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Zhang Z, Ye S, Bernhardt SM, Nelson HD, Velie EM, Borges VF, Woodward ER, Evans DGR, Schedin PJ. Postpartum Breast Cancer and Survival in Women With Germline BRCA Pathogenic Variants. JAMA Netw Open 2024; 7:e247421. [PMID: 38639936 PMCID: PMC11031688 DOI: 10.1001/jamanetworkopen.2024.7421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/18/2024] [Indexed: 04/20/2024] Open
Abstract
Importance In young-onset breast cancer (YOBC), a diagnosis within 5 to 10 years of childbirth is associated with increased mortality. Women with germline BRCA1/2 pathogenic variants (PVs) are more likely to be diagnosed with BC at younger ages, but the impact of childbirth on mortality is unknown. Objective To determine whether time between most recent childbirth and BC diagnosis is associated with mortality among patients with YOBC and germline BRCA1/2 PVs. Design, Setting, and Participants This prospective cohort study included women with germline BRCA1/2 PVs diagnosed with stage I to III BC at age 45 years or younger between 1950 and 2021 in the United Kingdom, who were followed up until November 2021. Data were analyzed from December 3, 2021, to November 29, 2023. Exposure Time between most recent childbirth and subsequent BC diagnosis, with recent childbirth defined as 0 to less than 10 years, further delineated to 0 to less than 5 years and 5 to less than 10 years. Main Outcomes and Measures The primary outcome was all-cause mortality, censored at 20 years after YOBC diagnosis. Mortality of nulliparous women was compared with the recent post partum groups and the 10 or more years post partum group. Cox proportional hazards regression analyses were adjusted for age, tumor stage, and further stratified by tumor estrogen receptor (ER) and BRCA gene status. Results Among 903 women with BRCA PVs (mean [SD] age at diagnosis, 34.7 [6.1] years; mean [SD] follow-up, 10.8 [9.8] years), 419 received a BC diagnosis 0 to less than 10 years after childbirth, including 228 women diagnosed less than 5 years after childbirth and 191 women diagnosed 5 to less than 10 years after childbirth. Increased all-cause mortality was observed in women diagnosed within 5 to less than 10 years post partum (hazard ratio [HR], 1.56 [95% CI, 1.05-2.30]) compared with nulliparous women and women diagnosed 10 or more years after childbirth, suggesting a transient duration of postpartum risk. Risk of mortality was greater for women with ER-positive BC in the less than 5 years post partum group (HR, 2.35 [95% CI, 1.02-5.42]) and ER-negative BC in the 5 to less than 10 years post partum group (HR, 3.12 [95% CI, 1.22-7.97]) compared with the nulliparous group. Delineated by BRCA1 or BRCA2, mortality in the 5 to less than 10 years post partum group was significantly increased, but only for BRCA1 carriers (HR, 2.03 [95% CI, 1.15-3.58]). Conclusions and Relevance These findings suggest that YOBC with germline BRCA PVs was associated with increased risk for all-cause mortality if diagnosed within 10 years after last childbirth, with risk highest for ER-positive BC diagnosed less than 5 years post partum, and for ER-negative BC diagnosed 5 to less than 10 years post partum. BRCA1 carriers were at highest risk for poor prognosis when diagnosed at 5 to less than 10 years post partum. No such associations were observed for BRCA2 carriers. These results should inform genetic counseling, prevention, and treatment strategies for BRCA PV carriers.
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Affiliation(s)
- Zhenzhen Zhang
- Division of Oncological Sciences, Oregon Health & Science University, Portland
- Knight Cancer Institute, Oregon Health & Science University, Portland
| | - Shangyuan Ye
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland
| | - Sarah M. Bernhardt
- Department of Cell, Developmental & Cancer Biology, Oregon Health & Science University, Portland
| | - Heidi D. Nelson
- Kaiser Permanente Bernard D. Tyson School of Medicine, Pasadena, California
| | - Ellen M. Velie
- Zilber College of Public Health, University of Wisconsin-Milwaukee, Milwaukee
- Departments of Medicine and Pathology, Medical College of Wisconsin, Milwaukee
| | - Virginia F. Borges
- Young Women’s Breast Cancer Translational Program, Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Emma R. Woodward
- Manchester Centre for Genomic Medicine, Manchester Academic Health Sciences Centre, Division of Evolution Infection and Genomic Science, St Mary’s Hospital, University of Manchester, Manchester, United Kingdom
- Prevent Breast Cancer Centre, University Hospital of South Manchester NHS Trust, Wythenshawe, Manchester, United Kingdom
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- Manchester Breast Centre, University of Manchester, Manchester, United Kingdom
| | - D. Gareth R. Evans
- Manchester Centre for Genomic Medicine, Manchester Academic Health Sciences Centre, Division of Evolution Infection and Genomic Science, St Mary’s Hospital, University of Manchester, Manchester, United Kingdom
- Prevent Breast Cancer Centre, University Hospital of South Manchester NHS Trust, Wythenshawe, Manchester, United Kingdom
- Manchester Centre for Genomic Medicine, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- Manchester Breast Centre, University of Manchester, Manchester, United Kingdom
| | - Pepper J. Schedin
- Knight Cancer Institute, Oregon Health & Science University, Portland
- Department of Cell, Developmental & Cancer Biology, Oregon Health & Science University, Portland
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Nelson HD, Ahrens K, Fu R. Unintended Pregnancy and Maternal and Infant Health Outcomes-Reply. JAMA 2023; 329:765-766. [PMID: 36881036 DOI: 10.1001/jama.2022.24657] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Affiliation(s)
- Heidi D Nelson
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Katherine Ahrens
- Public Health Program of the Muskie School of Public Service, University of Southern Maine, Portland
| | - Rongwei Fu
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
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Cantor AG, Nelson HD, Pappas M, Atchison C, Hatch B, Huguet N, Flynn B, McDonagh M. Telehealth for Women's Preventive Services for Reproductive Health and Intimate Partner Violence: a Comparative Effectiveness Review. J Gen Intern Med 2023; 38:1735-1743. [PMID: 36650334 PMCID: PMC9845023 DOI: 10.1007/s11606-023-08033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Telehealth delivery of preventive health services may improve access to care; however, its effectiveness and adverse effects are unknown. We conducted a comparative effectiveness review on the effectiveness and harms of telehealth interventions for women's reproductive health and intimate partner violence (IPV) services. METHODS We searched MEDLINE, Cochrane Library, CINAHL, and Scopus for English-language studies (July 2016 to May 2022) for randomized controlled trials (RCTs) and observational studies of telehealth strategies for women's reproductive health and IPV versus usual care. Two investigators identified studies and abstracted data using a predefined protocol. Study quality was assessed using study design-specific standardized methods; disagreements were resolved through consensus. RESULTS Eight RCTs, 1 nonrandomized trial, and 7 observational studies (n=10 731) were included (7 studies of contraceptive care and 9 of IPV services). Telehealth interventions to supplement contraceptive care demonstrated similar rates as usual care for contraceptive use, sexually transmitted infections, and pregnancy (low strength of evidence [SOE]); evidence on abortion was insufficient. Outcomes were also similar between telehealth interventions to replace or supplement IPV services and comparators for repeat IPV, depression, posttraumatic stress disorder, fear of partner, coercive control, self-efficacy, and safety behaviors (low SOE). In these studies, telehealth barriers included limited internet access, digital literacy, technical challenges, and confidentiality concerns. Strategies to ensure safety increased telehealth use for IPV services. Evidence on access, health equity, or harms was lacking. DISCUSSION Telehealth interventions for contraceptive care and IPV services demonstrate equivalent clinical and patient-reported outcomes versus in-person care, although few studies are available. Effective approaches for delivering these services and how to best mobilize telehealth, particularly for women facing barriers to care remain uncertain. TRIAL REGISTRATION PROSPERO CRD42021282298.
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Affiliation(s)
- Amy G Cantor
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC; 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA. .,Department of Family Medicine, School of Medicine, Oregon Health & Science University, BICC; 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA. .,Department of Obstetrics and Gynecology, School of Medicine, Oregon Health & Science University, BICC; 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Heidi D Nelson
- Kaiser Permanente Bernard D. Tyson School of Medicine, Pasadena, CA, USA
| | - Miranda Pappas
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC; 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Chandler Atchison
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC; 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Brigit Hatch
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, BICC; 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Nathalie Huguet
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, BICC; 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Brittny Flynn
- Oregon Health & Science University, School of Medicine, BICC; 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Marian McDonagh
- Pacific Northwest Evidence-Based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, BICC; 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
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Nelson HD, Darney BG, Ahrens K, Burgess A, Jungbauer RM, Cantor A, Atchison C, Eden KB, Goueth R, Fu R. Associations of Unintended Pregnancy With Maternal and Infant Health Outcomes: A Systematic Review and Meta-analysis. JAMA 2022; 328:1714-1729. [PMID: 36318133 PMCID: PMC9627416 DOI: 10.1001/jama.2022.19097] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
IMPORTANCE Unintended pregnancy is common in the US and is associated with adverse maternal and infant health outcomes; however, estimates of these associations specific to current US populations are lacking. OBJECTIVE To evaluate associations of unintended pregnancy with maternal and infant health outcomes during pregnancy and post partum with studies relevant to current clinical practice and public health in the US. DATA SOURCES Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE databases (January 1, 2000, to June 15, 2022) and manual review of reference lists. STUDY SELECTION Epidemiologic studies relevant to US populations that compared key maternal and infant health outcomes for unintended vs intended pregnancies and met prespecified eligibility criteria were included after investigators' independent dual review of abstracts and full-text articles. DATA EXTRACTION AND SYNTHESIS Investigators abstracted data from publications on study methods, participant characteristics, settings, pregnancy intention, comparators, confounders, and outcomes; data were validated by a second investigator. Risk of bias was independently dual rated by investigators using criteria developed by the US Preventive Services Task Force. Results of studies controlling for confounders were combined by using a profile likelihood random-effects model. MAIN OUTCOMES AND MEASURES Prenatal depression, postpartum depression, maternal experience of interpersonal violence, preterm birth, and infant low birth weight. RESULTS Thirty-six studies (N = 524 522 participants) were included (14 cohort studies rated good or fair quality; 22 cross-sectional studies); 12 studies used large population-based data sources. Compared with intended pregnancy, unintended pregnancy was significantly associated with higher odds of depression during pregnancy (23.3% vs 13.9%; adjusted odds ratio [aOR], 1.59 [95% CI, 1.35-1.92]; I2 = 85.0%; 15 studies [n = 41 054]) and post partum (15.7% vs 9.6%; aOR, 1.51 [95% CI, 1.40-1.70]; I2 = 7.1%; 10 studies [n = 82 673]), interpersonal violence (14.6% vs 5.5%; aOR, 2.22 [95% CI, 1.41-2.91]; I2 = 64.1%; 5 studies [n = 42 306]), preterm birth (9.4% vs 7.7%; aOR, 1.21 [95% CI, 1.12-1.31]; I2 = 1.7%; 10 studies [n = 94 351]), and infant low birth weight (7.3% vs 5.2%; aOR, 1.09 [95% CI, 1.02-1.21]; I2 = 0.0%; 8 studies [n = 87 547]). Results were similar in sensitivity analyses based on controlling for history of depression for prenatal and postpartum depression and on study design and definition of unintended pregnancy for relevant outcomes. Studies provided limited sociodemographic data and measurement of confounders and outcomes varied. CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis of epidemiologic observational studies relevant to US populations, unintended pregnancy, compared with intended pregnancy, was significantly associated with adverse maternal and infant outcomes. TRIAL REGISTRATION PROSPERO Identifier: CRD42020192981.
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Affiliation(s)
- Heidi D. Nelson
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Blair G. Darney
- Oregon Health & Science University, Portland
- Oregon Health & Science University/Portland State University School of Public Health, Portland
- Instituto Nacional de Salud Pública, Centro de Investigación en Salud Poblacional, Cuernavaca, México
| | - Katherine Ahrens
- Public Health Program of the Muskie School of Public Service, University of Southern Maine, Portland
| | - Amanda Burgess
- Public Health Program of the Muskie School of Public Service, University of Southern Maine, Portland
| | - Rebecca M. Jungbauer
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Amy Cantor
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Chandler Atchison
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Karen B. Eden
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Rose Goueth
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Rongwei Fu
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
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Cantor AG, Nelson HD, Pappas M, Atchison C. Preventing Obesity in Midlife Women: A Systematic Review for the Women's Preventive Services Initiative. Ann Intern Med 2022; 175:1275-1284. [PMID: 35914258 DOI: 10.7326/m22-0160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Despite high prevalence rates of obesity in the United States, no clinical guidelines exist for obesity prevention in midlife women who commonly experience weight gain. PURPOSE To evaluate evidence on the effectiveness and harms of behavioral interventions to reduce weight gain and improve health outcomes for women aged 40 to 60 years without obesity. DATA SOURCES English-language searches of Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (inception to 26 October 2021); ClinicalTrials.gov (October 2021); and reference lists of studies and reviews. STUDY SELECTION Randomized controlled trials (RCTs) enrolling predominantly midlife women comparing behavioral interventions to prevent weight gain with control groups and reporting health outcomes and potential harms. DATA EXTRACTION Dual extraction and quality assessment of individual studies. DATA SYNTHESIS Seven RCTs in 12 publications (n = 51 638) were included. Four RCTs showed statistically significant favorable differences in weight change for counseling interventions versus control groups (mean difference of weight change, -0.87 to -2.5 kg), whereas 1 trial of counseling and 2 trials of exercise showed no differences; 1 of 2 RCTs reported improved quality-of-life measures. Interventions did not increase measures of depression or stress in 1 trial; self-reported falls (37% vs. 29%; P < 0.001) and injuries (19% vs. 14%; P = 0.03) were higher with exercise counseling in 1 trial. LIMITATION Trials were generally small, heterogeneous, and lacked data on harms, long-term health outcomes, and specific patient populations. CONCLUSION Counseling interventions to prevent weight gain in women during midlife may result in modest differences in weight change without causing important harms. More research is needed to determine optimal content, frequency, length, and number of sessions required and should include additional patient populations. PRIMARY FUNDING SOURCE Health Resources and Services Administration.
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Affiliation(s)
- Amy G Cantor
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, and Departments of Family Medicine and Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon (A.G.C.)
| | - Heidi D Nelson
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California (H.D.N.)
| | - Miranda Pappas
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon (M.P., C.A.)
| | - Chandler Atchison
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon (M.P., C.A.)
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Chelmow D, Gregory KD, Witkop C, Hoffstetter S, Humphrey L, Picardo C, Stevermer JJ, Cantor AG, Nelson HD, Son S, Conry JA, Garcia F, Kendig SM, O'Reilly N, Qaseem A, Ramos D, Salganicoff A, Wood JK, Zahn C. Preventing Obesity in Midlife Women: A Recommendation From the Women's Preventive Services Initiative. Ann Intern Med 2022; 175:1305-1309. [PMID: 35914264 DOI: 10.7326/m22-0252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient advocacy representatives, developed a recommendation for counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI; 18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity with the long-term goals of optimizing health, function, and well-being. This recommendation is intended to guide clinical practice and coverage of clinical preventive health services for the Health Resources and Services Administration and other stakeholders. Clinicians providing preventive health care to women in primary care settings are the target audience for this recommendation. METHODS The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness and harms of interventions to prevent weight gain and obesity in women aged 40 to 60 years without obesity. Seven randomized clinical trials including 51 638 participants and using various counseling and behavioral interventions were included. Trials indicated favorable weight changes with interventions that were statistically significantly different from control groups in 4 of 5 trials of counseling, but not in 2 trials of exercise. Few harms were reported. RECOMMENDATION The WPSI recommends counseling midlife women aged 40 to 60 years with normal or overweight BMI (18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity.
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Affiliation(s)
- David Chelmow
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, Virginia (D.C.)
| | - Kimberly D Gregory
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California (K.D.G.)
| | - Catherine Witkop
- Departments of Preventive Medicine and Gynecologic Surgery & Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland (C.W.)
| | - Susan Hoffstetter
- Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, St. Louis, Missouri (S.H.)
| | | | - Carla Picardo
- Women's Wellness & Gynecology, Erie, and Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (C.P.)
| | - James J Stevermer
- Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia, Missouri (J.J.S.)
| | - Amy G Cantor
- Departments of Medical Informatics and Clinical Epidemiology, Family Medicine, and Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon (A.G.C.)
| | - Heidi D Nelson
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California (H.D.N.)
| | - Sarah Son
- American College of Obstetricians and Gynecologists, Washington, DC (S.S., N.O., C.Z.)
| | - Jeanne A Conry
- American College of Obstetricians and Gynecologists, Granite Bay, California (J.A.C.)
| | | | - Susan M Kendig
- Nurse Practitioners in Women's Health, Washington, DC (S.M.K.)
| | - Nancy O'Reilly
- American College of Obstetricians and Gynecologists, Washington, DC (S.S., N.O., C.Z.)
| | - Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q.)
| | - Diana Ramos
- University of Southern California Keck School of Medicine, Los Angeles, California (D.R.)
| | | | - Julie K Wood
- American Academy of Family Physicians, Leawood, Kansas (J.K.W.)
| | - Christopher Zahn
- American College of Obstetricians and Gynecologists, Washington, DC (S.S., N.O., C.Z.)
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Nelson HD, Cantor A, Jungbauer RM, Eden KB, Darney B, Ahrens K, Burgess A, Atchison C, Goueth R, Fu R. Effectiveness and Harms of Contraceptive Counseling and Provision Interventions for Women : A Systematic Review and Meta-analysis. Ann Intern Med 2022; 175:980-993. [PMID: 35605239 PMCID: PMC10185303 DOI: 10.7326/m21-4380] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The effectiveness and harms of contraceptive counseling and provision interventions are unclear. PURPOSE To evaluate evidence of the effectiveness of contraceptive counseling and provision interventions for women to increase use of contraceptives and reduce unintended pregnancy, as well as evidence of their potential harms. DATA SOURCES English-language searches of Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE (1 January 2000 to 3 February 2022) and reference lists of key studies and systematic reviews. STUDY SELECTION Randomized controlled trials of interventions providing enhanced contraceptive counseling, contraceptives, or both versus usual care or an active control. DATA EXTRACTION Dual extraction and quality assessment of studies; results combined using a profile likelihood random-effects model. DATA SYNTHESIS A total of 38 trials (43 articles [25 472 participants]) met inclusion criteria. Contraceptive use was higher with various counseling interventions (risk ratio [RR], 1.39 [95% CI, 1.16 to 1.72]; I 2 = 85.3%; 10 trials), provision of emergency contraception in advance of use (RR, 2.12 [CI, 1.79 to 2.36]; I 2 = 0.0%; 8 trials), and counseling or provision postpartum (RR, 1.15 [CI, 1.01 to 1.52]; I 2 = 6.6%; 5 trials) or at the time of abortion (RR, 1.19 [CI, 1.09 to 1.32]; I 2 = 0.0%; 5 trials) than with usual care or active controls in multiple clinical settings. Pregnancy rates were generally lower with interventions, although most trials were underpowered and did not distinguish pregnancy intention. Interventions did not increase risk for sexually transmitted infections (STIs) (RR, 1.05 [CI, 0.87 to 1.25]; I 2 = 0.0%; 5 trials) or reduce condom use (RR, 1.03 [CI, 0.94 to 1.13]; I 2 = 0.0%; 6 trials). LIMITATION Interventions varied; few trials were adequately designed to determine unintended pregnancy outcomes. CONCLUSION Contraceptive counseling and provision interventions that provide services beyond usual care increase contraceptive use without increasing STIs or reducing condom use. Contraceptive care in clinical practice could be improved by implementing enhanced contraceptive counseling, provision, and follow-up; providing emergency contraception in advance; and delivering contraceptive services immediately postpartum or at the time of abortion. PRIMARY FUNDING SOURCE Resources Legacy Fund. (PROSPERO: CRD42020192981).
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Affiliation(s)
- Heidi D Nelson
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California (H.D.N.)
| | - Amy Cantor
- Oregon Health & Science University, Portland, Oregon (A.C., R.M.J., K.B.E., C.A., R.G., R.F.)
| | - Rebecca M Jungbauer
- Oregon Health & Science University, Portland, Oregon (A.C., R.M.J., K.B.E., C.A., R.G., R.F.)
| | - Karen B Eden
- Oregon Health & Science University, Portland, Oregon (A.C., R.M.J., K.B.E., C.A., R.G., R.F.)
| | - Blair Darney
- Oregon Health & Science University and Portland State University School of Public Health, Portland, Oregon, and Instituto Nacional de Salud Pública, Centro de Investigación en Salud Poblacional, Cuernavaca, México (B.D.)
| | - Katherine Ahrens
- University of Southern Maine Muskie School of Public Service, Portland, Maine (K.A., A.B.)
| | - Amanda Burgess
- University of Southern Maine Muskie School of Public Service, Portland, Maine (K.A., A.B.)
| | - Chandler Atchison
- Oregon Health & Science University, Portland, Oregon (A.C., R.M.J., K.B.E., C.A., R.G., R.F.)
| | - Rose Goueth
- Oregon Health & Science University, Portland, Oregon (A.C., R.M.J., K.B.E., C.A., R.G., R.F.)
| | - Rongwei Fu
- Oregon Health & Science University, Portland, Oregon (A.C., R.M.J., K.B.E., C.A., R.G., R.F.)
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Cantor A, Dana T, Griffin JC, Nelson HD, Weeks C, Winthrop KL, Chou R. Screening for Chlamydial and Gonococcal Infections: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 326:957-966. [PMID: 34519797 DOI: 10.1001/jama.2021.10577] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE The 2014 US Preventive Services Task Force (USPSTF) recommendation statement supported the effectiveness of screening for chlamydia and gonorrhea in asymptomatic, sexually active women 24 years or younger and in older women at increased risk for infection, although evidence for screening in men was insufficient. OBJECTIVE To update the 2014 USPSTF review on screening for chlamydial and gonococcal infection in adults and adolescents, including those who are pregnant. DATA SOURCES Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Ovid MEDLINE (January 1, 2014, through May 28, 2020) with surveillance through May 21, 2021. STUDY SELECTION Randomized clinical trials and observational studies of screening effectiveness, accuracy of risk stratification and alternative screening methods, accuracy of tests, and screening harms. DATA EXTRACTION AND SYNTHESIS One investigator abstracted data; a second checked accuracy. Two investigators independently assessed study quality. MAIN OUTCOMES AND MEASURES Complications of infection; infection transmission or acquisition; diagnostic accuracy of anatomical site-specific testing and collection methods; screening harms. RESULTS Twenty-seven studies were included (N = 179 515). Chlamydia screening compared with no screening was significantly associated with reduced risk of pelvic inflammatory disease (PID) in 2 of 4 trials and with reduced hospital-diagnosed PID (0.24% vs 0.38%); relative risk, 0.6 [95% CI, 0.4-1.0]), but not clinic-diagnosed PID or epididymitis, in the largest trial. In studies of risk prediction instruments in asymptomatic women, age younger than 22 years demonstrated comparable accuracy to extensive criteria. Sensitivity of chlamydial testing was similar at endocervical (89%-100%) and self- and clinician-collected vaginal (90%-100%) sites for women and at meatal (100%), urethral (99%), and rectal (92%) sites for men but lower at pharyngeal sites (69.2%) for men who have sex with men. Sensitivity of gonococcal testing was 89% or greater for all anatomical samples. False-positive and false-negative testing rates were low across anatomical sites and collection methods. CONCLUSIONS AND RELEVANCE Screening for chlamydial infection was significantly associated with a lower risk of PID in young women. Risk prediction criteria demonstrated limited accuracy beyond age. Testing for asymptomatic chlamydial and gonococcal infections was highly accurate at most anatomical sites, including urine and self-collected specimens. Effectiveness of screening in men and during pregnancy, optimal screening intervals, and adverse effects of screening require further evaluation.
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Affiliation(s)
- Amy Cantor
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Department of Family Medicine, Oregon Health & Science University, Portland
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Tracy Dana
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Jessica C Griffin
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Heidi D Nelson
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Chandler Weeks
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Kevin L Winthrop
- Department of Medicine, Division of Infectious Diseases, Oregon Health & Science University, Portland
| | - Roger Chou
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
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Tosteson ANA, Tapp S, Titus LJ, Nelson HD, Longton GM, Bronson M, Pepe M, Carney PA, Onega T, Piepkorn MW, Knezevich SR, Barnhill R, Weinstock MA, Elder DE, Elmore JG. Association of Second-Opinion Strategies in the Histopathologic Diagnosis of Cutaneous Melanocytic Lesions With Diagnostic Accuracy and Population-Level Costs. JAMA Dermatol 2021; 157:1102-1106. [PMID: 34076664 PMCID: PMC8173465 DOI: 10.1001/jamadermatol.2021.1779] [Citation(s) in RCA: 2] [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] [Received: 12/09/2020] [Accepted: 04/14/2021] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Diagnostic variation among pathologists interpreting cutaneous melanocytic lesions could lead to suboptimal care. OBJECTIVE To estimate the potential association of second-opinion strategies in the histopathologic diagnosis of cutaneous melanocytic lesions with diagnostic accuracy and 1-year population-level costs in the US. DESIGN, SETTING, AND PARTICIPANTS Decision analysis with 1-year time horizon including melanocytic lesion diagnoses available from US pathologists participating in the Melanoma Pathology Study (M-Path) and from the study panel of reference pathologists who classified cases using the MPATH-Dx classification tool. M-Path data collection occurred from July 2013 through March 2015; analyses for the present study were performed between April 2015 and January 2021. EXPOSURES Various second-opinion strategies for interpretation of melanocytic cutaneous lesions. MAIN OUTCOMES AND MEASURES Estimated accuracy of pathologists' diagnoses, defined as concordance with the reference panel diagnoses, and 1-year postbiopsy medical costs under various second-opinion strategies. Expected percentage of concordant diagnoses, including percentages of overinterpretation and underinterpretation, and 1-year costs of medical care per 100 000 in the US population. RESULTS Decision-analytic model parameters were based on diagnostic interpretations for 240 cases by 187 pathologists compared with reference panel diagnoses. Without second opinions, 83.2% of diagnoses in the US were estimated to be accurate-ie, concordant with the reference diagnosis; with overinterpretation (8.0%) or underinterpretation (8.8%), and 16 850 misclassified diagnoses per 100 000 biopsies. Accuracy increased under all second-opinion strategies. Accuracy (87.4% concordance with 3.6% overinterpretation and 9.1% underinterpretation) and cost (an increase of more than $10 million per 100 000 biopsies per year) were highest when second opinions were universal (eg, performed on all biopsies), relative to no second opinions. A selective second-opinion strategy based on pathologists' desire or institutional requirements for a second opinion was most accurate (86.5% concordance; 4.4% overinterpretation; 9.1% underinterpretation) and would reduce costs by more than $1.9 million per 100 000 skin biopsies relative to no second opinions. Improvements in diagnostic accuracy with all second-opinion strategies were associated with reductions in overinterpretation but not underinterpretation. CONCLUSIONS AND RELEVANCE In this decision-analytic model, selective second-opinion strategies for interpretation of melanocytic skin lesions showed the potential to improve diagnostic accuracy and decrease costs relative to no second opinions or universal second opinions.
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Affiliation(s)
- Anna N. A. Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Stephanie Tapp
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Linda J. Titus
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | | | - Gary M. Longton
- Program in Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mackenzie Bronson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Margaret Pepe
- Program in Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Tracy Onega
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Michael W. Piepkorn
- Division of Dermatology, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | | | - Raymond Barnhill
- Departments of Pathology and Translational Research, Institut Curie, Paris, France
- Paris Sciences and Letters Research University, Paris, France
| | | | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Joann G. Elmore
- David Geffen School of Medicine, Department of Medicine, University of California, Los Angeles
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10
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Cantor AG, Nelson HD. Well-Woman Chart Is Useful in Guiding Preventive Care. Am Fam Physician 2021; 104:9-10. [PMID: 34264622] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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11
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Nelson HD, Cantor A, Wagner J, Jungbauer R, Fu R, Kondo K, Stillman L, Quiñones A. Effectiveness of Patient Navigation to Increase Cancer Screening in Populations Adversely Affected by Health Disparities: a Meta-analysis. J Gen Intern Med 2020; 35:3026-3035. [PMID: 32700218 PMCID: PMC7573022 DOI: 10.1007/s11606-020-06020-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [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] [Received: 05/30/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study evaluates the effectiveness of patient navigation to increase screening for colorectal, breast, and cervical cancer in populations adversely affected by health care disparities. METHODS Eligible studies were identified through English-language searches of Ovid® MEDLINE®, PsycINFO®, SocINDEX, and Veterans Affairs Health Services database (January 1, 1996, to July 5, 2019) and manual review of reference lists. Randomized trials and observational studies of relevant populations that evaluated the effectiveness of patient navigation on screening rates for colorectal, breast, or cervical cancer compared with usual or alternative care comparison groups were included. Two investigators independently abstracted study data and assessed study quality and applicability using criteria adapted from the U.S. Preventive Services Task Force. Discrepancies were resolved by consensus with a third reviewer. Results were combined using profile likelihood random effects models. RESULTS Thirty-seven studies met inclusion criteria (28 colorectal, 11 breast, 4 cervical cancers including 3 trials with multiple cancer types). Screening rates were higher with patient navigation for colorectal cancer overall (risk ratio [RR] 1.64; 95% confidence interval [CI] 1.42 to 1.92; I2 = 93.7%; 22 trials) and by type of test (fecal occult blood or immunohistochemistry testing [RR 1.69; 95% CI 1.33 to 2.15; I2 = 80.5%; 6 trials]; colonoscopy/endoscopy [RR 2.08; 95% CI 1.08 to 4.56; I2 = 94.6%; 6 trials]). Screening was also higher with navigation for breast cancer (RR 1.50; 95% CI 1.22 to 1.91; I2 = 98.6%; 10 trials) and cervical cancer (RR 1.11; 95% CI 1.05 to 1.19; based on the largest trial). The high heterogeneity of cervical cancer studies prohibited meta-analysis. Results were similar for colorectal and breast cancer regardless of prior adherence to screening guidelines, follow-up time, and study quality. CONCLUSIONS In populations adversely affected by disparities, colorectal, breast, and cervical cancer screening rates were higher in patients provided navigation services. Registration: PROSPERO: CRD42018109263.
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA. .,Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Amy Cantor
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.,Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jesse Wagner
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Rebecca Jungbauer
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Karli Kondo
- Evidence-based Synthesis Program, Portland VA Health Care System, Portland, OR, USA.,Office of Research Integrity, Oregon Health & Science University, Portland, OR, USA
| | - Lucy Stillman
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Ana Quiñones
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
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12
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Nelson HD, Cantor A, Pappas M, Weeks C. Screening for Anxiety in Adolescent and Adult Women: A Systematic Review for the Women's Preventive Services Initiative. Ann Intern Med 2020; 173:29-41. [PMID: 32510989 DOI: 10.7326/m20-0579] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Anxiety disorders are infrequently recognized during routine health care even though they are common in adolescent girls and adult women. PURPOSE To evaluate evidence on the effectiveness of screening for anxiety disorders in primary care in improving symptoms, function, and quality of life; harms of screening; accuracy of screening instruments; and effectiveness and harms of treatments. DATA SOURCES English-language searches of Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Health and Psychosocial Instruments (1 January 1996 to 4 November 2019); ClinicalTrials.gov (November 2019); and reference lists of studies and reviews. STUDY SELECTION Studies that enrolled adolescent girls and adult women not currently diagnosed with anxiety disorders, including pregnant or postpartum women, and compared clinical outcomes and harms between women who were and were not screened; diagnostic accuracy studies of screening instruments; and systematic reviews of randomized trials of behavioral and pharmacologic treatments. DATA EXTRACTION Dual extraction and quality assessment of individual studies. DATA SYNTHESIS No studies evaluated the overall effectiveness or harms of screening. Thirty-three studies and 2 systematic reviews (171 studies; 112 574 participants) evaluated the diagnostic accuracy of 27 screening instruments and their variations against a clinical diagnosis or other instruments. Most demonstrated moderate to high accuracy for adults (Generalized Anxiety Disorder scale: sensitivity, 70% to 97%; specificity, 50% to 89%), pregnant and postpartum women (Edinburgh Postnatal Depression Scale: sensitivity, 74%; specificity, 64%), and adolescents (Screen for Child Anxiety Related Emotional Disorders: sensitivity, 64% to 74%; specificity, 64% to 73%). Anxiety symptoms improved with cognitive behavioral therapy (246 randomized controlled trials; 17 209 participants) and antianxiety medications (126 randomized controlled trials; 8225 participants). LIMITATION Limited data on long-term harms of treatment and no treatment trials in pregnant or postpartum women. CONCLUSION Evidence on the overall effectiveness and harms of screening for anxiety is insufficient. Most screening instruments are moderately to highly accurate. Behavioral therapies and antianxiety medications effectively improve anxiety symptoms. PRIMARY FUNDING SOURCE Health Resources and Services Administration.
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., M.P., C.W.)
| | - Amy Cantor
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., M.P., C.W.)
| | - Miranda Pappas
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., M.P., C.W.)
| | - Chandler Weeks
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., M.P., C.W.)
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13
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Gregory KD, Chelmow D, Nelson HD, Van Niel MS, Conry JA, Garcia F, Kendig SM, O'Reilly N, Qaseem A, Ramos D, Salganicoff A, Son S, Wood JK, Zahn C. Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women's Preventive Services Initiative. Ann Intern Med 2020; 173:48-56. [PMID: 32510990 DOI: 10.7326/m20-0580] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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] [Indexed: 01/14/2023] Open
Abstract
DESCRIPTION The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives, developed a recommendation on screening for anxiety in adolescent and adult women to improve detection; achieve earlier diagnosis and treatment; and improve health, function, and well-being. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care to women, particularly in primary care settings. This recommendation applies to women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. METHODS The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness of screening, accuracy of screening instruments, and benefits and harms of treatments in adolescent girls and adult women. No studies directly evaluated the overall effectiveness or harms of screening for anxiety. Twenty-seven screening instruments and their variations were moderately to highly accurate in identifying anxiety (33 individual studies and 2 systematic reviews; 171 studies total). Symptoms improved and relapse rates decreased with psychological therapies (246 randomized controlled trials [RCTs] in 5 systematic reviews) and with selective serotonin reuptake inhibitors or selective serotonin and norepinephrine reuptake inhibitors (126 RCTs in 3 systematic reviews). The WPSI also considered the effect of screening on symptom progression and identification of associated and underlying conditions, as well as implementation factors. RECOMMENDATION The WPSI recommends screening for anxiety in women and adolescent girls aged 13 years or older who are not currently diagnosed with anxiety disorders, including pregnant and postpartum women. Optimal screening intervals are unknown, and clinical judgment should be used to determine frequency. When screening suggests the presence of anxiety, further evaluation is necessary to establish the diagnosis and determine appropriate treatment and follow-up.
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Affiliation(s)
| | - David Chelmow
- Virginia Commonwealth University School of Medicine, Richmond, Virginia (D.C.)
| | - Heidi D Nelson
- Oregon Health & Science University, Portland, Oregon (H.D.N.)
| | | | - Jeanne A Conry
- American College of Obstetricians and Gynecologists, Washington, DC (J.A.C., N.O., S.S., C.Z.)
| | | | - Susan M Kendig
- National Association of Nurse Practitioners in Women's Health, Washington, DC (S.M.K.)
| | - Nancy O'Reilly
- American College of Obstetricians and Gynecologists, Washington, DC (J.A.C., N.O., S.S., C.Z.)
| | - Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q.)
| | - Diana Ramos
- California Department of Public Health, Sacramento, California (D.R.)
| | | | - Sarah Son
- American College of Obstetricians and Gynecologists, Washington, DC (J.A.C., N.O., S.S., C.Z.)
| | - Julie K Wood
- American Academy of Family Physicians, Leawood, Kansas (J.K.W.)
| | - Christopher Zahn
- American College of Obstetricians and Gynecologists, Washington, DC (J.A.C., N.O., S.S., C.Z.)
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Eden KB, Ivlev I, Bensching KL, Franta G, Hersh AR, Case J, Fu R, Nelson HD. Use of an Online Breast Cancer Risk Assessment and Patient Decision Aid in Primary Care Practices. J Womens Health (Larchmt) 2020; 29:763-769. [PMID: 32159424 DOI: 10.1089/jwh.2019.8143] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: U.S. Preventive Services Task Force (USPSTF) recommendations for mammography screening, genetic counseling and testing for pathogenic BRCA1/2 mutations, and use of risk-reducing medications require assessment of breast cancer risk for clinical decision-making, but efficient methods for risk assessment in clinical practice are lacking. Materials and Methods: A cross-sectional study evaluating a web-based breast cancer risk assessment and decision aid (MammoScreen) was conducted in an academic general internal medicine clinic. All eligible women, 40-74 years of age without previous diagnosis of breast or ovarian cancer and who were enrolled in the Epic MyChart patient portal were invited. MammoScreen uptake and completion rates and consistency between breast cancer risk determined by MammoScreen and existing risk information in the Epic record were measured. Patient and physician experiences were summarized from interviews. Results: Of 448 invited participants, 339 (75.7%) read their MyChart invitation and 125 (36.9%) who read invitations enrolled in the study; 118 (94.4% of enrolled) completed MammoScreen. Twenty-one women were categorized as above-average risk from either MammoScreen data or the chart review and 7 (33.3%) were identified by both sources. Physicians and patients believed MammoScreen was easy to use and was helpful in identifying risks and facilitating shared decision-making. Conclusions: Breast cancer risk assessment and mammography screening decision support were efficiently implemented through a web-based tool for patients sent through an electronic patient portal. Integration of patient decision aids with risk algorithms in clinical practice may help support the implementation of USPSTF recommendations that include risk assessment and shared decision-making.
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Affiliation(s)
- Karen B Eden
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
| | - Ilya Ivlev
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon.,Center for Health Research, Kaiser Permanente, Portland, Oregon
| | | | - Gabriel Franta
- School of Medicine, Oregon Health and Science University, Portland, Oregon.,School of Public Health, Oregon Health and Science University, Portland, Oregon
| | - Alyssa R Hersh
- School of Medicine, Oregon Health and Science University, Portland, Oregon.,School of Public Health, Oregon Health and Science University, Portland, Oregon
| | - James Case
- Mongoose Projects, Inc., Corvallis, Oregon
| | - Rongwei Fu
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon.,School of Public Health, Oregon Health and Science University, Portland, Oregon
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon.,Department of Medicine, Oregon Health and Science University, Portland, Oregon
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15
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Nelson HD, Cantor A, Wagner J, Jungbauer R, Quiñones A, Stillman L, Kondo K. Achieving Health Equity in Preventive Services: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2020; 172:258-271. [PMID: 31931527 DOI: 10.7326/m19-3199] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Disadvantaged populations in the United States experience disparities in the use of preventive health services. PURPOSE To examine effects of barriers that create health disparities in 10 recommended preventive services for adults, and to evaluate the effectiveness of interventions to reduce them. DATA SOURCES English-language searches of Ovid MEDLINE, PsycINFO, SocINDEX, and the Veterans Affairs Health Services database (1 January 1996 to 5 July 2019); reference lists. STUDY SELECTION Trials, observational studies with comparison groups, and systematic reviews of populations adversely affected by disparities that reported effects of barriers on use of any of the 10 selected preventive services or that reported the effectiveness of interventions to reduce disparities in use of a preventive service by improving intermediate or clinical outcomes. DATA EXTRACTION Dual extraction and assessment of study quality, strength of evidence, and evidence applicability. DATA SYNTHESIS No studies reported effects of provider-specific barriers on preventive service use. Eighteen studies reporting effects of patient barriers, such as insurance coverage or lack of a regular provider, on preventive service use had mixed and inconclusive findings. Studies of patient-provider interventions (n = 12), health information technologies (n = 11), and health system interventions (n = 88) indicated higher cancer screening rates with patient navigation; telephone calls, prompts, and other outreach methods; reminders involving lay health workers; patient education; risk assessment, counseling, and decision aids; screening checklists; community engagement; and provider training. Single studies showed that clinician-delivered and technology-assisted interventions improved rates of smoking cessation and weight loss, respectively. LIMITATION Insufficient or low strength of evidence and applicability for most interventions except patient navigation, telephone calls and prompts, and reminders involving lay health workers. CONCLUSION In populations adversely affected by disparities, patient navigation, telephone calls and prompts, and reminders involving lay health workers increase cancer screening. PRIMARY FUNDING SOURCE National Institutes of Health Office of Disease Prevention through an interagency agreement with the Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109263).
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Amy Cantor
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Jesse Wagner
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Rebecca Jungbauer
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Ana Quiñones
- Oregon Health & Science University-Portland State University, Portland, Oregon (A.Q.)
| | - Lucy Stillman
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Karli Kondo
- Portland VA Health Care System and Oregon Health & Science University, Portland, Oregon (K.K.)
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16
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Piepkorn MW, Longton GM, Reisch LM, Elder DE, Pepe MS, Kerr KF, Tosteson ANA, Nelson HD, Knezevich S, Radick A, Shucard H, Onega T, Carney PA, Elmore JG, Barnhill RL. Assessment of Second-Opinion Strategies for Diagnoses of Cutaneous Melanocytic Lesions. JAMA Netw Open 2019; 2:e1912597. [PMID: 31603483 PMCID: PMC6804025 DOI: 10.1001/jamanetworkopen.2019.12597] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/15/2019] [Indexed: 11/14/2022] Open
Abstract
Importance Histopathologic criteria have limited diagnostic reliability for a range of cutaneous melanocytic lesions. Objective To evaluate the association of second-opinion strategies by general pathologists and dermatopathologists with the overall reliability of diagnosis of difficult melanocytic lesions. Design, Setting, and Participants This diagnostic study used samples from the Melanoma Pathology Study, which comprises 240 melanocytic lesion samples selected from a dermatopathology laboratory in Bellevue, Washington, and represents the full spectrum of lesions from common nevi to invasive melanoma. Five sets of 48 samples were evaluated independently by 187 US pathologists from July 15, 2013, through May 23, 2016. Data analysis was performed from April 2016 through November 2017. Main Outcomes and Measures Accuracy of diagnosis, defined as concordance with an expert consensus diagnosis of 3 experienced pathologists, was assessed after applying 10 different second-opinion strategies. Results Among the 187 US pathologists examining the 24 lesion samples, 113 were general pathologists (65 men [57.5%]; mean age at survey, 53.7 years [range, 33.0-79.0 years]) and 74 were dermatopathologists (49 men [66.2%]; mean age at survey, 46.4 years [range, 33.0-77.0 years]). Among the 8976 initial case interpretations, physicians desired second opinions for 3899 (43.4%), most often for interpretation of severely dysplastic nevi. The overall misclassification rate was highest when interpretations did not include second opinions and initial reviewers were all general pathologists lacking subspecialty training (52.8%; 95% CI, 51.3%-54.3%). When considering different second opinion strategies, the misclassification of melanocytic lesions was lowest when the first, second, and third consulting reviewers were subspecialty-trained dermatopathologists and when all lesions were subject to second opinions (36.7%; 95% CI, 33.1%-40.7%). When the second opinion strategies were compared with single interpretations without second opinions, the reductions in misclassification rates for some of the strategies were statistically significant, but none of the strategies eliminated diagnostic misclassification. Melanocytic lesions in the middle of the diagnostic spectrum had the highest misclassification rates (eg, moderately or severely dysplastic nevus, Spitz nevus, melanoma in situ, and pathologic stage [p]T1a invasive melanoma). Variability of in situ and thin invasive melanoma was relatively intractable to all examined strategies. Conclusions and Relevance The results of this study suggest that second opinions rendered by dermatopathologists improve reliability of melanocytic lesion diagnosis. However, discordance among pathologists remained high.
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Affiliation(s)
| | - Gary M. Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Lisa M. Reisch
- Department of Biostatistics, University of Washington, Seattle
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Margaret S. Pepe
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Anna N. A. Tosteson
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Heidi D. Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland
- Department of Medicine, Oregon Health & Science University, Portland
| | | | - Andrea Radick
- Department of Biostatistics, University of Washington, Seattle
| | - Hannah Shucard
- Department of Biostatistics, University of Washington, Seattle
| | - Tracy Onega
- Department of Epidemiology, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Biomedical Data Science, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Patricia A. Carney
- Department of Family Medicine and of Public Health and Preventive Medicine, Oregon Health and Science University, Portland
| | - Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
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Nelson HD, Fu R, Zakher B, Pappas M, McDonagh M. Medication Use for the Risk Reduction of Primary Breast Cancer in Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 322:868-886. [PMID: 31479143 DOI: 10.1001/jama.2019.5780] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Medications to reduce risk of breast cancer are effective for women at increased risk but also cause adverse effects. OBJECTIVE To update the 2013 US Preventive Services Task Force systematic review on medications to reduce risk of primary (first diagnosis) invasive breast cancer in women. DATA SOURCES Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, EMBASE, and MEDLINE (January 1, 2013, to February 1, 2019); manual review of reference lists. STUDY SELECTION Discriminatory accuracy studies of breast cancer risk assessment methods; randomized clinical trials of tamoxifen, raloxifene, and aromatase inhibitors for primary breast cancer prevention; studies of medication adverse effects. DATA EXTRACTION AND SYNTHESIS Investigators abstracted data on methods, participant characteristics, eligibility criteria, outcome ascertainment, and follow-up. Results of individual trials were combined by using a profile likelihood random-effects model. MAIN OUTCOMES AND MEASURES Probability of breast cancer in individuals (area under the receiver operating characteristic curve [AUC]); incidence of breast cancer, fractures, thromboembolic events, coronary heart disease events, stroke, endometrial cancer, and cataracts; and mortality. RESULTS A total of 46 studies (82 articles [>5 million participants]) were included. Eighteen risk assessment methods in 25 studies reported low accuracy in predicting the probability of breast cancer in individuals (AUC, 0.55-0.65). In placebo-controlled trials, tamoxifen (risk ratio [RR], 0.69 [95% CI, 0.59-0.84]; 4 trials [n = 28 421]), raloxifene (RR, 0.44 [95% CI, 0.24-0.80]; 2 trials [n = 17 806]), and the aromatase inhibitors exemestane and anastrozole (RR, 0.45 [95% CI, 0.26-0.70]; 2 trials [n = 8424]) were associated with a lower incidence of invasive breast cancer. Risk for invasive breast cancer was higher for raloxifene than tamoxifen in 1 trial after long-term follow-up (RR, 1.24 [95% CI, 1.05-1.47]; n = 19 747). Raloxifene was associated with lower risk for vertebral fractures (RR, 0.61 [95% CI, 0.53-0.73]; 2 trials [n = 16 929]) and tamoxifen was associated with lower risk for nonvertebral fractures (RR, 0.66 [95% CI, 0.45-0.98]; 1 trial [n = 13 388]) compared with placebo. Tamoxifen and raloxifene were associated with increased thromboembolic events compared with placebo; tamoxifen was associated with more events than raloxifene. Tamoxifen was associated with higher risk of endometrial cancer and cataracts compared with placebo. Symptomatic effects (eg, vasomotor, musculoskeletal) varied by medication. CONCLUSIONS AND RELEVANCE Tamoxifen, raloxifene, and aromatase inhibitors were associated with lower risk of primary invasive breast cancer in women but also were associated with adverse effects that differed between medications. Risk stratification methods to identify patients with increased breast cancer risk demonstrated low accuracy.
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University, Portland
| | - Bernadette Zakher
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
- School of Public Health, Oregon Health & Science University, Portland
| | - Miranda Pappas
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Marian McDonagh
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
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Nelson HD, Pappas M, Cantor A, Haney E, Holmes R. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2019; 322:666-685. [PMID: 31429902 DOI: 10.1001/jama.2019.8430] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Pathogenic mutations in breast cancer susceptibility genes BRCA1 and BRCA2 increase risks for breast, ovarian, fallopian tube, and peritoneal cancer in women; interventions reduce risk in mutation carriers. OBJECTIVE To update the 2013 US Preventive Services Task Force review on benefits and harms of risk assessment, genetic counseling, and genetic testing for BRCA1/2-related cancer in women. DATA SOURCES Cochrane libraries; MEDLINE, PsycINFO, EMBASE (January 1, 2013, to March 6, 2019, for updates; January 1, 1994, to March 6, 2019, for new key questions and populations); reference lists. STUDY SELECTION Discriminatory accuracy studies, randomized clinical trials (RCTs), and observational studies of women without recently diagnosed BRCA1/2-related cancer. DATA EXTRACTION AND SYNTHESIS Data on study methods, setting, population characteristics, eligibility criteria, interventions, numbers enrolled and lost to follow-up, outcome ascertainment, and results were abstracted. Two reviewers independently assessed study quality. MAIN OUTCOMES AND MEASURES Cancer incidence and mortality; discriminatory accuracy of risk assessment tools for BRCA1/2 mutations; benefits and harms of risk assessment, genetic counseling, genetic testing, and risk-reducing interventions. RESULTS For this review, 103 studies (110 articles; N = 92 712) were included. No studies evaluated the effectiveness of risk assessment, genetic counseling, and genetic testing in reducing incidence and mortality of BRCA1/2-related cancer. Fourteen studies (n = 43 813) of 8 risk assessment tools to guide referrals to genetic counseling demonstrated moderate to high accuracy (area under the receiver operating characteristic curve, 0.68-0.96). Twenty-eight studies (n = 8060) indicated that genetic counseling was associated with reduced breast cancer worry, anxiety, and depression; increased understanding of risk; and decreased intention for testing. Twenty studies (n = 4322) showed that breast cancer worry and anxiety were higher after testing for women with positive results and lower for others; understanding of risk was higher after testing. In 8 RCTs (n = 54 651), tamoxifen (relative risk [RR], 0.69 [95% CI, 0.59-0.84]; 4 trials), raloxifene (RR, 0.44 [95% CI, 0.24-0.80]; 2 trials), and aromatase inhibitors (RR, 0.45 [95% CI, 0.26-0.70]; 2 trials) were associated with lower risks of invasive breast cancer compared with placebo; results were not specific to mutation carriers. Mastectomy was associated with 90% to 100% reduction in breast cancer incidence (6 studies; n = 2546) and 81% to 100% reduction in breast cancer mortality (1 study; n = 639); oophorectomy was associated with 69% to 100% reduction in ovarian cancer (2 studies; n = 2108); complications were common with mastectomy. CONCLUSIONS AND RELEVANCE Among women without recently diagnosed BRCA1/2-related cancer, the benefits and harms of risk assessment, genetic counseling, and genetic testing to reduce cancer incidence and mortality have not been directly evaluated by current research.
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Miranda Pappas
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Amy Cantor
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Elizabeth Haney
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
| | - Rebecca Holmes
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland
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Titus LJ, Reisch LM, Tosteson ANA, Nelson HD, Frederick PD, Carney PA, Barnhill RL, Elder DE, Weinstock MA, Piepkorn MW, Elmore JG. Malpractice Concerns, Defensive Medicine, and the Histopathology Diagnosis of Melanocytic Skin Lesions. Am J Clin Pathol 2019; 150:338-345. [PMID: 30007278 DOI: 10.1093/ajcp/aqy057] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objectives The impact of malpractice concerns on pathologists' use of defensive medicine and interpretations of melanocytic skin lesions (MSLs) is unknown. Methods A total of 207 pathologists interpreting MSLs responded to a survey about past involvement in malpractice litigation, influence of malpractice concerns on diagnosis, and use of assurance behaviors (defensive medicine) to alleviate malpractice concerns. Assurance behaviors included requesting second opinions, additional slides, additional sampling, and ordering specialized tests. Results Of the pathologists, 27.5% reported that malpractice concerns influenced them toward a more severe MSL diagnosis. Nearly all (95.2%) pathologists reported practicing at least one assurance behavior due to malpractice concerns, and this practice was associated with being influenced toward a more severe MSL diagnosis (odds ratio, 2.72; 95% confidence interval, 1.41-5.26). Conclusions One of four US skin pathologists upgrade MSL diagnosis due to malpractice concerns, and nearly all practice assurance behaviors. Assurance behaviors are associated with rendering a more severe MSL diagnosis.
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Affiliation(s)
- Linda J Titus
- Department of Epidemiology and Pediatrics, Norris Cotton Cancer Center, Hanover, NH
| | - Lisa M Reisch
- Department of Medicine, Norris Cotton Cancer Center, Hanover, NH
| | - Anna N A Tosteson
- Departments of Medicine and Community and Family Medicine, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Hanover, NH
| | - Heidi D Nelson
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, Portland
| | - Paul D Frederick
- Department of Medicine, Norris Cotton Cancer Center, Hanover, NH
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie, Paris Sciences and Letters Research University, University of Paris Descartes, Paris, France
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Martin A Weinstock
- Center for Dermatoepidemiology, VA Medical Center, Providence Department of Dermatology, Rhode Island Hospital, Providence.,Departments of Dermatology and Epidemiology, Brown University, Providence, RI
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle.,Dermatopathology Northwest, Bellevue, WA
| | - Joann G Elmore
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
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20
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Hughes KE, Ostheller SR, Nelson HD, Gamelin DR. Copper's Role in the Photoluminescence of Ag 1- xCu xInS 2 Nanocrystals, from Copper-Doped AgInS 2 ( x ∼ 0) to CuInS 2 ( x = 1). Nano Lett 2019; 19:1318-1325. [PMID: 30584807 DOI: 10.1021/acs.nanolett.8b04905] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
A series of Ag1- xCu xInS2 nanocrystals (NCs) spanning from 0 ≤ x ≤ ∼1 was synthesized by partial cation exchange to identify copper's contributions to the electronic structure and spectroscopic properties of these NCs. Discrete midgap states appear above the valence band upon doping AgInS2 NCs with Cu+ (small x). Density functional theory calculations confirm that these midgap states are associated with the 3d valence orbitals of the Cu+ impurities. With increasing x, these impurity d levels gradually evolve to become the valence-band edge of CuInS2 NCs, but the highest-occupied orbital's description does not change significantly across the entire range of x. In contrast with this gradual evolution, Ag1- xCu xInS2 NC photoluminescence shifts rapidly with initial additions of Cu+ (small x) but then becomes independent of x beyond x > ∼0.20, all the way to CuInS2 ( x = 1.00). Data analysis suggests small but detectable hole delocalization in the luminescent excited state of CuInS2 NCs, estimated by Monte Carlo simulations to involve at most about four copper ions. These results provide unique insights into the luminescent excited states of these materials and they reinforce the description of CuInS2 NCs as "heavily copper-doped NCs" in which photogenerated holes are rapidly localized in copper 3d-based orbitals.
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Affiliation(s)
- Kira E Hughes
- Department of Chemistry , University of Washington , Seattle , Washington 98195-1700 , United States
| | - Sarah R Ostheller
- Department of Chemistry , University of Washington , Seattle , Washington 98195-1700 , United States
| | - Heidi D Nelson
- Department of Chemistry , University of Washington , Seattle , Washington 98195-1700 , United States
| | - Daniel R Gamelin
- Department of Chemistry , University of Washington , Seattle , Washington 98195-1700 , United States
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21
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Ahrens KA, Hutcheon JA, Ananth CV, Basso O, Briss PA, Ferré CD, Frederiksen BN, Harper S, Hernández‐Díaz S, Hirai AH, Kirby RS, Klebanoff MA, Lindberg L, Mumford SL, Nelson HD, Platt RW, Rossen LM, Stuebe AM, Thoma ME, Vladutiu CJ, Moskosky S. Report of the Office of Population Affairs' expert work group meeting on short birth spacing and adverse pregnancy outcomes: Methodological quality of existing studies and future directions for research. Paediatr Perinat Epidemiol 2019; 33:O5-O14. [PMID: 30300948 PMCID: PMC6378402 DOI: 10.1111/ppe.12504] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/09/2018] [Accepted: 08/12/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND The World Health Organization (WHO) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low- and middle-resource countries upon which most of the evidence is based. METHODS To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs (OPA) convened an expert work group meeting in Washington, DC, on 14-15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician-gynaecologists; biostatisticians; and experts in evidence synthesis related to women's health. RESULTS Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work. CONCLUSIONS This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting.
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Affiliation(s)
- Katherine A. Ahrens
- Office of Population AffairsOffice of the Assistant Secretary for HealthRockvilleMaryland
| | - Jennifer A. Hutcheon
- Department of Obstetrics and GynaecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Cande V. Ananth
- Department of Obstetrics and GynecologyVagelos College of Physicians and SurgeonsColumbia UniversityNew YorkNew York,Department of EpidemiologyJoseph L. Mailman School of Public HealthColumbia UniversityNew YorkNew York
| | - Olga Basso
- Department of Obstetrics and GynecologyRoyal Victoria HospitalResearch Institute of McGill University Health CentreMontrealQuebecCanada,Department of Epidemiology, Biostatistics and Occupational HealthMcGill UniversityMontrealQuebecCanada
| | - Peter A. Briss
- National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and PreventionAtlantaGeorgia
| | - Cynthia D. Ferré
- Maternal and Infant Health BranchDivision of Reproductive HealthNational Center for Chronic Disease Prevention and Health PromotionCenters for Disease Control and PreventionAtlantaGeorgia
| | - Brittni N. Frederiksen
- Office of Population AffairsOffice of the Assistant Secretary for HealthRockvilleMaryland
| | - Sam Harper
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill UniversityMontrealQuebecCanada
| | - Sonia Hernández‐Díaz
- Department of EpidemiologyHarvard T. H. Chan School of Public HealthBostonMassachusetts
| | - Ashley H. Hirai
- US Department of Health and Human ServicesHealth Resources and Services Administration, Maternal and Child Health BureauOffice of Epidemiology and ResearchRockvilleMaryland
| | - Russell S. Kirby
- Department of Community and Family HealthUniversity of South Florida College of Public HealthTampaFlorida
| | - Mark A. Klebanoff
- Center for Perinatal ResearchDepartments of Pediatrics and Obstetrics and Gynecology and Division of EpidemiologyThe Research Institute at Nationwide Children's HospitalThe Ohio State UniversityColumbusOhio
| | | | - Sunni L. Mumford
- Division of Intramural Population Health Research, Epidemiology BranchNational Institute of Child Health and Human DevelopmentBethesdaMaryland
| | - Heidi D. Nelson
- Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregon
| | - Robert W. Platt
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill UniversityMontrealQuebecCanada
| | - Lauren M. Rossen
- Reproductive Statistics BranchDivision of Vital StatisticsNational Center for Health StatisticsCenters for Disease Control and PreventionHyattsvilleMaryland
| | - Alison M. Stuebe
- Department of Obstetrics and GynecologyDepartment of Maternal and Child HealthGillings School of Global Public HealthUniversity of North Carolina School of MedicineChapel HillNorth Carolina
| | - Marie E. Thoma
- Department of Family ScienceUniversity of MarylandCollege ParkMaryland
| | - Catherine J. Vladutiu
- US Department of Health and Human ServicesHealth Resources and Services Administration, Maternal and Child Health BureauOffice of Epidemiology and ResearchRockvilleMaryland
| | - Susan Moskosky
- Office of Population AffairsOffice of the Assistant Secretary for HealthRockvilleMaryland
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Hutcheon JA, Nelson HD, Stidd R, Moskosky S, Ahrens KA. Short interpregnancy intervals and adverse maternal outcomes in high-resource settings: An updated systematic review. Paediatr Perinat Epidemiol 2019; 33:O48-O59. [PMID: 30311955 PMCID: PMC7380038 DOI: 10.1111/ppe.12518] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 07/16/2018] [Accepted: 07/29/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Currently, no federal guidelines provide recommendations on healthy birth spacing for women in the United States. This systematic review summarises associations between short interpregnancy intervals and adverse maternal outcomes to inform the development of birth spacing recommendations for the United States. METHODS PubMed/Medline, POPLINE, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, and a previous systematic review were searched to identify relevant articles published from 1 January 2006 and 1 May 2017. Included studies reported maternal health outcomes following a short versus longer interpregnancy interval, were conducted in high-resource settings, and adjusted estimates for at least maternal age. Two investigators independently assessed study quality and applicability using established methods. RESULTS Seven cohort studies met inclusion criteria. There was limited but consistent evidence that short interpregnancy interval is associated with increased risk of precipitous labour and decreased risks of labour dystocia. There was some evidence that short interpregnancy interval is associated with increased risks of subsequent pre-pregnancy obesity and gestational diabetes, and decreased risk of preeclampsia. Among women with a previous caesarean delivery, short interpregnancy interval was associated with increased risk of uterine rupture in one study. No studies reported outcomes related to maternal depression, interpregnancy weight gain, maternal anaemia, or maternal mortality. CONCLUSIONS In studies from high-resource settings, short interpregnancy intervals are associated with both increased and decreased risks of adverse maternal outcomes. However, most outcomes were evaluated in single studies, and the strength of evidence supporting associations is low.
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Affiliation(s)
- Jennifer A. Hutcheon
- Department of Obstetrics and GynaecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Heidi D. Nelson
- Department of Medical Informatics and Clinical EpidemiologyOregon Health & Science UniversityPortlandOregon
| | - Reva Stidd
- Atlas ResearchWashingtonDistrict of Columbia
| | - Susan Moskosky
- US Department of Health and Human ServicesOffice of Population Affairs, Office of the Assistant Secretary for HealthRockvilleMaryland
| | - Katherine A. Ahrens
- US Department of Health and Human ServicesOffice of Population Affairs, Office of the Assistant Secretary for HealthRockvilleMaryland
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Hutcheon JA, Moskosky S, Ananth CV, Basso O, Briss PA, Ferré CD, Frederiksen BN, Harper S, Hernández‐Díaz S, Hirai AH, Kirby RS, Klebanoff MA, Lindberg L, Mumford SL, Nelson HD, Platt RW, Rossen LM, Stuebe AM, Thoma ME, Vladutiu CJ, Ahrens KA. Good practices for the design, analysis, and interpretation of observational studies on birth spacing and perinatal health outcomes. Paediatr Perinat Epidemiol 2019; 33:O15-O24. [PMID: 30311958 PMCID: PMC6378590 DOI: 10.1111/ppe.12512] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/22/2018] [Accepted: 08/25/2018] [Indexed: 12/04/2022]
Abstract
BACKGROUND Meta-analyses of observational studies have shown that women with a shorter interpregnancy interval (the time from delivery to start of a subsequent pregnancy) are more likely to experience adverse pregnancy outcomes, such as preterm delivery or small for gestational age birth, than women who space their births further apart. However, the studies used to inform these estimates have methodological shortcomings. METHODS In this commentary, we summarise the discussions of an expert workgroup describing good practices for the design, analysis, and interpretation of observational studies of interpregnancy interval and adverse perinatal health outcomes. RESULTS We argue that inferences drawn from research in this field will be improved by careful attention to elements such as: (a) refining the research question to clarify whether the goal is to estimate a causal effect vs describe patterns of association; (b) using directed acyclic graphs to represent potential causal networks and guide the analytic plan of studies seeking to estimate causal effects; (c) assessing how miscarriages and pregnancy terminations may have influenced interpregnancy interval classifications; (d) specifying how key factors such as previous pregnancy loss, pregnancy intention, and maternal socio-economic position will be considered; and (e) examining if the association between interpregnancy interval and perinatal outcome differs by factors such as maternal age. CONCLUSION This commentary outlines the discussions of this recent expert workgroup, and describes several suggested principles for study design and analysis that could mitigate many potential sources of bias.
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Affiliation(s)
- Jennifer A. Hutcheon
- Department of Obstetrics and GynaecologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Susan Moskosky
- Office of Population AffairsOffice of the Assistant Secretary for HealthRockvilleMaryland
| | - Cande V. Ananth
- Department of Obstetrics and GynecologyIrving College of Physicians and SurgeonsColumbia UniversityNew YorkNew York,Department of EpidemiologyJoseph L. Mailman School of Public HealthColumbia UniversityNew YorkNew York
| | - Olga Basso
- Department of Obstetrics and GynecologyRoyal Victoria HospitalResearch Institute of McGill University Health CentreMontrealQuebecCanada,Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealQuebecCanada
| | - Peter A. Briss
- National Center for Chronic Disease Prevention and Health PromotionCenters for Disease Control and PreventionAtlantaGeorgia
| | - Cynthia D. Ferré
- Maternal and Infant Health BranchDivision of Reproductive HealthNational Center for Chronic Disease Prevention and Health PromotionCenters for Disease Control and PreventionAtlantaGeorgia
| | - Brittni N. Frederiksen
- Office of Population AffairsOffice of the Assistant Secretary for HealthRockvilleMaryland
| | - Sam Harper
- Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealQuebecCanada
| | - Sonia Hernández‐Díaz
- Department of EpidemiologyHarvard T. H. Chan School of Public HealthBostonMassachusetts
| | - Ashley H. Hirai
- US Department of Health and Human ServicesHealth Resources and Services AdministrationMaternal and Child Health BureauOffice of Epidemiology and ResearchRockvilleMaryland
| | - Russell S. Kirby
- Department of Community and Family HealthUniversity of South Florida College of Public HealthTampaFlorida
| | - Mark A. Klebanoff
- Division of EpidemiologyDepartments of Pediatrics and Obstetrics and GynecologyCenter for Perinatal ResearchThe Research Institute at Nationwide Children's HospitalThe Ohio State UniversityColumbus Ohio
| | | | - Sunni L. Mumford
- Epidemiology BranchDivision of Intramural Population Health ResearchNational Institute of Child Health and Human DevelopmentBethesdaMaryland
| | - Heidi D. Nelson
- Department of Medical Informatics and Clinical EpidemiologyOregon Health and Science UniversityPortlandOregon
| | - Robert W. Platt
- Department of Epidemiology, Biostatistics, and Occupational HealthMcGill UniversityMontrealQuebecCanada
| | - Lauren M. Rossen
- Reproductive Statistics BranchDivision of Vital StatisticsCenters for Disease Control and PreventionNational Center for Health StatisticsHyattsvilleMaryland
| | - Alison M. Stuebe
- Department of Obstetrics and GynecologyUniversity of North Carolina School of MedicineChapel HillNorth Carolina,Department of Maternal and Child HealthGillings School of Global Public HealthChapel HillNorth Carolina
| | - Marie E. Thoma
- Department of Family ScienceUniversity of MarylandCollege ParkMaryland
| | - Catherine J. Vladutiu
- US Department of Health and Human ServicesHealth Resources and Services AdministrationMaternal and Child Health BureauOffice of Epidemiology and ResearchRockvilleMaryland
| | - Katherine A. Ahrens
- Office of Population AffairsOffice of the Assistant Secretary for HealthRockvilleMaryland
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Onega T, Barnhill RL, Piepkorn MW, Longton GM, Elder DE, Weinstock MA, Knezevich SR, Reisch LM, Carney PA, Nelson HD, Radick AC, Elmore JG. Accuracy of Digital Pathologic Analysis vs Traditional Microscopy in the Interpretation of Melanocytic Lesions. JAMA Dermatol 2018; 154:1159-1166. [PMID: 30140929 PMCID: PMC6233746 DOI: 10.1001/jamadermatol.2018.2388] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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] [Received: 03/22/2018] [Accepted: 05/29/2018] [Indexed: 11/14/2022]
Abstract
Importance Use of digital whole-slide imaging (WSI) for dermatopathology in general has been noted to be similar to traditional microscopy (TM); however, concern has been noted that WSI is inferior for interpretation of melanocytic lesions. Since approximately 1 of every 4 skin biopsies is of a melanocytic lesion, the use of WSI requires verification before use in clinical practice. Objective To compare pathologists' accuracy and reproducibility in diagnosing melanocytic lesions using Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) categories when analyzing by TM vs WSI. Design, Setting, and Participants A total of 87 pathologists in community-based and academic settings from 10 US states were randomized with stratification based on clinical experience to interpret in TM format 180 skin biopsy cases of melanocytic lesions, including 90 invasive melanoma, divided into 5 sets of 36 cases (phase 1). The pathologists were then randomized via stratified permuted block randomization with block size 2 to interpret cases in either TM (n = 46) or WSI format (n = 41), with each pathologist interpreting the same 36 cases on 2 separate occasions (phase 2). Diagnoses were categorized as MPATH-Dx categories I through V, with I indicating the least severe and V the most severe. Main Outcomes and Measures Accuracy with respect to a consensus reference diagnosis and the reproducibility of repeated interpretations of the same cases. Results Of the 87 pathologists in the study, 46% (40) were women and the mean (SD) age was 50.7 (10.2) years. Except for class III melanocytic lesions, the diagnostic categories showed no significant differences in diagnostic accuracy between TM and WSI interpretation. Discordance was lower among class III lesions for the TM interpretation arm (51%; 95% CI, 46%-57%) than for the WSI arm (61%; 95% CI, 53%-69%) (P = .05). This difference is likely to have clinical significance, because 6% of TM vs 11% of WSI class III lesions were interpreted as invasive melanoma. Reproducibility was similar between the traditional and digital formats overall (66.4%; 95% CI, 63.3%-69.3%; and 62.7%; 95% CI, 59.5%-65.7%, respectively), and for all classes, although class III showed a nonsignificant lower intraobserver agreement for digital. Significantly more mitotic figures were detected with TM compared with WSI: mean (SD) TM, 6.72 (2.89); WSI, 5.84 (2.56); P = .002. Conclusions and Relevance Interpretive accuracy for melanocytic lesions was similar for WSI and TM slides except for class III lesions. We found no clinically meaningful differences in reproducibility for any of the diagnostic classes.
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Affiliation(s)
- Tracy Onega
- Departments of Medicine and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Raymond L. Barnhill
- Department of Pathology, Institut Curie, Paris Sciences and Lettres Research University, and Faculty of Medicine University of Paris Descartes, Paris, France
| | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | - Gary M. Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Martin A. Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island
- Departments of Dermatology and Epidemiology, Brown University, Providence, Rhode Island
| | | | - Lisa M. Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Patricia A. Carney
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland
| | - Heidi D. Nelson
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland
- Department of Medicine, School of Medicine, Oregon Health & Science University, Portland
- Providence Cancer Center, Providence Health and Services, Portland, Oregon
| | - Andrea C. Radick
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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O'Reilly N, Nelson HD, Conry JM, Frost J, Gregory KD, Kendig SM, Phipps M, Salganicoff A, Ramos D, Zahn C, Qaseem A. Screening for Urinary Incontinence in Women: A Recommendation From the Women's Preventive Services Initiative. Ann Intern Med 2018; 169:320-328. [PMID: 30105360 DOI: 10.7326/m18-0595] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION Recommendation on screening for urinary incontinence in women by the Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care for women, particularly in primary care settings. This recommendation applies to women of all ages, as well as adolescents. METHODS The WPSI developed this recommendation after evaluating evidence regarding the benefits and harms of screening for urinary incontinence in women. The evaluation included a systematic review of the accuracy of screening instruments and the benefits and harms of treatments. Indirect evidence was used to link screening and health outcomes in the chain of evidence that might support screening in the absence of direct evidence. The WPSI also considered the effect of screening on symptom progression and avoidance of costly and complex treatments, as well as implementation factors. RECOMMENDATION The WPSI recommends screening women for urinary incontinence annually. Screening ideally should assess whether women experience urinary incontinence and whether it affects their activities and quality of life. The WPSI recommends referring women for further evaluation and treatment if indicated.
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Affiliation(s)
- Nancy O'Reilly
- American College of Obstetricians and Gynecologists, Washington, DC (N.O., J.M.C., C.Z.)
| | - Heidi D Nelson
- Oregon Health & Science University, Portland, Oregon (H.D.N.)
| | - Jeanne M Conry
- American College of Obstetricians and Gynecologists, Washington, DC (N.O., J.M.C., C.Z.)
| | - Jennifer Frost
- American Academy of Family Physicians, Leawood, Kansas (J.F.)
| | | | - Susan M Kendig
- National Association of Nurse Practitioners in Women's Health, Washington, DC (S.M.K.)
| | - Maureen Phipps
- Women and Infants Hospital of Rhode Island, Providence, Rhode Island (M.P.)
| | | | - Diana Ramos
- California Department of Public Health, Sacramento, California (D.R.)
| | - Christopher Zahn
- American College of Obstetricians and Gynecologists, Washington, DC (N.O., J.M.C., C.Z.)
| | - Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q.)
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Nelson HD, Cantor A, Pappas M, Miller L. Screening for Urinary Incontinence in Women: A Systematic Review for the Women's Preventive Services Initiative. Ann Intern Med 2018; 169:311-319. [PMID: 30105353 DOI: 10.7326/m18-0225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Urinary incontinence is infrequently addressed during routine health care despite its high prevalence and adverse effects on health. PURPOSE To evaluate whether screening for urinary incontinence in women not previously diagnosed improves outcomes (symptoms, quality of life, and function) and to evaluate the accuracy of screening methods and potential harms of screening. DATA SOURCES English-language searches of Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (1 January 1996 to 30 March 2018); ClinicalTrials.gov (April 2018); and reference lists of studies and reviews. STUDY SELECTION Randomized trials, cohort studies, systematic reviews of studies that enrolled nonpregnant women without previously diagnosed urinary incontinence and compared clinical outcomes and adverse effects between women who were and were not screened, and diagnostic accuracy studies that reported performance measures of screening tests. DATA EXTRACTION Dual extraction and quality assessment of individual studies. DATA SYNTHESIS No studies evaluated the overall effectiveness or harms of screening. Seventeen studies evaluated the diagnostic accuracy of 18 screening questionnaires against a clinical diagnosis or results of diagnostic tests. Of these, 14 poor-quality studies were based in referral clinics, enrolled only symptomatic women, or had other limitations. One good-quality and 2 fair-quality studies (evaluating 4 methods) enrolled women not recruited on the basis of symptoms. Areas under the receiver-operating characteristic curve for stress, urge, and any type of incontinence in these studies were 0.79, 0.88, and 0.88 for the Michigan Incontinence Symptom Index; 0.85, 0.83, and 0.87 for the Bladder Control Self-Assessment Questionnaire; and 0.68, 0.82, and 0.75 for the Overactive Bladder Awareness Tool. The Incontinence Screening Questionnaire had a sensitivity of 66% and specificity of 80% for any type of incontinence. LIMITATION Studies enrolled few participants, often from symptomatic referral populations; used various reference standards; and infrequently reported CIs. CONCLUSION Evidence is insufficient on the overall effectiveness and harms of screening for urinary incontinence in women. Limited evidence in general populations suggests fairly high accuracy for some screening methods. PRIMARY FUNDING SOURCE Health Resources and Services Administration.
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Affiliation(s)
- Heidi D Nelson
- Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., M.P., L.M.)
| | - Amy Cantor
- Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., M.P., L.M.)
| | - Miranda Pappas
- Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., M.P., L.M.)
| | - Liev Miller
- Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., M.P., L.M.)
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Elder DE, Piepkorn MW, Barnhill RL, Longton GM, Nelson HD, Knezevich SR, Pepe MS, Carney PA, Titus LJ, Onega T, Tosteson ANA, Weinstock MA, Elmore JG. Pathologist characteristics associated with accuracy and reproducibility of melanocytic skin lesion interpretation. J Am Acad Dermatol 2018; 79:52-59.e5. [PMID: 29524584 PMCID: PMC6016831 DOI: 10.1016/j.jaad.2018.02.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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] [Received: 09/18/2017] [Revised: 01/31/2018] [Accepted: 02/21/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Diagnostic interpretations of melanocytic skin lesions vary widely among pathologists, yet the underlying reasons remain unclear. OBJECTIVE Identify pathologist characteristics associated with rates of accuracy and reproducibility. METHODS Pathologists independently interpreted the same set of biopsy specimens from melanocytic lesions on 2 occasions. Diagnoses were categorized into 1 of 5 classes according to the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis system. Reproducibility was determined by pathologists' concordance of diagnoses across 2 occasions. Accuracy was defined by concordance with a consensus reference standard. Associations of pathologist characteristics with reproducibility and accuracy were assessed individually and in multivariable logistic regression models. RESULTS Rates of diagnostic reproducibility and accuracy were highest among pathologists with board certification and/or fellowship training in dermatopathology and in those with 5 or more years of experience. In addition, accuracy was high among pathologists with a higher proportion of melanocytic lesions in their caseload composition and higher volume of melanocytic lesions. LIMITATIONS Data gathered in a test set situation by using a classification tool not currently in clinical use. CONCLUSION Diagnoses are more accurate among pathologists with specialty training and those with more experience interpreting melanocytic lesions. These findings support the practice of referring difficult cases to more experienced pathologists to improve diagnostic accuracy, although the impact of these referrals on patient outcomes requires additional research.
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Affiliation(s)
- David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Dermatopathology Northwest, Bellevue, Washington
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie, Paris, France; University of Paris Descartes, Paris, France
| | - Gary M Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon; Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | | | - Margaret S Pepe
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon
| | - Linda J Titus
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire; Department of Pediatrics, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Tracy Onega
- Department of Biomedical Data Science, Department of Epidemiology, Norris Cotton Cancer Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Anna N A Tosteson
- Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire; Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Martin A Weinstock
- Center for Dermatoepidemiology, VA Medical Center, Providence Department of Dermatology, Rhode Island Hospital, Providence, Rhode Island; Department of Dermatology, Brown University, Providence, Rhode Island; Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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Radick AC, Phipps AI, Piepkorn MW, Nelson HD, Barnhill RL, Elder DE, Reisch LM, Frederick PD, Elmore JG. Characteristics and diagnostic performance of pathologists who enjoy interpreting melanocytic lesions. Dermatol Online J 2018; 24:13030/qt96g5q3sz. [PMID: 30142708 PMCID: PMC6463485] [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] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 06/08/2023] Open
Abstract
Diagnostic discrepancy among pathologists interpreting melanocytic skin lesions (MSL) is an ongoing concern for patient care. Given that job satisfaction could impact patient care, this study aimed to characterize which pathologists enjoy interpreting MSL and estimate the association between enjoyment and diagnostic accuracy. Pathologists' demographics, training, and experience were obtained by a cross-sectional survey. Associations between these characteristics and self-reported enjoyment when interpreting MSL were estimated by Pearson's Chi-square tests. Diagnostic accuracy was determined by comparing pathologists' MSL interpretations with reference standard diagnoses. Associations between enjoyment and diagnostic accuracy were evaluated by generalized estimating equations (GEE) models. One hundred and eighty-seven (90%) pathologists completed the study. Seventy percent agreed that interpreting MSL is enjoyable. Pathologists who enjoyed interpreting MSL were more likely to be board certified and/or fellowship trained in dermatopathology (P=0.008), have ?10 years of experience (P=0.010) and have an MSL caseload of ?60 per month (P=<0.001). After adjustment, there was no association between enjoyment and diagnostic accuracy. Our data suggest that job dissatisfaction does not adversely affect diagnostic accuracy in the interpretation of melanocytic lesions, which is of importance given the progressive increase in annual biopsy rates and the attendant work demands imposed on pathologists.
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Affiliation(s)
- Andrea C Radick
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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Elmore JG, Elder DE, Barnhill RL, Knezevich SR, Longton GM, Titus LJ, Weinstock MA, Pepe MS, Nelson HD, Reisch LM, Radick AC, Piepkorn MW. Concordance and Reproducibility of Melanoma Staging According to the 7th vs 8th Edition of the AJCC Cancer Staging Manual. JAMA Netw Open 2018; 1:e180083. [PMID: 30556054 PMCID: PMC6294444 DOI: 10.1001/jamanetworkopen.2018.0083] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The recently updated American Joint Committee on Cancer (AJCC) classification of cancer staging, the AJCC Cancer Staging Manual, 8th edition (AJCC 8), includes revisions to definitions of T1a vs T1b or greater. The Melanoma Pathology Study database affords a comparison,of pathologists' concordance and reproducibility in the microstaging of melanoma according to both the existing 7th edition (AJCC 7) and the new AJCC 8. OBJECTIVE To compare AJCC 7 and AJCC 8 to examine whether changes to the definitions of T1a and T1b or greater are associated with changes in concordance and reproducibility. DESIGN SETTING AND PARTICIPANTS In this diagnostic study conducted as part of the national Melanoma Pathology Study across US states, 187 pathologists interpreting melanocytic skin lesions in practice completed 4342 independent case interpretations of 116 invasive melanoma cases. A consensus reference diagnosis and participating pathologists' interpretations were classified into the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis class IV (T1a) or class V ( T1b) using both the AJCC 7 and AJCC 8 criteria. MAIN OUTCOMES AND MEASURES Concordance with consensus reference diagnosis, interobserver reproducibility, and intraobserver reproducibility. RESULTS For T1a diagnoses, participating pathologists' concordance with the consensus reference diagnosis increased from 44% (95% CI, 41%-48%) to 54% (95% CI, 51%-57%) using AJCC 7 and AJCC 8 criteria, respectively. The concordance for cases of T1b or greater increased from 72% (95% CI, 69%-75%) to 78% (95% CI, 75%-80%). Intraobserver reproducibility of diagnoses also improved, increasing from 59% (95% CI, 56%-63%) to 64% (95% CI, 62%-67%) for T1a invasive melanoma, and from 74% (95% CI, 71%-76%) to 77% (95% CI, 74%-79%) for T1b or greater invasive melanoma cases. CONCLUSIONS AND RELEVANCE Melanoma staging in AJCC 8 shows greater reproducibility and higher concordance with a reference standard. Improved classification of invasive melanoma can be expected after implementation of AJCC 8, suggesting a positive impact on patients. However, despite improvement, concordance and reproducibility remain low.
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Affiliation(s)
- Joann G. Elmore
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Raymond L. Barnhill
- Department of Pathology, Institut Curie, Paris, France
- Paris Sciences and Lettres Research University, Paris, France
- Faculty of Medicine, University of Paris Descartes, Paris, France
| | | | - Gary M. Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Linda J. Titus
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Martin A. Weinstock
- Center for Dermatoepidemiology, Providence Veterans Affair Medical Center, Providence, Rhode Island
- Department of Dermatology, Brown University, Providence, Rhode Island
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Margaret S. Pepe
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Heidi D. Nelson
- Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health and Science University, Portland
- Department of Medicine, School of Medicine, Oregon Health and Science University, Portland
| | - Lisa M. Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Andrea C. Radick
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Michael W. Piepkorn
- Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
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Nelson HD, Lui L, Ensrud K, Cummings SR, Cauley JA, Hillier TA. Associations of Smoking, Moderate Alcohol Use, and Function: A 20-Year Cohort Study of Older Women. Gerontol Geriatr Med 2018; 4:2333721418766127. [PMID: 29619404 PMCID: PMC5871045 DOI: 10.1177/2333721418766127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 12/12/2017] [Revised: 02/09/2018] [Accepted: 02/15/2018] [Indexed: 11/20/2022] Open
Abstract
Objective: The objective of this study is to determine whether the health effects of smoking and moderate alcohol use persist with aging. Method: Smoking status, alcohol use, and measures of function and health were obtained from 9,704 women aged ≥65 years at baseline and over 10- and 20-year follow-up periods. Adjusted multiple linear and logistic regression and Cox proportional hazard models estimated associations. Results: Current versus never smokers had worse walking speed, self-reported health, difficulty with instrumental activities of daily living (IADLs), and depression at 10 years and higher death rates at 10 and 20 years. Moderate versus never drinkers had better grip strength, walking speed, self-reported health, and less difficulty with IADLs and were less likely to live in nursing homes at 10 years and die at 10 and 20 years. Discussion: Among aging women over 20 years, smoking is associated with worse physical function, including death, while moderate alcohol use is associated with better outcomes.
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Affiliation(s)
| | - Lily Lui
- California Pacific Medical Center, San Francisco, CA, USA
| | - Kris Ensrud
- University of Minnesota, Minneapolis, MN, USA
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Radick AC, Phipps AI, Piepkorn MW, Nelson HD, Barnhill RL, Elder DE, Reisch LM, Frederick PD, Elmore JG. Characteristics and diagnostic performance of pathologists who enjoy interpreting melanocytic lesions. Dermatol Online J 2018. [DOI: 10.5070/d3246040708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Abstract
OBJECTIVE Suicide rates in veteran and military populations in the United States are high. This article reviews studies of the accuracy of methods to identify individuals at increased risk of suicide and the effectiveness and adverse effects of health care interventions relevant to U.S. veteran and military populations in reducing suicide and suicide attempts. METHODS Trials, observational studies, and systematic reviews relevant to U.S. veterans and military personnel were identified in searches of MEDLINE, PsycINFO, SocINDEX, and Cochrane databases (January 1, 2008, to September 11, 2015), on Web sites, and in reference lists. Investigators extracted and confirmed data and dual-rated risk of bias for included studies. RESULTS Nineteen studies evaluated accuracy of risk assessment methods, including models using retrospective electronic records data and clinician- or patient-rated instruments. Most methods demonstrated sensitivity ≥80% or area-under-the-curve values ≥.70 in single studies, including two studies based on electronic records of veterans and military personnel, but specificity varied. Suicide rates were reduced in six of eight observational studies of population-level interventions. Only two of ten trials of individual-level psychotherapy reported statistically significant differences between treatment and usual care. CONCLUSIONS Risk assessment methods have been shown to be sensitive predictors of suicide and suicide attempts, but the frequency of false positives limits their clinical utility. Research to refine these methods and examine clinical applications is needed. Studies of suicide prevention interventions are inconclusive; trials of population-level interventions and promising therapies are required to support their clinical use.
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Affiliation(s)
- Heidi D Nelson
- Dr. Nelson and Dr. Kansagara are with the Department of Medical Informatics and Clinical Epidemiology and Dr. Denneson, Dr. O'Neil, and Dr. Teo are with the Department of Psychiatry, all in the School of Medicine at Oregon Health and Science University, Portland. Dr. Denneson, Dr. O'Neil, Dr. Kansagara, and Dr. Teo are also with the Center to Improve Veteran Involvement in Care, Portland Department of Veterans Affairs Medical Center, Portland, Oregon, where Ms. Low is affiliated. Mr. Bauer is with the Department of Psychology, University of Southern Mississippi, Hattiesburg
| | - Lauren M Denneson
- Dr. Nelson and Dr. Kansagara are with the Department of Medical Informatics and Clinical Epidemiology and Dr. Denneson, Dr. O'Neil, and Dr. Teo are with the Department of Psychiatry, all in the School of Medicine at Oregon Health and Science University, Portland. Dr. Denneson, Dr. O'Neil, Dr. Kansagara, and Dr. Teo are also with the Center to Improve Veteran Involvement in Care, Portland Department of Veterans Affairs Medical Center, Portland, Oregon, where Ms. Low is affiliated. Mr. Bauer is with the Department of Psychology, University of Southern Mississippi, Hattiesburg
| | - Allison R Low
- Dr. Nelson and Dr. Kansagara are with the Department of Medical Informatics and Clinical Epidemiology and Dr. Denneson, Dr. O'Neil, and Dr. Teo are with the Department of Psychiatry, all in the School of Medicine at Oregon Health and Science University, Portland. Dr. Denneson, Dr. O'Neil, Dr. Kansagara, and Dr. Teo are also with the Center to Improve Veteran Involvement in Care, Portland Department of Veterans Affairs Medical Center, Portland, Oregon, where Ms. Low is affiliated. Mr. Bauer is with the Department of Psychology, University of Southern Mississippi, Hattiesburg
| | - Brian W Bauer
- Dr. Nelson and Dr. Kansagara are with the Department of Medical Informatics and Clinical Epidemiology and Dr. Denneson, Dr. O'Neil, and Dr. Teo are with the Department of Psychiatry, all in the School of Medicine at Oregon Health and Science University, Portland. Dr. Denneson, Dr. O'Neil, Dr. Kansagara, and Dr. Teo are also with the Center to Improve Veteran Involvement in Care, Portland Department of Veterans Affairs Medical Center, Portland, Oregon, where Ms. Low is affiliated. Mr. Bauer is with the Department of Psychology, University of Southern Mississippi, Hattiesburg
| | - Maya O'Neil
- Dr. Nelson and Dr. Kansagara are with the Department of Medical Informatics and Clinical Epidemiology and Dr. Denneson, Dr. O'Neil, and Dr. Teo are with the Department of Psychiatry, all in the School of Medicine at Oregon Health and Science University, Portland. Dr. Denneson, Dr. O'Neil, Dr. Kansagara, and Dr. Teo are also with the Center to Improve Veteran Involvement in Care, Portland Department of Veterans Affairs Medical Center, Portland, Oregon, where Ms. Low is affiliated. Mr. Bauer is with the Department of Psychology, University of Southern Mississippi, Hattiesburg
| | - Devan Kansagara
- Dr. Nelson and Dr. Kansagara are with the Department of Medical Informatics and Clinical Epidemiology and Dr. Denneson, Dr. O'Neil, and Dr. Teo are with the Department of Psychiatry, all in the School of Medicine at Oregon Health and Science University, Portland. Dr. Denneson, Dr. O'Neil, Dr. Kansagara, and Dr. Teo are also with the Center to Improve Veteran Involvement in Care, Portland Department of Veterans Affairs Medical Center, Portland, Oregon, where Ms. Low is affiliated. Mr. Bauer is with the Department of Psychology, University of Southern Mississippi, Hattiesburg
| | - Alan R Teo
- Dr. Nelson and Dr. Kansagara are with the Department of Medical Informatics and Clinical Epidemiology and Dr. Denneson, Dr. O'Neil, and Dr. Teo are with the Department of Psychiatry, all in the School of Medicine at Oregon Health and Science University, Portland. Dr. Denneson, Dr. O'Neil, Dr. Kansagara, and Dr. Teo are also with the Center to Improve Veteran Involvement in Care, Portland Department of Veterans Affairs Medical Center, Portland, Oregon, where Ms. Low is affiliated. Mr. Bauer is with the Department of Psychology, University of Southern Mississippi, Hattiesburg
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Marchioro A, Whitham PJ, Nelson HD, De Siena MC, Knowles KE, Polinger VZ, Reid PJ, Gamelin DR. Strong Dependence of Quantum-Dot Delayed Luminescence on Excitation Pulse Width. J Phys Chem Lett 2017; 8:3997-4003. [PMID: 28763227 DOI: 10.1021/acs.jpclett.7b01426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- Arianna Marchioro
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Patrick J. Whitham
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Heidi D. Nelson
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Michael C. De Siena
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Kathryn E. Knowles
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Victor Z. Polinger
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Philip J. Reid
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Daniel R. Gamelin
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
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Tosteson ANA, Yang Q, Nelson HD, Longton G, Soneji SS, Pepe M, Geller B, Carney PA, Onega T, Allison KH, Elmore JG, Weaver DL. Second opinion strategies in breast pathology: a decision analysis addressing over-treatment, under-treatment, and care costs. Breast Cancer Res Treat 2017; 167:195-203. [PMID: 28879558 DOI: 10.1007/s10549-017-4432-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 07/29/2017] [Indexed: 02/06/2023]
Abstract
PURPOSE To estimate the potential near-term population impact of alternative second opinion breast biopsy pathology interpretation strategies. METHODS Decision analysis examining 12-month outcomes of breast biopsy for nine breast pathology interpretation strategies in the U.S. health system. Diagnoses of 115 practicing pathologists in the Breast Pathology Study were compared to reference-standard-consensus diagnoses with and without second opinions. Interpretation strategies were defined by whether a second opinion was sought universally or selectively (e.g., 2nd opinion if invasive). Main outcomes were the expected proportion of concordant breast biopsy diagnoses, the proportion involving over- or under-interpretation, and cost of care in U.S. dollars within one-year of biopsy. RESULTS Without a second opinion, 92.2% of biopsies received a concordant diagnosis. Concordance rates increased under all second opinion strategies, and the rate was highest (95.1%) and under-treatment lowest (2.6%) when all biopsies had second opinions. However, over-treatment was lowest when second opinions were sought selectively for initial diagnoses of invasive cancer, DCIS, or atypia (1.8 vs. 4.7% with no 2nd opinions). This strategy also had the lowest projected 12-month care costs ($5.907 billion vs. $6.049 billion with no 2nd opinions). CONCLUSIONS Second opinion strategies could lower overall care costs while reducing both over- and under-treatment. The most accurate cost-saving strategy required second opinions for initial diagnoses of invasive cancer, DCIS, or atypia.
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Affiliation(s)
- Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, One Medical Center Drive Level 5 WTRB, Lebanon, NH, 03756, USA.
| | - Qian Yang
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health Sciences University, Portland, OR, USA
| | - Gary Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Samir S Soneji
- The Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, One Medical Center Drive Level 5 WTRB, Lebanon, NH, 03756, USA
| | - Margaret Pepe
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Berta Geller
- Department of Family Medicine, University of Vermont, Burlington, VT, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health Sciences University, Portland, OR, USA
| | - Tracy Onega
- Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Donald L Weaver
- Department of Pathology, UVM Cancer Center, University of Vermont, Burlington, VT, USA
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Lott JP, Wang Q, Titus LJ, Onega T, Nelson HD, Weinstock MA, Elmore JG, Tosteson ANA. Temporal trends in healthcare utilization following primary melanoma diagnosis among Medicare beneficiaries. Br J Dermatol 2017; 177:845-853. [PMID: 28369774 DOI: 10.1111/bjd.15530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Little is known about the impact of primary melanoma diagnosis on healthcare utilization and changes in utilization over time. OBJECTIVES To evaluate population-based temporal trends in healthcare utilization following primary melanoma diagnosis. METHODS We conducted a before-and-after multiple time series study of Medicare beneficiaries aged ≥ 66 years with primary melanoma diagnoses between 2000 and 2009 using the Surveillance, Epidemiology, and End Results Medicare database. Primary exposure was time from primary melanoma diagnosis at 3-6 months and 6-24 months postdiagnosis. Covariates included tumour-, patient- and geographical-level characteristics and healthcare utilization in the 6 months before diagnosis. Poisson regression was used to estimate population-based risk-adjusted utilization rates for skin biopsies, benign skin excisions, internal medicine office visits and dermatology office visits. RESULTS The study population included 56 254 patients with first diagnoses of primary melanoma. Most patients were ≥ 75 years old (56·8%), male (62·1%), and had in situ melanoma (42·4%) or localized invasive melanoma (45·9%). From 2000 to 2009, risk-adjusted skin biopsy rates 24 months postdiagnosis increased from 358·3 to 541·3 per 1000 person-years (P < 0·001), and dermatology visits increased from 989·0 to 1535·6 per 1000 person-years (P < 0·001). Benign excisions and internal medicine visits remained stable. In 2000, risk-adjusted skin biopsy rates 6 months postdiagnosis increased by 208·5 relative to the 6 months before diagnosis (148·7 vs. 357·2) compared with an observed absolute increase of 272·5 (290·9 vs. 563·1) in 2009. Trends in dermatology visits were similar. CONCLUSIONS Utilization of skin biopsies and dermatology office visits following primary melanoma diagnosis has increased substantially over time. These results may inform optimization of care delivery for melanoma within the Medicare population.
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Affiliation(s)
- J P Lott
- Cornell Scott-Hill Health Center, New Haven, CT, U.S.A
| | - Q Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Norris Cotton Cancer Center, Lebanon, NH, U.S.A
| | - L J Titus
- Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - T Onega
- Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - H D Nelson
- Pacific Northwest Evidence-Based Practice Center, Oregon Health & Science University, Portland, OR, U.S.A.,Department of Medical Informatics, Oregon Health & Science University, Portland, OR, U.S.A.,Department of Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR, U.S.A.,Providence Cancer Center, Providence Health and Services, Portland, OR, U.S.A
| | - M A Weinstock
- Dermatoepidemiology Unit, US Department of Veterans Affairs Medical Center, Providence, RI, U.S.A.,Department of Dermatology, Rhode Island Hospital, Providence, RI, U.S.A.,Department of Dermatology, Brown University School of Medicine, Providence, RI, U.S.A.,Department of Epidemiology, Brown University School of Medicine, Providence, RI, U.S.A
| | - J G Elmore
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, U.S.A
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
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Elmore JG, Barnhill RL, Elder DE, Longton GM, Pepe MS, Reisch LM, Carney PA, Titus LJ, Nelson HD, Onega T, Tosteson ANA, Weinstock MA, Knezevich SR, Piepkorn MW. Pathologists' diagnosis of invasive melanoma and melanocytic proliferations: observer accuracy and reproducibility study. BMJ 2017; 357:j2813. [PMID: 28659278 PMCID: PMC5485913 DOI: 10.1136/bmj.j2813] [Citation(s) in RCA: 242] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 12/22/2022]
Abstract
Objective To quantify the accuracy and reproducibility of pathologists' diagnoses of melanocytic skin lesions.Design Observer accuracy and reproducibility study.Setting 10 US states.Participants Skin biopsy cases (n=240), grouped into sets of 36 or 48. Pathologists from 10 US states were randomized to independently interpret the same set on two occasions (phases 1 and 2), at least eight months apart.Main outcome measures Pathologists' interpretations were condensed into five classes: I (eg, nevus or mild atypia); II (eg, moderate atypia); III (eg, severe atypia or melanoma in situ); IV (eg, pathologic stage T1a (pT1a) early invasive melanoma); and V (eg, ≥pT1b invasive melanoma). Reproducibility was assessed by intraobserver and interobserver concordance rates, and accuracy by concordance with three reference diagnoses.Results In phase 1, 187 pathologists completed 8976 independent case interpretations resulting in an average of 10 (SD 4) different diagnostic terms applied to each case. Among pathologists interpreting the same cases in both phases, when pathologists diagnosed a case as class I or class V during phase 1, they gave the same diagnosis in phase 2 for the majority of cases (class I 76.7%; class V 82.6%). However, the intraobserver reproducibility was lower for cases interpreted as class II (35.2%), class III (59.5%), and class IV (63.2%). Average interobserver concordance rates were lower, but with similar trends. Accuracy using a consensus diagnosis of experienced pathologists as reference varied by class: I, 92% (95% confidence interval 90% to 94%); II, 25% (22% to 28%); III, 40% (37% to 44%); IV, 43% (39% to 46%); and V, 72% (69% to 75%). It is estimated that at a population level, 82.8% (81.0% to 84.5%) of melanocytic skin biopsy diagnoses would have their diagnosis verified if reviewed by a consensus reference panel of experienced pathologists, with 8.0% (6.2% to 9.9%) of cases overinterpreted by the initial pathologist and 9.2% (8.8% to 9.6%) underinterpreted.Conclusion Diagnoses spanning moderately dysplastic nevi to early stage invasive melanoma were neither reproducible nor accurate in this large study of pathologists in the USA. Efforts to improve clinical practice should include using a standardized classification system, acknowledging uncertainty in pathology reports, and developing tools such as molecular markers to support pathologists' visual assessments.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98104, USA
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie Institute Hospital, University of Paris Descartes Faculty of Medicine University, Paris, France
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Gary M Longton
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Margaret S Pepe
- Program in Biostatistics, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lisa M Reisch
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98104, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Linda J Titus
- Departments of Epidemiology and Pediatrics, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Heidi D Nelson
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
- Providence Cancer Center, Providence Health and Services, Portland, OR, USA
| | - Tracy Onega
- Geisel School of Medicine at Dartmouth, Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Biomedical Data Science, Department of Epidemiology, Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Anna N A Tosteson
- Departments of Medicine and Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Martin A Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, RI, USA
- Departments of Dermatology and Epidemiology, Brown University, Providence, RI, USA
| | | | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Dermatopathology Northwest, Bellevue, WA, USA
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Onega T, Weaver DL, Frederick PD, Allison KH, Tosteson ANA, Carney PA, Geller BM, Longton GM, Nelson HD, Oster NV, Pepe MS, Elmore JG. The diagnostic challenge of low-grade ductal carcinoma in situ. Eur J Cancer 2017; 80:39-47. [PMID: 28535496 DOI: 10.1016/j.ejca.2017.04.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/30/2017] [Accepted: 04/05/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Diagnostic agreement among pathologists is 84% for ductal carcinoma in situ (DCIS). Studies of interpretive variation according to grade are limited. METHODS A national sample of 115 pathologists interpreted 240 breast pathology test set cases in the Breast Pathology Study and their interpretations were compared to expert consensus interpretations. We assessed agreement of pathologists' interpretations with a consensus reference diagnosis of DCIS dichotomised into low- and high-grade lesions. Generalised estimating equations were used in logistic regression models of rates of under- and over-interpretation of DCIS by grade. RESULTS We evaluated 2097 independent interpretations of DCIS (512 low-grade DCIS and 1585 high-grade DCIS). Agreement with reference diagnoses was 46% (95% confidence interval [CI] 42-51) for low-grade DCIS and 83% (95% CI 81-86) for high-grade DCIS. The proportion of reference low-grade DCIS interpretations over-interpreted by pathologists (i.e. categorised as either high-grade DCIS or invasive cancer) was 23% (95% CI 19-28); 30% (95% CI 26-34) were interpreted as a lower diagnostic category (atypia or benign proliferative). Reference high-grade DCIS was under-interpreted in 14% (95% CI 12-16) of observations and only over-interpreted 3% (95% CI 2-4). CONCLUSION Grade is a major factor when examining pathologists' variability in diagnosing DCIS, with much lower agreement for low-grade DCIS cases compared to high-grade. These findings support the hypothesis that low-grade DCIS poses a greater interpretive challenge than high-grade DCIS, which should be considered when developing DCIS management strategies.
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Affiliation(s)
- Tracy Onega
- Department of Biomedical Data Science, Department of Epidemiology, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
| | - Donald L Weaver
- Department of Pathology, University of Vermont and UVM Cancer Center, Burlington, VT, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Anna N A Tosteson
- Department of Medicine, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, VT 05401, USA
| | - Gary M Longton
- Department of Biostatistics, University of Washington, Seattle, WA 98101, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Department of Medical Informatics and Clinical Epidemiology and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Natalia V Oster
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Margaret S Pepe
- Department of Biostatistics, University of Washington, Seattle, WA 98101, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Samples LS, Rendi MH, Frederick PD, Allison KH, Nelson HD, Morgan TR, Weaver DL, Elmore JG. Surgical implications and variability in the use of the flat epithelial atypia diagnosis on breast biopsy specimens. Breast 2017; 34:34-43. [PMID: 28475933 DOI: 10.1016/j.breast.2017.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/31/2017] [Accepted: 04/06/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Flat epithelial atypia (FEA) is a relatively new diagnostic term with uncertain clinical significance for surgical management. Any implied risk of invasive breast cancer associated with FEA is contingent upon diagnostic reproducibility, yet little is known regarding its use. MATERIALS AND METHODS Pathologists in the Breast Pathology Study interpreted one of four 60-case test sets, one slide per case, constructed from 240 breast biopsy specimens. An electronic data form with standardized diagnostic categories was used; participants were instructed to indicate all diagnoses present. We assessed participants' use of FEA as a diagnostic term within: 1) each test set; 2) 72 cases classified by reference as benign without FEA; and 3) six cases classified by reference as FEA. 115 pathologists participated, providing 6900 total independent assessments. RESULTS Notation of FEA ranged from 0% to 35% of the cases interpreted, with most pathologists noting FEA on 4 or more test cases. At least one participant noted FEA in 34 of the 72 benign non-FEA cases. For the 6 reference FEA cases, participant agreement with the case reference FEA diagnosis ranged from 17% to 52%; diagnoses noted by participating pathologists for these FEA cases included columnar cell hyperplasia, usual ductal hyperplasia, atypical lobular hyperplasia, and atypical ductal hyperplasia. CONCLUSIONS We observed wide variation in the diagnosis of FEA among U.S. pathologists. This suggests that perceptions of diagnostic criteria and any implied risk associated with FEA may also vary. Surgical excision following a core biopsy diagnosis of FEA should be reconsidered and studied further.
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Affiliation(s)
- Laura S Samples
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Mara H Rendi
- Department of Pathology, University of Washington School of Medicine, 1959 NE Pacific St., Box 356100, Seattle, WA, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, 300 Pasteur Drive, Lane 235, Stanford, CA 94305, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code FM, Portland, OR 97239, USA
| | - Thomas R Morgan
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Given Courtyard, 89 Beaumont Ave, Burlington, VT 05405, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, 325 Ninth Ave, Box 359780, Seattle, WA 98104, USA.
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Nelson HD, Hinterding SOM, Fainblat R, Creutz SE, Li X, Gamelin DR. Mid-Gap States and Normal vs Inverted Bonding in Luminescent Cu+- and Ag+-Doped CdSe Nanocrystals. J Am Chem Soc 2017; 139:6411-6421. [DOI: 10.1021/jacs.7b01924] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Heidi D. Nelson
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Stijn O. M. Hinterding
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Rachel Fainblat
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Sidney E. Creutz
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Xiaosong Li
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Daniel R. Gamelin
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
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Geller BM, Nelson HD, Weaver DL, Frederick PD, Allison KH, Onega T, Carney PA, Tosteson ANA, Elmore JG. Characteristics associated with requests by pathologists for second opinions on breast biopsies. J Clin Pathol 2017; 70:947-953. [PMID: 28465449 DOI: 10.1136/jclinpath-2016-204231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 03/22/2017] [Accepted: 03/29/2017] [Indexed: 01/14/2023]
Abstract
AIMS Second opinions in pathology improve patient safety by reducing diagnostic errors, leading to more appropriate clinical treatment decisions. Little objective data are available regarding the factors triggering a request for second opinion despite second opinion consultations being part of the diagnostic system of pathology. Therefore we sought to assess breast biopsy cases and interpreting pathologists characteristics associated with second opinion requests. METHODS Collected pathologist surveys and their interpretations of 60 test set cases were used to explore the relationships between case characteristics, pathologist characteristics and case perceptions, and requests for second opinions. Data were evaluated by logistic regression and generalised estimating equations. RESULTS 115 pathologists provided 6900 assessments; pathologists requested second opinions on 70% (4827/6900) of their assessments 36% (1731/4827) of these would not have been required by policy. All associations between case characteristics and requesting second opinions were statistically significant, including diagnostic category, breast density, biopsy type, and number of diagnoses noted per case. Exclusive of institutional policies, pathologists wanted second opinions most frequently for atypia (66%) and least frequently for invasive cancer (20%). Second opinion rates were higher when the pathologist had lower assessment confidence, in cases with higher perceived difficulty, and cases with borderline diagnoses. CONCLUSIONS Pathologists request second opinions for challenging cases, particularly those with atypia, high breast density, core needle biopsies, or many co-existing diagnoses. Further studies should evaluate whether the case characteristics identified in this study could be used as clinical criteria to prompt system-level strategies for mandating second opinions.
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Affiliation(s)
- Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, Vermont, USA
| | - Heidi D Nelson
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University; and Providence Cancer Center, Portland, Oregon, USA
| | - Donald L Weaver
- Department of Pathology, University of Vermont and UVM Cancer Center, Burlington, Vermont, USA
| | - Paul D Frederick
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Tracy Onega
- Departments of Biomedical Data Science and Epidemiology, Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, New Hampshire, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Anna N A Tosteson
- Norris Cotton Cancer Center and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, New Hampshire, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Elmore JG, Longton GM, Pepe MS, Carney PA, Nelson HD, Allison KH, Geller BM, Onega T, Tosteson ANA, Mercan E, Shapiro LG, Brunyé TT, Morgan TR, Weaver DL. A Randomized Study Comparing Digital Imaging to Traditional Glass Slide Microscopy for Breast Biopsy and Cancer Diagnosis. J Pathol Inform 2017; 8:12. [PMID: 28382226 PMCID: PMC5364740 DOI: 10.4103/2153-3539.201920] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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: 10/27/2016] [Accepted: 01/18/2017] [Indexed: 01/19/2023] Open
Abstract
Background: Digital whole slide imaging may be useful for obtaining second opinions and is used in many countries. However, the U.S. Food and Drug Administration requires verification studies. Methods: Pathologists were randomized to interpret one of four sets of breast biopsy cases during two phases, separated by ≥9 months, using glass slides or digital format (sixty cases per set, one slide per case, n = 240 cases). Accuracy was assessed by comparing interpretations to a consensus reference standard. Intraobserver reproducibility was assessed by comparing the agreement of interpretations on the same cases between two phases. Estimated probabilities of confirmation by a reference panel (i.e., predictive values) were obtained by incorporating data on the population prevalence of diagnoses. Results: Sixty-five percent of responding pathologists were eligible, and 252 consented to randomization; 208 completed Phase I (115 glass, 93 digital); and 172 completed Phase II (86 glass, 86 digital). Accuracy was slightly higher using glass compared to digital format and varied by category: invasive carcinoma, 96% versus 93% (P = 0.04); ductal carcinoma in situ (DCIS), 84% versus 79% (P < 0.01); atypia, 48% versus 43% (P = 0.08); and benign without atypia, 87% versus 82% (P < 0.01). There was a small decrease in intraobserver agreement when the format changed compared to when glass slides were used in both phases (P = 0.08). Predictive values for confirmation by a reference panel using glass versus digital were: invasive carcinoma, 98% and 97% (not significant [NS]); DCIS, 70% and 57% (P = 0.007); atypia, 38% and 28% (P = 0.002); and benign without atypia, 97% and 96% (NS). Conclusions: In this large randomized study, digital format interpretations were similar to glass slide interpretations of benign and invasive cancer cases. However, cases in the middle of the spectrum, where more inherent variability exists, may be more problematic in digital format. Future studies evaluating the effect these findings exert on clinical practice and patient outcomes are required.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Gary M Longton
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Margaret S Pepe
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; Department of Biostatistics, University of Washington School of Public Health, Seattle, WA 98104, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, OR 97239, USA
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR 97239, USA; Providence Cancer Center, Providence Health and Services Oregon, Portland, OR 97213, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, VT 05405, USA
| | - Tracy Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Ezgi Mercan
- Department of Computer Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Linda G Shapiro
- Department of Computer Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Tad T Brunyé
- Department of Psychology, Tufts University, Medford, MA 02155, USA
| | - Thomas R Morgan
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Donald L Weaver
- Department of Pathology, UVM Cancer Center, University of Vermont, Burlington, VT 05405, USA
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Weinstock MA, Lott JP, Wang Q, Titus LJ, Onega T, Nelson HD, Pearson L, Piepkorn M, Barnhill RL, Elmore JG, Tosteson ANA. Skin biopsy utilization and melanoma incidence among Medicare beneficiaries. Br J Dermatol 2017; 176:949-954. [PMID: 27639256 DOI: 10.1111/bjd.15077] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Melanoma incidence has increased in recent decades in the U.S.A. Uncertainty remains regarding how much of this increase is attributable to greater melanoma screening activities, potential detection bias and overdiagnosis. OBJECTIVES To use a cross-sectional ecological analysis to evaluate the relationship between skin biopsy and melanoma incidence rates over a more recent time period than prior reports. METHODS Examination of the association of biopsy rates and melanoma incidence (invasive and in situ) in SEER-Medicare data (including 10 states) for 2002-2009. RESULTS The skin biopsy rate increased by approximately 50% (6% per year) throughout this 8-year period, from 7012 biopsies per 100 000 persons in 2002 to 10 528 biopsies per 100 000 persons in 2009. The overall melanoma incidence rate increased approximately 4% (< 1% per year) over the same time period. The incidence of melanoma in situ increased approximately 10% (1% per year), while the incidence of invasive melanoma increased from 2002 to 2005 then decreased from 2006 to 2009. Regression models estimated that, on average, for every 1000 skin biopsies performed, an additional 5·2 (95% confidence interval 4·1-6·3) cases of melanoma in situ were diagnosed and 8·1 (95% confidence interval 6·7-9·5) cases of invasive melanoma were diagnosed. When considering individual states, some demonstrated a positive association between biopsy rate and invasive melanoma incidence, others an inverse association, and still others a more complex pattern. CONCLUSIONS Increased skin biopsies over time are associated with increased diagnosis of in situ melanoma, but the association with invasive melanoma is more complex.
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Affiliation(s)
- M A Weinstock
- Center for Dermatoepidemiology, US Department of Veterans Affairs Medical Center, Providence, RI, U.S.A.,Department of Dermatology, Rhode Island Hospital, Providence, RI, U.S.A.,Departments of Dermatology and Epidemiology, Brown University, Providence, RI, U.S.A
| | - J P Lott
- Cornell Scott-Hill Health Center, New Haven, CT, U.S.A
| | - Q Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - L J Titus
- Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - T Onega
- Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - H D Nelson
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR, U.S.A.,Providence Cancer Center, Providence Health and Services, Portland, OR, U.S.A
| | - L Pearson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
| | - M Piepkorn
- Department of Medicine, Division of Dermatology, University of Washington School of Medicine, Seattle, WA, U.S.A.,Dermatopathology Northwest, Bellevue, WA, U.S.A
| | - R L Barnhill
- Department of Pathology, Institut Curie, and Faculty of Medicine, University of Paris Descartes, Paris, France
| | - J G Elmore
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, U.S.A
| | - A N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A.,Norris Cotton Cancer Center, Lebanon, NH, U.S.A.,Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, U.S.A
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Onega T, Reisch LM, Frederick PD, Geller BM, Nelson HD, Lott JP, Radick AC, Elder DE, Barnhill RL, Piepkorn MW, Elmore JG. Use of Digital Whole Slide Imaging in Dermatopathology. J Digit Imaging 2017; 29:243-53. [PMID: 26546178 DOI: 10.1007/s10278-015-9836-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 11/26/2022] Open
Abstract
Digital whole slide imaging (WSI) is an emerging technology for pathology interpretation, with specific challenges for dermatopathology, yet little is known about pathologists' practice patterns or perceptions regarding WSI for interpretation of melanocytic lesions. A national sample of pathologists (N = 207) was recruited from 864 invited pathologists from ten US states (CA, CT, HI, IA, KY, LA, NJ, NM, UT, and WA). Pathologists who had interpreted melanocytic lesions in the past year were surveyed in this cross-sectional study. The survey included questions on pathologists' experience, WSI practice patterns and perceptions using a 6-point Likert scale. Agreement was summarized with descriptive statistics to characterize pathologists' use and perceptions of WSI. The majority of participating pathologists were between 40 and 59 years of age (62%) and not affiliated with an academic medical center (71%). Use of WSI was seen more often among dermatopathologists and participants affiliated with an academic medical center. Experience with WSI was reported by 41%, with the most common type of use being for education and testing (CME, board exams, and teaching in general, 71%), and clinical use at tumor boards and conferences (44%). Most respondents (77%) agreed that accurate diagnoses can be made with this technology, and 59% agreed that benefits of WSI outweigh concerns. However, 78% of pathologists reported that digital slides are too slow for routine clinical interpretation. The respondents were equally split as to whether they would like to adopt WSI (49%) or not (51%). The majority of pathologists who interpret melanocytic lesions do not use WSI, but among pathologists who do, use is largely for CME, licensure/board exams, and teaching. Positive perceptions regarding WSI slightly outweigh negative perceptions. Understanding practice patterns with WSI as dissemination advances may facilitate concordance of perceptions with adoption of the technology.
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Affiliation(s)
- Tracy Onega
- Department of Biomedical Data Science, Department of Epidemiology, Norris Cotton Cancer Center, Lebanon, NH, USA.
- Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
| | | | | | - Berta M Geller
- Department of Family Medicine, University of Vermont Burlington, Burlington, VT, USA
| | | | | | | | - David E Elder
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie, Paris, France
- University of California, Los Angeles, CA, USA
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Dermatopathology Northwest, Bellevue, WA, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington, Seattle, WA, USA
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Titus L, Barnhill RL, Lott JP, Piepkorn MW, Elder DE, Chb MB, Frederick PD, Nelson HD, Carney PA, Knezevich SR, Weinstock MA, Elmore JG. The influence of tumor regression, solar elastosis, and patient age on pathologists' interpretation of melanocytic skin lesions. J Transl Med 2017; 97:187-193. [PMID: 27892931 PMCID: PMC5280085 DOI: 10.1038/labinvest.2016.120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 09/12/2016] [Accepted: 10/11/2016] [Indexed: 11/09/2022] Open
Abstract
It is not known whether patient age or tumor characteristics such as tumor regression or solar elastosis influence pathologists' interpretation of melanocytic skin lesions (MSLs). We undertook a study to determine the influence of these factors, and to explore pathologist's characteristics associated with the direction of diagnosis. To meet our objective, we designed a cross-sectional survey study of pathologists' clinical practices and perceptions. Pathologists were recruited from diverse practices in 10 states in the United States. We enrolled 207 pathologist participants whose practice included the interpretation of MSLs. Our findings indicated that the majority of pathologists (54.6%) were influenced toward a less severe diagnosis when patients were <30 years of age. Most pathologists were influenced toward a more severe diagnosis when patients were >70 years of age, or by the presence of tumor regression or solar elastosis (58.5%, 71.0%, and 57.0%, respectively). Generally, pathologists with dermatopathology board certification and/or a high caseload of MSLs were more likely to be influenced, whereas those with more years' experience interpreting MSL were less likely to be influenced. Our findings indicate that the interpretation of MSLs is influenced by patient age, tumor regression, and solar elastosis; such influence is associated with dermatopathology training and higher caseload, consistent with expertise and an appreciation of lesion complexity.
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Affiliation(s)
- Linda Titus
- Departments of Epidemiology and of Pediatrics, Geisel School of Medicine at Dartmouth, and the Norris Cotton Cancer Center, Lebanon, NH
| | - Raymond L. Barnhill
- Departments of Pathology, Institut Curie and Faculty of Medicine, University of Paris Descartes, Paris, France
| | | | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Dermatopathology Northwest, Bellevue, WA
| | | | - MB Chb
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Paul D. Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Heidi D. Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR
| | - Patricia A. Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | | | - Martin A. Weinstock
- Center for Dermatoepidemiology, VA Medical Center, Providence Department of Dermatology, Rhode Island Hospital; Departments of Dermatology and Epidemiology, Brown University, Providence, RI
| | - Joann G. Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
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Jackson SL, Frederick PD, Pepe MS, Nelson HD, Weaver DL, Allison KH, Carney PA, Geller BM, Tosteson ANA, Onega T, Elmore JG. Diagnostic Reproducibility: What Happens When the Same Pathologist Interprets the Same Breast Biopsy Specimen at Two Points in Time? Ann Surg Oncol 2016; 24:1234-1241. [PMID: 27913946 DOI: 10.1245/s10434-016-5695-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgeons may receive a different diagnosis when a breast biopsy is interpreted by a second pathologist. The extent to which diagnostic agreement by the same pathologist varies at two time points is unknown. METHODS Pathologists from eight U.S. states independently interpreted 60 breast specimens, one glass slide per case, on two occasions separated by ≥9 months. Reproducibility was assessed by comparing interpretations between the two time points; associations between reproducibility (intraobserver agreement rates); and characteristics of pathologists and cases were determined and also compared with interobserver agreement of baseline interpretations. RESULTS Sixty-five percent of invited, responding pathologists were eligible and consented; 49 interpreted glass slides in both study phases, resulting in 2940 interpretations. Intraobserver agreement rates between the two phases were 92% [95% confidence interval (CI) 88-95] for invasive breast cancer, 84% (95% CI 81-87) for ductal carcinoma-in-situ, 53% (95% CI 47-59) for atypia, and 84% (95% CI 81-86) for benign without atypia. When comparing all study participants' case interpretations at baseline, interobserver agreement rates were 89% (95% CI 84-92) for invasive cancer, 79% (95% CI 76-81) for ductal carcinoma-in-situ, 43% (95% CI 41-45) for atypia, and 77% (95% CI 74-79) for benign without atypia. CONCLUSIONS Interpretive agreement between two time points by the same individual pathologist was low for atypia and was similar to observed rates of agreement for atypia between different pathologists. Physicians and patients should be aware of the diagnostic challenges associated with a breast biopsy diagnosis of atypia when considering treatment and surveillance decisions.
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Affiliation(s)
- Sara L Jackson
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Margaret S Pepe
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, Portland, USA.,Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, USA
| | - Donald L Weaver
- Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, USA
| | - Anna N A Tosteson
- Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, USA.,Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Tracy Onega
- Department of Community and Family Medicine, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, USA
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Elmore JG, Tosteson AN, Pepe MS, Longton GM, Nelson HD, Geller B, Carney PA, Onega T, Allison KH, Jackson SL, Weaver DL. Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study. BMJ 2016; 353:i3069. [PMID: 27334105 PMCID: PMC4916777 DOI: 10.1136/bmj.i3069] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate the potential effect of second opinions on improving the accuracy of diagnostic interpretation of breast histopathology. DESIGN Simulation study. SETTING 12 different strategies for acquiring independent second opinions. PARTICIPANTS Interpretations of 240 breast biopsy specimens by 115 pathologists, one slide for each case, compared with reference diagnoses derived by expert consensus. MAIN OUTCOME MEASURES Misclassification rates for individual pathologists and for 12 simulated strategies for second opinions. Simulations compared accuracy of diagnoses from single pathologists with that of diagnoses based on pairing interpretations from first and second independent pathologists, where resolution of disagreements was by an independent third pathologist. 12 strategies were evaluated in which acquisition of second opinions depended on initial diagnoses, assessment of case difficulty or borderline characteristics, pathologists' clinical volumes, or whether a second opinion was required by policy or desired by the pathologists. The 240 cases included benign without atypia (10% non-proliferative, 20% proliferative without atypia), atypia (30%), ductal carcinoma in situ (DCIS, 30%), and invasive cancer (10%). Overall misclassification rates and agreement statistics depended on the composition of the test set, which included a higher prevalence of difficult cases than in typical practice. RESULTS Misclassification rates significantly decreased (P<0.001) with all second opinion strategies except for the strategy limiting second opinions only to cases of invasive cancer. The overall misclassification rate decreased from 24.7% to 18.1% when all cases received second opinions (P<0.001). Obtaining both first and second opinions from pathologists with a high volume (≥10 breast biopsy specimens weekly) resulted in the lowest misclassification rate in this test set (14.3%, 95% confidence interval 10.9% to 18.0%). Obtaining second opinions only for cases with initial interpretations of atypia, DCIS, or invasive cancer decreased the over-interpretation of benign cases without atypia from 12.9% to 6.0%. Atypia cases had the highest misclassification rate after single interpretation (52.2%), remaining at more than 34% in all second opinion scenarios. CONCLUSION Second opinions can statistically significantly improve diagnostic agreement for pathologists' interpretations of breast biopsy specimens; however, variability in diagnosis will not be completely eliminated, especially for breast specimens with atypia.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Anna Na Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, NH, USA Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - Gary M Longton
- Program in Biostatistics and Biomathematics, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon; and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Berta Geller
- Department of Family Medicine, University of Vermont, Burlington, VT, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Tracy Onega
- Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara L Jackson
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Donald L Weaver
- Department of Pathology; and UVM Cancer Center, University of Vermont, Burlington, VT, USA
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Abstract
IMPORTANCE Screening for syphilis infection is currently recommended for high-risk individuals, including those with previous syphilis infection, an infected sexual partner, HIV infection, or more than 4 sex partners in the preceding year. OBJECTIVE To update a 2004 systematic review of studies of syphilis screening effectiveness, test accuracy, and screening harms in nonpregnant adults and adolescents. DATA SOURCES Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews through October 2015 and Ovid MEDLINE (January 2004 to October 2015), with updated search through March 2016. STUDY SELECTION English-language trials and observational studies of screening effectiveness, test accuracy, and screening harms in nonpregnant adults and adolescents. DATA EXTRACTION AND SYNTHESIS One investigator abstracted data, a second checked data for accuracy, and 2 investigators independently assessed study quality using predefined criteria. MAIN OUTCOMES AND MEASURES Transmission of disease, including HIV; complications of syphilis; diagnostic accuracy; and harms of screening. RESULTS No evidence was identified regarding the effectiveness of screening on clinical outcomes or the effectiveness of risk assessment instruments; the harms of screening; or the effectiveness of screening in average-risk, nonpregnant adolescents or adults or high-risk individuals other than men who have sex with men (MSM) or men who are HIV positive. Four non-US studies indicated higher rates of syphilis detection with screening every 3 months vs 6 or 12 months for early syphilis in HIV-positive men or MSM. For example, there was an increased proportion of asymptomatic, higher-risk MSM in Australia (n = 6789 consultations) receiving a diagnosis of early syphilis when tested every 3 months vs annually (53% vs 16%, P = .001), but no difference among low-risk MSM. Treponemal and nontreponemal tests were accurate in asymptomatic individuals (sensitivity >85%, specificity >91%) in 3 studies but required confirmatory testing. Reverse sequence testing with an initial automated treponemal test yielded more false reactive test results than with rapid plasma reagin in 2 studies, one with a low-prevalence US population (0.6% vs 0.0%, P = .03) and another in a higher-prevalence Canadian population (0.26% vs 0.13%). CONCLUSIONS AND RELEVANCE Screening HIV-positive men or MSM for syphilis every 3 months is associated with improved syphilis detection. Treponemal or nontreponemal tests are accurate screening tests but require confirmation. Research is needed on the effect of screening on clinical outcomes; effective screening strategies, including reverse sequence screening, in various patient populations; and harms of screening.
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Affiliation(s)
- Amy G Cantor
- Pacific Northwest Evidence-based Practice Center, Departments of Medical Informatics and Clinical Epidemiology, Family Medicine, and Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Miranda Pappas
- Pacific Northwest Evidence-based Practice Center, Portland, Oregon
| | - Monica Daeges
- Pacific Northwest Evidence-based Practice Center, Portland, Oregon
| | - Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland4Providence Cancer Center, Providence Health and Services, Portland, Oregon
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Elmore JG, Nelson HD, Pepe MS, Longton GM, Tosteson ANA, Geller B, Onega T, Carney PA, Jackson SL, Allison KH, Weaver DL. Variability in Pathologists' Interpretations of Individual Breast Biopsy Slides: A Population Perspective. Ann Intern Med 2016; 164:649-55. [PMID: 26999810 PMCID: PMC5064832 DOI: 10.7326/m15-0964] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The effect of physician diagnostic variability on accuracy at a population level depends on the prevalence of diagnoses. OBJECTIVE To estimate how diagnostic variability affects accuracy from the perspective of a U.S. woman aged 50 to 59 years having a breast biopsy. DESIGN Applied probability using Bayes' theorem. SETTING B-Path (Breast Pathology) Study comparing pathologists' interpretations of a single biopsy slide versus a reference consensus interpretation from 3 experts. PARTICIPANTS 115 practicing pathologists (6900 total interpretations from 240 distinct cases). MEASUREMENTS A single representative slide from each of the 240 cases was used to estimate the proportion of biopsies with a diagnosis that would be verified if the same slide were interpreted by a reference group of 3 expert pathologists. Probabilities of confirmation (predictive values) were estimated using B-Path Study results and prevalence of biopsy diagnoses for women aged 50 to 59 years in the Breast Cancer Surveillance Consortium. RESULTS Overall, if 1 representative slide were used per case, 92.3% (95% CI, 91.4% to 93.1%) of breast biopsy diagnoses would be verified by reference consensus diagnoses, with 4.6% (CI, 3.9% to 5.3%) overinterpreted and 3.2% (CI, 2.7% to 3.6%) underinterpreted. Verification of invasive breast cancer and benign without atypia diagnoses is highly probable; estimated predictive values were 97.7% (CI, 96.5% to 98.7%) and 97.1% (CI, 96.7% to 97.4%), respectively. Verification is less probable for atypia (53.6% overinterpreted and 8.6% underinterpreted) and ductal carcinoma in situ (DCIS) (18.5% overinterpreted and 11.8% underinterpreted). LIMITATIONS Estimates are based on a testing situation with 1 slide used per case and without access to second opinions. Population-adjusted estimates may differ for women from other age groups, unscreened women, or women in different practice settings. CONCLUSION This analysis, based on interpretation of a single breast biopsy slide per case, predicts a low likelihood that a diagnosis of atypia or DCIS would be verified by a reference consensus diagnosis. This diagnostic grey zone should be considered in clinical management decisions in patients with these diagnoses. PRIMARY FUNDING SOURCE National Cancer Institute.
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Knowles KE, Hartstein KH, Kilburn TB, Marchioro A, Nelson HD, Whitham PJ, Gamelin DR. Luminescent Colloidal Semiconductor Nanocrystals Containing Copper: Synthesis, Photophysics, and Applications. Chem Rev 2016; 116:10820-51. [DOI: 10.1021/acs.chemrev.6b00048] [Citation(s) in RCA: 233] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Kathryn E. Knowles
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Kimberly H. Hartstein
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Troy B. Kilburn
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Arianna Marchioro
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Heidi D. Nelson
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Patrick J. Whitham
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
| | - Daniel R. Gamelin
- Department of Chemistry, University of Washington, Seattle, Washington 98195-1700, United States
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Frederick PD, Nelson HD, Carney PA, Brunyé TT, Allison KH, Weaver DL, Elmore JG. The Influence of Disease Severity of Preceding Clinical Cases on Pathologists' Medical Decision Making. Med Decis Making 2016; 37:91-100. [PMID: 27037007 DOI: 10.1177/0272989x16638326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/30/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND Medical decision making may be influenced by contextual factors. We evaluated whether pathologists are influenced by disease severity of recently observed cases. METHODS Pathologists independently interpreted 60 breast biopsy specimens (one slide per case; 240 total cases in the study) in a prospective randomized observational study. Pathologists interpreted the same cases in 2 phases, separated by a washout period of >6 months. Participants were not informed that the cases were identical in each phase, and the sequence was reordered randomly for each pathologist and between phases. A consensus reference diagnosis was established for each case by 3 experienced breast pathologists. Ordered logit models examined the effect the pathologists' diagnoses on the preceding case or the 5 preceding cases had on their diagnosis for the subsequent index case. RESULTS Among 152 pathologists, 49 provided interpretive data in both phases I and II, 66 from only phase I, and 37 from phase II only. In phase I, pathologists were more likely to indicate a more severe diagnosis than the reference diagnosis when the preceding case was diagnosed as ductal carcinoma in situ (DCIS) or invasive cancer (proportional odds ratio [POR], 1.28; 95% confidence interval [CI], 1.15-1.42). Results were similar when considering the preceding 5 cases and for the pathologists in phase II who interpreted the same cases in a different order compared with phase I (POR, 1.17; 95% CI, 1.05-1.31). CONCLUSION Physicians appear to be influenced by the severity of previously interpreted test cases. Understanding types and sources of diagnostic bias may lead to improved assessment of accuracy and better patient care.
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Affiliation(s)
- Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA (PDF, JGE)
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR, USA (HDN)
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA (PAC)
| | - Tad T Brunyé
- Center for Applied Brain & Cognitive Sciences, Tufts University, Medford, MA, USA (TTB)
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA (KHA)
| | - Donald L Weaver
- Department of Pathology, University of Vermont and UVM Cancer Center, Burlington, VT, USA (DLW)
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA (PDF, JGE)
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