Robert C. Burack

The early detection of cancer in the primary-care setting: Factors associated with the acceptance and completion of recommended procedures

Effective cancer control efforts in the primary-care setting require that patients accept and are able to complete recommended early detection procedures. We thus assessed the extent to which procedure nonacceptance or noncompletion limited accomplishment of detection procedures offered as components of routine health care. We also examined the relationship of provider and patient factors to successful procedure accomplishment. Of 221 patients offered procedures by their primary-care provider, 58 (27%) initially declined at least one recommendation, with acceptance rates ranging from 98% for breast exam to 59% for sigmoidoscopy. Furthermore, only 50% of patients offered stool occult blood testing or sigmoidoscopy, 61% offered mammography, and 69% offered Pap smear were able to complete the procedures. Pap smear and mammography were more likely to be initially accepted by those patients with more years of formal education and were less likely to be completed by those with private insurance coverage. Among a subgroup of 76 patients completing a telephone interview, personal health beliefs were not consistently associated with procedure acceptance or completion. These results suggest that both the initial nonacceptance of procedures and the subsequent barriers to their completion limit the efficacy of cancer screening efforts in the primary-care setting. Future research will be required to develop an explanatory model or to propose a targeted intervention.

Homocysteine and Reclassification of Cardiovascular Disease Risk

OBJECTIVES The purpose of this study was to examine whether adding homocysteine (Hcy) to a model based on traditional cardiovascular disease (CVD) risk factors improves risk classification. BACKGROUND Data on using Hcy to reclassify individuals in various risk categories beyond traditional approaches have not been adequately scrutinized. METHODS We performed a post hoc analysis of the MESA (Multi-Ethnic Study of Atherosclerosis) and NHANES III (National Health and Nutrition Examination Survey III) datasets. Hcy was used to predict composite CVD and hard coronary heart disease (CHD) events in the MESA study and CVD and CHD mortality in the NHANES III survey using adjusted Cox-proportional hazard analysis. Reclassification of CHD events was performed using a net reclassification improvement (NRI) index with a Framingham risk score (FRS) model with and without Hcy. RESULTS Hcy level (>15 μmol/l) significantly predicted CVD (adjusted hazard ratio [aHR]: 1.79, 95% confidence intervals [CI]: 1.19 to 1.95; p = 0.006) and CHD events (aHR: 2.22, 95% CI: 1.20 to 4.09; p = 0.01) in the MESA trial and CVD (aHR: 2.72, 95% CI: 2.01 to 3.68; p < 0.001) and CHD mortality (aHR: 2.61, 95% CI: 1.83 to 3.73; p < 0.001) in the NHANES III, after adjustments for traditional risk factors and C-reactive protein. The level of Hcy, when added to FRS, significantly reclassified 12.9% and 18.3% of the overall and 21.2% and 19.2% of the intermediate-risk population from the MESA and NHANES cohorts, respectively. The categoryless NRI also showed significant reclassification in both MESA (NRI: 0.35, 95% CI: 0.17 to 0.53; p < 0.001) and NHANES III (NRI: 0.57, 95% CI: 0.43 to 0.71; p < 0.001) datasets. CONCLUSIONS From these 2 disparate population cohorts, we found that addition of Hcy level to FRS significantly improved risk prediction, especially in individuals at intermediate risk for CHD events.

PROMOTING SCREENING MAMMOGRAPHY IN INNER-CITY SETTINGS : THE SUSTAINED EFFECTIVENESS OF COMPUTERIZED REMINDERS IN A RANDOMIZED CONTROLLED TRIAL

OBJECTIVES The authors conducted a randomized controlled trial to evaluate the sustained effectiveness of a computerized reminder system in promoting mammography during a second year of continuing intervention at three primary care practices of a Health Department and a health maintenance organization in Detroit, Michigan. METHODS Out-of-pocket mammography cost was eliminated for all participants (limited intervention). Computer-generated reminders promoting physician referral for mammography were placed in the medical records of women due for mammography 1 month in advance of their due date (full intervention). RESULTS Among 1,225 year 2 visitors, mammography rates were 44% for full intervention versus 28% for limited intervention at the health department (adjusted odds ratio [OR] for effect of full intervention 1.84; 95% confidence interval [CI]: 1.40-2.40) and 45% for full versus 46% for limited at the health maintenance organization (adjusted OR 1.06; 95% CI 0.80-1.42). These second year results contrasted with those observed for year 1, during which a significant effect of full intervention was demonstrated for both organizations. After controlling for patient characteristics and site, the effect sizes of full intervention were reduced significantly in the second year compared with the first year (P = 0.05). CONCLUSIONS The effect of computerized mammography reminders can be sustained in a second year of continued intervention, but individual practice sites and organizations vary in their responsiveness to the intervention. Strategies to promote periodic and repetitive procedure use must identify and address time-varying barriers to their effectiveness.

Health status and mammography use among older women

OBJECTIVE: To assess the extent to which an age-associated reduction in mammography use can be explained by declining self-reported health status.DESIGN: We analyzed data from the 1992 National Health Interview Survey (NHIS) and Cancer Control Supplement. Logistic regression analysis was used to evaluate the association between age, health status (self-reported health and limitations in major activity), and other variables potentially related to mammography use within the past 1 year (recent mammography).PARTICIPANTS: Of 12,035 NHIS respondents we restricted our analysis to the 1,772 women aged 50 years or older who reported one or more lifetime mammograms. We excluded women without a mammogram (n=937) because we were interested in factors related to recent use versus past use of mammography.MEASUREMENTS AND MAIN RESULTS: The percentage of women with a recent mammogram declined with increasing age, and the age association was independent of other factors including health status (adjusted odds ratio [OR] comparing women aged 75 years or older with those aged 50 to 64 years was 0.54; 95% confidence interval [CI] 0.41, 0.70). This age effect persisted in an analysis restricted to women reporting good or better health (adjusted OR was 0.60, 95% CI 0.44, 0.80).CONCLUSION: The observed decline in recent mammography use with advancing age was not explained by variation in health status. Because healthy elderly women may live long enough to realize the potential benefit of screening mammography, factors responsible for its reduced use should be identified. Doing so will allow for the selective promotion of screening mammography among those older women most likely to benefit.

How reminders given to patients and physicians affected Pap smear use in a health maintenance organization: Results of a randomized controlled trial

Despite its effectiveness as a method of controlling cervical carcinoma, the use of Pap smear testing remains incomplete, and its promotion in the primary care setting provides an important opportunity for intervention.

The effect of adding Pap smear information to a mammography reminder system in an HMO: results of randomized controlled trial

BACKGROUND While reminders can promote cancer screening in primary care, little is known about the potential interaction between multiple reminders. METHODS We conducted a randomized controlled trial to compare the effect of combined Pap smear plus mammogram reminders and mammogram-only reminders among 2471 women 40 years of age or older enrolled in a health maintenance organization serving a predominantly Medicaid-eligible population. Reminders included both a mailed letter for the woman and a medical record prompt. RESULTS Intervention assignment was unassociated with differences in rates of visitation to family medicine or internal medicine or completion of mammography during the study year. Compared to women assigned to mammogram-only reminder treatment, those assigned to the combined Pap smear plus mammogram reminder intervention were more likely to visit a gynecologist (34% compared to 29%, adjusted odds ratio = 1.33, 95% confidence interval 1.08-1.63) and to complete a Pap smear (30% compared to 23%, adjusted odds ratio = 1.39, 95% confidence interval 1.07-1.89). CONCLUSIONS In the study setting, the addition of Pap smear to mammography reminders has a procedure-specific effect, increasing gynecology visits and Pap smear use while neither increasing nor decreasing other primary care visits or mammography. We find no evidence of reinforcement or competition between these reminders.

Cardiovascular risk factors and obesity: are baseline levels of blood pressure, glucose, cholesterol and uric acid elevated prior to weight gain?

The increased risk of cardiovascular morbidity and mortality experienced by the obese may be partially mediated through alterations induced in other associated risk factors. The attribution of this cardiovascular risk to obesity presumes that levels of those risk factors are not elevated independently of, or prior to, weight gain. We therefore examined baseline levels of blood pressure, glucose, cholesterol, and uric acid within age and sex specific strata of a population of 4015 individuals followed an average of 15 years to determine if an increasing level of fatness (weight/height 2) at follow-up was associated with elevation of other risk factors at baseline. After controlling for baseline fatness we were unable to demonstrate any consistent relationship between future fatness and baseline elevation of any of the factors. The magnitude of the partial correlation coefficients for those age 6-24 or 25-65 years at baseline were less than 0.11 for all of the risk factors. While a metabolic predisposition may link obesity to alterations of other risk factors it appears unlikely that their elevation commonly precedes weight gain. A pre-existing elevation of risk factors has not resulted in the misattribution of cardiovascular risk to obesity.

Mammography use among women as a function of age and patient involvement in decision-making.

OBJECTIVE: To assess the extent to which self‐reported patient involvement in decision‐making for initiation of mammography differs with age.

PATTERNS OF USE OF MAMMOGRAPHY AMONG INNER-CITY DETROIT WOMEN : CONTRASTS BETWEEN A HEALTH DEPARTMENT, HMO, AND PRIVATE HOSPITAL

This study assessed the pattern of utilization of mammography among 2,880 inner-city minority women 40 years of age or older who received ongoing primary care services during 1988 or 1989 at four practice sites operated by a health department (two sites), Health Maintenance Organization (HMO), and private hospital. Mammography referral could be documented for 23% to 32% of age eligible women and completed mammograms for 15% to 26%. Among women without a mammogram, 85% had never been referred while 15% were referred but unable to complete the procedure. In multiple logistic regression analysis, factors associated with mammography include age less than 70 years, presence of a breast cancer risk factor and more frequent clinic visits. Mammography was somewhat more frequent at the HMO and hospital clinic than at the health department, but this relationship varied with the womens previous visit and mammography experience. At sites serving uninsured women, mammography use was not associated with the presence or absence of health insurance. It is concluded that the underutilization of mammography is a substantial barrier to the early detection of breast cancer in each of the three different health care organizations studied, and that interventions to improve breast cancer control should focus upon facilitating physician referral practices.

The effect of patient reminders on the use of screening mammography in an urban health department primary care setting

Mammography screening continues to be under-utilized, especially among women from lower socioeconomic groups. In order to determine whether having direct access to health care services has an effect on mammography use among low income women, we conducted a randomized trial of two alternative letter reminders among 1,717 women who were enrolled at two locations of a multi-site inner city health department in Detroit. All participants were 39 1/2 years of age and older and were due for a screening mammogram at randomization. A physician-directed reminder form was placed in each of the participant’s medical records at the beginning of the study. In addition participants were randomized to receive either a letter directing them to visit their primary care physician, a letter directing them to contact the clinic directly to schedule a mammogram, or no letter. Study participants were predominantly African–American, two-thirds of whom were over age 50, and who had minimal health insurance coverage. During the intervention year, mammograms were completed by 179 out of 967 study women at site one (18.5%), and 90 out of 750 study women at site two (12%). A multivariate model controlling for the simultaneous effect of age, insurance type, visit history and past mammography use, showed no significant independent effect of either type of letter reminder on mammography completion during the study year. In conclusion, letters targeted at women due for screening mammograms did not have a beneficial effect on mammography utilization above and beyond that of a physician medical record reminder.