Julie M. Kapp

Association between exposure to childhood and lifetime traumatic events and lifetime pathological gambling in a twin cohort.

The present study seeks to estimate the strength of the association between exposure to lifetime traumatic events and gambling problems while accounting for the potential contribution of psychiatric disorders, genetic factors, and family environmental influences. In 2002, structured diagnostic interviews were conducted with 1675 male twins to obtain data on exposure to traumatic events and pathological gambling. Multinomial regression tested for associations between each traumatic event and three levels of problem gambling (1–2 symptoms, at risk; 3–4 symptoms, problem gambling, and 5 or more symptoms, pathological gambling). Analyses of data from twin pairs discordant for gambling behavior controlled for genetic and family environmental factors. After adjustment for covariates, child abuse (relative risk [RR] = 2.31), child neglect (RR = 5.53), witnessing someone badly hurt or killed (RR = 2.83), and physical attack (RR = 3.39) were associated with pathological gambling. Genetic and family environmental factors significantly contributed to the association between exposure to traumatic events and one or more symptoms of problem gambling. Exposure to childhood and lifetime traumatic events are significantly associated with problem and pathological gambling. These associations are partially accounted for by psychiatric covariates and genetic and family environmental factors.

Racial and ethnic differences in mammography use among U.S. women younger than age 40

Objective Evidence-based recommendations for routine breast cancer screening suggest that women begin mammography at age 40, although some women receive a mammogram before that age. Little is known about mammography use among younger women, especially with respect to race and ethnicity. Methods We used data from the 2005 National Health Interview Survey to examine racial/ethnic differences in mammography use among U.S. women ages 30–39. We examined descriptive characteristics of women who reported ever having a mammogram, and used logistic regression to estimate associations between race/ethnicity and mammography use among women at average risk for breast cancer. Results Our sample comprised 3,098 women (18% Hispanic, 13% non-Hispanic [NH] black, 69% NH white), of whom 29% reported having ever had a mammogram. NH black women were more likely than NH white women to report ever having a mammogram and receiving multiple mammograms before age 40 among women of average risk. Patterns of mammography use for Hispanic women compared to NH white women varied. Conclusion Findings suggest differential utilization of mammograms by race/ethnicity among women outside current recommendations and of average risk. Future studies should examine the role of practice patterns and patient–provider communication.

Updating public health teaching methods in the era of social media.

Julie M. Kapp, MPH, PHDab Joseph W. LeMaster, MD, MPHa M. Boden Lyon, MEdc Beilei Zhang, MSd Michael C. Hosokawa, EdD* Web 2.01 describes the interactive, collective intelligence of todays Internet experience. Web-based information technologies, such as social media, enhance public health practice through the accelerated dissemination of health promo tion and disease detection information. Social media sites such as YouTube

Associations of physical activity and body mass index with activities of daily living in older adults.

Research reports about the associations of leisure-time physical activity (LPA) and Body Mass Index (BMI) with activities of daily living (ADL) - or instrumental activities of daily living (IADL)-dependent disability in older adults are inconclusive. Data were obtained from the 2000 Missouri Older Adult Needs Assessment Survey. Logistic regression was used to examine the associations of LPA and BMI with ADL-or IADL-dependent disability, while controlling for factors known to be associated with LPA, BMI, ADL and IADL. ADL-or IADL dependency decreased with LPA and increased with BMI regardless of each other’s level, presence of functional limitation, education, gender, race-ethnicity, and health care coverage. Physically active individuals were less likely than inactive ones to be ADL- or IADL-dependent. BMI was modestly associated with ADL- or IADL-dependency and this relationship was confounded by LPA. If confirmed by well designed longitudinal studies, LPA and BMI independent associations with ADL- or IADL-dependent disability lends supports to a strategy for improving older adult quality of life through improved physical activity. Etiological studies on the associations between risk factors and quality of life outcomes in older adults should consider the joint confounding effect of LPA and BMI.

Interdisciplinary collaboration: the voices of hospice medical directors.

The value of interdisciplinary collaboration is a significant aspect of the palliative care philosophy, as identified by the founder of the modern hospice movement Cecily Saunders. The purpose of this descriptive study was to explore the experiences of hospice medical directors within this collaborative context. Open-ended interviews with 17 hospice medical directors were done and their responses were thematically analyzed. These narratives present a very positive collaborative experience by these medical directors in their hospice settings. Assisting medical directors to find time and financial opportunities for professional development and support within their role was found to be an opportunity to further improve collaboration.

A prospective assessment of racial/ethnic differences in future mammography behavior among women who had early mammography

Background: Twenty-nine percent of women, aged 30 to 39, report having had a mammogram, though sensitivity and specificity are low. We investigate racial/ethnic differences in future mammography behavior among women who had a baseline screening mammogram prior to age 40. Methods: Using 1994–2008 data from the Breast Cancer Surveillance Consortium (BCSC), we identified 29,390 women aged 35 to 39 with a baseline screening mammogram. We followed this cohort for 2 outcomes: (i) future BCSC mammography between ages 40 and 45; and (2) among those, delay in screening mammography until ages 43 to 45 compared with ages 40 to 42. Using adjusted log-linear models, we estimated the relative risk (RR) of these outcomes by race/ethnicity, while also considering the impact of false-positive/true-negative (FP/TN) baseline mammography results on these outcomes. Results: Relative to non-Hispanic white women, Hispanic women had an increased risk of no future BCSC mammography (RR: 1.21, 95% CI: 1.13–1.30); Asian women had a decreased risk (RR: 0.67, 95% CI: 0.61–0.74). Women with a FP result, compared with a TN result, had a decreased risk of no future BCSC mammography (RR: 0.89, 95% CI: 0.85–0.95). Among those with future BCSC screening mammography, African American women were more likely to delay the timing (RR: 1.26, 95% CI: 1.09–1.45). The interaction between race/ethnicity and FP/TN baseline results was not significant. Conclusions: Race/ethnicity is differentially associated with future BCSC mammography and the timing of screening mammography after age 40. Impact: These findings introduce the need for research that examines disparities in lifetime mammography use patterns from the initiation of mammography screening. Cancer Epidemiol Biomarkers Prev; 20(4); 600–8. ©2011 AACR.

Are there racial/ethnic disparities among women younger than 40 undergoing mammography?

While the probability of a woman developing invasive breast cancer at age <40 is low (<1%), mammography use reported among younger women (age <40) is substantial, and varies by race/ethnicity. Little detail is known about mammography use among women aged <40, particularly by race/ethnicity. We describe racial/ethnic differences in: (1) mammography indication after considering underlying risk factors (breast symptoms and family history); (2) follow-up recommendations, and (3) mammography outcomes for first mammograms in women aged <40. These 1996–2005 Breast Cancer Surveillance Consortium data are prospectively pooled from seven U.S. mammography registries. Our community-based sample included 99,615 women aged 18–39 who self-reported race/ethnicity and presented for a first mammogram (screening or diagnostic) with no history of breast cancer. Multivariable analyses controlled for registry site, age, family history of breast cancer, symptoms, and exam year. Overall, 73.6% of the women in our sample were seen for a screening mammogram. Following screening mammography, African American (AA) women were more likely than white women to be recommended for additional workup [relative risk (RR): 1.15 (95% CI: 1.07–1.23)]. Following diagnostic mammography, AA [RR: 1.30 (95% CI: 1.17–1.44)] and Asian [RR: 1.44 (95% CI: 1.26–1.64)] women were more likely to be recommended for biopsy, fine-needle aspiration, or surgical consultation. Depending on race/ethnicity, and considering the rate of true positive to total first screening mammograms of younger women, a women has a likelihood of a true positive of 1 in 363–1,122; she has a likelihood of a false positive of 1 in 7–10. This study of community-based practice found racial/ethnic variability in mammography indication, recommendations, and outcomes among women undergoing first mammography before 40. These findings highlight important areas for future research to understand the motivating factors for these practice patterns and the implications of early mammography use.

Hospice medical directors: a survey of one state.

INTRODUCTION Little research exists regarding hospice medical directors (HMD). This project describes the HMDs background and training, clinical roles, and current function within the hospice organization and their interdisciplinary groups. METHODS A survey was mailed to each licensed hospice that was also a member of the state hospice association in one state. Thirty-one HMDs from 31 hospice programs (40% response rate) in one state responded. RESULTS Findings show that the role of the HMD in this state is primarily part-time and filled by primary care physicians. Most HMDs report being satisfied with their positions. No more than one third belong to any one professional association and no physician in this survey was certified in palliative care by the American Board of Medical Specialties. The role for most of these HMDs centers around their clinical contribution to the team. DISCUSSION Despite the 2008 revisions in the regulations, the HMD roles still vary across hospices, and requirements regarding the specialty, training, and education for physicians are not specified. Professional associations for HMDs should target these part-time physicians in an effort to build a comprehensive organization represented by all types of HMDs. CONCLUSION The part-time nature of HMDs has important implications for professional organizations and policy makers. Palliative care certification and continuing education opportunities need to be made available to these physicians. Additionally, new changes requiring face-to-face visits for recertification should consider the part-time nature of HMD work and the difficulties that the requirement will have in both cost for the hospice and access to primary care in rural areas.

Physician Recommendations for Mammography in Women Aged 70 and Older

OBJECTIVES: To estimate the percentage of U.S. women aged 70 and older who reported a recent mammography recommendation and to identify whether factors suggesting limited life expectancy, such as comorbidities, are associated with a lower probability of a reported recommendation.

Visualizing Complex Adaptive Systems: A Case Study of the Missouri Maternal, Infant, and Early Childhood Home Visiting Program

Background: The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program was created by the 2010 Patient Protection and Affordable Care Act. MIECHV provides comprehensive services to at-risk families through evidence-based home visiting programs. Purpose: The following question is addressed: Does the Missouri MIECHV system meet the definition of a complex adaptive system (CAS)? Methods: A systematic review was conducted of documents related to MIECHV programs (federal, state, and local levels), and to affiliated programs with a home visiting and early childhood (aged birth to 5 years) scope. The organizations’ fit was identified for the scope of early childhood home visiting programs, and then its relationship extracted to MIECHV and its affiliates. Results: MIECHV meets the definition of a CAS, being dynamic, massively entangled, scale independent, transformative, and emergent. Over 250 organizations were identified; 19 federal and 79 state organizations; 24 nonprofits at the federal level, 31 at the state; over 150 community-level agencies; and 13 home visiting models implemented in Missouri. Implications: A considerable amount of organizational complexity exists within the MIECHV system and among its affiliates with a home visiting and early childhood scope. The complexity of the system challenges its potential for effective and efficient implementation, coordination, sustainability, and evaluation, and increases the potential for redundancy, overlap, and fragmentation. Evaluating a CAS requires acknowledgement of its complexity, beyond traditional approaches to evaluation. Creating visualization tools of federal, state, and local stakeholders and their relationships is a practical approach for aligning, organizing, and communicating the work flow.