Larry G. Kessler

Potential for cancer related health services research using a linked Medicare-tumor registry database.

The National Cancer Institute and the Health Care Financing Administration share a strong research interest in cancer costs, access to cancer prevention and treatment services, and cancer patient outcomes. To develop a database for such research, the two agencies have undertaken a collaborative effort to link Medicare Program data with the Surveillance, Epidemiology, and End Results (SEER) Program database. The SEER Program is a system of 9 population-based tumor registries that collect standardized clinical information on cases diagnosed in separate, geographically defined areas covering approximately 10% of the US population. Using a deterministic matching algorithm, the records of 94% of SEER registry cases diagnosed at age 65 or older between 1973 to 1989, or more than 610,000 persons, were successfully linked with Medicare claims files. The resulting database, combining clinical characteristics with information on utilization and costs, will permit the investigation of the contribution of various patient and health care setting factors to treatment patterns, costs, and medical outcomes.

Cervical cancer screening: who is not screened and why?

BACKGROUND The decline in death rates from cervical cancer in the United States has been widely attributed to the use of Papanicolaou (Pap) smears for early detection of cervical cancer. METHODS Pap smear screening rates, beliefs about appropriate screening intervals and factors affecting screening were examined using 1987 National Health Interview Survey data. RESULTS Results indicate that through age 69, Blacks are screened at similar or higher rates than Whites. Hispanics, particularly those speaking only or mostly Spanish, are least likely to have received a Pap smear within the last three years. Of women who had never heard of or never had a Pap smear, nearly 80 percent reported contact with a medical practitioner in the past two years, while more than 90 percent reported a contact in the past five years. Overall, the most frequently reported reason for not having a recent Pap smear was procrastinating or not believing it was necessary. CONCLUSIONS Thus, in developing screening programs, Hispanics, particularly Spanish speakers, must be targeted. In addition, educational programs should target unscreened women who forego the test due to underestimating its importance, procrastination, or because their medical care provider did not suggest the procedure. Women must be intensively educated that Pap smears should be scheduled routinely to detect asymptomatic cervical cancer.

Changes in the use of screening mammography: evidence from the 1987 and 1990 National Health Interview Surveys.

OBJECTIVES Mammography rates reported by women in the National Health Interview Surveys of 1990 and 1987 are examined. Why this screening modality is not more frequently used is explored. METHODS Data from the 1987 and 1990 National Health Interview Surveys, conducted by the National Center for Health Statistics, are cross-tabulated and compared. RESULTS In 1987, approximately 17% of women over 40 years of age reported having had a screening mammogram in the previous year. In 1990, the rate doubled. Race declined in importance; income and education remained strong, positive predictors of screening. CONCLUSIONS Despite this dramatic increase, two thirds of women are not having screening mammograms. Use was not higher primarily because women did not realize that screening mammography tests for breast cancer in asymptomatic women. Primary care physicians are the main source of health education for screening mammography. The data suggest that public health programs to promote screening mammography should especially target primary care physicians and women with low incomes and education. Likewise, health care providers should ensure that their patients are referred to facilities that deliver high-quality mammography at low cost to make the procedure more accessible.

Psychiatric diagnoses of medical service users: evidence from the Epidemiologic Catchment Area Program.

Based on data from the five sites of the National Institute of Mental Health-sponsored Epidemiologic Catchment Area (ECA) Program, this paper examines the prevalence of psychiatric disorder among recent medical service users versus nonusers, with a particular focus on affective disorders, substance abuse/dependence, and phobias. The rate of current Diagnostic Interview Schedule (DIS) disorders among medical users in all five ECA sites is 21.7 per cent (slightly higher than general population rates) versus 16.7 per cent among nonusers; there is generally no difference between users and nonusers with past DIS diagnoses. Affective disorders were among the most common mental disorders of medical service users, especially among females, with little variation between sites: females: users: 6.9 per cent to 9.3 per cent, nonusers: 3.4 per cent to 6.4 per cent, and males: users: 3.3 per cent to 6.5 per cent, nonusers: 1.2 per cent to 4.1 per cent. Rates of phobias among persons using medical services are also higher than among nonusers. Substance abuse disorders are at least as common among persons who use medical services (8 per cent to 14 per cent of male users) as among those who do not (9 per cent to 11 per cent of male nonusers). The high rates of affective disorders among women and of substance abuse among male medical service users underscore the need to increase the ability of general medical practitioners to recognize and manage or refer these conditions.

Estimating the Treatment Costs of Breast and Lung Cancer

The Continuous Medicare History Sample File (CMHSF) was used to derive an estimate of the lifetime direct medical expenses attributable to two chronic diseases, lung cancer and female breast cancer. These two cancers are the leading cancer causes of death in men and women in the United States. They inflict large costs on the population, both direct and indirect, but the costs have been difficult to measure. The primary obstacle to quantification is the intermittent and long-term nature of treatment for these diseases. A complete record of expenses cannot usually be obtained from one source, however, a review of all the national health surveys, as well as the Medicare statistical files identified the CMHSF, which is maintained by the Health Care Financing Administration in a format suitable for calculation of cumulative medical expenses. Some of the pertinent features of the CMHSF include the following: 1) it is a nationally representative sample of the Medicare population, 2) it is longitudinal covering an 8-year period from 1974 to 1981, 3) it captures the majority of medical expenses for each enrollee, and 4) it can be linked to other national data bases such as the National Death Index. Charges for three phases of cancer treatment were derived from the file: initial therapy, maintenance care, and terminal care. A method is described for computing the present value of lifetime treatment costs from the phase-specific charges. The lifetime cost of treating breast cancer in 1984 dollars is

The prevalence of cancer among adults in the United States: 1987

36,926 and lung cancer is

Is the Supply of Mammography Machines Outstripping Need and Demand?: An Economic Analysis

12,510.

A longitudinal study of offset in the use of nonpsychiatric services following specialized mental health care

No national data exist on the prevalence of cancer in the United States population. The authors report the first estimates of prevalence rates of cancer from a population‐based sample of the adult population of the United States. Estimates are based on responses collected from the Cancer Control Supplements of the National Health Interview Survey, a population‐based sample survey of all people older than 17 years of age in the United States in 1987. Of 44,123 adults questioned, 1593 said they had a nonskin cancer. In 1987, after adjustments, the overall prevalence rate of all types of cancer, excluding nonme‐lanoma skin cancer, was 3230 per 100,000 adults; the rates for men and women were 1930 and 4412, respectively. The authors estimate that, in 1987, 5.7 million adults in the United States were survivors of nonskin cancer, 3.3% of the adult population. Approximately 89,000 adults had cancer during childhood, or 1.6% of the total. Approximately 3.6 million people were at least 5‐year survivors and 900,000 adults had their disease diagnosed during the year before interview. Despite the potential for underreporting and misclassification, these national estimates are in general accord with figures estimated from other sources. Increasing survival after cancer, especially childhood and adolescent cancer, indicates the importance of continued monitoring to provide information needed to plan for adequate health services.

Factors influencing the diagnosis of mental disorder among primary care patients

The number of dedicated mammography machines installed in the United States has grown explosively. It is estimated that almost 10,000 machines will be installed by 1990, whereas the projected demand for screening mammography will require only approximately 2,600 machines, if the machines are used in a moderately efficient manner. The excess supply of mammography resources raises concern from an economic perspective for several reasons. First, such a condition means that health care resources are being used inefficiently. Second, the low average utilization rate of mammography equipment implied by these results necessitates charging a high price-over

A model for making project funding decisions at the National Cancer Institute

100, on average-to cover costs. This price is above the