Few current data are available regarding factors associated with participation in cancer screening examinations in the general population.
To identify factors associated with participation in cancer ...screening examinations, random population samples of 25- to 74-year-old men and women in six various-sized communities in three upper-Midwestern states (n = 4,915) were surveyed in 1987-1989. Multivariate-adjusted means were calculated and compared using analysis of covariance.
Statistically significant (P < 0.05) strong predictors (other than age and sex) of ever having had a specific cancer screening test were as follows (the numbers in parentheses following each listed association are the absolute maximum differences in mean proportions among the levels of the predictors): (1) rectal examination: higher education (14%); (2) fecal occult blood testing: higher education (6%) and never smoker (5%); (3) sigmoidoscopy: higher income (7%) and higher education (6%); and (5) mammography: higher income (25%), higher education (8%), and a positive family history of breast cancer (7%). There were no strong predictors (out of nine) of ever having had a Papanicolaou smear or a breast self-examination.
The largest differences among the population for participation in cancer screening examinations involves income and the two most expensive cancer screening tests: higher income is a strong predictor of having a mammogram and, to a lesser extent, of having a sigmoidoscopy. The most consistent predictor of participation in cancer screening examinations across all cancer screening tests is education: higher education is a predictor of having each kind of cancer screening test.
To determine population knowledge, attitudes, and personal practices regarding prevention and early detection of cancer, random population samples of 25- to 74-year-old men and women in six ...various-sized communities in three upper-midwestern states (N = 4,915) were administered surveys and interviews during 1987-1989.
Four-fifths of respondents believed cancer to be preventable. Knowledge of warning signs/symptoms of cancer and of leading causes of cancer, however, was low. Over 95% of women had had a Papanicolaou smear and a clinical breast exam or had performed a breast self-exam; 65.7% of those ages 50-65 years had had a mammogram. Among men and women ages 50-65 years, 77% had had a digital rectal exam; 52.5%, a fecal occult blood test; and 48.3%, a sigmoidoscopy.
Conditions are favorable for an increase in mammography, including favorable attitudes toward cancer prevention, strong consensus among policy-making organizations regarding guidelines for obtaining mammograms, and high levels of adherence to these recommendations by women who have had at least their first mammogram. Challenges now include acceptance of these guidelines by physicians, mammogram affordability/availability, and demonstration of efficacious, cost-effective, and reliable colorectal/prostate cancer screening tests.
BACKGROUND. The accuracy and completeness of the SEER-Medicare data for measuring cancer-related therapy have not been extensively evaluated.
OBJECTIVES. To investigate the best method for measuring ...cancer-related surgery among patients in the SEER-Medicare database.
SUBJECTS. A total of 149,970 incident cases of breast, colorectal, endometrial, lung, pancreatic, and prostate cancer diagnosed between 1991 and 1993.
MEASURES. The most invasive surgical procedure identified through Medicare’s inpatient, physician, and hospital outpatient claims was compared with corresponding data from the SEER files.
RESULTS. Agreement between the SEER and Medicare files was generally highest for resection and radical surgery (eg, κ 0.70–0.90). While there was less agreement regarding no surgical therapy and biopsy individually, the concordance of the two sources in excluding cancer-directed surgery was high. Compared with inpatient data alone, using the combined inpatient, physician, and outpatient data increased concordance between SEER and Medicare for less invasive procedures.
CONCLUSIONS. The agreement of SEER and Medicare data appears to be good for major surgical procedures and for excluding persons who did not undergo cancer-directed surgery. Both the SEER and the Medicare data captured a small number of surgeries not reported in the other file. Therefore, where possible, using both data sources will enhance identification of surgeries. Because the analysis was performed with linked data, the accuracy of surgical claims in Medicare data alone cannot be assessed.
Women with coronary artery disease are treated differently than men. Although mortality has been studied, functional outcomes for women and men have not been prospectively compared.
The Manitoba ...Health Reform Impact Study used hospital databases to identify all residents aged 45 years and older in Manitoba who were hospitalized for a myocardial infarction between October 1, 1991, and September 30, 1992. Cohort members were interviewed twice, an average of 16 and 25 months after hospitalization. Baseline and follow-up measures included treatments (eg, physician visits, diagnostic testing, revascularization, and cardiac medications), physical health status (physical component summary PCS score derived from the Medical Outcomes Study Short Form 36), reinfarction, and mortality.
Of the 820 patients who completed the initial survey, 31 died during the follow-up period, and 734 completed the follow-up survey. Data were complete for the primary outcome (PCS score) and all relevant covariates for the 677 patients who were included in this study Women constituted 34% of this cohort. Although women had more physician visits during follow-up, they were less likely to have undergone treadmill testing or angiography (odds ratio, 0.68; 95% confidence interval, 0.46-0.99). Women were equally likely to report taking beta-adrenergic blocking agents, but were less likely than men to report the use of aspirin (odds ratio, 0.69; 95% confidence interval, 0.48-0.98). After adjusting for baseline differences in PCS scores, age, income, social supports, and the levels of angina and dyspnea, the PCS score for women declined by 1.4 points, while the score for men improved by 0.2 points (P = .03). During the follow-up period, reinfarction and mortality rates were low overall, but were not different in men and women.
In this cohort of patients with known coronary artery disease, we found less aggressive treatment of coronary artery disease and less use of aspirin among women than among men during 1 year of observation. After controlling for baseline differences, women with coronary artery disease experienced a more rapid decline in physical health status than did men during 1 year of follow-up.
While disparities in access to care are well documented, little is known about the quality of mental health care received by racial and ethnic minorities. We examined the quality of mental health ...care received by elderly enrollees in Medicare + Choice plans.
An observational study was performed using individual-level Health Plan Employer Data and Information Set data. From 4182 to 5,016,028 individuals 65 years or older and enrolled in Medicare + Choice plans in 1999 were involved in different measures. Rates of mental health inpatient discharges, average length of stay, percentage of members receiving mental health services, rates of follow-up after hospitalization for mental illness, optimal practitioner contacts for antidepressant medication management, and effective acute- and continuation-phase treatment were assessed.
Compared with whites, minorities received substantially less follow-up after hospitalization for mental illness. The 30-day follow-up rates for whites, African Americans, Asians, and Hispanics were 60.2%, 42.4%, 54.1%, and 52.6%, respectively. Minorities also had lower rates of antidepressant medication management for newly diagnosed episodes of depression. The rates of optimal practitioner contacts for whites, African Americans, Asians, and Hispanics were 12.5%, 12.0%, 11.1%, and 10.6%; the rates of effective acute-phase treatment were 60.1%, 48.5%, 40.7%, and 57.6%; and the rates of effective continuation-phase treatment were 46.7%, 32.7%, 31.9%, and 39.6%, respectively. The statistically significant disparities persisted after adjusting for effects of age, sex, income, plan model, profit status, and region of the country.
The overall quality of mental health care for people enrolled in Medicare + Choice managed care plans is far from optimal. There are large and persistent racial differences that merit further attention to better understand their underlying causes and solutions.
The process of designing research protocols for testing treatment effects and reporting the results of such research demands both explicit and implicit value judgments. When measuring the effects of ...alternative treatments, those judgments can include decisions about what outcomes to measure and for which persons they should be measured, how to aggregate disparate outcomes, and how to decide whether differences are substantial enough to differentiate between treatments. Researchers and reviewers often do not acknowledge problems of this sort, and default solutions are based on common usage rather than any epistemologic justification. Acknowledging the value commitments inherent in choices about research methods should serve to increase variation in methods rather than constrain them within conventional patterns. Especially with research intended to shape policy and practice, more thoughtful choices, humility in recognizing the limits of available methods, and flexibility in establishing the thresholds for significant differences for each study seem to be justified. The choices researchers make should be documented and the reasons for those choices should be given explicitly in publications and presentations so that readers and other users of the information are enabled and expected to bear more responsibility for interpreting and applying the findings appropriately.
Medicare risk health maintenance organizations (HMOs) are an increasingly common alternative to fee-for-service Medicare. To date, there has been no examination of whether the HMO program is ...preferentially used by blacks or by persons living in lower-income areas or whether race and income are associated with reversing Medicare HMO selection. This question is important because evidence suggests that these beneficiaries receive poorer care under the fee-for-service-system than do whites and persons from wealthier areas. Medicare enrollment data from South Florida were examined for 1990 to 1993. Four overlapping groups of enrollees were examined: all age-eligible (age 65 and over) beneficiaries in 1990; all age-eligible beneficiaries in 1993; all age-eligible beneficiaries residing in South Florida during the period 1990 to 1993; and all beneficiaries who became age-eligible for Medicare benefits between 1990 and 1993. The associations between race or income and choice of Medicare option were examined by logistic regression. The association between the demographic characteristics and time staying with a particular option was examined with Kaplan-Meier methods and Cox Proportional Hazards modeling. Enrollment in Medicare risk HMOs steadily increased over the 4-year study period. In the overall Medicare population, the following statistically significant patterns of enrollment in Medicare HMOs were seen: enrollment of blacks was two times higher than that of non-blacks; enrollment decreased with age; and enrollment decreased as income level increased. For the newly eligible population, initial selection of Medicare option was strongly linked to income; race effects were weak but statistically significant. The data for disenrollment from an HMO revealed a similar demographic pattern. At 6 months, higher percentages of blacks, older beneficiaries (older than 85), and individuals from the lowest income area (less than $15,000 per year) had disenrolled. A small percentage of beneficiaries moved between HMOs and FFS plans multiple times. These data on Medicare HMO populations in South Florida, an area with a high concentration of elderly individuals and with one of the highest HMO enrollment rates in the country, indicate that enrollment into and disenrollment from Medicare risk HMOs are associated with certain demographic characteristics, specifically, black race or residence in a low-income area.
This study compares use of the hospice benefit in Medicare fee-for-service (FFS) and Medicare risk-health maintenance organization (HMO) options in South Florida in 1992. A higher percentage of ...deaths occurred in hospice in the HMO option than in the FFS option. Compared to individuals in the FFS option, HMO-enrolled hospice users had longer lengths of hospice stay, lower 7-day mortality and higher 180-day (6 month) survival. These differences are consistent with the physician's financial incentives associated with the two programs. Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com
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