Martha Goodrich

Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry.

OBJECTIVES:Detection and removal of adenomas and clinically significant serrated polyps (CSSPs) is critical to the effectiveness of colonoscopy in preventing colorectal cancer. Although longer withdrawal time has been found to increase polyp detection, this association and the use of withdrawal time as a quality indicator remains controversial. Few studies have reported on withdrawal time and serrated polyp detection. Using data from the New Hampshire Colonoscopy Registry, we examined how an endoscopists withdrawal time in normal colonoscopies affects adenoma and serrated polyp detection.METHODS:We analyzed 7,996 colonoscopies performed in 7,972 patients between 2009 and 2011 by 42 endoscopists at 14 hospitals, ambulatory surgery centers, and community practices. CSSPs were defined as sessile serrated polyps and hyperplastic polyps proximal to the sigmoid. Adenoma and CSSP detection rates were calculated based on median endoscopist withdrawal time in normal exams. Regression models were used to estimate the association of increased normal withdrawal time and polyp, adenoma, and CSSP detection.RESULTS:Polyp and adenoma detection rates were highest among endoscopists with 9 min median normal withdrawal time, and detection of CSSPs reached its highest levels at 8–9 min. Incident rate ratios for adenoma and CSSP detection increased with each minute of normal withdrawal time above 6 min, with maximum benefit at 9 min for adenomas (1.50, 95% confidence interval (CI) (1.21, 1.85)) and CSSPs (1.77, 95% CI (1.15, 2.72)). When modeling was used to set the minimum withdrawal time at 9 min, we predicted that adenomas and CSSPs would be detected in 302 (3.8%) and 191 (2.4%) more patients. The increase in detection was most striking for the CSSPs, with nearly a 30% relative increase.CONCLUSIONS:A withdrawal time of 9 min resulted in a statistically significant increase in adenoma and serrated polyp detection. Colonoscopy quality may improve with a median normal withdrawal time benchmark of 9 min.

Factors associated with interval adherence to mammography screening in a population-based sample of New Hampshire women.

Interval adherence to mammography screening continues to be lower than experts advise. The authors evaluated, using a population‐based mammography registry, factors associated with adherence to recommended mammography screening intervals.

Distinct patterns of DNA methylation in conventional adenomas involving the right and left colon.

Recent studies have shown two distinct non-CIMP methylation clusters in colorectal cancer, raising the possibility that DNA methylation, involving non-CIMP genes, may play a role in the conventional adenoma–carcinoma pathway. A total of 135 adenomas (65 left colon and 70 right colon) were profiled for epigenome-wide DNA methylation using the Illumina HumanMethylation450 BeadChip. A principal components analysis was performed to examine the association between variability in DNA methylation and adenoma location. Linear regression and linear mixed effects models were used to identify locus-specific differential DNA methylation in adenomas of right and left colon. A significant association was present between the first principal component and adenoma location (P=0.007), even after adjustment for subject age and gender (P=0.009). A total of 168 CpG sites were differentially methylated between right- and left-colon adenomas and these loci demonstrated enrichment of homeobox genes (P=3.0 × 10−12). None of the 168 probes were associated with CIMP genes. Among CpG loci with the largest difference in methylation between right- and left-colon adenomas, probes associated with PRAC (prostate cancer susceptibility candidate) gene showed hypermethylation in right-colon adenomas whereas those associated with CDX2 (caudal type homeobox transcription factor 2) showed hypermethylation in left-colon adenomas. A subgroup of left-colon adenomas enriched for current smokers (OR=6.1, P=0.004) exhibited a methylation profile similar to right-colon adenomas. In summary, our results indicate distinct patterns of DNA methylation, independent of CIMP genes, in adenomas of the right and left colon.

The influence of smoking, gender, and family history on colorectal adenomas.

Evidence independently links smoking, family history, and gender with increased risk of adenomatous polyps. Using data from the New Hampshire Colonoscopy Registry (2004–2006), we examined the relation of combined risk factors with adenoma occurrence in 5,395 individuals undergoing screening colonoscopy. Self-reported data on smoking, family history and other factors were linked to pathology reports identifying adenomatous polyps and modeled with multiple logistic regression. In adjusted models a >15 pack-year smoking history increased the likelihood of an adenoma (OR = 1.54, 95% CI 1.28–1.86), although ≤15 pack-years did not (OR = 1.07, 95% CI 0.87–1.32). Gender-stratified models showed a significantly increased risk of adenoma at lower smoking exposure even for men (OR = 1.32; 95% CI:1.00–1.76), but not for women (OR = 0.85; 95% CI:0.61–1.14). An ordered logistic regression model of adenoma occurrence showed a smoking history of ≥15 pack-years associated with 61% higher odds of adenoma at successively larger size categories (95% CI 1.34–1.93). For individuals with a family history of colorectal cancer, smoking does not further increase the risk of adenomas. Smoking duration is linked to occurrence and size of adenoma, especially for men.

Matching colonoscopy and pathology data in population-based registries: development of a novel algorithm and the initial experience of the New Hampshire Colonoscopy Registry

BACKGROUND The quality of polyp-level data in a population-based registry depends on the ability to match each polypectomy recorded by the endoscopist to a specific diagnosis on the pathology report. OBJECTIVE To review impediments encountered in matching colonoscopy and pathology data in a population-based registry. DESIGN New Hampshire Colonoscopy Registry data from August 2006 to November 2008 were analyzed for prevalence of missing reports, discrepancies between colonoscopy and pathology reports, and the proportion of polyps that could not be matched because of multiple polyps submitted in the same container. SETTING New Hampshire Colonoscopy Registry. PATIENTS This study involved all consenting patients during the study period. INTERVENTION Develop an algorithm for capturing number, size, location, and histology of polyps and for defining and flagging discrepancies to ensure data quality. MAIN OUTCOME MEASUREMENTS The proportion of polyps with no assumption or discrepancy, the proportion of patient records eligible for determining the adenoma detection rate (ADR), and the number of patients with ≥3 adenomas. RESULTS Only 50% of polyps removed during this period were perfectly matched, with no assumption or discrepancy. Records from only 69.9% and 29.7% of eligible patients could be used to determine the ADR and the number of patients with ≥3 adenomas, respectively. LIMITATIONS Rates of missing reports may have been higher in the early phase of establishment of the registry. CONCLUSION This study highlights the impediments in collecting polyp-level data in a population-based registry and provides useful parameters for evaluating the quality and accuracy of data obtained from such registries.

Beyond polarization, public preferences suggest policy opportunities to address aging, dying, and family caregiving

Despite well-documented deficiencies and widespread suffering experienced by millions of elderly or ill Americans and their families, politicians rarely address end-of-life issues. Citizen Forums in New Hampshire surveyed 463 people regarding aging, serious illness, and caregiving. More than 80% indicated it was very or extremely important to have their dignity respected, preferences honored, pain controlled, and to not leave family with debt. Less than half strongly endorsed being kept alive as long as possible, prayed with or for, or having assisted-suicide available. Over 80% strongly endorsed palliative care requirements clinical licensure and reimbursement, expansion of family caregiver leave, respite care, and bereavement support. By avoiding actions which elicit strong divergence of opinion and focusing on actions on which consensus exists, public officials and candidates can respond to problems and improve care and experience for frail elders, dying Americans, and their families.

Discovery of breast cancers within 1 year of a normal screening mammogram: how are they found?

PURPOSE We sought to determine how breast cancers that occur within 1 year after a normal mammogram are discovered. METHODS Using population-based mammography registry data from 2000–2002, we identified 143 women with interval breast cancers and 481 women with screen-detected breast cancers. We surveyed women’s primary care clinicians to assess how the interval breast cancers were found and factors associated with their discovery. RESULTS Women with interval cancers were twice as likely to have a personal history of breast cancer (30.1%) as women with screen-detected cancers (13.6%). Among women with interval cancers, one half of the invasive tumors (49.5%) were discovered when women initiated a health care visit because of a breast concern, and 16.8% were discovered when a clinician found an area of concern while conducting a routine clinical breast examination. Having a lump and both a personal and a family history of breast cancer was the most common reason why women initiated a health care visit (44%) (P <.01). CONCLUSIONS Women with interval cancers are most likely to initiate a visit to a primary care clinician when they have 2 or more breast concerns. These concerns are most likely to include having a lump and a personal and/or family history of breast cancer. Women at highest risk for breast cancer may need closer surveillance by their primary care clinicians and may benefit from a strong educational message to come for a visit as soon as they find a lump.

False-positive mammography and depressed mood in a screening population: findings from the New Hampshire Mammography Network

BACKGROUND False positives occur in approximately 11% of screening mammographies in the USA and may be associated with psychologic sequelae. METHODS We sought to examine the association of false-positive mammography with depressed mood among women in a screening population. Using data from a state-based mammography registry, women who completed a standardized questionnaire between 7 May 2001 and 2 June 2003, a follow-up questionnaire between 19 June 2003 and 8 October 2004 and who received at least one screening mammogram during this interval were identified. False positives were examined in relation to depressed mood. RESULTS Eligibility criteria were met by 13 491 women with a median age of 63.9 (SD = 9.6). In the study population, 2107 (15.62%) experienced at least one false positive mammogram and 450 (3.34%) met criteria for depressed mood. Depressed mood was not significantly associated with false positives in the overall population [OR = 0.96; 95% confidence interval (CI) = 0.72-1.28], but this association was seen among Non-White women (OR = 3.23; 95% CI = 1.32-7.91). CONCLUSION Depressed mood may differentially affect some populations as a harm associated with screening mammography.

Factors Associated with Preoperative Magnetic Resonance Imaging Use among Medicare Beneficiaries with Nonmetastatic Breast Cancer

Preoperative breast magnetic resonance imaging (MRI) use among Medicare beneficiaries with breast cancer has substantially increased from 2005 to 2009. We sought to identify factors associated with preoperative breast MRI use among women diagnosed with ductal carcinoma in situ (DCIS) or stage I–III invasive breast cancer (IBC). Using Surveillance, Epidemiology, and End Results and Medicare data from 2005 to 2009 we identified women ages 66 and older with DCIS or stage I–III IBC who underwent breast‐conserving surgery or mastectomy. We compared preoperative breast MRI use by patient, tumor and hospital characteristics stratified by DCIS and IBC using multivariable logistic regression. From 2005 to 2009, preoperative breast MRI use increased from 5.9% to 22.4% of women diagnosed with DCIS and 7.0% to 24.3% of women diagnosed with IBC. Preoperative breast MRI use was more common among women who were younger, married, lived in higher median income zip codes and had no comorbidities. Among women with IBC, those with lobular disease, smaller tumors (<1 cm) and those with estrogen receptor negative tumors were more likely to receive preoperative breast MRI. Women with DCIS were more likely to receive preoperative MRI if tumors were larger (>2 cm). The likelihood of receiving preoperative breast MRI is similar for women diagnosed with DCIS and IBC. Use of MRI is more common in women with IBC for tumors that are lobular and smaller while for DCIS MRI is used for evaluation of larger lesions.

New Hampshire critical access hospitals: CEOs' report on ethical challenges.

&NA; Research into the importance of organizational healthcare ethics has increasingly appeared in healthcare publications. However, to date, few published studies have examined ethical issues from the perspective of healthcare executives, and no empirical study has addressed organizational ethics with an explicit focus on rural hospitals. For our study, we sought to identify the frequency of ethical conflicts occurring within 12 general categories (domains) of administrative activities. Also, we wanted to determine what ethics resources are currently available and whether additional resources would be helpful. We conducted a structured telephone interview of all 13 chief executive officers (CEOs) of critical access hospitals in New Hampshire. All the CEOs in the study indicated that they encountered ethical conflicts. On average, the three most frequently noted domains were organizational‐professional staff relations, reimbursement, and clinical care. All CEOs indicated they would like to have additional ethics resources to address these conflicts. This study verified that CEOs encounter a broad spectrum of ethical conflicts and need additional ethics resources to address them. Because this study used a small sample of CEOs and represented only one New England state, further ethics‐related research in rural healthcare facilities is warranted. Follow‐up study would allow for (1) a higher level of generalization of the findings, (2) clarity regarding specific ethical dilemmas that rural healthcare executives encounter, and (3) an assessment of ethics resources and training that healthcare executives need to address the ethical conflicts.