTICIPANTS: Representative sample of U.S. women age 21 and older who denied a history of cancer (N=16,467). MEASUREMENTS: Pap smear screening frequency, categorized as no regular screening or screening at 1 of 3 discrete screening intervals (every year, every 2 years, or every 3 years) based on each woman’s reported number of Pap smears in the previous 6 years. RESULTS: The vast majority (93%) of American women report having had at least one Pap smear in their lifetime. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, 17% report a 2-year screening interval, 16% report being screened every 3 years, and 11% are not being screened regularly. Even the very elderly report frequent screening—38% of women age 75 to 84 and 20% of women age 85 and older reported annual Pap smears. Overall, 20% of women reported having had at least one abnormal Pap smear. Among these women, rates of frequent Pap smear screening are considerably higher—80% undergo annual screening, with only a modest decline in screening frequency with increasing age. CONCLUSIONS: The majority of American women report being screened for cervical cancer more frequently than recommended. Lengthening the screening interval would not only reduce the volume of specimens that cytotechnologists are required to read, but would also reduce the follow-up testing after abnormal smears.

Too Little? Too Much? Primary Care Physicians' Views on US Health Care: A Brief Report

BACKGROUND Some believe that a substantial amount of US health care is unnecessary, suggesting that it would be possible to control costs without rationing effective services. The views of primary care physicians-the frontline of health care delivery-are not known. METHODS Between June and December 2009, we conducted a nationally representative mail survey of US primary care physicians (general internal medicine and family practice) randomly selected from the American Medical Association Physician Masterfile (response rate, 70%; n=627). RESULTS Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians). Almost all physicians (95%) believe that physicians vary in what they would do for identical patients; 76% are interested in learning how aggressive or conservative their own practice style is compared with that of other physicians in their community. CONCLUSIONS Many US primary care physicians believe that their own patients are receiving too much medical care. Malpractice reform, realignment of financial incentives, and more time with patients could remove pressure on physicians to do more than they feel is needed. Physicians are interested in feedback on their practice style, suggesting they may be receptive to change. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00853918.

Utilization and Expenditures on Chiropractic Care in the United States from 1997 to 2006

OBJECTIVE To investigate national utilization and expenditures on chiropractic care between 1997 and 2006. DATA SOURCE The nationally representative Medical Expenditure Panel Survey (MEPS). STUDY DESIGN We performed descriptive analyses and generated national estimates from data obtained from U.S. adult (>or=18 years) MEPS respondents who reported having visited a chiropractor (annual sample size between 789 and 1,082). For each year, we examined the estimated total national expenditure, the total number of U.S. adults who received chiropractic care, the total number of ambulatory visits to U.S. chiropractors, and the inflation-adjusted charges and expenditures per U.S. adult chiropractic patient. PRINCIPAL FINDINGS The total number of U.S. adults who visited a chiropractor increased 57 percent from 7.7 million in 2000 to 12.1 million in 2003. From 1997 to 2006, the inflation-adjusted national expenditures on chiropractic care increased 56 percent from U.S.

The burden of prevention: downstream consequences of Pap smear testing in the elderly

3.8 billion to U.S.

Medical center characteristics associated with PSA screening in elderly veterans with limited life expectancy.

5.9 billion. Inflation-adjusted total mean expenditures per patient and expenditures per office visit remained unchanged. CONCLUSION The large increase in U.S. adult expenditures on chiropractic care between 1997 and 2006 was due to a 57 percent increase in the total number of U.S. adult chiropractic patients that occurred from 2000 to 2003. From 2003 to 2006, the total number of U.S. adult chiropractic patients has remained stable.

Did You Hear the One About the Doctor? An Examination of Doctor Jokes Posted on Facebook

Context: Although cervical cancer is an unusual cause of death among women 65 and older, most elderly women in the US report continuing to undergo periodic Pap smear screening. Objective: To describe the incidence of Pap smears and downstream testing among elderly women. Setting: Claims-based analysis of female Medicare enrollees age 65 and older. Methods: Using three years of Medicare Part B 5% Files (1995-1997), we differentiated between women undergoing screening Pap smears and those undergoing Pap smears for surveillance of previous abnormalities or Pap smear follow-up. We determined the proportion of elderly women undergoing Pap smear testing and rates of downstream testing and procedures after an initial Pap smear. Results: Four million female Medicare beneficiaries over 65 years underwent Pap smear testing between 1995 and 1997, representing 25% of the eligible population. After adjusting for underbilling for Pap smears under Medicare, 43% of women over 65 are estimated to have undergone Pap smear testing during the 3-year period. The large majority (90%) of Pap smears were for screening, while 10% were done for surveillance or follow-up. For every 1000 women with a screening Pap smear, 39 had at least one downstream intervention within eight months of the initial Pap smear, including seven women who underwent colposcopy and two women who had other surgical procedures. Rates of downstream interventions were considerably higher for women undergoing Pap smear follow-up (302 per 1000 with at least one downstream intervention), and surveillance of previous abnormalities (209 per 1000 with a downstream intervention). Conclusion: Cervical cancer screening is widespread among elderly American women, and follow-up testing is not uncommon, particularly among the ten percent of women who appear to be in a cycle of repeated testing. This substantial volume of testing occurs despite the rarity of cervical cancer deaths and unknown benefits of screening in this age group.

MP32-12 HARNESSING FULL TEXT PATHOLOGY DATA FROM THE ELECTRONIC HEALTH RECORD TO ADVANCE BLADDER CANCER CARE – DEVELOPMENT OF A NATURAL LANGUAGE PROCESSING SYSTEM TO GENERATE LONGITUDINAL PATHOLOGY DATA

ABSTRACTBACKGROUNDAlthough guidelines recommend against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, screening is common.OBJECTIVEWe sought to identify medical center characteristics associated with screening in this population.DESIGN/PARTICIPANTSWe conducted a prospective study of 622,262 screen-eligible men aged 70+ seen at 104 VA medical centers in 2003.MAIN MEASURESPrimary outcome was the percentage of men at each center who received PSA screening in 2003, based on VA data and Medicare claims. Men were stratified into life expectancy groups ranging from favorable (age 70–79 with Charlson score = 0) to limited (age 85+ with Charlson score ≥1 or age 70+ with Charlson score ≥4). Medical center characteristics were obtained from the 1999–2000 VA Survey of Primary Care Practices and publicly available VA data sources.KEY RESULTSAmong 123,223 (20%) men with limited life expectancy, 45% received PSA screening in 2003. Across 104 VAs, the PSA screening rate among men with limited life expectancy ranged from 25-79% (median 43%). Higher screening was associated with the following center characteristics: no academic affiliation (50% vs. 43%, adjusted RR = 1.14, 95% CI 1.04–1.25), a ratio of midlevel providers to physicians ≥3:4 (55% vs. 45%, adjusted RR = 1.20, 95% CI 1.09–1.32) and location in the South (49% vs. 39% in the West, adjusted RR = 1.25, 95% CI 1.12–1.40). Use of incentives and high scores on performance measures were not independently associated with screening. Within centers, the percentages of men screened with limited and favorable life expectancies were highly correlated (r = 0.90).CONCLUSIONSSubstantial practice variation exists for PSA screening in older men with limited life expectancy across VAs. The high center-specific correlation of screening among men with limited and favorable life expectancies indicates that PSA screening is poorly targeted according to life expectancy.

Evaluating clinical management decisions by recent graduates in the era of high-value, cost-conscious care--reply.

Background Social networking sites such as Facebook have become immensely popular in recent years and present a unique opportunity for researchers to eavesdrop on the collective conversation of current societal issues. Objective We sought to explore doctor-related humor by examining doctor jokes posted on Facebook. Methods We performed a cross-sectional study of 33,326 monitored Facebook users, 263 (0.79%) of whom posted a joke that referenced doctors on their Facebook wall during a 6-month observation period (December 15, 2010 to June 16, 2011). We compared characteristics of so-called jokers to nonjokers and identified the characteristics of jokes that predicted joke success measured by having elicited at least one electronic laugh (eg, an LOL or “laughing out loud”) as well as the total number of Facebook “likes” the joke received. Results Jokers told 156 unique doctor jokes and were the same age as nonjokers but had larger social networks (median Facebook friends 227 vs 132, P<.001) and were more likely to be divorced, separated, or widowed (P<.01). In 39.7% (62/156) of unique jokes, the joke was at the expense of doctors. Jokes at the expense of doctors compared to jokes not at the expense of doctors tended to be more successful in eliciting an electronic laugh (46.5% vs 37.3%), although the association was statistically insignificant. In our adjusted models, jokes that were based on current events received considerably more Facebook likes (rate ratio [RR] 2.36, 95% CI 0.97-5.74). Conclusions This study provides insight into the use of social networking sites for research pertaining to health and medicine, including the world of doctor-related humor.

Screening Men for Prostate and Colorectal Cancer in the United States: Does Practice Reflect the Evidence?

provided by family physicians (66%). At the beginning of the study period, serum testosterone measured in an estimated 43% of men, and this increased in the pre-intervention time period by 0.2% per month; there was no significant change in this trend after Nov 2014 (p1⁄40.27). We identified 60,209 men with a new diagnosis of prostate cancer. The median age was 67 (IQR 61-74), and approximately 2/3 were stage 1 or 2. At the beginning of the study period, bone scans were performed in an estimated 18% of men undergoing active surveillance, and this decreased by 0.05% per month in the pre-intervention time period; there was no significant change in this trend after Nov 2014 (p1⁄40.07). CONCLUSIONS: In Ontario, there was no evidence of a significant change in two practice patterns that were subject of the Choosing Wisely Urology recommendations. Further mechanisms for translating these and future recommendations into behavior change may be necessary.