Reconstruction of massive midfoot bone and soft tissue loss as a result of blast injury

Lower extremity blast injuries represent a unique challenge to surgeons and often involve complex, limb-threatening wounds with extensive soft tissue and bone loss. Surgical treatment of these injuries can be difficult because of limited autogenous resources for reconstruction of the defect. In this article, we describe a technique for medial column reconstruction using iliac crest bone graft and soft tissue coverage with an abductor hallucis rotational flap combined with a split-thickness skin graft. This method addresses the extensive bone and soft tissue defects that frequently characterize blast injuries to the foot, and may be applicable in other situations where trauma or infection has caused extensive destruction of the medial column.

How patient reactions to hospital care attributes affect the evaluation of overall quality of care, willingness to recommend, and willingness to return

Patient satisfaction is a critical part of the quality outcomes of healthcare. Every industry is interested in customer satisfaction because satisfied customers are loyal customers. Healthcare is no exception. Many research studies assume that satisfied patients are more likely to recommend their providers to their friends and to return when they need care again. Although this assumption sounds logical, we argue that three dependent variables-the Evaluation of Overall Quality of Care, Willingness to Recommend, and Willingness to Return-are unique constructs. Thus, we examine how patient reactions (experiences) to different hospital care attributes (factors or dimensions) influence these dependent variables. Our study analyzed a comprehensive patient satisfaction data set collected by BJC HealthCare. We used a multiple linear regression model with a scatter term to analyze 14,432 cases. In Evaluation of Overall Quality of Care model, we found that the nursing care attribute showed the strongest influence, followed by staff care. In assessing the other two models-Willingness to Recommend and Willingness to Return-we found that staff care showed the strongest influence, followed by nursing care. Patients put a different emphasis or a different priority on their reactions to hospital care attributes, depending on which outcome they arrive at. In addition, we found that patients are disproportionately influenced by a weak or poor attribute reaction, which is a conjunctive strategy (risk averse). In general, nursing care and staff care should be the first priority for improvement. This may be good news because these areas are under the control of hospital managers.

Patient satisfaction: focusing on "excellent"

In an emerging competitive market such as healthcare, managers should focus on achieving excellent ratings to distinguish their organization from others. When it comes to customer loyalty, "excellent" has a different meaning. Customers who are merely satisfied often do not come back. The purpose of this study was to find out what influences adult patients to rate their overall experience as "excellent." The study used patient satisfaction data collected from one major academic hospital and four community hospitals. After conducting a multiple logistic regression analysis, certain attributes were shown to be more likely than others to influence patients to rate their experiences as excellent. The study revealed that staff care is the most influential attribute, followed by nursing care. These two attributes are distinctively stronger drivers of overall satisfaction than are the other attributes studied (i.e., physician care, admission process, room, and food). Staff care and nursing care are under the control of healthcare managers. If improvements are needed, they can be accomplished through training programs such as total quality management or continuous quality improvement, through which staff employees and nurses learn to be sensitive to patients' needs. Satisfying patients' needs is the first step toward having loyal patients, so hospitals that strive to ensure their patients are completely satisfied are more likely to prosper.

Measured environmental contributions to cannabis abuse/dependence in an offspring of twins design

Genetic and environmental factors are known to contribute to cannabis abuse/dependence (CAD). We sought to determine the magnitude of the contribution from measured environmental variables to offspring cannabis dependence in a design that controls for familial vulnerability. Data come from a study of 725 twin members of the Vietnam Era Twin Registry, 720 of their biological offspring (age 18-32 years) and 427 mothers. Data were obtained on offspring perception of family and peer support and substance use behaviors and offspring CAD. After adjusting for familial risk, and environmental covariates, CAD was significantly more likely among male offspring (OR=2.73; 95% CI: 1.69-4.41). Offspring CAD was associated with reporting: siblings used illicit drugs (OR=3.40; 95% CI: 1.81-6.38), a few friends used drugs (OR=2.72; 95% CI: 1.04-7.09), a quarter or more friends used drugs (OR=8.30; 95% CI: 3.09-22.33) and one-half or more 12th grade peers used drugs (OR=3.17; 95% CI: 1.42-7.08). Perceived sibling, friend and school peer substance use are strongly associated with CAD in young adults even after accounting for latent familial risk and for multiple measured intra-family and extra-family environmental influences.

Comparison of mortality risk adjustment using a clinical data algorithm (American College of Surgeons National Surgical Quality Improvement Program) and an administrative data algorithm (Solucient) at the case level within a single institution

BACKGROUND

There is great interest in efficiently evaluating health care quality, but there is controversy over the use of administrative versus clinical data methods. We sought to compare actual mortality with risk-adjusted expected mortality in a sample population calculated by two different methods; one based on preexisting administrative records and one based on chart reviews.

STUDY DESIGN

We examined a sample of patients (n = 1,234) undergoing surgical procedures at an academic teaching hospital during 1 year. The first risk-adjustment method was that used by the National Surgical Quality Improvement Program, which is based on dedicated medical record review. The second method was that used by Solucient, LLC, which is based on preexisting administrative records.

RESULTS

The ratio of observed to expected mortality for this population set was higher using the National Surgical Quality Improvement Program algorithm (1.1; 95% CI, 0.8 to 1.5) than using the Solucient algorithm (0.9; 95% CI, 0.6 to 1.2) but neither estimate was notably different from 1.0. Similarly, when observed to expected mortality ratios were calculated separately for each quartile of mortality, there were no marked differences within quartiles, although minor differences with potential importance were noted. Fit was comparable by age categories, gender, and American Society of Anesthesiologists' categories. A number of actual deaths had higher predicted mortality scores using the Solucient algorithm.

CONCLUSIONS

Risk-adjusted mortality estimates were comparable using administrative or clinical data. Minor performance differences might still have implications. Because of the potential lower cost of using administrative data, this type of algorithm can be an efficient alternative and should continue to be investigated.

Factors associated with pathological gambling at 10-year follow-up in a national sample of middle-aged men

BACKGROUND

The present analyses will expand on previous reports by considering the impact of eight psychiatric disorders and genetic vulnerability to problem (P) and pathological gambling gambling (PG). methods: Diagnoses of DSM-III-R life-time P and PG were derived in 1992 and past-year P and PG in 2002 from 1675 individual twins from the Vietnam Era Twin Registry. Logistic regression was used to predict past-year P and PG as a function of socio-demographics and life-time co-occurring psychiatric disorders including gambling problems measured in 1992. Co-twin analyses accounted for familial contributions to past-year gambling problems.

RESULTS

High school or greater educational attainment was associated with less likelihood of current P and PG. With the exception of alcohol dependence and generalized anxiety/panic, all disorders studied remained associated significantly with an increase risk of past-year P and PG after adjusting for 1992 gambling symptoms. Past-year P and PG was associated significantly with the number of pathological gambling symptoms reported in 1992. After controlling for genetic and family environmental factors, one or more 1992 symptoms were associated with 2002 symptoms.

CONCLUSIONS

Education and substance dependence, mood and antisocial personality disorders were associated with current gambling. A history of PG symptoms is the strongest predictor of past-year problem gambling.

An intervention to improve secondary prevention of coronary heart disease

BACKGROUND

Translating guidelines into clinical practice has proved to be quite difficult, even when the guidelines are well accepted and noncontroversial. Both computerized reminders and academic detailing have been effective in changing physician prescribing behavior. In this study, we sought to use these methods, mediated by clinical pharmacists, to improve adherence to the secondary prevention guidelines in hospitalized patients with myocardial infarction.

METHODS

A randomized, prospective study was performed in which computerized alerts identifying hospitalized patients with elevated troponin I levels were routed to clinical pharmacists. The pharmacists then conducted academic detailing for physicians caring for patients with acute myocardial infarction who were randomized to the intervention group. Patients in the control group received standard care. The main outcome measure was the proportion of patients discharged on a regimen of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and statins.

RESULTS

The intervention had a significant impact on the proportion of patients discharged on a regimen of angiotensin-converting enzyme inhibitors (328/365 [89.9%] vs 409/488 [83.8%], intervention vs control, respectively, P = .02), and statins (344/365 [94.2%] vs 436/488 [89.3%], P = .02). There was no statistical impact on beta-blocker (350/365 [95.9%] vs 448/488 [91.8%], P = .10) or aspirin use (352/365 [96.4%] vs 471/488 [96.5%], P = .87). When all 4 classes were considered together, 305 (83.6%) of 365 patients vs 343 (70.3%) of 488 patients were discharged on a regimen of all secondary prevention medications to which they did not have a contraindication (P<.001).

CONCLUSION

A computerized alert with pharmacist-mediated academic detailing is an effective means to increase adherence to secondary prevention guidelines for coronary heart disease.

Patients' concerns about medical errors during hospitalization

BACKGROUND

A clear understanding of patients' understanding and perceived risk of medical errors is needed. Multiwave telephone interviews were conducted in 2002 with 1,656 inpatients from 12 Midwestern hospitals regarding patients' conceptualization of medical errors and perceived risk of seven types of medical errors.

RESULTS

Patients defined medical errors to include not only clinical mistakes but also falls, communication problems, and responsiveness. Ninety-four percent of respondents reported their medical safety as good, very good, or excellent, but 39% experienced at least one error-related concern, most commonly medication errors (17% of respondents), nursing mistakes (15%), and problems with medical equipment (10%). Frequency of concerns was associated with reduced willingness to recommend the hospital (p < .001).

DISCUSSION

If patients' definition of medical errors is broader than the traditional medical definition, providers should clarify the term "error" to ensure effective communication. Most patients felt a high level of medical safety but a sizeable proportion experienced a concern about an error during hospitalization. The selective nature of concerns and the impact of patient and hospital characteristics provide insight into ways to engage patients in error prevention programs.

A Discordant Twin Study of Premorbid Cognitive Ability in Schizophrenia

Twin studies are advantageous because sources of genetic and environmental variation are equated in ways that are not possible in standard case-control designs. We examined premorbid cognitive ability by comparing Armed Forces Qualification Test scores administered at the time of military enlistment in 21 schizophrenia-discordant twin pairs and 860 matched control twins. Scores were significantly lower in schizophrenia probands than in their nonpsychotic co-twins; co-twins were midway between probands and control twins. Effects were reduced when the discordant pairs were extended to include 33 psychosis-discordant pairs. Compared with controls, education at enlistment was significantly lower in psychosis probands and in co-twins from both schizophrenia- and psychosis-disordant pairs. Co-twins from psychosis-discordant pairs had significantly lower education at midlife than controls. Results suggest that cognitive ability is influenced by familial vulnerability for schizophrenia or psychosis, and that premorbid cognitive ability is lower in schizophrenia versus psychosis in general. Educational advancement may be slightly slowed by this familial vulnerability, but results were equivocal with regard to attenuation of one's ultimate educational attainment.

Associations of physical activity and body mass index with activities of daily living in older adults

Research reports about the associations of leisure-time physical activity (LPA) and Body Mass Index (BMI) with activities of daily living (ADL)- or instrumental activities of daily living (IADL)-dependent disability in older adults are inconclusive. Data were obtained from the 2000 Missouri Older Adult Needs Assessment Survey. Logistic regression was used to examine the associations of LPA and BMI with ADL- or IADL-dependent disability, while controlling for factors known to be associated with LPA, BMI, ADL and IADL. ADL- or IADL-dependency decreased with LPA and increased with BMI regardless of each other's level, presence of functional limitation, education, gender, race-ethnicity, and health care coverage. Physically active individuals were less likely than inactive ones to be ADL- or IADL-dependent. BMI was modestly associated with ADL- or IADL-dependency and this relationship was confounded by LPA. If confirmed by well designed longitudinal studies, LPA and BMI independent associations with ADL- or IADL-dependent disability lends supports to a strategy for improving older adult quality of life through improved physical activity. Etiological studies on the associations between risk factors and quality of life outcomes in older adults should consider the joint confounding effect of LPA and BMI.

Association between exposure to childhood and lifetime traumatic events and lifetime pathological gambling in a twin cohort

The present study seeks to estimate the strength of the association between exposure to lifetime traumatic events and gambling problems while accounting for the potential contribution of psychiatric disorders, genetic factors, and family environmental influences. In 2002, structured diagnostic interviews were conducted with 1675 male twins to obtain data on exposure to traumatic events and pathological gambling. Multinomial regression tested for associations between each traumatic event and three levels of problem gambling (1-2 symptoms, at risk; 3-4 symptoms, problem gambling, and 5 or more symptoms, pathological gambling). Analyses of data from twin pairs discordant for gambling behavior controlled for genetic and family environmental factors. After adjustment for covariates, child abuse (relative risk [RR]=2.31), child neglect (RR=5.53), witnessing someone badly hurt or killed (RR=2.83), and physical attack (RR=3.39) were associated with pathological gambling. Genetic and family environmental factors significantly contributed to the association between exposure to traumatic events and one or more symptoms of problem gambling. Exposure to childhood and lifetime traumatic events are significantly associated with problem and pathological gambling. These associations are partially accounted for by psychiatric covariates and genetic and family environmental factors.

Improving adherence to coronary heart disease secondary prevention medication guidelines at a community hospital

Using a two-period group randomized study, we tested whether a technology assisted pharmacist intervention improved physician adherence to coronary heart disease (CHD) secondary prevention medication guidelines. After an observation period, physician practices were randomized to intervention or control arms. In the intervention arm, alerts prompted a pharmacist to communicate with the responsible physician about secondary prevention medications. The intervention significantly improved the proportion of patients discharged on appropriate secondary prevention medications.

Heritability of SF-36 Among Middle-Age, Middle-Class, Male???Male Twins

OBJECTIVE

We sought to examine the relative importance of genetic and environmental factors for the MOS SF-36; a widely used, valid, and reliable measure of health-related quality of life and to discuss incorporating genetic influences into health services research.

DATA SOURCES

Data are from a nationally distributed, nonclinical cohort of 2928 middle age, middle-class, male-male twin members of the Vietnam Era Twin Registry.

STUDY DESIGN

This was a secondary data analysis, classic twin heritability analysis.

DATA COLLECTION

A telephone survey was used to collect information on alcohol-related problems and health services use, including the SF-36.

PRINCIPAL FINDINGS

Variance component analyses indicated that additive genetic factors accounted for 17% to 33% of the variance for each of the 8 domains of the SF-36. Shared environment accounted for 0% to 12% of the variance for each domain, with the majority of variance for each domain accounted for by nonshared, or unique environment and error. Physical and mental health summary measures indicated that approximately one-third of the variance was accounted for by additive genetic factors and the remainder accounted for by nonshared environment and error. Clinical condition, history of alcohol dependence, had a small-but-significant influence for all domains. Including condition proved to be a better-fitting model. However, confidence intervals temper uniform statistical significance for genetic factors.

CONCLUSIONS

This study assessed the heritability of the SF-36 in a nonclinical, community sample of middle age, middle-class all-male twins. The moderate genetic effects on SF-36 domain and summary measures are new findings and thus may affect interpretations of SF-36 as a measure of health-related quality of life. Ideally, trait-based measures should identify genetic sources of variation and thus help understand any bias of the true effects of SF-36. Still the majority of variance is accounted for by nonshared or unique environmental factors and error. By extension, increased understanding of the importance of genetic and environmental factors that influence either predictors or outcomes of interest will expand the level of scientific debate in health services research and improve predictability.

Heritability of Word Recognition in Middle-Aged Men Varies as a Function of Parental Education

Although it is of lifelong importance, reading ability is studied primarily in children and adolescents. We examined variation in word recognition in 347 middle-aged male twin pairs. Overall heritability (a2) was 0.45, and shared environmental influences (c2) were 0.28. However, parental education moderated heritability such that a2 was 0.21 at the lowest parental education level and 0.69 at the highest level; c2 was 0.52 and 0.00, respectively. This constitutes a parental education x environment interaction. The higher heritability was due to a decrease in the magnitude of shared environmental factors, rather than an increase in the magnitude of genetic factors. Other cognitive studies have reported gene x environment interactions, but patterns may differ as a function of age or specific cognitive abilities. Our results suggest that shared environmental factors in families with low parental education have long-lasting effects on word recognition ability, well beyond any critical period for developing reading proficiency.

Patient concerns about medical errors in emergency departments

OBJECTIVE

Despite large numbers of emergency encounters, little is known about how emergency department (ED) patients conceptualize their risk of medical errors. This study examines how safe ED patients feel from medical errors, which errors are of greatest concern, how concerns differ by patient and hospital characteristics, and the relationship between concerns and willingness to return for future care.

METHODS

Multiwave telephone interviews of 767 patients from 12 EDs were conducted. Patients were asked about their medical safety, concern about eight types of medical errors, and satisfaction with care.

RESULTS

Eighty-eight percent of patients believed that their safety from medical errors had been good, very good, or excellent; 38% of patients reported experiencing at least one specific error-related concern, most commonly misdiagnosis (22% of all patients), physician errors (16%), medication errors (16%), nursing errors (12%), and wrong test/procedure (10%). Concerns were associated with gender (p < 0.01), age (p < 0.0001), ethnicity (p < 0.001), length of stay (p < 0.001), ED volume (p < 0.0001), day of week (p < 0.0001), and hospital type (p < 0.0001). Concerns were highly related to a patient's willingness to return to the ED.

CONCLUSIONS

The majority of ED patients felt relatively safe from medical errors, yet a significant percentage of patients experienced concern about a specific error during their emergency encounter. Concerns varied by both patient and hospital characteristics and were highly linked to patient satisfaction. The selective nature of concerns may suggest that patients are attuned to cues they perceive to be linked to specific medical errors, but efforts to involve patients in error detection/prevention programs will be challenging given the stressful and intimidating nature of ED encounters.

Stability, consistency, and heritability of electrodermal response lability in middle-aged male twins

We examined individual differences in nonspecific electrodermal response (EDR) lability in terms of retest stability, cross-situational consistency, and heritability in a sample of 345 adult monozygotic and dizygotic twin pairs. We also examined the phenotypic and genetic relationships between EDR lability and speed of habituation of the specific EDR to a nonsignal stimulus. Individual variation in EDR lability showed substantial retest stability and cross-situational consistency and also predicted resistance to specific EDR habituation. Structural equation modeling showed that the covariation among EDR lability measures and resistance to specific EDR habituation operated through a single latent phenotype, which was influenced in approximately equal measure by genetic and unique environmental factors. We discuss these findings in terms of an information processing account of individual differences in phasic EDR activation.

Genetic and environmental effects on offspring alcoholism: new insights using an offspring-of-twins design

CONTEXT

Although there is now considerable evidence that genetic effects play a critical role in the development of alcohol dependence (AD), theoretical and methodological limitations of this literature require caution in describing the etiology and development of this disorder.

OBJECTIVE

To disentangle genetic and environmental effects on AD by means of the infrequently used, yet potentially powerful, offspring-of-twins design.

DESIGN

Offspring of twins.

PARTICIPANTS

Male monozygotic and dizygotic twins concordant or discordant for AD and control pairs from the Vietnam Era Twin Registry were assessed, as were the offspring of these twins and the mothers of these offspring.

INTERVENTIONS

Structured psychiatric interviews.

MAIN OUTCOME MEASURES

Participants' psychiatric, alcohol abuse (AA), and AD histories (DSM-IV).

RESULTS

Offspring of monozygotic and dizygotic twins with a history of AD were significantly more likely to exhibit AA or AD than were offspring of nonalcoholic fathers. Offspring of an alcohol-abusing monozygotic twin whose co-twin was AD were also more likely to exhibit AD than were offspring of nonalcoholic twins. In contrast, offspring of an unaffected (ie, no history of abuse or dependence) monozygotic twin whose co-twin was AD were no more likely to exhibit AA or AD than were offspring of nonalcoholic twins.

CONCLUSIONS

These findings support the hypothesis that family environmental effects do make a difference in accounting for offspring outcomes, in particular, that a low-risk environment (ie, the absence of parental alcoholism) can moderate the impact of high genetic risk regarding offspring for the development of alcohol-use disorders.

Hospital performance with myocardial reperfusion therapy: are hospitals capable of meeting established guidelines?

OBJECTIVES

To determine whether hospitals are capable of delivering myocardial reperfusion therapy in a manner consistent with the American College of Cardiology/American Heart Association guidelines. DATA SOURCE AND STUDY SETTING: Data from the National Registry of Myocardial Infarction (NRMI)-2 and NRMI-3 were used. NRMI is an observational study, sponsored by Genentech, conducted from June 1994 through June 2000 and involving 1876 hospitals and 1,310,030 patients across the United States. The protocol calls for collecting data on all patients with a diagnosis of acute myocardial infarction. The setting was community and tertiary hospitals in the United States.

STUDY DESIGN

This observational study used process capability analysis.

PRINCIPAL FINDINGS

Overall, no hospital was deemed capable of delivering myocardial reperfusion therapy consistent with the American College of Cardiology/American Heart Association guidelines. The highest thrombolytic and angioplasty CPUs were 0.44 and 0.52, respectively-well below the traditional value of 1.0 signifying minimum capability. In addition, among the hospitals examined, there remained a wide degree of variability in process capability, ranging from -0.69 to 0.52.

CONCLUSIONS

Myocardial reperfusion therapy performance measurement systems relying solely on mean time-to-reperfusion conceal true process performance, thereby obscuring quality improvement opportunities and strategies for improvement. Health care providers, purchasers, regulators, and other organizations interested in measuring and improving health care quality are encouraged to incorporate process capability analysis into their myocardial reperfusion therapy performance measurement and quality management systems.

Reconsidering models of patient satisfaction and behavioral intentions

This article considers several models of how patients integrate their reactions to hospital attributes and how these reactions impact their overall satisfaction and behavioral intentions. It finds that patients combine their reactions to the attributes by means of noncompensatory and nonlinear models to form their overall satisfaction or behavioral intentions.

Outcomes of the Learn, Share & Live breast cancer education program for older urban women

OBJECTIVES

This study assessed whether the Learn, Share & Live breast cancer education program resulted in favorable, replicable, and sustainable outcomes.

METHODS

The program was implemented at index (year 1) and replication (year 2) sites. Baseline interviews (year 1; n = 240) and 2 follow-up telephone interviews (years 2 and 3; n = 337 and 323) were used to assess postintervention changes.

RESULTS

From baseline to year 2, mammography adherence and stage of adoption improved at the index site relative to the replication site. Knowledge scores and percentages of respondents reporting that a friend had spoken with them about mammography improved significantly. Improvements were sustained through year 3 (2 years postintervention). In year 3, replication participants showed improvements in regard to knowledge and perceived mammography benefits, and there was a trend toward increased adherence. Site differences in postintervention adherence may have stemmed from respective choices of follow-up activities.

CONCLUSIONS

The study outcomes affirm the impact of Learn, Share & Live, indicating a replicated and sustained program effect. Future studies should continue longer follow-up and explore the importance of providing mammography opportunities along with education.

The impact of sociodemographics, comorbidity and symptom recency on health-related quality of life in alcoholics

OBJECTIVE

To obtain estimates of the relationship between alcoholism and health-related quality of life (HRQL) in twin pairs discordant for alcohol dependence.

METHOD

In 1995, 1,258 male-male twin pair members of the Vietnam Era Twin Registry (total Registry N = 7.375 pairs) were administered a modified Medical Outcomes Study 36 Item Short Form (SF-36) and the Diagnostic Interview Schedule (DIS) to obtain measures of HRQL and a DSM-III-R criteria lifetime diagnosis of alcohol dependence. Mean within pair differences on eight separate SF-36 subscales were calculated for 436 remitted (no alcohol symptoms in the past 5 years) alcohol-dependent discordant twin pairs and for 194 recent (at least one alcohol symptom in the past 5 years) alcohol-dependent discordant pairs before and after adjustment for covariates. Covariates included lifetime physical illness, lifetime psychiatric disorders, lifetime drug dependence, lifetime nicotine dependence, current marital status, current income and severity.

RESULTS

In the unadjusted analysis remitted alcoholic twins compared to their nonalcoholic co-twins reported significantly lower mean scores for six of eight SF-36 subscales. Recent alcoholic twins, compared to their nonalcoholic co-twins, reported significantly lower mean scores for all of the SF-36 subscales. However, after simultaneous adjustment for all covariates, no SF-36 subscale mean, except "vitality" among recent alcoholic twins, was significantly different between alcoholic twins and their nonalcoholic co-twins.

CONCLUSIONS

Differences in HRQL between alcoholic and nonalcoholic co-twins is due to covariation from physical and psychiatric problems, drug and nicotine dependence, marital status, income and severity.

Sociodemographic and health status characteristics with prostate cancer screening in a national cohort of middle-aged male veterans

OBJECTIVES

To characterize variables associated with obtaining prostate cancer screening in a nonclinical, nationally distributed, middle-aged male population.

METHODS

Telephone interviews were administered to 2652 individual members of the Vietnam Era Twin Registry in 1992 and 1995. Dependent variables were self-report measures of having had a digital rectal examination (DRE) and/or a prostate-specific antigen (PSA) test in the past 5 years. Independent variables were current measures of age, household income, education, race, insurance, source of care, and lifetime measures of physical condition, psychiatric illness, and alcohol and nicotine dependence.

RESULTS

Thirty-five percent of the sample reported having had a PSA and DRE within the past 5 years. Prevalence of obtaining either a PSA or DRE varied with age, income, education, and race. Subjects with a regular source of care, a regular physician, and health insurance reported higher rates of having had a DRE or PSA and DRE. Persons with a physical or psychiatric illness reported more screening. A multiple regression model revealed that having a regular source of care, having a regular physician, physical illness, psychiatric illness, minority status, higher income, and age predicted having had some form of screening.

CONCLUSIONS

A substantial portion of middle-aged men have had both a PSA and DRE performed at least once in the preceding 5 years. It may be possible to further improve prostate cancer screening participation by directing educational programs at men who are not in contact with the healthcare system. If the PSA and DRE screening guidelines that are finally adopted discourage screening among low-risk men younger than age 50, educational programs that emphasize age screening criteria may be warranted.