A Randomized Controlled Trial of Animal-assisted Activities for Pediatric Oncology Patients: Psychosocial and Microbial Outcomes

INTRODUCTION

Evidence about the effectiveness and safety of dog visits in pediatric oncology is limited.

METHOD

We conducted a randomized controlled trial (n=26) of dog visits versus usual care among pediatric oncology inpatients. Psychological functioning and microbial load from hand wash samples were evaluated. Parental anxiety was a secondary outcome.

RESULTS

We did not observe a difference in the adjusted mean present functioning score (-3.0; 95% confidence interval [CI], -12.4 to 6.4). The difference in microbial load on intervention versus control hands was -0.04 (95% CI, -0.60 to 0.52) log10 CFU/mL, with an upper 95% CI limit below the prespecified noninferiority margin. Anxiety was lower in parents of intervention versus control patients.

DISCUSSION

We did not detect an effect of dog visits on functioning; however, our study was underpowered by low recruitment. Visits improved parental anxiety. With hand sanitization, visits did not increase hand microbial levels.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT03471221.

Validation of human immunodeficiency virus diagnosis codes among women enrollees of a U.S. health plan

BACKGROUND

Efficiently identifying patients with human immunodeficiency virus (HIV) using administrative health care data (e.g., claims) can facilitate research on their quality of care and health outcomes. No prior study has validated the use of only ICD-10-CM HIV diagnosis codes to identify patients with HIV.

METHODS

We validated HIV diagnosis codes among women enrolled in a large U.S. integrated health care system during 2010-2020. We examined HIV diagnosis code-based algorithms that varied by type, frequency, and timing of the codes in patients' claims data. We calculated the positive predictive values (PPVs) and 95% confidence intervals (CIs) of the algorithms using a medical record-confirmed diagnosis of HIV as the gold standard.

RESULTS

A total of 272 women with ≥ 1 HIV diagnosis code in the administrative claims data were identified and medical records were reviewed for all 272 women. The PPV of an algorithm classifying women as having HIV as of the first HIV diagnosis code during the observation period was 80.5% (95% CI: 75.4-84.8%), and it was 93.9% (95% CI: 90.0-96.3%) as of the second. Little additional increase in PPV was observed when a third code was required. The PPV of an algorithm based on ICD-10-CM-era codes was similar to one based on ICD-9-CM-era codes.

CONCLUSION

If the accuracy measure of greatest interest is PPV, our findings suggest that use of ≥ 2 HIV diagnosis codes to identify patients with HIV may perform well. However, health care coding practices may vary across settings, which may impact generalizability of our results.

Effects of the COVID-19 Pandemic on Animal-Assisted Activities in Pediatric Hospitals

INTRODUCTION

The goal of this study was to document current hospital-based animal-assisted activities (AAA) practices.

METHOD

We contacted 20 hospitals and asked about their AAA programs, including COVID-19 precautions.

RESULTS

Eighteen of 20 hospitals responded. Before 2020, all offered either in-person only (n = 17) or both in-person and virtual AAA visits (n = 1). In early 2022, 13 provided in-person visits; the five hospitals that had not resumed in-person visits planned to restart. Most hospitals stopped group visits. Most required that patients and handlers be free of COVID-19 symptoms and that handlers be vaccinated and wear masks and eye protection. Most did not require COVID-19 vaccination for patients. None required handlers to test negative for COVID-19.

DISCUSSION

The COVID-19 pandemic impacted hospital-based pediatric AAA. Future studies should assess the effectiveness of virtual AAA and of precautions to prevent COVID-19 transmission between patients and AAA volunteers.

Validation of International Classification of Diseases, Tenth Revision, Clinical Modification Diagnosis Codes for Heart Failure Subtypes

PURPOSE

To estimate the positive predictive value (PPV) of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for identifying HF subtypes.

METHODS

We validated ICD-10-CM HF diagnosis codes among Kaiser Permanente Washington enrollees who were ≥18 years of age and had an ICD-10-CM HF diagnosis code during 2017-2018 and a procedure code for an echocardiogram in the 12 months before through 6 months after the HF code. Left ventricular ejection fraction (LVEF) ascertained from medical chart review was used as the gold standard for classifying patients as having reduced ejection fraction (rEF), mid-range ejection fraction (mEF), or preserved ejection fraction (pEF).

RESULTS

Among 6,194 eligible patients, we randomly sampled 1,000 for medical chart review. A total of 974 patients had LVEF information in their chart. The ICD-10-CM HF code group with the highest PPV for rEF was I50.2x, "Systolic (congestive) heart failure", PPV=41.4% (95% CI, 34.5%-48.7%); and the highest PPV for mEF or rEF was also I50.2x, PPV=70.2% (95% CI, 63.1%-76.4%). The highest PPV for pEF was the I50.3x group, "Diastolic (congestive) heart failure", PPV=92.0% (95% CI, 88.1%-94.7%); and the highest PPV for mEF or pEF was also I50.3x, PPV=97.7% (95% CI, 95.1%-99.0%).

CONCLUSIONS

If the accuracy measure of greatest interest is PPV, our results suggest that ICD-10-CM HF codes alone may not be adequate for identifying patients with rEF but may be adequate for identifying patients with pEF. HF coding practices may vary across settings, which may impact generalizability of our findings.

Variation in the receipt of human papilloma virus co-testing for cervical screening: Individual, provider, facility and healthcare system characteristics

Since 2012, cervical cancer screening guidelines allow for choice of screening test for women age 30-65 years (i.e., Pap every 3 years or Pap with human papillomavirus co-testing every 5 years). Intended to give patients and providers options, this flexibility reflects a trend in the growing complexity of screening guidelines. Our objective was to characterize variation in cervical screening at the individual, provider, clinic/facility, and healthcare system levels. The analysis included 296,924 individuals receiving screening from 3626 providers at 136 clinics/facilities in three healthcare systems, 2010 to 2017. Main outcome was receipt of co-testing vs. Pap alone. Co-testing was more common in one healthcare system before the 2012 guidelines (adjusted odds ratio (AOR) of co-testing at the other systems relative to this system 0.00 and 0.50) but was increasingly implemented over time in a second with declining uptake in the third (2017: AORs shifted to 7.32 and 0.01). Despite system-level differences, there was greater heterogeneity in receipt of co-testing associated with providers than clinics/facilities. In the three healthcare systems, providers in the highest quartile of co-testing use had an 8.35, 8.81, and 25.05-times greater odds of providing a co-test to women with the same characteristics relative to the lowest quartile. Similarly, clinics/ facilities in the highest quartile of co-testing use had a 4.20, 3.14, and 6.56-times greater odds of providing a co-test relative to the lowest quartile. Variation in screening test use is associated with health system, provider, and clinic/facility levels even after accounting for patient characteristics.

De-implementation of cervical cancer screening before age 21

In 2012, United States consensus guidelines were modified to recommend that cervical cancer screening not begin before age 21 and, since 2014, the Health Effectiveness Data and Information Set (HEDIS), a health plan quality measurement too, has included a measure for non-recommended cervical cancer screening among females ages 16-20. Our goal was to describe prevalence over time of cervical cancer screening before age 21 following the 2012 guideline change, and provide information to help understand how rapidly new guidelines may be disseminated and implemented into clinical practice. We used longitudinal clinical and administrative data from three diverse healthcare systems in the Population-based Research to Optimize the Screening Process (PROSPR II) consortium to examine annual trends in screening before age 21. We identified 55,316 average-risk, screening-eligible females ages 18-20 between 2011 and 2017. For each calendar year, we estimated the proportion of females who received a Papanicolaou (Pap) test. We observed a steady decline in the proportion of females under age 21 who received a Pap test, from an average of 8.3% in 2011 to <1% in 2017 across the sites. The observed steady decline suggests growing adherence to the 2012 consensus guidelines. This trend was consistent across diverse geographic regions, healthcare systems, and patient populations, strengthening the generalizability of the results; however, since we only had 1-2 years of study data prior to the consensus guidelines, we cannot discern whether screening under age 21 was already in decline. Nonetheless, these results provide data to compare with other guideline changes to de-implement non-recommended screening practices.

Prevalence of prescription opioid use during pregnancy in eight US health plans during 2001-2014

PURPOSE

To estimate prevalence of prescription opioid use during pregnancy in eight US health plans during 2001-2014.

METHODS

We conducted a cohort study of singleton live birth deliveries. Maternal characteristics were ascertained from health plan and/or birth certificate data and opioids dispensed during pregnancy from health plan pharmacy records. Prevalence of prescription opioid use during pregnancy was calculated for any use, cumulative days of use, and number of dispensings.

RESULTS

We examined prevalence of prescription opioid use during pregnancy in each health plan. Tennessee Medicaid had appreciably greater prevalence of use compared to the seven other health plans. Thus, results for the two groups were reported separately. In the seven health plans (n = 587 093 deliveries), prevalence of use during pregnancy was relatively stable at 9%-11% throughout 2001-2014. In Tennessee Medicaid (n = 256 724 deliveries), prevalence increased from 29% in 2001 to a peak of 36%-37% in 2004-2010, and then declined to 28% in 2014. Use for ≥30 days during pregnancy was stable at 1% in the seven health plans and increased from 2% to 7% in Tennessee Medicaid during 2001-2014. Receipt of ≥5 opioid dispensings during pregnancy increased in the seven health plans (0.3%-0.6%) and Tennessee Medicaid (3%-5%) during 2001-2014.

CONCLUSION

During 2001-2014, prescription opioid use during pregnancy was more common in Tennessee Medicaid (peak prevalence in late 2000s) compared to the seven health plans (relatively stable prevalence). Although a small percentage of women had opioid use during pregnancy for ≥30 days or ≥ 5 dispensings, they represent thousands of women during 2001-2014.

Validity of ICD-10-CM diagnoses to identify hospitalizations for serious infections among patients treated with biologic therapies

PURPOSE

Identifying hospitalizations for serious infections among patients dispensed biologic therapies within healthcare databases is important for post-marketing surveillance of these drugs. We determined the positive predictive value (PPV) of an ICD-10-CM-based diagnostic coding algorithm to identify hospitalization for serious infection among patients dispensed biologic therapy within the FDA's Sentinel Distributed Database.

METHODS

We identified health plan members who met the following algorithm criteria: (1) hospital ICD-10-CM discharge diagnosis of serious infection between July 1, 2016 and August 31, 2018; (2) either outpatient/emergency department infection diagnosis or outpatient antimicrobial treatment within 7 days prior to hospitalization; (3) inflammatory bowel disease, psoriasis, or rheumatological diagnosis within 1 year prior to hospitalization, and (4) were dispensed outpatient biologic therapy within 90 days prior to admission. Medical records were reviewed by infectious disease clinicians to adjudicate hospitalizations for serious infection. The PPV (95% confidence interval [CI]) for confirmed events was determined after further weighting by the prevalence of the type of serious infection in the database.

RESULTS

Among 223 selected health plan members who met the algorithm, 209 (93.7% [95% CI, 90.1%-96.9%]) were confirmed to have a hospitalization for serious infection. After weighting by the prevalence of the type of serious infection, the PPV of the ICD-10-CM algorithm identifying a hospitalization for serious infection was 80.2% (95% CI, 75.3%-84.7%).

CONCLUSIONS

The ICD-10-CM-based algorithm for hospitalization for serious infection among patients dispensed biologic therapies within the Sentinel Distributed Database had 80% PPV for confirmed events and could be considered for use within pharmacoepidemiologic studies.

Validity of diagnosis and procedure codes for identifying neural tube defects in infants

PURPOSE

The use of validated criteria to identify birth defects in electronic healthcare databases can avoid the cost and time-intensive efforts required to conduct chart reviews to confirm outcomes. This study evaluated the validity of various case-finding methodologies to identify neural tube defects (NTDs) in infants using an electronic healthcare database.

METHODS

This analysis used data generated from a study whose primary aim was to evaluate the association between first-trimester maternal prescription opioid use and NTDs. The study was conducted within the Medication Exposure in Pregnancy Risk Evaluation Program. A broad approach was used to identify potential NTDs including diagnosis and procedure codes from inpatient and outpatient settings, death certificates and birth defect flags in birth certificates. Potential NTD cases were chart abstracted and confirmed by clinical experts. Positive predictive values (PPVs) and 95% confidence intervals (95% CI) are reported.

RESULTS

The cohort included 113 168 singleton live-born infants: 55 960 infants with opioid exposure in pregnancy and 57 208 infants unexposed in pregnancy. Seventy-three potential NTD cases were available for the validation analysis. The overall PPV was 41% using all diagnosis and procedure codes plus birth certificates. Restricting approaches to codes recorded in the infants' medical record or to birth certificate flags increased the PPVs (72% and 80%, respectively) but missed a substantial proportion of confirmed NTDs.

CONCLUSIONS

Codes in electronic healthcare data did not accurately identify confirmed NTDs. These results indicate that chart review with adjudication of outcomes is important when conducting observational studies of NTDs using electronic healthcare data.

Changes in use of opioid therapy after colon cancer diagnosis: a population-based study

PURPOSE

To describe patterns of opioid use in cancer survivors.

METHODS

In a cohort study of colon cancer patients diagnosed during 1995-2014 and enrolled at two Kaiser Permanente regions, we constructed quarterly measures of opioid use from 1 year before cancer diagnosis through 5 years after diagnosis to examine changes in use. Measures included any use, incident use, regular use (use ≥ 45 days in a 91-day quarter), and average daily dose (converted to morphine milligram equivalent, MME). We also assessed temporal trends of opioid use.

RESULTS

Of 2,039 colon cancer patients, 11-15% received opioids in the four pre-diagnosis quarters, 68% in the first quarter after diagnosis, and 15-17% in each subsequent 19 quarters. Regular opioid use increased from 3 to 5% pre-diagnosis to 5-7% post diagnosis. Average dose increased from 15 to 17 MME/day pre-diagnosis to 14-22 MME/day post diagnosis (excluding the quarter in which cancer was diagnosed). Among post-diagnosis opioid users, 73-95% were on a low dose (< 20 MME/day). Over years, regular use of opioids increased in survivorship with no change in dosage.

CONCLUSION

Opioid use slightly increased following a colon cancer diagnosis, but high-dose use was rare. Research is needed to differentiate under- versus over-treatment of cancer pain.

Factors associated with employment discontinuation among older and working age survivors of oropharyngeal cancer

BACKGROUND

Oropharyngeal cancer survivors experience difficulty returning to work after treatment. To better understand specific barriers to returning to work, we investigated factors associated with discontinuing employment among older and working-age survivors.

METHODS

The sample included 675 oropharyngeal cancer survivors (median: 6 years posttreatment) diagnosed from 2000 to 2013 and employed at diagnosis. Relative risk models were constructed to examine the independent associations of demographic and health factors, and symptom experiences per the MD Anderson Symptom Inventory - Head and Neck Module (MDASI-HN) with posttreatment employment, overall and by age (<60 years vs ≥60 years at survey).

RESULTS

Symptom interference was not statistically significantly associated with posttreatment employment status among respondents ≥60 years. Among working-age respondents <60 years, symptom interference was strongly associated with posttreatment employment.

CONCLUSIONS

Efforts to assess and lessen symptom burden in working-age survivors should be evaluated as approaches to support regaining core functions needed for continued employment.

Early Pregnancy Hemoglobin A1C and Pregnancy Outcomes: A Population-Based Study

OBJECTIVE

Women with prediabetes are identified from screening for overt diabetes in early pregnancy, but the clinical significance of prediabetes in pregnancy is unclear. We examined whether prediabetes in early pregnancy was associated with risks of adverse outcomes.

STUDY DESIGN

We conducted a retrospective cohort study of pregnant women enrolled in Kaiser Permanente Washington from 2011 to 2014. Early pregnancy hemoglobin A1C (A1C) values, covariates, and outcomes were ascertained from electronic medical records and state birth certificates. Women with prediabetes (A1C of 5.7-6.4%) were compared with those with normal A1C levels (<5.7%) for risk of gestational diabetes mellitus (GDM) and other outcomes including preeclampsia, primary cesarean delivery, induction of labor, large/small for gestational age, preterm birth, and macrosomia. We used modified Poisson's regression to calculate adjusted relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

Of 7,020 women, 239 (3.4%) had prediabetes. GDM developed in 48% of prediabetic women compared with 11% of women with normal A1C levels (adjusted RR: 2.8, 95% CI: 2.4-3.3). Prediabetes was not associated with all other adverse maternal and neonatal outcomes.

CONCLUSION

Prediabetes in early pregnancy is a risk factor for GDM. Future research is needed to elucidate whether early intervention may reduce this risk.

Use of antidepressants after colon cancer diagnosis and risk of recurrence

OBJECTIVE

Prior research examining the association between use of antidepressants after colon cancer diagnosis and risk of recurrence is scant. We evaluated this association among colon cancer patients diagnosed at two integrated health care delivery systems in the United States.

METHODS

We conducted a cohort study of stage I to IIIA colon cancer patients diagnosed at greater than or equal to 18 years of age at Kaiser Permanente Colorado and Kaiser Permanente Washington during 1995 to 2014. We used pharmacy records to identify dispensings for antidepressants and tumor registry records and patients' medical charts to identify cancer recurrences. Using Cox proportional hazards models, we estimated the adjusted hazard ratio (HR) of colon cancer recurrence comparing patients who used antidepressants after diagnosis to those who did not. We also evaluated the risk associated with use of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) separately.

RESULTS

Among the 1923 eligible colon cancer patients, 807 (42%) used an antidepressant after diagnosis and 139 had a colon cancer recurrence during an average 5.6 years of follow-up. Use of antidepressants after colon cancer diagnosis was not associated with risk of recurrence (HR: 1.14; 95% confidence interval [CI], 0.69-1.87). The HR for use of SSRIs was 1.22 (95% CI, 0.64-2.30), and for TCAs, it was 1.18 (95% CI, 0.68-2.07).

CONCLUSIONS

Our findings suggest that use of antidepressants after colon cancer diagnosis was common and not associated with risk of recurrence. Future larger studies with greater power to examine risk associated with individual antidepressants would be valuable additions to the evidence base.

Birth Weight and Birth Weight for Gestational Age in Relation to Risk of Hospitalization with Primary Hypertension in Children and Young Adults

Introduction Low birth weight has been associated with an increased risk of hypertension in children. Less clear is whether high birth weight is also associated with risk. We evaluated overall and age-specific risks of primary hypertension in children and young adults associated with birth weight and birth weight for gestational age. Methods We conducted a population-based case-control study using linked Washington State birth certificate and hospital discharge data from 1987 to 2003. Cases were persons hospitalized with primary hypertension at 8-24 years of age (n = 533). Controls were randomly selected among those born in the same years who were not hospitalized with hypertension (n = 25,966). Results Birth weight was not related to risk of primary hypertension overall, except for a suggestion of an increased risk associated with birth weight ≥4500 g relative to 3500-3999 g (odds ratio (OR) 1.55; 95 % confidence interval (CI) 0.96-2.49). Compared to children born appropriate weight for gestational age, those born small (SGA) (OR 1.32; 95 % CI 1.02-1.71) and large for gestational age (LGA) (OR 1.30; 95 % CI 1.00-1.71) had increased risks of primary hypertension. These overall associations were due to increased risks of hypertension at 15-24 years of age; no associations were observed with risk at 8-14 years of age. Discussion In this study, both SGA and LGA were associated with increased risks of primary hypertension. Our findings suggest a possible nonlinear (U-shaped) association between birth weight for gestational age and primary hypertension risk in children and young adults.

Symptom burden in long-term head and neck cancer survivors

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Background: The symptom burden faced by long-term head and neck cancer survivors could inform clinical decision making but it is not well understood. Methods: In 2016 we surveyed current enrollees of Group Health (an integrated health care delivery system in Washington State) who were aged ≥18 years when diagnosed with head and neck cancer in 2011 (n = 54). Symptoms experienced in the past 24 hours were assessed using the validated MD Anderson Symptom Inventory head and neck cancer module (MDASI-HN). Survivors were asked to report on a 10-point scale the severity of the problem at its worst (“not present” to “as bad as you can imagine”). Self-reported risk factor and demographic information were also collected. Results: Eighty percent of persons responded to the survey (n = 43) via web questionnaire (n = 12), mailed questionnaire (n = 26) or telephone interview (n = 5). One person who reported to have not been diagnosed with head and neck cancer was excluded, leaving 42 participants. Overall, 29% had no more than mild symptoms (all MDASI-HN symptoms rated <5 ), 43% had no more than moderate symptoms (all MDASI-HN symptoms rated <7 ), 57% had one or more symptoms rated as severe (at least one MDASI-HN symptom rated ≥7 ), and 45% had two or more symptoms rated as severe. The symptoms most commonly rated as severe were: dry mouth (38%), difficulty swallowing or chewing (17%), pain (17%), fatigue (17%), disturbed sleep (15%), feeling sad (15%), choking or coughing (15%), problems with tasting food (15%), problems with teeth or gums (15%), problems with mucus in the mouth or throat (12%), and feeling distressed (12%). Persons who rated one or more symptom as severe were more likely than those who did not to have had cancer recurrence (44% versus 6%), receipt of cancer treatment in the previous three years (36% versus 17%), age ≥65 years at diagnosis (63% versus 17%), non-white race (21% versus 6%), no more than high school education (33% versus 17%), current unemployment/disability/retirement (71% versus 44%), and annual household income <$100,000 (71% versus 56%). Conclusions: In the context of limited data on this topic, in this small study we found that it was not uncommon for five-year survivors of head and neck cancer to experience one or more symptoms which they rated as being a severe problem.

Screening for Skin Cancer in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Skin cancer, primarily melanoma, is a leading cause of morbidity and mortality in the United States.

OBJECTIVE

To provide an updated systematic review for the US Preventive Services Task Force regarding clinical skin cancer screening among adults.

DATA SOURCES

MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials were searched for relevant studies published from January 1, 1995, through June 1, 2015, with surveillance through February 16, 2016.

STUDY SELECTION

English-language studies conducted in asymptomatic populations 15 years and older at general risk for skin cancer.

DATA EXTRACTION AND SYNTHESIS

Relevant data were abstracted, and study quality was rated.

MAIN OUTCOMES AND MEASURES

Melanoma incidence and mortality, harms from cancer screening, diagnostic accuracy, and stage distribution.

RESULTS

No randomized clinical trials were identified. There was limited evidence on the association between skin cancer screening and mortality. A German ecologic study (n = 360,288) found a decrease of 0.8 per 100,000 melanoma deaths in a region with population-based skin cancer screening compared with no change or slight increases in comparison regions. The number of excisions needed to detect 1 skin cancer from clinical visual skin examinations varied by age and sex; for example, 22 for women 65 years or older compared with 41 for women aged 20 to 34 years. In 2 studies of performing visual skin examination, sensitivity to detect melanoma was 40.2% and specificity was 86.1% when conducted by primary care physicians (n = 16,383). Sensitivity was 49.0% and specificity was 97.6% when skin examinations were performed by dermatologists (n = 7436). In a case-control study of melanoma (n = 7586), cases diagnosed with thicker lesions (>0.75 mm) had an odds ratio of 0.86 (95% CI, 0.75-0.98) for receipt of a physician skin examination in the prior 3 years compared with controls. Eight cohort studies (n = 236,485) demonstrated a statistically significant relationship between the degree of disease involvement at diagnosis and melanoma mortality, regardless of the characterization of the stage or lesion thickness. Tumor thickness greater than 4.0 mm was associated with increased melanoma mortality compared with thinner lesions, and late stage at diagnosis was associated with increased all-cause mortality.

CONCLUSIONS AND RELEVANCE

Only limited evidence was identified for skin cancer screening, particularly regarding potential benefit of skin cancer screening on melanoma mortality. Future research on skin cancer screening should focus on evaluating the effectiveness of targeted screening in those considered to be at higher risk for skin cancer.

Prophylactic oophorectomy rates in relation to a guideline update on referral to genetic counseling

OBJECTIVE

We sought to determine whether prophylactic oophorectomy rates changed after the introduction of a 2007 health plan clinical guideline recommending systematic referral to a genetic counselor for women with a personal or family history suggestive of an inherited susceptibility to breast/ovarian cancer.

METHODS

We conducted a retrospective cohort study of female members of Group Health, an integrated delivery system in Washington State. Subjects were women aged ≥ 35 years during 2004-2009 who reported a personal or family history consistent with an inherited susceptibility to breast/ovarian cancer. Personal and family history information was collected on a questionnaire completed when the women had a mammogram. We ascertained oophorectomies from automated claims data and determined whether surgeries were prophylactic by medical chart review. Rates were age-adjusted and age-adjusted incidence rate ratios (IRR) and 95% confidence intervals (CI) were computed using Poisson regression.

RESULTS

Prophylactic oophorectomy rates were relatively unchanged after compared to before the guideline change, 1.0 versus 0.8/1000 person-years, (IRR=1.2; 95% CI: 0.7-2.0), whereas bilateral oophorectomy rates for other indications decreased. Genetic counseling receipt rates doubled after the guideline change (95% CI: 1.7-2.4) from 5.1 to 10.2/1000 person-years. During the study, bilateral oophorectomy rates were appreciably greater in women who saw a genetic counselor compared to those who did not regardless of whether they received genetic testing as part of their counseling.

CONCLUSION

A doubling in genetic counseling receipt rates lends support to the idea that the guideline issuance contributed to sustained rates of prophylactic oophorectomies in more recent years.

Administrative data algorithms to identify second breast cancer events following early-stage invasive breast cancer

BACKGROUND

Studies of breast cancer outcomes rely on the identification of second breast cancer events (recurrences and second breast primary tumors). Cancer registries often do not capture recurrences, and chart abstraction can be infeasible or expensive. An alternative is using administrative health-care data to identify second breast cancer events; however, these algorithms must be validated against a gold standard.

METHODS

We developed algorithms using data from 3152 women in an integrated health-care system who were diagnosed with stage I or II breast cancer in 1993-2006. Medical record review served as the gold standard for second breast cancer events. Administrative data used in algorithm development included procedures, diagnoses, prescription fills, and cancer registry records. We randomly divided the cohort into training and testing samples and used a classification and regression tree analysis to build algorithms for classifying women as having or not having a second breast cancer event. We created several algorithms for researchers to use based on the relative importance of sensitivity, specificity, and positive predictive value (PPV) in future studies.

RESULTS

The algorithm with high specificity and PPV had 89% sensitivity (95% confidence interval [CI] = 84% to 92%), 99% specificity (95% CI = 98% to 99%), and 90% PPV (95% CI = 86% to 94%); the high-sensitivity algorithm had 96% sensitivity (95% CI = 93% to 98%), 95% specificity (95% CI = 94% to 96%), and 74% PPV (95% CI = 68% to 78%).

CONCLUSIONS

Algorithms based on administrative data can identify second breast cancer events with high sensitivity, specificity, and PPV. The algorithms presented here promote efficient outcomes research, allowing researchers to prioritize sensitivity, specificity, or PPV in identifying second breast cancer events.

Tradeoffs between accuracy measures for electronic health care data algorithms

OBJECTIVE

We review the uses of electronic health care data algorithms, measures of their accuracy, and reasons for prioritizing one measure of accuracy over another.

STUDY DESIGN AND SETTING

We use real studies to illustrate the variety of uses of automated health care data in epidemiologic and health services research. Hypothetical examples show the impact of different types of misclassification when algorithms are used to ascertain exposure and outcome.

RESULTS

High algorithm sensitivity is important for reducing the costs and burdens associated with the use of a more accurate measurement tool, for enhancing study inclusiveness, and for ascertaining common exposures. High specificity is important for classifying outcomes. High positive predictive value is important for identifying a cohort of persons with a condition of interest but that need not be representative of or include everyone with that condition. Finally, a high negative predictive value is important for reducing the likelihood that study subjects have an exclusionary condition.

CONCLUSION

Epidemiologists must often prioritize one measure of accuracy over another when generating an algorithm for use in their study. We recommend researchers publish all tested algorithms-including those without acceptable accuracy levels-to help future studies refine and apply algorithms that are well suited to their objectives.

Pregnancy history and risk of endometrial cancer

BACKGROUND

Epidemiologic studies are consistent in finding that women who have had at least one birth are less likely to develop endometrial cancer. Less clear is whether timing of pregnancies during reproductive life influences risk, and the degree to which incomplete pregnancies are associated with a reduced risk.

METHODS

We evaluated pregnancy history in relation to endometrial cancer risk using data from a series of 4 population-based endometrial cancer case-control studies of women 45-74 years of age (1712 cases and 2134 controls) during 1985-2005 in western Washington State. Pregnancy history and information on other potential risk factors were collected by in-person interviews.

RESULTS

Older age at first birth was associated with a reduced risk of endometrial cancer after adjustment for number of births and age at last birth (test for trend P = 0.004). The odds ratio comparing women at least 35 years of age at their first birth with those younger than 20 years was 0.34 (95% confidence interval = 0.14-0.84). Age at last birth was not associated with risk after adjustment for number of births and age at first birth (test for trend P = 0.830). Overall, a history of incomplete pregnancies was not associated with endometrial cancer risk to any appreciable degree.

CONCLUSIONS

In this study, older age at first birth was more strongly associated with endometrial cancer risk than was older age at last birth. To date, there remains some uncertainty in the literature on this issue.

Long-term use of supplemental vitamins and minerals does not reduce the risk of urothelial cell carcinoma of the bladder in the VITamins And Lifestyle study

PURPOSE

Urothelial carcinoma has the highest lifetime treatment cost of any cancer, making it an ideal target for preventative therapies. Previous work has suggested that certain vitamin and mineral supplements may reduce the risk of urothelial carcinoma. We used the prospective VITamins And Lifestyle cohort to examine the association of all commonly taken vitamin and mineral supplements as well as 6 common anti-inflammatory supplements with incident urothelial carcinoma in a United States population.

MATERIALS AND METHODS

A total of 77,050 eligible VITAL participants completed a detailed questionnaire at baseline on supplement use and cancer risk factors. After 6 years of followup 330 incident urothelial carcinoma cases in the cohort were identified via linkage to the Seattle-Puget Sound SEER cancer registry. We analyzed use of supplemental vitamins (multivitamins, beta-carotene, retinol, folic acid, and vitamins B1, B3, B6, B12, C, D and E), minerals (calcium, iron, magnesium, zinc and selenium) and anti-inflammatory supplements (glucosamine, chondroitin, saw palmetto, ginkgo biloba, fish oil and garlic). For each supplement the hazard ratios (risk ratios) for urothelial carcinoma comparing each category of users to nonusers, and 95% CIs, were determined using Cox proportional hazards regression, adjusted for potential confounders.

RESULTS

None of the vitamin, mineral or anti-inflammatory supplements was significantly associated with urothelial carcinoma risk in age adjusted or multivariate models.

CONCLUSIONS

The results of this study do not support the use of commonly taken vitamin or mineral supplements or 6 common anti-inflammatory supplements for the chemoprevention of urothelial carcinoma.

Body-mass index and mortality among 1.46 million white adults

BACKGROUND

A high body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) is associated with increased mortality from cardiovascular disease and certain cancers, but the precise relationship between BMI and all-cause mortality remains uncertain.

METHODS

We used Cox regression to estimate hazard ratios and 95% confidence intervals for an association between BMI and all-cause mortality, adjusting for age, study, physical activity, alcohol consumption, education, and marital status in pooled data from 19 prospective studies encompassing 1.46 million white adults, 19 to 84 years of age (median, 58).

RESULTS

The median baseline BMI was 26.2. During a median follow-up period of 10 years (range, 5 to 28), 160,087 deaths were identified. Among healthy participants who never smoked, there was a J-shaped relationship between BMI and all-cause mortality. With a BMI of 22.5 to 24.9 as the reference category, hazard ratios among women were 1.47 (95 percent confidence interval [CI], 1.33 to 1.62) for a BMI of 15.0 to 18.4; 1.14 (95% CI, 1.07 to 1.22) for a BMI of 18.5 to 19.9; 1.00 (95% CI, 0.96 to 1.04) for a BMI of 20.0 to 22.4; 1.13 (95% CI, 1.09 to 1.17) for a BMI of 25.0 to 29.9; 1.44 (95% CI, 1.38 to 1.50) for a BMI of 30.0 to 34.9; 1.88 (95% CI, 1.77 to 2.00) for a BMI of 35.0 to 39.9; and 2.51 (95% CI, 2.30 to 2.73) for a BMI of 40.0 to 49.9. In general, the hazard ratios for the men were similar. Hazard ratios for a BMI below 20.0 were attenuated with longer-term follow-up.

CONCLUSIONS

In white adults, overweight and obesity (and possibly underweight) are associated with increased all-cause mortality. All-cause mortality is generally lowest with a BMI of 20.0 to 24.9.

Use of supplements of multivitamins, vitamin C, and vitamin E in relation to mortality

In this cohort study, the authors evaluated how supplemental use of multivitamins, vitamin C, and vitamin E over a 10-year period was related to 5-year total mortality, cancer mortality, and cardiovascular disease (CVD) mortality. Participants (n = 77,719) were Washington State residents aged 50-76 years who completed a mailed self-administered questionnaire in 2000-2002. Adjusted hazard ratios and 95% confidence intervals were computed using Cox regression. Multivitamin use was not related to total mortality. However, vitamin C and vitamin E use were associated with small decreases in risk. In cause-specific analyses, use of multivitamins and use of vitamin E were associated with decreased risks of CVD mortality. The hazard ratio comparing persons who had a 10-year average frequency of multivitamin use of 6-7 days per week with nonusers was 0.84 (95% confidence interval: 0.70, 0.99); and the hazard ratio comparing persons who had a 10-year average daily dose of vitamin E greater than 215 mg with nonusers was 0.72 (95% confidence interval: 0.59, 0.88). In contrast, vitamin C use was not associated with CVD mortality. Multivitamin and vitamin E use were not associated with cancer mortality. Some of the associations we observed were small and may have been due to unmeasured healthy behaviors that were more common in supplement users.

Hepatocellular carcinoma incidence trends in Canada: analysis by birth cohort and period of diagnosis

BACKGROUND AND AIMS

We examined birth cohort and calendar period trends in hepatocellular carcinoma (HCC) incidence in Canada (1976-2000). We also projected HCC incidence rates through 2015.

PATIENTS AND METHODS

Data were obtained from the Canadian Cancer Registry on all cases of HCC diagnosed among persons aged 20 years and older in Canada from 1976 to 2000 and was used to describe trends in HCC incidence rates.

RESULTS

We found that age-adjusted HCC incidence rates increased faster in males compared with females, 3.4% per year [95% confidence interval (CI): 3.0-3.8%] vs 2.2% per year (95% CI: 1.5-2.8%). An increasing birth cohort trend accelerated among males around the 1940 birth cohort and decelerated among females around the 1935 birth cohort. For calendar period trends, the increasing HCC risk was relatively constant over time among males whereas there was an acceleration in HCC risk around 1988 among females. Age-adjusted HCC incidence rates were projected to increase 73% in males and 28% in females from 1996 to 2015.

CONCLUSIONS

Our results suggest that HCC incidence rates will continue to increase in Canada during the next decade as persons born in more recent birth cohorts, who face a relatively greater risk for HCC, age.

Location of residence associated with the likelihood of patient visit to the preoperative assessment clinic

BACKGROUND

Outpatient preoperative assessment clinics were developed to provide an efficient assessment of surgical patients prior to surgery, and have demonstrated benefits to patients and the health care system. However, the centralization of preoperative assessment clinics may introduce geographical barriers to utilization that are dependent on where a patient lives with respect to the location of the preoperative assessment clinic.

METHODS

The association between geographical distance from a patient's place of residence to the preoperative assessment clinic, and the likelihood of a patient visit to the clinic prior to surgery, was assessed for all patients undergoing surgery at a tertiary health care centre in a major Canadian city. The odds of attending the preoperative clinic were adjusted for patient characteristics and clinical factors.

RESULTS

Patients were less likely to visit the preoperative assessment clinic prior to surgery as distance from the patient's place of residence to the clinic increased (adjusted OR = 0.52, 95% CI 0.44-0.63 for distances between 50-100 km, and OR = 0.26, 95% CI 0.21-0.31 for distances greater than 250 km). This 'distance decay' effect was remarkable for all surgical specialties.

CONCLUSION

The present study demonstrates that the likelihood of a patient visiting the preoperative assessment clinic appears to depend on the geographical location of patients' residences. Patients who live closest to the clinic tend to be seen more often than patients who live in rural and remote areas. This observation may have implications for achieving the goals of equitable access, and optimal patient care and resource utilization in a single universal insurer health care system.

Complementary and alternative medicine use by Canadian patients with inflammatory bowel disease: results from a national survey

OBJECTIVE

Previous studies of complementary and alternative medicine (CAM) use by patients with inflammatory bowel disease (IBD) have relied on samples from specialty clinics. The aim of this study was to determine the prevalence of use and perceived outcomes of CAM in a large, diverse IBD population.

METHODS

A postal survey of the members of the Crohn's and Colitis Foundation of Canada gathered data on demographic, disease, and conventional IBD treatment characteristics, and on the use and perceived effects of CAM. Respondents were characterized as not using CAM, as past or present users of CAM for their IBD, or as present users of CAM for other reasons. Comparisons between groups were made with the chi(2) test.

RESULTS

The final sample included 2847 IBD patients. Current or past use of CAM for IBD was reported by 1332 patients, of whom 666 continued their use of CAM. Use was lowest in the eastern provinces and highest in the west. Only 15% had used CAM before their IBD diagnosis. Herbal therapies were the most commonly used (41% of CAM users). Improvements in sense of well-being, IBD symptoms, and sense of control over the disease were the most commonly reported benefits. Only 16% of prior CAM users reported any adverse effect of CAM use. A complementary practitioner was consulted by 34%. During the previous year, 46% had spend more than $250 on CAM.

CONCLUSIONS

Use of CAM by IBD patients is very common. Most of these patients attribute significant benefits to their CAM use. Few report significant adverse events.

A national survey on the patterns of treatment of inflammatory bowel disease in Canada

BACKGROUND

There is a general lack of information on the care of inflammatory bowel disease (IBD) in a broad, geographically diverse, non-clinic population. The purposes of this study were (1) to compare a sample drawn from the membership of a national Crohn's and Colitis Foundation to published clinic-based and population-based IBD samples, (2) to describe current patterns of health care use, and (3) to determine if unexpected variations exist in how and by whom IBD is treated.

METHODS

Mailed survey of 4453 members of the Crohn's and Colitis Foundation of Canada. The questionnaire, in members stated language of preference, included items on demographic and disease characteristics, general health behaviors and current and past IBD treatment. Each member received an initial and one reminder mailing.

RESULTS

Questionnaires were returned by 1787, 913, and 128 people with Crohn's disease, ulcerative colitis and indeterminate colitis, respectively. At least one operation had been performed on 1159 Crohn's disease patients, with risk increasing with duration of disease. Regional variation in surgical rates in ulcerative colitis patients was identified. 6-mercaptopurine/azathioprine was used by 24% of patients with Crohn's disease and 12% of patients with ulcerative colitis (95% CI for the difference: 8.9%-15%). In patients with Crohn's disease, use was not associated with gender, income or region of residence but was associated with age and markers of disease activity. Infliximab was used by 112 respondents (4%), the majority of whom had Crohn's disease. Variations in infliximab use based on region of residence and income were not seen. Sixty-eight percent of respondents indicated that they depended most on a gastroenterologist for their IBD care. There was significant regional variation in this. However, satisfaction with primary physician did not depend on physician type (for example, gastroenterologist versus general practitioner).

CONCLUSION

This study achieved the goal of obtaining a large, geographically diverse sample that is more representative of the general IBD population than a clinic sample would have been. We could find no evidence of significant regional variation in medical treatments due to gender, region of residence or income level. Differences were noted between different age groups, which deserves further attention.