Judith K. Zemencuk

Breast cancer screening in the United States and Canada, 1994: socioeconomic gradients persist.

OBJECTIVES This study compared rates of annual mammography screening across socioeconomic status between the United States and Canada in 1994. METHODS Population-based cross-sectional surveys were used to compare the rates. RESULTS Screening rates were higher in the United States than in Canada for women aged 50 to 69 years (47.3% vs 38.8%; P < .01). Women with higher education and with higher incomes were more likely to receive screening in both countries, with no significant differences between countries. CONCLUSIONS For women aged 50 to 69 years, screening rates in Canada have substantially increased relative to those in the United States. However, disparities in screening across levels of socioeconomic status persist in both countries.

FOUR-YEAR PROSPECTIVE EVALUATION OF COMMUNITY- ACQUIRED BACTEREMIA: EPIDEMIOLOGY, MICROBIOLOGY, AND PATIENT OUTCOME

The objectives of this study were to (1) describe the epidemiology and microbiology of community-acquired bacteremia; (2) determine the crude mortality associated with such infections; and (3) identify independent predictors of mortality. All patients with clinically significant community-acquired bacteremia admitted to a university-affiliated Veterans Affairs medical center from January 1994 through December 1997 were evaluated. During the study period, 387 bacteremic episodes occurred in 334 patients. Staphylococcus aureus, Escherichia coli, and coagulase-negative staphylococci were the most commonly isolated organisms; the most frequent sources were the urinary tract and intravascular catheters. Approximately 14% of patients died. Patient characteristics independently associated with increased mortality included shock (OR 3.7, p = 0.02) and renal failure (OR 4.0, p = 0.003). The risk of death was also higher in those whose source was pneumonia (OR 6.3, p = 0.03) or an intra-abdominal site (OR 10.7, p = 0.02), or if multiple sources were identified (OR 13.4, p = 0.003). Community-acquired bacteremia is often device-related and may be preventable. Strategies that have been successful in preventing nosocomial device-related bacteremia should be adapted to the outpatient setting.

Correlates of Surgical Treatment Type for Women with Noninvasive and Invasive Breast Cancer

There is concern that breast-conserving surgery is underused in some breast cancer patient subpopulations, including women with ductal carcinoma in situ (DCIS), an early-stage form of the disease. We conducted a population-based study to identify correlates of surgical treatment type and patient satisfaction, comparing women with DCIS and those with invasive disease. We used telephone interview and mailed survey of 183 women recently diagnosed with breast cancer (oversampling for women with DCIS), identified from the Metropolitan Detroit Cancer Surveillance System (response rate 71.2%). Overall, 52.5% of study subjects received a mastectomy (48.9%, 45.8%, and 73.5% of women with DCIS, local disease, and regional disease, respectively, p < 0.05). One third of women did not perceive that they were given a choice between surgical types, and an additional one third of women received a surgeon recommendation, most of whom received the treatment recommended. Patient attitudes, such as concerns about the clinical benefits and risks of specific surgery options, were important correlates of treatment choice but did not vary by stage of disease. Knowledge about differences in clinical benefits and risks between surgery options was low. Finally, satisfaction with the decision-making process was significantly lower in women who did not perceive a choice between surgery options. Correlates of breast cancer surgery type appeared to be similar for women with DCIS and invasive breast cancer, with surgeons playing a dominant role in the process. Results also suggested that the decision-making process may be as important for patient satisfaction as the treatment chosen.

Patients’ Desires and Expectations for Medical Care in Primary Care Clinics

To explore whether patients’ desires for and expectations of medical care differ between the United States and Canada, we surveyed 652 patients and 105 physicians at primary care sites in Michigan and Ontario. Patient desires were similar at both sites, but expectations were higher in Michigan. Michigan physicians gave higher estimates of patient desire than physicians in Ontario. Physicians at both sites, however, similarly underestimated patients’ desires. These between-site differences in expectation may reflect differences both in general cultural factors and in patient exposure to different clinical policies within the medical systems.

When there is too much to do

AbstractBACKGROUND: Recent evidence suggests that patients are receiving only 50% of recommended processes of care. It is important to understand physician priorities among recommended interventions and how these priorities are influenced both intentionally as well as unintentionally. METHODS: A survey was mailed to all primary care physicians (PCPs) from two VA hospital networks (N=289), one of which had participated in a broad, evidence-based guideline development effort 8 to 12 months earlier, and all endocrinologists nationwide in the VA (N=213); response rate, 63% (n=315). Using the method of paired comparisons, we assessed physician priorities among 11 clinical triggers for interventions in the management of an uncomplicated patient with type 2 diabetes. RESULTS: Both PCPs and specialists consistently identified several high-impact clinical triggers for treatment as the highest priority interventions (hemoglobin A1c=9.5%, diastolic blood pressure [DBP]=95 mm Hg, low-density lipoprotein=145 mg/dl). Several low-impact interventions that are commonly used as performance measures also received relatively high ratings. Treatments that have recently been found to be highly beneficial were often rated as being of low importance (e.g., treating when DBP=88 mm Hg). Almost 80% of PCPs rated tight glycemic control as more important than tight DBP control, in direct contrast to clinical trial evidence. Specialists’ ratings followed the same general pattern, but were more consistent with the epidemiological evidence. The PCPs at the sites that participated in the guideline intervention rated blood pressure control significantly higher. CONCLUSION: Although several high-priority aspects of diabetes care were clearly identified, there were also notable examples of ratings that were clearly inconsistent with the epidemiological literature. Recommendations based upon more recent evidence were substantially underrated and some guidelines used as performance measures were relatively overrated. These results support the arguments that a more proactive approach is needed to facilitate rapid dissemination of new high-priority findings, and that intervention priority, and not just ease of measurement, should be considered carefully when disseminating guidelines and when selecting performance measures.

Is Mastectomy Overused? A Call for an Expanded Research Agenda

Surgery is the cornerstone of definitive treatment for most women with breast cancer. By the mid-1980s, several randomized trials had demonstrated that lumpectomy with radiation therapy confers the same survival benefit as modified radical mastectomy for women without metastatic disease (Fisher, Bauer, Margolese, et al. 1985; National Institutes of Health 1990). Since that time, clinicians, researchers, patients, and women’s health advocates have voiced numerous concerns regarding women’s experiences with breast cancer surgery. A primary concern in both clinical medicine and public discourse is that, given that there are two surgical alternatives, mastectomy is overused. There have been several “framings” or definitions of problems regarding breast cancer surgical treatment over the past 2 decades. Early discussions of problems or controversies in breast cancer treatment focused on the issue of patient informed consent (Montini 1997; Nayfield, Bongiovanni, Alciati, et al. 1994). Media attention given to women who had awakened from a diagnostic biopsy to find that their breast had been removed fueled public outcry. Concerns about breast cancer surgeons’ disregard for informed consent requirements were coupled with perceptions that there was an unusual slowness to the acceptance and dissemination of lumpectomy with radiation therapy as an appropriate surgical alternative to mastectomy (Montini 1997). More recent research and discussion regarding breast cancer surgical treatment have centered around the fact that mastectomy remains the most common surgical approach in many geographic regions and patient subgroups. Patient advocacy groups, along with some clinicians and policymakers, have argued that too many women receive mastectomies. Breast conserving surgery (BCS) with radiation is perceived as a superior surgical choice for most women because it is less invasive, preserves the breast, and may thus serve to reduce body image concerns, sexual functioning problems, and/or other psychosocial sequela postsurgery. There is some empirical evidence suggesting that postsurgical psychological adjustment may be less difficult for women receiving BCS (Levy, Herberman, Lee, et al. 1989; Margolis, Goodman, Rubin, et al. 19891; Schain, Findlay, D’Angelo, et al. 1985). In a meta-analysis, Moyer (1997) found small advantages for BCS in regard to postsurgical psychological, marital, and sexual adjustment. Not all studies, however, support the premise that postsurgical quality of life is better for women receiving BCS compared with mastectomy (Ganz, Schag, Lee, et al. 1992; Irwig and Bennetts 1997). The surgical approaches may be equivalent in terms of adjustment to or satisfaction with the surgery. Even so, some argue that equivalence should not be construed as justification for a higher use of mastectomy (Page and Jensen 1996; Starreveld 1997). If the treatments are truly equal, then policies and practices should emphasize the use of BCS. Indeed, the National Cancer Institute Consensus Development Conference on the treatment of early stage breast cancer declared that although the treatments are equivalent in most respects, BCS is preferable because it preserves the breast (National Institutes of Health 1990). Based on this literature, researchers have largely focused on the relative use of the two procedures as measures of progress and quality of care. The results of this research suggest that the use of BCS increased slowly and minimally in many areas while stagnating in others (Farrow, Hunt, and Samet 1992; Lazovich et al. 1991; Samet, Hunt, and Farrow 1994). In addition, mastectomy remains the most common surgical treatment for breast cancer patients in many regions. Lazovich, Solomon, Thomas, et al. (1999) reported that for stage I breast cancer during 1995, the rate of BCS ranged from 41% to 71% across Surveillance, Epidemiology, and End Results (SEER) tumor registries. For stage II patients, mastectomy was the most common surgical approach in all SEER regions. These findings, coupled with the fact that breast cancer surgical treatment also varies by provider/hospital characteristics and patient sociodemographics (such as age, race and socioeconomic characteristics), are viewed as evidence that problems still exist in terms of the overuse of mastectomy (Michalski and Nattinger 1997; Morris et al. 2000; National Cancer Policy Board 1999; Nattinger, Gottlieb, Hoffman, et al. 1996; Nattinger, Gottlieb, Veum, et al. 1992). Research has also demonstrated that BCS with radiation therapy affords the same survival rate as mastectomy for women with ductal carcinoma in situ, some of whom are perceived as optimal candidates for breast conservation (Boyages, Delaney, and Taylor 1999; Fisher, Dignam, Tan-Chiu, et al. 1999; Silverstein 1998). However, modified radical mastectomy remains the most common surgical treatment for women with in situ breast cancer in several population-based tumor registry areas, a fact that is viewed as additional evidence that BCS is underutilized (Ernster, Barclay, Kerlikowske, et al. 1996; Morrow 1996; Talamonti 1996; Winchester et al. 1995). Concerns about overtreatment with mastectomy and lack of patient informed consent, voiced primarily by women’s health advocacy groups and some clinicians/researchers, motivated the passage of legislative mandates regarding breast cancer treatment in 20 states between 1979 and 1999 (Montini 1997; Nayfield, Bongiovanni, Alciati, et al. 1994). Almost all of these laws require that information regarding surgical treatment alternatives be provided to breast cancer patients in an informative and unbiased fashion. Nattinger, Hoffman, Shapiro, et al. (1996), using SEER trend data to estimate the impact of these legislative mandates, observed an increase in the rate of BCS that was slightly above expected in three of four SEER sites after a law was passed. However, within a year, BCS rates in all sites reverted to the expected levels. These results—using BCS rates as the litmus test—suggest that breast cancer treatment disclosure laws have had only a small, transient effect on breast cancer surgery in practice.

What effect does increasing inpatient time have on outpatient-oriented internist satisfaction?

AbstractOBJECTIVE: Because career satisfaction among general internists is relatively low, we sought to understand the impact on satisfaction of general internists managing patients both in and outside of the hospital. Using data from a national survey, we asked, “Among outpatient-oriented general internists (i.e., internists who spend less than 50% of their clinical time caring for inpatients), what effect does time spent in the hospital have on physician satisfaction, stress, and burnout?” DESIGN/PARTICIPANTS: The Physician Worklife Study, in which 5,704 physicians in primary and specialty nonsurgical care selected from the American Medical Association’s Masterfile were surveyed (adjusted response rate=52%), was used. Our analyses focused on clinically active outpatient-oriented general internists (N=339). MEASUREMENTS AND MAIN RESULTS: We constructed multivariate linear models to test for statistically significant associations between the amount of time spent seeing inpatients and physician satisfaction as measured by several satisfaction scales. Even after controlling for total hours worked and other possible confounding variables, we found that increased time working in the hospital was significantly associated with decreases in satisfaction with administration, specialty, autonomy, and personal time, and significantly associated with an increase in life stress. There was also a significant association between increased time spent in the hospital and burnout. CONCLUSIONS: Our findings imply that there may be a tension between the practice of inpatient and outpatient medicine by general internists, and suggest that fewer hospital duties may increase career satisfaction for outpatient-oriented internists. Although additional studies are warranted in order to better understand why these relationships exist, our data suggest that the hospitalist model of inpatient care might be one approach to alleviate stress and improve satisfaction for many general internists.