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Kolomaya A, Amin S, Lin C. The association of health insurance with the survival of cancer patients with brain metastases at diagnosis. Tech Innov Patient Support Radiat Oncol 2021; 20:46-53. [PMID: 34926840 PMCID: PMC8652000 DOI: 10.1016/j.tipsro.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/15/2021] [Accepted: 11/19/2021] [Indexed: 11/14/2022] Open
Abstract
Patients with brain metastases at diagnosis have limited life expectancy. A patient’s insurance is associated with different overall survivals. Those with private insurance were most likely to receive all treatments modalities. Black patients are disproportionally represented in Medicaid or uninsured groups.
Background Synchronous brain metastases (SBMs) are a presentation of stage IV cancers with limited treatment options. This study examines the association between health insurance status and overall survival (OS) of patients with SBMs using the National Cancer Database (NCBD). Methods We queried the NCDB for patients with SBMs from 2010 to 2015. Included cases were from seven primary cancers. Patients were grouped based on their insurance status. We assessed the association of insurance with OS using a Cox proportional hazards model adjusted for age at diagnosis, sex, race, education level, income level, residential area, treatment facility type, Charlson-Deyo comorbidity status, year of diagnosis, primary tumor type, and receipt of chemotherapy, radiation therapy (RT), immunotherapy, and primary site surgery. Results Of 97,659 patients included, those who had Medicaid, Medicare, or without health insurance were less likely to receive brain RT, chemotherapy, and/or surgery of the primary cancer site compared to privately insured patients. In multivariable COX analysis, patients with Medicare (HR = 1.11, 95% CI: 1.09–1.14, P < 0.001), Medicaid (HR = 1.11, 95% CI: 1.09–1.13, P < 0.001), or no insurance (HR = 1.18, 95% CI: 1.14–1.22, P < 0.001) were associated with decreased OS compared to private insurance. Conclusion After retrospective analysis, Medicaid, Medicare, and no insurance were all associated with worse OS compared to private insurance. Future studies can focus on determining the factors associated with insurance status and factors contributing to improved OS stratified by insurance status.
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Affiliation(s)
- Alex Kolomaya
- College of Medicine, University of Nebraska Medical Center, 42nd and Emile St, Omaha, NE 68198, United States
| | - Saber Amin
- Department of Radiation Oncology, University of Nebraska Medical Center, 986861 Nebraska Medical Center, Omaha, NE 68198-6861, United States
| | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, 986861 Nebraska Medical Center, Omaha, NE 68198-6861, United States
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Jafari F, Safaei AM, Hosseini L, Asadian S, Kamangar TM, Zadehbagheri F, Rezaeian N. The role of cardiac magnetic resonance imaging in the detection and monitoring of cardiotoxicity in patients with breast cancer after treatment: a comprehensive review. Heart Fail Rev 2020; 26:679-697. [PMID: 33029698 DOI: 10.1007/s10741-020-10028-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 01/04/2023]
Abstract
The use of chemotherapy medicines for breast cancer (BC) has been associated with an increased risk of cardiotoxicity. In recent years, there have been growing interests regarding the application of cardiovascular magnetic resonance (CMR) imaging, a safe and noninvasive modality, with the potential to identify subtle morphological and functional changes in the myocardium. In this investigation, we aimed to review the performance of various CMR methods in diagnosing cardiotoxicity in BC, induced by chemotherapy or radiotherapy. For this purpose, we reviewed the literature available in PubMed, MEDLINE, Cochrane, Google Scholar, and Scopus databases. Our literature review showed that CMR is a valuable modality for identifying and predicting subclinical cardiotoxicity induced by chemotherapy. The novel T1, T2, and extracellular volume mapping techniques may provide critical information about cardiotoxicity, in addition to other CMR features such as functional and structural changes. However, further research is needed to verify the exact role of these methods in identifying cardiotoxicity and patient management. Since multiple studies have reported the improvement of left ventricular performance following the termination of chemotherapy regimens, CMR remains an essential imaging tool for the prediction of cardiotoxicity and, consequently, decreases the mortality rate of BC due to heart failure.
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Affiliation(s)
- Fatemeh Jafari
- Department of Radiation Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran.,Radiation Oncology Research Center (RORC), Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Afsane Maddah Safaei
- Radiation Oncology Research Center (RORC), Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Hosseini
- North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Sanaz Asadian
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Tara Molanaie Kamangar
- Radiation Oncology Research Center (RORC), Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Nahid Rezaeian
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Wu AM, Morse AR, Seiple WH, Talwar N, Hansen SO, Lee PP, Stein JD. Reduced Mammography Screening for Breast Cancer among Women with Visual Impairment. Ophthalmology 2021; 128:317-23. [PMID: 32682837 DOI: 10.1016/j.ophtha.2020.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/07/2020] [Accepted: 07/08/2020] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Timely mammography to screen for breast cancer in accordance with the United States Preventive Services Task Force (USPSTF) recommendations can reduce morbidity and mortality substantially. This study assessed whether the odds of undergoing screening mammography are similar for women with and without visual impairment (VI). DESIGN Retrospective, longitudinal cohort study. PARTICIPANTS Women aged 65 to 72 years enrolled in fee-for-service Medicare from January 1, 2008, through December 31, 2015. METHODS Patients with no vision loss (NVL), partial vision loss (PVL), and severe vision loss (SVL) were matched 1:1:1 based on age, race, time in Medicare, urbanicity of residence, and overall health. Women with pre-existing breast cancer were excluded. Multivariable conditional logistic regression modeling compared the odds of undergoing screening mammography within a 2-year follow-up period among the 3 groups. MAIN OUTCOMES MEASURES Proportion of participants undergoing mammography and adjusted odds ratios (ORs) of undergoing mammography within 2 years of follow-up. RESULTS A total of 1044 patients were matched (348 in each group). The mean ± standard deviation age at the index date was 69.0 ± 1.5 years for all 3 groups. The proportion of women undergoing 1 mammography screening or more within the 2-year follow-up was 69.0% (n = 240), 56.9% (n = 198), and 56.0% (n = 195) for the NVL, PVL, and SVL groups, respectively (P = 0.0005). The mean ± standard deviation number of mammography screenings undergone per patient during the 5-year period (3-year look-back plus 2-year follow-up) was 3.1 ± 2.0, 2.5 ± 2.0, and 2.3 ± 2.1 for the NVL, PVL, and SVL groups, respectively (P < 0.0001). Women with SVL had 42% decreased odds (OR, 0.58; 95% CI, 0.37-0.90; P = 0.01), and those with PVL had 44% decreased odds (OR, 0.56; CI, 0.36-0.87; P = 0.009) of undergoing mammography during follow-up compared with those with NVL. CONCLUSIONS Women with VI were significantly less likely to undergo mammography screening for breast cancer than women without VI. Clinicians should look for ways to help ensure that patients with VI undergo mammography and other preventive screenings as recommended by the USPSTF.
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West DS, Greene P, Pulley L, Kratt P, Gore S, Weiss H, Siegfried N. Stepped-Care, Community Clinic Interventions to Promote Mammography Use among Low-Income Rural African American Women. Health Educ Behav 2016; 31:29S-44S. [PMID: 15296690 DOI: 10.1177/1090198104266033] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Few studies have investigated community clinic-based interventions to promote mammography screening among rural African American women. This study randomized older low-income rural African American women who had not participated in screening in the previous 2 years to a theory-based, personalized letter or usual care; no group differences in mammography rate were evident at 6-month follow-up. Women who had not obtained a mammogram were then randomized to a tailored call delivered by community health care workers or a tailored letter. There were no group differences in mammography rates after the second 6-month follow-up. However, among women who had never had a mammogram, the tailored call was more effective in promoting mammography use. Tailored counseling may be an effective screening promotion strategy for hard-to-reach rural African American women with no history of screening. Further research into this strategy may facilitate efforts to reduce health disparities in underserved low-income rural African American populations.
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Affiliation(s)
- Delia Smith West
- University of Arkansas Medical Sciences, College of Public Health, 4301West Markham Street, #820, Little Rock, AR72205, USA.
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Dawes AJ, Louie R, Nguyen DK, Maggard-Gibbons M, Parikh P, Ettner SL, Ko CY, Zingmond DS. The impact of continuous Medicaid enrollment on diagnosis, treatment, and survival in six surgical cancers. Health Serv Res 2014; 49:1787-811. [PMID: 25256223 PMCID: PMC4254125 DOI: 10.1111/1475-6773.12237] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To examine the effect of Medicaid enrollment on the diagnosis, treatment, and survival of six surgically relevant cancers among poor and underserved Californians. DATA SOURCES California Cancer Registry (CCR), California's Patient Discharge Database (PDD), and state Medicaid enrollment files between 2002 and 2008. STUDY DESIGN We linked clinical and administrative records to differentiate patients continuously enrolled in Medicaid from those receiving coverage at the time of their cancer diagnosis. We developed multivariate logistic regression models to predict death within 1 year for each cancer after controlling for sociodemographic and clinical variables. DATA COLLECTION/EXTRACTION METHODS All incident cases of six cancers (colon, esophageal, lung, pancreas, stomach, and ovarian) were identified from CCR. CCR records were linked to hospitalizations (PDD) and monthly Medicaid enrollment. PRINCIPAL FINDINGS Continuous enrollment in Medicaid for at least 6 months prior to diagnosis improves survival in three surgically relevant cancers. Discontinuous Medicaid patients have higher stage tumors, undergo fewer definitive operations, and are more likely to die even after risk adjustment. CONCLUSIONS Expansion of continuous insurance coverage under the Affordable Care Act is likely to improve both access and clinical outcomes for cancer patients in California.
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Affiliation(s)
- Aaron J Dawes
- Department of Surgery, David Geffen School of Medicine at the University of CaliforniaLos Angeles, 757 Westwood Plaza, B711, Los Angeles, CA 90095
- Robert Wood Johnson Clinical Scholars Program, University of CaliforniaLos Angeles, CAVA Greater Los Angeles Healthcare SystemLos Angeles, CA
| | - Rachel Louie
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of CaliforniaLos Angeles, CA
| | - David K Nguyen
- Department of Surgery, David Geffen School of Medicine at the University of CaliforniaLos Angeles, CA
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at the University of CaliforniaLos AngelesVA Greater Los Angeles Healthcare SystemLos Angeles, CA
| | - Punam Parikh
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of CaliforniaLos Angeles, CA
- Department of Surgery, David Geffen School of Medicine at the University of CaliforniaLos Angeles, CA
| | - Susan L Ettner
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of CaliforniaLos Angeles, CA
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health at the University of CaliforniaLos Angeles, CA
| | - Clifford Y Ko
- Department of Surgery, David Geffen School of Medicine at the University of CaliforniaLos AngelesVA Greater Los Angeles Healthcare SystemLos Angeles, CA
| | - David S Zingmond
- Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of CaliforniaLos Angeles, CA
- Department of Surgery, David Geffen School of Medicine at the University of CaliforniaLos Angeles, CA
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Pruitt SL, Shim MJ, Mullen PD, Vernon SW, Amick BC. Association of area socioeconomic status and breast, cervical, and colorectal cancer screening: a systematic review. Cancer Epidemiol Biomarkers Prev 2010; 18:2579-99. [PMID: 19815634 DOI: 10.1158/1055-9965.epi-09-0135] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Although numerous studies have examined the association of area socioeconomic status (SES) and cancer screening after controlling for individual SES, findings have been inconsistent. A systematic review of existing studies is timely to identify conceptual and methodologic limitations and to provide a basis for future research directions and policy. OBJECTIVE The objectives were to (a) describe the study designs, constructs, methods, and measures; (b) describe the independent association of area SES and cancer screening; and (c) identify neglected areas of research. METHODS We searched six electronic databases and manually searched cited and citing articles. Eligible studies were published before 2008 in peer-reviewed journals in English, represented primary data on individuals ages > or = 18 years from developed countries, and measured the association of area and individual SES with breast, cervical, or colorectal cancer screening. RESULTS Of 19 eligible studies, most measured breast cancer screening. Studies varied widely in research design, definitions, and measures of SES, cancer screening behaviors, and covariates. Eight employed multilevel logistic regression, whereas the remainder analyzed data with standard single-level logistic regression. The majority measured one or two indicators of area and individual SES; common indicators at both levels were poverty, income, and education. There was no consistent pattern in the association between area SES and cancer screening. DISCUSSION The gaps and conceptual and methodologic heterogeneity in the literature to date limit definitive conclusions about an underlying association between area SES and cancer screening. We identify five areas of research deserving greater attention in the literature.
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Affiliation(s)
- Sandi L Pruitt
- Division of Health Behavior Research, Washington University School of Medicine, Campus Box 8504, 4444 Forest Park Avenue, Suite 6700, St. Louis, MO 63108, USA.
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Durbecq V, Ameye L, Veys I, Paesmans M, Desmedt C, Sirtaine N, Sotiriou C, Bernard-Marty C, Nogaret J, Piccart M, Larsimont D. A significant proportion of elderly patients develop hormone-dependant “luminal-B” tumours associated with aggressive characteristics. Crit Rev Oncol Hematol 2008; 67:80-92. [DOI: 10.1016/j.critrevonc.2007.12.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Revised: 12/11/2007] [Accepted: 12/19/2007] [Indexed: 11/26/2022] Open
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Purc-Stephenson RJ, Gorey KM. Lower adherence to screening mammography guidelines among ethnic minority women in America: a meta-analytic review. Prev Med 2008; 46:479-88. [PMID: 18295872 DOI: 10.1016/j.ypmed.2008.01.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 12/30/2007] [Accepted: 01/08/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study investigates the association between ethnic minority status and receiving a screening mammogram within the past 2 years among American women over 50. METHOD The findings from 33 studies identified from interdisciplinary research databases (1980 to 2006) were synthesized. Separate pooled analyses compared white non-Hispanics to African Americans (28 outcomes), Hispanics (18 outcomes), and Asian/Pacific Islanders (10 outcomes). RESULTS Using the random effects model, results showed that African Americans were screened less than white non-Hispanics at a marginal level (OR 0.87, 95% CI 0.75, 1.00). Larger and significant discrepancies were observed for Hispanics (OR 0.65, 95% CI 0.50, 0.85) and Asian/Pacific Islanders (OR 0.63, 95% CI 0.39, 0.99) compared to white non-Hispanics. However, among studies controlling for socioeconomic status, ethnic differences in mammography screening were no longer significant for African Americans (OR 1.05, 95% CI 0.71, 1.76), Hispanics (OR 1.08, 95% CI 0.64, 1.93), or Asian/Pacific Islanders (OR 1.08, 95% CI 0.64, 1.93). Subgroup analyses further showed that geographical region, sampling method, and data collection strategy significantly impacted results. CONCLUSIONS This study found evidence that ethnic minority-screening mammography differences exist but were impacted by socioeconomic status. Implications for interpreting existing knowledge and future research needs are discussed.
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Abstract
BACKGROUND Individuals without medical insurance or with limited insurance are less likely than those with broader insurance coverage to receive preventive services and to seek timely medical care. The authors examined the associations of insurance status with stage at diagnosis among women with breast cancer. METHODS This study included women age >/=40 years who were diagnosed with invasive breast cancer from 1998 to 2003 and who were reported to the National Cancer Data Base. Multivariable logistic regression analyses were used to examine the associations of insurance status with more advanced-stage breast cancer at diagnosis while controlling for other patient characteristics. RESULTS Among the 533,715 women with breast cancer who were included in the current analysis, the proportions with advanced-stage (III/IV) cancer at diagnosis ranged from 8% among privately insured patients to 18% among uninsured patients and 19% among Medicaid patients; differences in the proportions of women with advanced-stage cancer were statistically significant (P < .0001). Regression analyses indicated that, compared with privately insured patients, uninsured patients and Medicaid patients had a greater likelihood of diagnosis at stage II (odds ratio [OR], approximately approximately 1.5) or at stages III/IV (OR, 2.4) versus stage I (P < .001). Black and Hispanic patients also were significantly more likely than white patients to be diagnosed at a more advanced stage (P < .001). CONCLUSIONS The results from this study provided strong evidence that patients without health insurance or with Medicaid coverage, as well as black and Hispanic patients, were more likely to present with advanced-stage breast cancer. These results are consistent with other reports that have documented less use of preventive services, including mammography, among uninsured women and delays in diagnosis and treatment for black and Hispanic women.
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Affiliation(s)
- Michael T Halpern
- Epidemiology and Surveillance Research, American Cancer Society, Atlanta, Georgia, USA.
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Fukuda Y, Nakamura K, Takano T. Reduced likelihood of cancer screening among women in urban areas and with low socio-economic status: a multilevel analysis in Japan. Public Health 2005; 119:875-84. [PMID: 16054179 DOI: 10.1016/j.puhe.2005.03.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Revised: 02/15/2005] [Accepted: 03/29/2005] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To elucidate socio-economic predictors of participation in cancer screening in Japanese women, paying attention to regional variations. METHODS In a nationally representative sample of women aged 40--64 years (n=15,224) in Japan, the relationships of self-reported attendance at screening for stomach, colon, uterine and breast cancers with individual characteristics (marital status, occupation and household income) and regional variables (living in a metropolitan area or not, and per capita income) were examined using multilevel analysis. RESULTS The participation rate ranged from 21.6% for colon cancer to 32.5% for uterine cancer. Being married, employed and having a higher household income were significantly associated with a higher likelihood of cancer screening for all types of cancer: the adjusted odds ratio in the lowest income quintile ranged from 0.45 for uterine cancer to 0.53 for colon cancer compared with the highest income quintile. There was significant regional variance, and living in a metropolitan area and per capita income were associated with a reduced likelihood of cancer screening. CONCLUSIONS Women with lower socio-economic status and living in urban areas are less likely to participate in cancer screening in Japan. Cancer screening should be encouraged in urban areas, taking account of the socio-economic inequalities.
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Affiliation(s)
- Y Fukuda
- Health Promotion/International Health, Division of Public Health, Graduate School of Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
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Haggstrom DA, Phillips KA, Liang SY, Haas JS, Tye S, Kerlikowske K. Variation in screening mammography and Papanicolaou smear by primary care physician specialty and gatekeeper plan (United States). Cancer Causes Control 2004; 15:883-92. [PMID: 15577290 DOI: 10.1007/s10552-004-1138-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess whether the specialty of a patient's primary care physician or being part of a gatekeeper plan influence breast and cervical cancer screening. METHODS Cross-sectional study of women in a national sample. For mammography, we studied women aged 40 and above, and for Papanicolaou (Pap) smear, women aged 18-65 years. Screening mammography or Pap smear within the previous two years was measured by patient self-report. The key independent variables were primary care physician specialty and whether the patient had a gatekeeper. RESULTS Among women seen by a family practice physician, there was a higher probability of being screened if the patient was part of a gatekeeper plan than if the patient was not part of a gatekeeper plan: mammography (OR = 1.35; 95% CI = 1.20-1.52) and Pap smear (OR = 1.60; 95% CI = 1.34-1.91). Among women seen by an internal medicine physician, cancer screening did not vary significantly by gatekeeper status. CONCLUSIONS The impact of gatekeeper plans upon cancer screening varies according to the primary care physician's specialty. Policy interventions designed to increase cancer screening should take into account different responses to gatekeeper requirements among different types of providers.
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Affiliation(s)
- David A Haggstrom
- San Francisco General Hospital, Division of General Internal Medicine, University of California, San Francisco.
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Abstract
BACKGROUND The authors evaluated the two indicators of metastatic proclivity (namely, virulence [V; the rate of appearance of distant metastases] and metastagenicity [M; the ultimate likelihood of developing distant metastases]) of breast carcinoma in elderly women. The authors then compared these characteristics with the corresponding characteristics in a cohort of younger women to determine whether breast carcinoma was more indolent in women age > 70 years, as is commonly believed in the medical community. METHODS The authors examined 2136 women who underwent mastectomy without adjuvant systemic therapy at The University of Chicago Hospitals (Chicago, IL) between 1927 and 1987. The median follow-up period was 12.3 years. Distant disease-free survival (DDFS) was determined for women who did not receive systemic therapy. V and M were obtained from log-linear plots of DDFS. RESULTS No significant difference in tumor size at presentation was observed among women age < 40 years, women ages 40-70 years, and women age > 70 years (P = 0.86), whereas significantly fewer women age > 70 years presented with positive lymph nodes compared with younger women (P = 0.05). In women with negative lymph node status, there was a higher DDFS rate among patients ages 40-70 years (81% at 10 years) compared with patients age > 70 years (65% at 10 years; P = 0.018). There was no significant age-related difference among women with lymph node-positive disease (P = 0.2). For example, the 10-year DDFS rate for women ages 40-70 years was 33%, compared with 38% for women age > 70 years. Among those with lymph node-negative disease, V was 3% per year for women ages 40-70 years as well as women age > 70 years. Among women with lymph node-negative disease, M was 0.20 for patients ages 40-70 years and 0.35 for patients age > 70 years. In women with positive lymph node status, both V (11% per year vs. 10% per year) and M (0.70 vs. 0.65) were similar in both age groups. CONCLUSIONS Fewer women age > 70 years had lymph node involvement at presentation. However, when this finding was taken into account, the authors found no evidence that breast carcinoma was more indolent in women age > 70 years. These results support the use of similar diagnostic and therapeutic efforts for elderly women and younger women, with modification for elderly women based only on comorbidity.
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Affiliation(s)
- Rachana Singh
- Department of Radiation and Cellular Oncology, The University of Chicago Hospitals, Chicago, Illinois 60637, USA
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Abstract
Mammography use is monitored through Medicare billing claims; however, the sensitivity of this data source has not been previously described. This study included 10,852 Colorado women ages 65 and older with a mammogram in 1998 as registered by the Colorado Mammography Project who were Medicare fee-for-service (FFS) enrollees. These records were matched to Medicare billing data to assess the proportion of those mammograms submitted for payment to Medicare. The overall sensitivity of the FFS Medicare billing data for screening mammography was 85 percent. Medicare billing claims were less sensitive for younger women, African Americans, women with some college education, and women with supplementary private insurance. In Colorado, the Medicare FFS billing claims understates mammography usage by 15 percent. Care must be taken when comparing mammography use derived from Medicare billing claims, as the sensitivity of billing data can vary substantially by age, race, and socioeconomic status.
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Hahn K. Older ethnic women in faith communities. J Gerontol Nurs 2003; 29:5-12. [PMID: 12874934 DOI: 10.3928/0098-9134-20030701-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Karen Hahn
- Center for Faith and Health Initiatives, Houston, Texas, USA
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Freeman JL, Goodwin JS, Zhang D, Nattinger AB, Freeman DH. Measuring the performance of screening mammography in community practice with Medicare claims data. Women Health 2003; 37:1-15. [PMID: 12733550 DOI: 10.1300/j013v37n02_01] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Few studies have examined the outcomes of screening mammography in community practice, particularly the extent of false positive exams among older asymptomatic women. RESEARCH DESIGN Subjects were female Medicare beneficiaries, age 67 or older, residing in one of eleven SEER areas, with no evidence of breast cancer. Medicare claims data were used to identify their screening mammograms over two time periods, 1993-1995 and 1996-1998, and to measure their use of follow-up diagnostic testing (diagnostic mammography, breast ultrasound and breast biopsy) within three months of the screening mammogram. RESULTS There were significant differences among the rates of diagnostic testing for each age group (67-74; 75+ ) by year, but no clear trend toward higher or lower rates over time. Although rates of diagnostic testing differed significantly by geographic region in both time periods 1993-1995 and 1996-1998, estimates of specificity for all regions were within AHRQ clinical practice guidelines (specificity greater than 90%). Specificity significantly improved with the volume of the radiologist's practice for the latter time period (1996-1998) but not for the former (1993-1995). CONCLUSION Medicare claims offer an accessible population-based source of data for mammography performance indicators. As such, they offer a low cost method for evaluating individual mammography practices as well as monitoring the impact of reimbursement policies, practice guidelines and laws mandating requirements for accrediting facilities.
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Affiliation(s)
- Jean L Freeman
- Sealy Center on Aging, Department of Preventive Medicine & Community Health, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0860, USA.
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Eisner EJ, Zook EG, Goodman N, Macario E. Knowledge, attitudes, and behavior of women ages 65 and older on mammography screening and Medicare: results of a national survey. Women Health 2003; 36:1-18. [PMID: 12555798 DOI: 10.1300/j013v36n04_01] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Compared to younger women, women 65+ will experience the greatest increase in new breast cancer cases. In 1991, Medicare began offering partial reimbursement for screening mammography every 2 years. METHODS In 1999, the National Cancer Institute (NCI) conducted a telephone survey on breast cancer, mammography, and Medicare reimbursement with a sample of households containing women ages 65+ using random-digit-dialing. Results were weighted to provide nationally representative estimates of U.S. women 65+. NCI compared 1999 results with similar data from a 1992 AARP survey. RESULTS Of the 814 women surveyed, 88% had had at least one mammogram in their lifetime; within this group, 80% had received their most recent mammogram 2 years ago or less. Only 57%, however, knew about recommendations to have a mammogram every 1-2 years. Approximately one-third indicated that they were not as concerned about getting breast cancer as when they were younger, and/or that women without risk factors could be less vigilant about mammograms. More than 75% were aware of Medicare coverage, but only 58% had used Medicare to help pay for their last mammogram. Minority women were almost twice as likely to be unaware of Medicare coverage. RECOMMENDATIONS (1) Highlight that breast cancer risk increases with age (and does not decline in the absence of risk factors) and communicate the correct frequency for having mammograms; (2) expand primary care physicians' roles in promoting mammography screening for women 65+; and (3) provide Medicare coverage information to older women, particularly those not taking advantage of this benefit.
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Affiliation(s)
- Ellen J Eisner
- Office of Communications, National Cancer Institute, Bethesda, MD 20892, USA
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Innos K, Horn-Ross PL. Recent trends and racial/ethnic differences in the incidence and treatment of ductal carcinoma in situ of the breast in California women. Cancer 2003; 97:1099-106. [PMID: 12569612 DOI: 10.1002/cncr.11104] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The rapid increase in the incidence of ductal carcinoma in situ (DCIS) of the breast in the U.S. has been associated with the widespread adoption of screening mammography. Little is known regarding the incidence and treatment of DCIS in women of racial/ethnic groups other than white and black. The current investigation examined recent trends and racial/ethnic differences in the incidence and treatment of DCIS in California. METHODS All cases of DCIS diagnosed in women age > or = 40 years in California between 1988-1999 were included. Age-adjusted incidence rates for white, black, Hispanic, and Asian-Pacific Islander women were calculated using the 2000 U.S. female population as the standard. The estimated annual percent change (EAPC) in the rates was calculated using least squares regression. RESULTS The average annual age-adjusted incidence of DCIS (1988-1999) was 45.3 per 100,000 in white women, 35.0 in black women, 30.9 in Asian-Pacific Islander women, and 21.8 in Hispanic women. Although a steady increase in the incidence of DCIS was noted in all racial/ethnic groups over the study period, Asian-Pacific Islander women were found to have experienced the steepest increase (EAPC = 9.1%), particularly in the age group 50-64 years (EAPC = 12.0%). The DCIS incidence was reported to increase with age in white, black, and Hispanic women, but remained fairly constant after the age of 50 years in Asian-Pacific Islanders. The proportion of women with DCIS treated with mastectomy decreased from 53% in 1988 to 32% in 1999. Younger women and Asian-Pacific Islander women reportedly were more likely to undergo mastectomy. CONCLUSIONS Considerable differences by race/ethnicity and age were observed in DCIS incidence and the change in the incidence in California between 1988 and 1999. Further information is needed to determine whether these differences are because of differential utilization of screening mammography or biologic characteristics of DCIS lesions.
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Affiliation(s)
- Kaire Innos
- Northern California Cancer Center, Union City, California, USA.
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Randolph WM, Mahnken JD, Goodwin JS, Freeman JL. Using Medicare data to estimate the prevalence of breast cancer screening in older women: comparison of different methods to identify screening mammograms. Health Serv Res 2002; 37:1643-57. [PMID: 12546290 PMCID: PMC1464039 DOI: 10.1111/1475-6773.10912] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To compare different methods for defining screening mammograms with Medicare claims and their impact on estimates of breast cancer screening rates. METHODS Medicare outpatient facility and physician claims for 61,962 women in 1993 and 59,652 women in 1998 were reviewed for evidence of receipt of screening mammography. We compared the estimates of screening mammography use derived from CPT (Current Procedure Terminology) codes to categorize mammograms as screening or diagnostic versus using an algorithm that uses CPT codes plus breast-related diagnoses in the prior two years. We also compared estimates obtained from review of physician claims alone, facility claims alone, or the combination of the two sources of claims. RESULTS Use of physician claims alone produced estimates of screening rates similar to rates calculated from use of both physician and outpatient (facility) claims. In 1993, the CPT code for screening mammography underestimated the rate of screening compared to estimates generated by using the algorithm (8.3 percent versus 18.0 percent prevalence, p<0.001). By 1998, the screening prevalence rate generated from using the CPT code for screening mammography more closely approximated the rate generated by the algorithm (23.0 percent versus 25.1 percent). By all methods of estimating screening mammography with Medicare claims, its prevalence increased substantially between 1993 and 1998. CONCLUSION Providers increased their use of the screening mammography code in their charges to Medicare during the 1990s. This has improved the claims' ability to distinguish screening from diagnostic mammograms, but screening rates computed with claims continue to fall below those generated from self-reports of mammography use among general populations of older women.
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Abstract
BACKGROUND Evaluating the use and effectiveness of cancer screening is an important component of cancer control programs. Medicare claims may be a useful source of data when screening older populations, but they are limited in terms of completeness and the ability to distinguish screening tests from those provided for diagnosis or surveillance. RESEARCH DESIGN A review of the major screening modalities for breast, colorectal, and prostate cancer, Medicare's policies for covering these tests, and the procedure codes used to identify them in Medicare claims. RESULTS Although Medicare's coverage has been extended to include screening mammography, colonoscopy, sigmoidoscopy, fecal occult blood tests, double-contrast barium enema, and prostate-specific antigen tests, providers have been slow to adopt the corresponding screening codes. CONCLUSION Challenges persist in measuring screening use, and innovative approaches are required to distinguish screening tests from diagnostic and follow-up evaluations.
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Affiliation(s)
- Jean L Freeman
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas 77555-0460, USA.
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Abstract
OBJECTIVES To determine an upper age limit or quantifiable level of comorbidity that would render mammography screening ineffectual in decreasing mortality in women aged 65 and older. DESIGN Retrospective cohort study. SETTING Upper midwestern United States. PARTICIPANTS Five thousand one hundred eighty-six predominantly Caucasian women aged 65 to 101 diagnosed with invasive breast cancer from 1986 through 1994. Data were obtained from The Upper Midwest Tumor Registry System, a regional consortium database in Minnesota, North Dakota, and South Dakota. MEASUREMENTS Relative risks (RRs) of death were computed for patients with mammographically detected tumors, stratified by age and comorbidity. Survival analysis was performed, stratified by level of comorbidity and method of tumor detection. RESULTS Patients with mammographically detected tumors and no comorbidity experienced significantly lower RRs of death in every age group (range P <.001 to P =.039). Women with mammographically detected tumors and mild to moderate comorbidity had RRs of death as follows: age 65 to 69 (RR = 0.32, 95% confidence interval (CI) = 0.15-0.69), age 70 to 74, (RR = 0.45, 95% CI = 0.22-0.91); age 75 to 79 (RR = 0.47, 95% CI = 0.25-0.88), age 80 and older (RR = 0.52, 95% CI = 0.33-0.80). Women with severe or multiple comorbidities experienced no improvement in survival with mammographically detected tumors. CONCLUSIONS Mammographic detection of breast cancer may be associated with a significantly decreased risk of death for older women of all ages, even for women with mild to moderate levels of comorbidity, but for older women with severe or multiple comorbidities, mammography is not associated with improvement in overall survival.
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Affiliation(s)
- Carol P McPherson
- Oncology Research Program, Park Nicollet Institute, 3800 Park Nicollet Boulevard, 2-South, Minneapolis, MN 55416, USA. mcphec@parknicollet .com
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Abstract
Previous studies have found that educational differences in mortality are weaker among the elderly. In this study I examine whether either cohort or period effects may have influenced the interpretation of age effects. Six 10-year birth cohorts are followed over 30 years through decennial censuses. Differential survival is inferred from changes in the relative proportions of a cohort in each education category as the cohort ages. In cross-section, younger persons generally show stronger education effects on survival, although this pattern is clearer for women than for men. There is evidence of period effects. Within cohorts, relative survival tends to increase with age.
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Affiliation(s)
- D S Lauderdale
- Department of Health Studies, University of Chicago, 5841 S. Maryland Ave., MC2007, Chicago, IL 60637, USA.
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Abstract
BACKGROUND In 1991, a policy change extended finan cial coverage for biennial mammography to holders of Medicare part B. The impact of this decision on mammography use was examined by comparing mammography use among Medicare-eligible and ineligible women in the years before (1990) and after (1993) the policy change, using National Health Interview Survey (NHIS) data, controlling for socioeconomic indicators and for having a usual source of medical care. METHODS The Medicare-eligible group consists of 2,419 women ages 65-69 years and women ages 60-64 years who are Medicare-eligible. The Medicare-ineligible group consists of 1,872 women ages 60-64 years. The analysis used logistic regressions and compared women who had undergone mammography in the prior 2 years and controlled for race, ethnicity, socioeconomic status, insurance status, and usual source of care. RESULTS Medicare reimbursement of mammography appears to have increased the number of Medicare-eligible women who had had a mammogram in the 2 years prior to the survey. However, the analyses suggested that disparities in mammography use due to access to primary care and socioeconomic status persisted after the change in Medicare coverage. Analyses indicated that having additional insurance was the only significant predictor of having a usual source of care among the Medicare population. CONCLUSIONS This analysis suggests that simply removing financial barriers to mammography for older women (such as the 1998 elimination of a deductible payment for mammograms provided under Medicare) may have limited effectiveness. The strong relationship between having a usual source of care and mammography suggests that disparities in mammography use may reflect inequalities in access to health care in general.
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Affiliation(s)
- M Kelaher
- Mailman School of Public Health, Columbia University, New York, NY 10032, USA.
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Gorey KM, Holowaty EJ, Fehringer G, Laukkanen E, Richter NL, Meyer CM. An international comparison of cancer survival: metropolitan Toronto, Ontario, and Honolulu, Hawaii. Am J Public Health 2000; 90:1866-72. [PMID: 11111258 PMCID: PMC1446420 DOI: 10.2105/ajph.90.12.1866] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Comparisons of cancer survival in Canadian and US metropolitan areas have shown consistent Canadian advantages. This study tests a health insurance hypothesis by comparing cancer survival in Toronto, Ontario, and Honolulu, Hawaii. METHODS Ontario and Hawaii registries provided a total of 9190 and 2895 cancer cases (breast and prostate, 1986-1990, followed until 1996). Socioeconomic data for each person's residence at the time of diagnosis were taken from population censuses. RESULTS Socioeconomic status and cancer survival were directly associated in the US cohort, but not in the Canadian cohort. Compared with similar patients in Honolulu, residents of low-income areas in Toronto experienced 5-year survival advantages for breast and prostate cancer. In support of the health insurance hypothesis, between-country differences were smaller than those observed with other state samples and the Canadian advantage was larger among younger women. CONCLUSIONS Hawaii seems to provide better cancer care than many other states, but patients in Toronto still enjoy a significant survival advantage. Although Hawaii's employer-mandated health insurance coverage seems an effective step toward providing equitable health care, even better care could be expected with a universally accessible, single-payer system.
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Affiliation(s)
- K M Gorey
- School of Social Work, University of Windsor, Ontario, Canada.
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Abstract
OBJECTIVES To explore how culture may play a part in breast cancer screening, early detection, and efforts to decrease breast mortality. DATA SOURCES Journal articles published in the past 20 years on cultural aspects of cancer prevention and control. CONCLUSIONS Research seems directed more at discovering cultural differences than at identifying similarities on how culture influences breast cancer screening and early detection. The influences of poverty and lack of educational opportunities account for much of what is termed cultural difference. IMPLICATIONS FOR NURSING PRACTICE Improving practice through an informed understanding of culture calls for considerable self-education and a fundamental refinement of care delivery.
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Affiliation(s)
- N C Facione
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco 94143-0610, USA
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Abstract
No upper age limit exists for Medicare benefits for mammography screening, but benefits for women older than age 75 remain unclear. From a clinical perspective, it would be useful to know if there is an upper age limit for women beyond which screening for breast cancer will not extend life. Using a decision-analysis model, the author examined the utility of screening using cohorts of women age 75 to 79, 80 to 84, and 85 and older, with and without cognitive impairment. The analysis evaluated different scenarios of the benefit of biennial screening versus no screening for women who had no prior screening and women who had participated in a regular screening program. Screening increased Quality Adjusted Life Years (QALYs) at all ages. Marginal savings in life expectancy adjusted for quality of life for women with no prior screening ranged from 43.5 days for healthy 75 to 79-year-old women to 25.9 days for women older than age 85. Among cognitively impaired women who were never screened, savings ranged from 20 to 5.5 days for the three age cohorts. Biennial screening among women who had been screened continuously resulted in substantially smaller life expectancy savings, from 3.3 days for healthy individuals age 75 to 79 to less than 1 day for women older than age 85. Cost effectiveness analysis indicated the reduction in costs associated with managing recurrent disease gained by early diagnosis with mammography was greatest among the population with no prior screening. Although the increase in QALYs was consistently lower for cognitively impaired women than for their healthy counterparts, the presence of cognitive impairment did not alter the finding that screening increased QALYs.
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Affiliation(s)
- D C Messecar
- Oregon Health Sciences University School of Nursing, SN-4N, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098, USA
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Abstract
OBJECTIVE Women's health centers have been increasing in number but remain relatively unstudied. We examined patient expectations and quality of care at a hospital-based women's health center compared with those at a general medicine clinic. DESIGN Cross-sectional survey. SETTING University hospital-affiliated women's health and general internal medicine clinics. PARTICIPANTS An age-stratified random sample of 2,000 women over 18 years of age with at least two visits to either clinic in the prior 24 months. We confined the analysis to 706 women respondents who identified themselves as primary care patients of either clinic. MEASUREMENTS AND MAIN RESULTS Personal characteristics, health care utilization, preferences and expectations for care, receipt of preventive services, and satisfaction with provider and clinic were assessed for all respondents. Patients obtaining care at the general internal medicine clinic were older and had more chronic diseases and functional limitations than patients receiving care at the women's health center. Women's health center users (n = 357) were more likely than general medicine clinic users ( n = 349) to prefer a female provider ( 57% vs 32%, p =.0001) and to have sought care at the clinic because of its focus on women's health (49% vs 17%, p =. 0001). After adjusting for age and self-assessed health status, women's health center users were significantly more likely to report having had mammography (odds ratio [OR] 4.0, 95% confidence interval [CI] 1.1, 15.2) and cholesterol screening (OR 1.6, 95% CI 1.0, 2.6) but significantly less likely to report having undergone flexible sigmoidoscopy (OR 0.5, 95% CI 0.3, 0.9). There were no significant differences between the clinics on receipt of counseling about hormone replacement therapy or receipt of Pap smear, or in satisfaction. CONCLUSIONS These results suggest that, at least in this setting, women's health centers provide care to younger women and those with fewer chronic medical conditions and may meet a market demand. While the quality of gender-specific preventive care may be modestly better in women's health centers, the quality of general preventive care may be better in general medical clinics.
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Affiliation(s)
- E A Phelan
- Department of Medicine, University of Washington, Seattle, USA.
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