Karen Gold

Patterns of breast carcinoma treatment in older women: Patient preference and clinical and physician influences

Older women have high rates of breast carcinoma, and there are substantial variations in the patterns of care for this population group.

Incorporating biomarkers of exposure and genetic susceptibility into smoking cessation treatment: effects on smoking-related cognitions, emotions, and behavior change.

In this article the authors report on the short-term impact of incorporating biomarker feedback about exposure and genetic susceptibility into minimal-contact quit-smoking counseling (QSC). Four hundred and twenty-seven smokers were randomized to 1 of 3 treatments: (a) QSC, (b) QSC + exposure biomarker feedback (EBF) about carbon monoxide in exhaled breath, or (b) QSC + EBF + biomarker feedback about genetic susceptibility to lung cancer (SBF). We observed significant immediate positive effects of SBF, compared with EBF and QSC on perceived risk, perceived quitting benefits, and fear arousal. However, at the 2-month follow-up, there were no group differences in quit rates. SBF did lead to significant reductions in the number of cigarettes smoked for smokers who were in the preparation stage. Smokers in the EBF and QSC conditions showed reductions in depressive symptoms by 2 months, but smokers in the SBF condition did not. In the context of QSC, genetic feedback may heighten vulnerability and possibly promote distress, but may not immediately enhance quitting in most smokers.

Variations in breast carcinoma treatment in older Medicare beneficiaries: Is it black and white?

To evaluate associations between race and breast carcinoma treatment.

Development and validation of a rhinoconjunctivitis and asthma symptom score for use as an outcome measure in clinical trials

BACKGROUND The measurement of health outcomes has become a priority for assessing and containing health care costs. OBJECTIVE To develop and fully validate a simple symptom scale assessing both asthma and rhinoconjunctivitis, two interdependent conditions. METHODS A self-administered questionnaire of 31 items was tested in 102 patients with asthma and rhinoconjunctivitis between September 1992 and December 1994. The items were rated on a six-point Likert scale ranging from none to extremely severe and included commonly recorded symptoms of inflammation such as irritation, congestion, and discharge in the skin, eyes, nose, sinus, pharynx, and chest. RESULTS Validation included (1) responsiveness: scores for 18 patients evaluated during an emergency room visit were statistically significantly different from those recorded after recovery and in a control group of 24 patients with asthma; (2) reliability: external consistency was 0.8 at 1 week, and internal consistency was 0.8 for individual organs and 0.7 for individual symptoms; (3) validity: a five-point scale better captured the distribution of values; irrelevant and redundant items were eliminated. The optimal questionnaire included 21 items. CONCLUSIONS The symptom score was applicable, responsive, reliable, and valid. Used with existing validated tools such as treatment needs and quality of life assessment, it may provide a comprehensive picture of allergic airway disease for quality assurance or research purposes.

Measuring and predicting surgeons' practice styles for breast cancer treatment in older women.

Background.Few measures exist to assess physicians’ practice style, and there are few data on physicians’ practice styles and patterns of care. Objectives.To use clinical vignettes to measure surgeons’ “propensity” for local treatments for early-stage breast cancer and to describe factors associated with propensity. Research Design and Subjects.A cross-sectional mailed survey with telephone follow-up of a random sample of 1,000 surgeons treating Medicare beneficiaries in fee-for-service settings. Measures.Outcome measures include treatment propensity, self-reported practice, and actual treatment received by the surgeons’ patients. Results.Propensities were significantly associated with actual treatment, controlling for covariates. Area Medicare fees were the strongest predictor of propensity, followed by region, attitudes, volume, and gender. For instance, after other factors were considered, surgeons practicing in areas with the highest breast-conserving surgery (BCS) fees were 8.61 (95% CI 2.26–32.73) times more likely to have a BCS propensity than surgeons in areas with the lowest fees. Surgeons with the strongest beliefs in patient participation in treatment decisions were nearly 6 times (95% CI 1.67–20.84) more likely to have a BCS propensity than surgeons with the lowest such beliefs, controlling for covariates. Male surgeons were also independently more likely to have a mastectomy propensity than female surgeons. Conclusions.Surgeons’ propensities explain some of the observed variations in breast cancer treatment patterns among older women. Standardized scenarios provide a practical method to measure practice style and could be used to evaluate physician contributions to shared decision making, practice patterns, costs and outcomes, and adherence to guidelines.

Patient and provider characteristics that affect the use of axillary dissection in older women with Stage I–II breast carcinoma

Axillary dissection for the evaluation and treatment of patients with breast carcinoma often is not performed in older women. The objective of this study was to examine patient, clinical, and surgeon characteristics associated with the use of axillary dissection after breast‐conserving surgery (BCS).

Imputing Physical Health Status Scores Missing Owing to Mortality: Results of a Simulation Comparing Multiple Techniques

Background.Having missing data complicates the statistical analysis of health-related quality-of-life (HRQOL) data and, depending on the extent and nature of missing data, can introduce significant bias in treatment comparisons. Objective.We evaluated the bias associated with 4 different imputation methods for estimating physical health status (PHS) scores missing as a result of mortality. Methods.A simulation study was conducted in which we systematically varied mortality rates from 0% to 30% and change in PHS scores from −20 to 20 on a 100-point scale for a 2-group clinical trial with follow-up over 18 months. The 4 imputation methods were last value carried forward (LVCF), arbitrary substitution (ARBSUB), empirical Bayes (BAYES), and within-subject modeling (WSMOD). Pseudo–root mean square residuals (RMSRs) and differences between true and estimated slopes were used to evaluate how well the imputation methods reproduced the true characteristics of the simulated population data. Results.ARBSUB and BAYES methods have the smallest RMSRs compared with LVCF and WSMOD across all mortality rates. As the rate of missing data resulting from mortality increased, all imputation techniques deviated more from population data. The BAYES technique was best at reproducing group slopes in cases with differential mortality rates or when mortality rates exceeded 15%. WSMOD and LVCF significantly underestimated changes in PHS. Conclusions.The different imputation methods produced comparable results when there were few missing data. The BAYES approach most closely estimated true population differences and change in PHS regardless of missing data rates. These findings are limited to physical health and functioning measures.

Item responsiveness of a rhinitis and asthma symptom score during a pollen season.

Twenty-one asthma patients with allergic rhinitis completed a series of self-administered questionnaires (21-item symptom score for rhinosinusitis and asthma, bother scale, McMaster Asthma Quality of Life Questionnaire [MAQOL] and Euroqol) at 2-week intervals from August to November 1994. Relative responsiveness of the instruments was assessed in reference to the maximum and minimum average scores for MAQOL, with area under the curve (AUC) and correlation coefficients between the different instruments. Symptom score, MAQOL, and bother scale provided similar results for both extreme values and AUC, whereas Euroqol utilities were less responsive. These results suggest that the symptom scores and bother scales are responsive and valid, and might prove valuable in everyday practice, clinical trials, and quality assurance programs.

Evaluating Statistics Texts Used in Education

Evaluating texts is an important activity associated with teaching statistics. Surprisingly, the statistical education literature offers little guidance on how these evaluations should be conducted. This lack of guidance may be at least partly responsible for the fact that published evaluations of statistics texts almost invariably employ evaluation criteria that lack any theory-based rationale. This failing is typically compounded by a lack of empirical evidence supporting the usefulness of the criteria. This article describes the construction and piloting of instruments for evaluating statistics texts that are grounded in the statistical education and text evaluation literatures. The study is an initial step in a line of research which we hope will result in the establishment and maintenance of a database of evaluations of statistical texts. Evaluative information of this kind should assist instructors wrestling with text selection decisions and individuals charged with performing evaluations, such as journal reviewers, and should ultimately benefit the direct consumers of these texts—the students.