Pamela B. Peele

Decreased Use of Adjuvant Breast Cancer Therapy in a Randomized Controlled Trial of a Decision Aid with Individualized Risk Information

Objective . Oncology patients often seek involvement in their medical consultations. Such involvement is endorsed by most health care providers and mirrored in practice guidelines. However, oncologists exhibit great variation in how they provide patients with disease-relevant information, and many remain reluctant to do so at all. The authors examined the impact of a patient-specific decision aid on women’s decisions about adjuvant therapy for breast cancer. Method . 386 women with breast cancer were randomized to receive either an informational pamphlet about adjuvant therapy (usual care) or a patient-specific, evidence-based decision aid about adjuvant therapy. The authors compared rates of adjuvant therapy between the groups controlling for age, education, marital status, race, tumor severity, and practice type of their physician (university-based or community-based). Results . Among women with low tumor severity, only 58% (35/60) of women in the decision aid group chose adjuvant therapy, compared to 87% (33/38) of their counterparts in usual care (P < 0.01). Conclusions . This study illustrates the important impact of medical decision aids on treatment choices, particularly for patients for whom treatment has little benefit. In the case of adjuvant therapy for breast cancer, providing individualized, evidence-based risk information for shared decision making resulted in fewer women with low tumor severity choosing adjuvant treatment.

Recruiting older adults for clinical trials.

More than 400 community-dwelling older adults were recruited into a clinical trial which compared the effectiveness of diagnosis and treatment through geriatric assessment with that provided through usual community physician care. Six recruitment methods were utilized: referrals, solicitations, presentations, media, mailings, and fliers. Each method is described and its results reported in terms of numbers recruited, yield, and cost per participant. The most efficient method was referrals; the method producing the largest number was presentations; the least effective method was fliers. Problems and solutions are discussed, and guidelines for recruiting older adults are suggested. These guidelines include: monitoring with accompanying adaptation, targeting the groups most likely to benefit, providing incentives, and reducing uncertainty among potential participants.

Cost Comparison Between Watchful Waiting With Active Surveillance and Active Treatment of Clinically Localized Prostate Cancer

OBJECTIVES In part because of concern regarding overtreatment in men with prostate cancer, watchful waiting with active surveillance (WWAS) has been increasingly used in men diagnosed with low-risk prostate cancer. The present study investigates the difference in costs between men with low-risk prostate cancer treated with up-front radical prostatectomy (RP) versus WWAS. METHODS A cost model was constructed using data from centers that have published their results in men who were followed up with WWAS compared with the actual costs of up-front RP calculated from a high volume center. Two WWAS arms of 15-year duration were created in which the follow-up protocol and conversion rate to active treatment were varied. RESULTS The cost of up-front RP including costs of surgery, complications, and follow up for 15 years was

Depression and occupational injury: Results of a pilot investigation

15 235 per person. Costs of WWAS were estimated using annual conversion rates from WWAS to RP of both 5% and 7%. Costs per person in the WWAS arms ranged from

Benefit limits in managed behavioral health care: Do they matter?

6558 to

Effect of different recruitment sources on the composition of a bipolar disorder case registry

11 992 in the scenarios created which represent a 43%-78.7% reduction in costs when compared with men undergoing up-front RP. CONCLUSIONS Watchful waiting with active surveillance is being increasingly used in hopes of decreasing the potential overtreatment of prostate cancer in men with low-risk disease. The present study suggests that WWAS is likely to markedly decrease costs when compared with active treatment with RP.

Long-Term Health Outcomes of a Decision Aid: Data from a Randomized Trial of Adjuvant! in Women with Localized Breast Cancer:

Objective: Even mild clinical depression can cause decreased vigilance, attention span, increased irritability, and insomnia—all well-known precursors to occupational injury. This pilot project explores the relationship between occupational injury and depression. Method: One hundred twenty-one individuals with recent work-related injuries and 140 without work-related injuries completed a self-administered depression screening instrument (PHQ-9). We compared the two groups using bivariate analyses. The impact of depression on injury was examined using logistic regression analysis controlling for employment history, marital status, age, and sex. Results: Overall, injured workers in this study were not more likely to be depressed than a comparison group of uninjured workers. However, injured women had significantly higher depression scores than noninjured women (P = 0.04); no such difference was found for men. Conclusions: These data suggest that depression may serve as a precursor to occupational injury for women.

Effectiveness of a Wellness Program for Individuals With Spina Bifida and Spinal Cord Injury Within an Integrated Delivery System

More than half of Americans with insurance coverage for mental health services are enrolled in plans that carve out behavioral health care services with a vendor specializing in the management of these services. However, utilization management has not taken the place of benefit limitations. Do benefit limits matter? This article reports the percentage of enrollees in managed behavioral health care carve-out plans that encounter benefit limits. Estimates are provided on the impact and savings of imposing benefit limits on enrollees in unrestricted plans. Costs to eliminate benefit limits are estimated to be very small. This study finds that benefit limits do matter but only to a very small number of plan enrollees. Furthermore, the results of this study show that for inpatient limits, children are especially vulnerable. These issues have important implications for discussions about the impact of managed care in mental health and for discussions concerning parity legislation.

Using Decision Trees to Manage Hospital Readmission Risk for Acute Myocardial Infarction, Heart Failure, and Pneumonia

Abstract  Background: Conducting research on low-prevalence conditions presents an ongoing challenge for clinical and services researchers. Recruitment through health professionals versus other forms of self-referral may affect study group composition. Methods: We compared members of a voluntary case registry for bipolar disorder who were recruited through a variety of sources including health professionals, support groups, an Internet website, and mailings, brochures, and other general public relations activities. We also compared the cost of recruitment methods. We hypothesized that self-referred registry members would be of higher socioeconomic status and less likely to be in treatment compared to members recruited through health professionals. Results: Registrants referred through the Internet and patient support groups were better educated and more likely to be married than other registrants. However, Internet registrants were younger, had fewer lifetime hospitalizations and were more likely to be working. Nearly all registrants were in treatment with a psychiatrist. Local registrants were predominantly recruited through health professionals and public presentations. Registrants outside of the local region most often learned about the registry from patient support groups and the Internet. Local registrants were less likely to be using non-lithium mood stabilizers. Recruitment through public relations efforts was the most expensive method of recruitment, and the Internet website was the cheapest. Conclusions: Diverse recruitment methods can expand the population available for clinical trials. For services research, the Internet and patient support groups are less expensive ways to identify persons served in diverse settings and health plans, but these recruitment methods yield a sample that is better educated than the remainder of the population. It remains a difficult task to identify minorities and persons not in treatment.

Evaluating welfare losses in the health care market

Purpose . Women with localized breast cancer face difficult decisions about adjuvant therapy. Several decision aids are available to help women choose between treatment options. Decision aids are known to affect treatment choices and may therefore affect patient survival. The authors aimed to model the effects of the Adjuvant! decision aid on expected survival in women with early stage breast cancer. Patients and Methods . Data were obtained from a randomized trial of Adjuvant! (n = 395). To calculate the effects of the decision aid on survival, the authors used the Adjuvant! survival predictions as a surrogate endpoint. Data from each arm were entered separately into statistical models to estimate change in survival associated with receiving the Adjuvant! decision aid. Results . Most women (∼ 85%) chose a treatment option that maximized predicted survival. The effects of the decision aid on outcome could not be modeled because a small number of women (n = 12, 3%) chose treatment options associated with a large (5%—14%) loss in survival. These women—most typically estrogen receptor positive but refusing hormonal therapy—were equally divided between Adjuvant! and control groups and were not distinguished by medical or demographic factors. Conclusions . Expected benefit from treatment is a key variable in understanding patient behavior. A small number of women refuse adjuvant treatment associated with large increases in predicted survival, even when they are explicitly informed about the degree of benefit they would forgo. Investigation of the effects of decision aids on cancer survival is unlikely to be fruitful due to power considerations.