Jane G. Zapka

Breast cancer screening by mammography: utilization and associated factors.

The status of mammography screening experience and factors related to utilization were examined in six towns serviced by physician staffs at five hospitals. Data were collected via random digit dial telephone interview of a probability sample of 1184 women, aged 45-75 years. The results showed that 55% of the women reported ever having had a mammogram. Of those who had ever had a mammogram, 21% reported that the mammogram in the past year was their first one. Of those women who are over 50 and had ever had a mammogram, 57% reported one in the past year. Analyses demonstrated that a combination of demographic factors, certain beliefs and knowledge, having a regular physician, social interaction and media exposure are independently related to ever having a mammogram, and to having one in the past year. Despite anecdotal and empirical evidence that the proportion of women ever having had a mammogram has substantially increased in the past several years, increasing utilization among older and lower-income women provides a challenge for public health.

Healthcare system factors and colorectal cancer screening.

BACKGROUND Developing effective programs to promote colorectal cancer (CRC) screening requires understanding of the effect of healthcare system factors on access to screening and adherence to guidelines. METHODS This study assessed the role of insurance status, type of plan, the frequency of preventive health visits, and provider recommendation on utilization of CRC screening tests using a cross-sectional, random-digit-dial survey of 1002 Massachusetts residents aged > or =50. RESULTS A broad definition of CRC screening status included colonoscopy or barium enema (screening or diagnostic) within 10 years, flexible sigmoidoscopy (FSIG) within 5 years, and fecal occult blood testing (FOBT) in the past year as options; 51.7% of subjects aged 50 to 64 and 61.5% of older subjects were current. The uninsured had the lowest current testing rate. Among insured participants, type of insurance had little impact on CRC testing; older subjects enrolled in HMOs had marginally higher rates, although not statistically significant. Increased frequency of preventive health visits and ever receiving a physicians recommendation for FSIG or ever receiving FOBT cards were associated with higher rates of CRC screening among both age groups. CONCLUSIONS Even when broad criteria are used to define current CRC screening status, a substantial proportion of the age-eligible population remains underscreened. Obtaining regular preventive care and receiving a physicians recommendation for screening appear to be potent facilitators of screening that should be considered in designing promotional efforts.

Age and sex differences in presentation of symptoms among patients with acute coronary disease: the REACT Trial. Rapid Early Action for Coronary Treatment

BACKGROUND There are few data on possible age and sex differences in presentation of symptoms for patients with acute coronary disease. OBJECTIVE To investigate demographic differences in presentation of symptoms at the time of hospital presentation for acute myocardial infarction (AMI) and unstable angina. METHODS The medical records of patients who presented with chest pain and who also had diagnoses of AMI (n = 889) or unstable angina (n = 893) on discharge from 43 hospitals were reviewed as part of data collection activities of the Rapid Early Action for Coronary Treatment trial based in 10 pair-matched communities throughout the USA. RESULTS Dyspnea (49%), arm pain (46%), sweating (35%), and nausea (33%) were commonly reported by men and women of all ages in addition to the presenting complaint of chest pain. After we had controlled for various characteristics through regression modeling, older persons with AMI were significantly less likely than were younger persons to complain of arm pain and sweating, and men were significantly less likely to report vomiting than were women. Among persons with unstable angina, arm pain and sweating were reported significantly less often by elderly patients. Nausea and back, neck, and jaw pain were more common complaints of women. CONCLUSIONS Results of this study suggest that there are differences between symptoms at presentation of men and women, and those in various age groups, hospitalized with acute coronary disease. Clinicians should be aware of these differences when diagnosing and managing patients suspected to have coronary heart disease.

Effects of HIV antibody test knowledge on subsequent sexual behaviors in a cohort of homosexually active men.

This study assesses the effects of HIV (human immunodeficiency virus) antibody testing on subsequent (one year) sexual behavior among 270 homosexual men at a Boston community health center, 21 per cent of whom were unaware of their test result. Except for the number of steady partners, the levels of all sexual activities of all groups of study participants declined over time. No effects of test awareness of antibody status were found on protective behavior for receptive anogenital contact. Elimination of unprotected insertive anogenital contact (by elimination of the practice or by condom use) was reported somewhat more often among seropositive men who became aware of their test result. Increased negative emotional reactions were reported by HIV seropositive men who were aware of their test result. These results suggest some behavioral impact of HIV antibody test knowledge in this cohort, but may not be generalizable to other populations.

Interval adherence to mammography screening guidelines

The objectives of this research were to document adherence to mammography screening guidelines among women over 50 years of age and to investigate factors related to adherence. Selected sociodemographic variables—personal breast health history, provider-related variables, and medical care utilization—were studied. Data were collected through a random digit dial telephone survey of 693 women from two geographic areas. While 48% had had a mammogram in the last year, only 20% reported at least two recent mammograms at yearly intervals. Adherence was significantly associated with having a higher income, being white, being 51 to 64 years old and having had breast symptoms and/or a family history of breast cancer. Additionally, women who had a regular physician, higher frequency of clinical breast examination, and a recent physician visit were more adherent. Women enrolled in Health Maintenance Organizations (HMOs) and/or covered by commercial plans were more adherent than women with no insurance or with entitlement coverage only. These relationships were generally maintained in multivariate analysis. While this study is consistent with others that demonstrate increasing adoption of mammographic screening, it also illustrates that the goal of regular screening according to guidelines has yet to be achieved.

Introduction: Understanding and Influencing Multilevel Factors Across the Cancer Care Continuum

Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicines six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.

Contributions of weight perceptions to weight loss attempts: differences by body mass index and gender

Previous studies have consistently observed that women are more likely to perceive themselves as overweight compared to men. Similarly, women are more likely than men to report trying to lose weight. Less is known about the impact that self-perceived weight has on weight loss behaviors of adults and whether this association differs by gender. We conducted a cross-sectional analysis among an employee sample (n=899) to determine the association of self-perceived weight on evidence-based weight loss behaviors across genders, accounting for body mass index (BMI) and demographic characteristics. Women were more likely than men to consider themselves to be overweight across each BMI category, and were more likely to report attempting to lose weight. However, perceiving oneself to be overweight was a strong correlate for weight loss attempts across both genders. The effect of targeting accuracy of self-perceived weight status in weight loss interventions deserves research attention.

Improving Colorectal Cancer Screening in Primary Care Practice: Innovative Strategies and Future Directions

Colorectal cancer (CRC) screening has been supported by strong research evidence and recommended in clinical practice guidelines for more than a decade. Yet screening rates in the United States remain low, especially relative to other preventable diseases such as breast and cervical cancer. To understand the reasons, the National Cancer Institute and Agency for Healthcare Research and Quality sponsored a review of CRC screening implementation in primary care and a program of research funded by these organizations. The evidence base for improving CRC screening supports the value of a New Model of Primary Care Delivery: 1. a team approach, in which responsibility for screening tasks is shared among other members of the practice, would help address physicians’ lack of time for preventive care; 2. information systems can identify eligible patients and remind them when screening is due; 3. involving patients in decisions about their own care may enhance screening participation; 4. monitoring practice performance, supported by information systems, can help target patients at increased risk because of family history or social disadvantage; 5. reimbursement for services outside the traditional provider—patient encounter, such as telephone and e-mail contacts, may foster enhanced screening delivery; 6. training opportunities in communication, cultural competence, and use of information technologies would improve provider competence in core elements of screening programs. Improvement in CRC screening rates largely depends on the efforts of primary care practices to implement effective systems and procedures for screening delivery. Active engagement and support of practices are essential for the enormous potential of CRC screening to be realized.

The perceptions and practices of pediatricians: tobacco intervention

Objectives. To investigate pediatrician self-reported intervention practices related to tobacco use and cessation. We queried about practices with three groups 1) children/adolescents who do not smoke; 2) children/adolescents who smoke; and 3) parents, and the relationship of counseling practices with the personal and professional practice-related factors of pediatricians. Design. Mailed anonymous survey regarding their self-reported tobacco use prevention and cessation intervention practices. Population. Random sample of 350 pediatricians in one state. Results. A response rate of 75% was achieved. Pediatricians reported the greatest counseling practice in encouraging children/adolescents to not start smoking, followed by counseling adolescents who smoke. The lowest practice score was for intervening with parents who smoke. The age, gender, site of practice (eg, HMO, solo practice), and subspecialty status of the pediatricians were not related to practice. Pediatricians who reported at least some community involvement in local tobacco control efforts reported significantly higher levels of smoking cessation counseling with both children and adolescents and with parents who smoke. Pediatricians who reported previous training in counseling about tobacco issues also reported significantly higher levels of counseling of both adolescent smokers and parents who smoke but not of children and adolescents who do not smoke. Higher role perception, believing that smoking cessation counseling provided by pediatricians can be effective, and self-efficacy, were predictive of intervention with all three groups. The perceived barriers scale was not related to intervention with any group. Conclusions. Pediatricians are missing opportunities to help their patients to stop smoking and to prevent smoking initiation. Pediatricians are intervening least frequently with parents who smoke. Practices should be tailored to the specific target group.

Interventions for patients, providers, and health care organizations

Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors—public policy, organizational systems and practice settings, clinicians, and patients—influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues. Cancer 2004.