John T. Philbrick

Uptake Rates for Breast Cancer Genetic Testing: A Systematic Review

Purpose: Individuals and families dealing with the possibility of hereditary cancer risk face numerous decisions, including whether to obtain genetic testing. The purpose of this article is to determine what is known about the rate at which people obtain cancer genetic testing. Methods: Using MEDLINE, CINAHL, and PSYCHINFO plus reviewing reference lists of relevant articles, we identified 40 studies in May 2002 that addressed breast cancer–related decisions, enrolled adult participants, were published in 1990 or more recently, were peer-reviewed primary clinical studies, addressed genetic testing either alone or in combination with genetic counseling, and reported rates at which participants showed interest in and/or underwent cancer genetic testing. Information regarding study design, participants, and genetic testing uptake rates was recorded. Each article was reviewed for methodologic quality using a flexible quality review system applicable to all study types. Results: Of the 40 studies, 25 provided information about hypothetical genetic testing decisions, 14 about real decisions, and 1 about both. Mean hypothetical uptake was 66% (range, 20-96%) and real uptake was 59% (range, 25-96%). Multivariate logistic regression analyses found that decision type (real/hypothetical), personal and family history of breast cancer, and variability in sampling strategy, recruitment setting, and criteria for real and hypothetical uptake were independently associated with uptake. Our systematic review identified additional explanations for uptake variability (investigator influences, small sample sizes, variability in target populations, lack of clearly described sampling strategies, sampling methods open to bias, and variability in reporting associated risk factors). Conclusion: In addition to clinical characteristics, research methodologic issues are likely to be major determinants of variability in published breast cancer genetic testing uptake rates. An understanding of these issues will clarify to clinicians why their clinical experience may not be congruent with published rates and help guide future research. (Cancer Epidemiol Biomarkers Prev 2006;15(5):840–55)

Use of Ambulatory Electrocardiographic (Holter) Monitoring

PURPOSE To evaluate the clinical efficacy of ambulatory electrocardiographic (ECG) monitoring and to develop guidelines for its use in clinical practice. DATA IDENTIFICATION Studies reported since January 1978 were identified both through computer searches using Index Medicus and extensive manual searching of bibliographies of identified articles. STUDY SELECTION Only studies that fulfilled methodologic criteria designed to limit bias were reviewed. DATA EXTRACTION Information describing population and study results was assessed in four major categories (variability, diagnosis, prognosis, and therapy guidance) for both arrhythmia monitoring and ST-segment analysis. RESULTS OF DATA ANALYSIS The day-to-day variability of arrhythmia and myocardial ischemia detected by ambulatory ECG monitoring may be considerable in an individual patient. Caution must therefore be used in interpreting serial tests. Ambulatory ECG monitoring with diary correlation permits documentation of cardiac arrhythmias causing symptoms, but the diagnostic yield is low unless symptoms are frequent. Such monitoring can provide information about prognosis in patients after acute myocardial infarction. The amount of prognostic information obtained is modest and is outweighed by other measures. There is insufficient information to make conclusions about such monitoring and prognosis in other conditions. Serial ambulatory ECG monitoring may be used to assess the effect of an antiarrhythmic drug in patients with frequent and reproducible ventricular ectopy. The effect of arrhythmia suppression on survival is uncertain. Because of its low sensitivity and specificity, analysis of ST-segment changes during ambulatory ECG monitoring is inaccurate in establishing or excluding the presence of coronary disease. Although anti-ischemic interventions reduce the frequency and duration of ST-segment changes on monitoring, there are no data on the utility of using reduction or elimination of the changes as the endpoint of therapy. CONCLUSIONS Ambulatory ECG monitoring can provide diagnostic, prognostic, and therapeutic information in many situations, but similar information often may be better obtained in other ways.

Patient Decisions About Breast Cancer Chemoprevention: A Systematic Review and Meta-Analysis

PURPOSE Women at high risk of breast cancer face the complex decision of whether to take tamoxifen or raloxifene for breast cancer chemoprevention. We investigated what is known about decisions of women regarding chemoprevention. METHODS Using MEDLINE, CINAHL, and PSYCINFO, plus reviewing reference lists of relevant articles, in December 2009 we identified 13 studies that addressed patient decisions about breast cancer chemoprevention, were published in 1995 or later, were peer-reviewed primary clinical studies, and reported rates at which participants showed interest in (hypothetical uptake) or accepted (real uptake) chemoprevention medications. RESULTS Nine studies provided information about hypothetical breast cancer chemoprevention decisions (mean uptake rate, 24.7%) and five provided information about real decisions (mean uptake rate, 14.8%). The range of rates was wide, and each of the hypothetical uptake studies assessed interest differently. A logistic regression model found significant correlation with uptake of decision type (hypothetical versus real, odds ratio [OR] = 1.65; 95% CI, 1.26 to 2.16), educational or decision support intervention (provided v not, OR = 0.21; 95% CI, 0.17 to 0.27), and cohort risk for breast cancer (high-risk v general population, OR = 0.65; 95% CI, 0.56 to 0.75). Perceived vulnerability to breast cancer was consistently correlated with increased uptake, and concern for adverse effects was correlated with reduced uptake. All studies used a correlational/descriptive design, and most studies used convenience sampling strategies. CONCLUSION Breast cancer chemoprevention uptake rates are low and variation is wide. Hypothetical uptake rates are higher than real uptake, and interventions markedly reduce uptake. Research is needed that uses reproducible sampling methods and examines decision support strategies that lead to quality decisions.

The prevalence of mental disorders in rural office practice.

AbstractOBJECTIVE: To determine the prevalence of mental disorders in rural primary care office practice. DESIGN: Patient interview; chart review. SETTING: Two rural primary care office practices. PATIENTS: Three hundred-fifty scheduled or walk-in patients age 18 years or older. MEASUREMENTS: Medical Outcomes Study 36-Item Short-Form Health Survey (MOS SF-36), the Primary Care Evaluation of Mental Disorders (PRIME-MD), physical health using Greenfield’s index of coexistent disease (ICED), and health care utilization using the number of office visits and total office and laboratory charges six months before until six months after the interview. RESULTS: Of these patients 34% met criteria for one or more of the 18 mental disorders evaluated by the PRIME-MD; 19% met criteria for specific disorders according to criteria from theDiagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R). Mood disorders were most common (21.7%), followed by anxiety disorders (12.3%), somatoform disorders (11.1%), probable alcohol abuse or dependence (6.0%), and eating disorders (2.0%). By logistic regression, there was an association of age, sex, race (black), and education with lower prevalence of various mental disorder categories. Even after adjustment for demographic variables and physical health (ICED score), those with PRIME-MD diagnoses had significantly lower function as measured by the eight MOS SF-36 scales and higher utilization of office services (p<.001). CONCLUSIONS: The prevalence of mental disorders in rural primary care office practice is as high as in urban office practice.

Causes of variation in reported in-hospital CPR survival: a critical review

Abstract The objective of this study was to determine the sources of the wide variation in reported in-hospital cardiopulmonary resuscitation (CPR) survival. English-language articles published between 1972 and 1994 pertaining to in-hospital CPR survival in adults were obtained from MEDLINE, Current Contents, and relevant reference lists. Studies were required to enroll consecutive patients, separate data for prehospital arrests from in-hospital arrests, and use survival to hospital discharge as an outcome measure. Study characteristics were noted and the strength of the research methods were judged using eight methodologic standards. Overall survival to discharge among the 68 studies that met the inclusion criteria ranged from 0 to 28.9%. Studies were performed in diverse settings using diverse research methods. Only the patient population studied was associated with reported overall survival ( P = 0.008). Studies performed in general medical wards, medical intensive care units, elderly populations, or cancer patients, reported lower survival rates than studies performed in hospital-wide populations. Mean survival rates for clinical subgroups also varied widely. The heterogeneity of the studies prohibited pooling subgroup data. Studies of in-hospital CPR are more notable for their differences than for their similarities. It is therefore only possible to provide rough estimates of overall survival and survival for patients with particular clinical characteristics. Differences in overall cohort disease severity, as reflected by the specific patient population studied, explain much of this variation. However, variation caused by differences in the use of DNR orders, case definition, subgroup definition and treatment cannot be underestimated. Future studies will need to address each of these sources of heterogeneity.

Effectiveness of percutaneous coronary interventions to prevent recurrent coronary events in patients on chronic hemodialysis

Patients on chronic hemodialysis undergoing percutaneous coronary revascularization have similar rates of procedural success and in-hospital event rates when compared with a matched cohort. However, patients on chronic hemodialysis have a marked increase in 36-month target vessel revascularization, myocardial infarction, and death rates.

Free clinics: a national survey.

Objectives:To describe the scope and value of services provided by free clinics across the United States. Methods:Mail survey of directors of free clinics registered in the Free Clinic Directory of the Free Clinic Foundation of America, November 2001, concerning the calendar year 2001. Results:Eighty two percent (281/355) of clinics responded. Seventy five percent of clinics described their target population as the “uninsured” and 23% as “low income”. Fifty five percent had income based eligibility criteria of 200% Federal poverty level or less. Clinics provided a mean of 5,989 patient visits/year and 11,202 prescriptions/year to 2,311 unique patients. 61.8% of patients were female, 80.4% between ages 19 to 64, 55.1% white, 21.8% black, and 18.7% Hispanic. Clinics were open 29.7 hours/week, 4.1 days/week, and 32.9% had a licensed pharmacy. The mean annual budget was

Healthy patients who perceive poor health and their use of primary care services

458,028 and clinics were staffed by 156.7 volunteers and 6.9 paid employees per clinic. Conclusions:Free clinics have become an established part of the safety net for the uninsured. The differences among the clinics are striking, supporting the conclusion that a variety of approaches to the care of the underserved can be used. However, despite their efforts, the responding free clinics manage to provide care to only 650,000 of the nation’s 41 million uninsured.

Fever in the clinical diagnosis of acute pyelonephritis

Objective:To determine what proportion of patients who have poor health perceptions are physically healthy and to explore why some patients perceive a healthy state while others perceive illness.Design:A prospective consecutive series of office patients completed the Rand Corporation’s General Health Perceptions Questionnaire, and their physicians rated their physical health. Their use of health care services was determined for the following 12 months.Setting:A rural teaching office practice.Patients:Of 243 adult patients asked to complete the questionnaire, 32 were excluded, for dementia (8), illiteracy (4), illness (8), incomplete questionnaires (6), and other reasons (6). 208 patients (86%) formed the final study group.Measurements and main results:62 of 208 patients had poor health perception scores. 39 of the 62 were rated by physicians as physically healthy and were not statistically different in physical health ratings or numbers of prescribed medications from the 146 patients who had higher health perception scores. However, these 39 patients had significantly more health-related worry, acute pain, and depression than did the other 146 patients. They also made more office visits and telephone calls and had higher total primary care charges.Conclusions:This study suggests that 21% of adult primary care patients (39 of 208) have health perceptions lower than expected for their levels of physical health. These low health perceptions are correlated with increased emotional distress and higher utilization of health care resources. Strategies to identify these patients and interventions to improve their views of their health could reduce utilization.

ED management of acute pyelonephritis in women: a cohort study.

Acute pyelonephritis is a clinical syndrome that can be confused with other conditions. To investigate this problem, a retrospective cohort study was conducted using two mutually exclusive sets of clinical criteria for acute pyelonephritis in women 15 years of age or older who presented to the emergency department of a university hospital. All patients had pyuria, and one group had documented fever (temperature of > or = 37.8 degrees C) while the other group had a temperature of < 37.8 degrees C but had other evidence of possible upper tract infection. The study cohort was comprised of 103 febrile and 201 afebrile patients. Afebrile hospitalized patients were ultimately found to have another diagnosis more often than were the febrile hospitalized patients (35% v 7%; P = .02), and the afebrile nonhospitalized patients were more likely to have another diagnosis than were the febrile nonhospitalized patients (13% v 0%; P = .004). Other diagnoses included cholecystitis, pelvic inflammatory disease, and diverticulitis. The positive predictive value of the definition of pyelonephritis in the febrile group was 0.98, and it was 0.84 for the afebrile group. Physicians examining patients with clinical evidence of acute pyelonephritis but without objective fever should be alert for alternative diagnoses.