A time and motion study of junior doctor work patterns on the weekend: a potential contributor to the weekend effect?

BACKGROUND

Patients admitted to hospital on weekends have a greater risk of mortality compared to patients admitted on weekdays. Junior medical officers (JMO) make up the majority of medical staff on weekends. No previous study has quantified JMO work patterns on weekends.

AIM

To describe and quantify JMO work patterns on weekends and compare them with patterns previously observed during the week.

METHODS

Observational time and motion study of JMO working weekends using the Work Observation Method by Activity Timing (WOMBAT; Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia) software. Descriptive statistics were used to determine the proportion of total observed time spent in tasks.

RESULTS

Weekend JMO predominately spent time in indirect care (32.0%), direct care (23.0%) and professional communication (22.1%). JMO spent 20.9% of time multitasking and were interrupted, on average, every 9 min. Weekend JMO spent significantly more time in direct care compared with weekdays (13.0%; P < 0.001) and nights (14.3%; P < 0.001). Weekend JMO spent significantly less time on breaks (8.5%), with less than 1 h in an 11-h shift, compared with JMO during weekdays (16.4%; P = 0.004) and nights (27.6%; P = <0.001). Weekend JMO were interrupted at a higher rate (6.6/h) than on weekdays (rate ratio (RR) 2.9, 95% confidence intervals (CI) 2.6, 3.3) or nights (RR 5.1, 95% CI 4.2, 6.1). Multitasking on weekends (20.9%) was comparable to weekdays (18.9%; P = 0.19) but significantly higher than nights (6.4%; P = <0.001).

CONCLUSION

On weekends, JMO had few breaks, were interrupted frequently and engaged in high levels of multitasking. This pattern of JMO work could be a potential contributing factor to the weekend effect in terms of JMO abilities to respond safely and adequately to care demands.

Timeliness of breast cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

6571

Background: To examine intervals between breast cancer screening, diagnosis, and treatment initiation among low income and uninsured women in the National Breast and Cervical Cancer Early Detection Program during two time periods. Methods: We examined diagnostic and treatment intervals for the time periods of 1996–2000 and 2001–2005 to evaluate program progress. The intervals were defined as: (1) time between mammography and final diagnosis for all women receiving an abnormal mammogram result (including suspicious abnormality (SA), highly suspicious for malignancy (HSM) and assessment is incomplete (AI)) or abnormal clinical breast exam and; (2) time between diagnosis and treatment initiation among those diagnosed with cancer. Covariates including mammography result, age at screening, race/ethnicity, and metropolitan/urban/rural classification of residence were included in the analysis. Results: For the entire study period, 369,557 women screened for breast cancer through the NBCCEDP had abnormal screen results. For 1996–2000 and 2001–2005 time periods, the median interval to diagnosis after screening was 25 days and 23 days respectively. For those 22,302 women found to have cancer, the median interval from diagnosis to treatment increased from 12 days in the first time period to 14 days in the later time period. Overall, time to diagnosis improved from 1996–2000 compared to 2001–2005. However, time to treatment initiation was slightly longer (median increased by 2–3 days). Using data from the most recent period of 2001–2005, 93% of women with cancer initiated treatment within 120 days of screening. Conclusions: The goal of the NBCCEDP is to assure that women receive timely, quality breast cancer screening and diagnostic services and initiate treatment. Our data show that the program is meeting these goals. Disparities in breast cancer incidence, mortality and survival should diminish once all women have access to breast cancer early detection and treatment services.

No significant financial relationships to disclose.

A case-control study evaluating differences in resource utilization between diabetic and non-diabetic cancer patients undergoing chemotherapy

6126

Background: Patients with diabetes mellitus (DM) and cancer have been noted to have worse overall and disease-free survival compared to those without DM. However, there is a paucity of data addressing why diabetic cancer patients have worse outcomes. We performed a retrospective case-control study to evaluate cancer patients undergoing chemotherapy comparing persons with and without DM to evaluate differences in resource utilization and mortality. Methods: Using chart review and tumor registry data from January 2001 through December 2003, we identified DM patients 18 years or older, treated with chemotherapy at the Gainesville Veterans Administration Medical Center (GVAMC) for lung, colon, or head and neck cancer. Non-diabetic (Non-DM) controls were matched for age, cancer type and stage. A comorbidity score was calculated based on a previously validated measurement scale, Adult Comorbidity Evaluation 27 (ACE-27). The primary outcome measure was the number of inpatient hospital days in the first year after diagnosis. Secondary outcome measures included the total number of outpatient visits, emergency room (ER) visits, infusion room visits for chemotherapy, blood transfusions, home health consults, telephone calls, and mortality. Results: A total of 42 DM cases and 42 non-DM controls were identified who had undergone similar treatments with radiation and surgery. The DM patients had higher comorbidity ACE 27 scores when corrected for the cancer being treated, median 3.0 versus 2.0, p < 0.005. The table summarizes the results. Mortality was the same (15) for both the DM and non-DM patients at one year. Conclusions: Cancer patients with DM undergoing chemotherapy have significantly more comorbidities and utilize more outpatient visits compared to non-DM. However, all other measures of resource utilization and mortality appear similar. Further studies to identify causes of increased utilization should be done.

[Table: see text]

No significant financial relationships to disclose.

Adequacy of follow-up after an abnormal fecal occult blood test (FOBT) result

6035

Background: Annual fecal occult blood testing (FOBT) is the only colon cancer screening shown to reduce colon cancer incidence and mortality in randomized controlled trials. The true benefits of screening are only realized when total colon examination (TCE) is performed as follow-up to an abnormal screening result. Methods: We used the 2000 National Health Interview Survey (NHIS) Cancer Control Supplement, a nationally representative sample of households, to examine follow-up after abnormal FOBT and the content of this follow-up. Persons who reported undergoing an FOBT were the population of interest. Reasons for FOBT, results of test, and follow-up after an abnormal FOBT were examined. Inadequate follow-up after a positive FOBT included no follow-up or another FOBT. TCE was defined as sigmoidoscopy with double contrast barium enema (DCBE) or colonoscopy. We used SUDAAN to obtain population estimates. Results: We included 4,908 respondents who indicated they had undergone FOBT (79.8% as part of the routine physical examination, 14.7% for a specific problem, 2.0% as follow-up of a previous abnormal test/screening examine, 1.4% family history). Overall, 5.7% of respondents reported an abnormal test, varying by reason for test (3.5% for screening and 16.9% for those who had FOBT done for a specific problem). For those reporting an abnormal FOBT during screening, 62.9% had some follow-up diagnostic procedures. Fifty-three percent reported having a TCE as defined above. Forty-seven percent either had no further evaluation, another FOBT or incomplete colon examination with sigmoidoscopy alone, and DCBE only or a surgical evaluation. Those who had FOBT completed for a specific problem had more surgical evaluations (18.4%) and fewer TCEs (44.3%). Conclusions: Among a nationally-representative sample of adults who reported FOBT as a screening test for colorectal cancer, close to 63% had some type of follow-up. Only 53% of those with a positive screening FOBT had a TCE. These results suggest that the full potential of CRC screening is not being realized, and point to the need to improve follow-up of abnormal FOBT results.

No significant financial relationships to disclose.

Early-stage breast cancer treatment among medically underserved women diagnosed in a national screening program, 1992-1995

BACKGROUND

Little research has been conducted on the breast cancer treatment of low income, underserved women. This study was designed to describe initial treatment of breast cancer among low-income women diagnosed through federally funded screening programs in Detroit, Michigan, and the states of New Mexico and California; and to compare the treatment received by program women with early-stage breast cancer with that of all women diagnosed in those regions.

METHODS

Data from the three screening programs were linked with cancer registry data from the corresponding geographic areas. All women diagnosed between 1992 and 1995 through the state-based screening programs and all women contemporaneously diagnosed with breast cancer in the three regions were studied. Descriptive analyses were done of the proportion of women with breast cancer receiving treatment; the proportion of early-stage breast cancer (stage I or II) cases treated with breast-conserving surgery, and the proportion treated with mastectomy; and among women with breast-conserving surgery, the proportion receiving radiation therapy. Logistic regression models controlled for age and stage at diagnosis, race or ethnicity and geographic region.

RESULTS

Less than 2% of program women diagnosed with breast cancer received no treatment. More than two of five women with early-stage breast cancer underwent breast-conserving surgery, with 72% of these women receiving radiation therapy. Multivariate regression analysis revealed that women with stage IIA or IIB breast cancer had lower odds of undergoing breast-conserving surgery than women with stage I (0.51 [95% CI = 0.30-0.87] and 0.36 [95% CI = 0.19-0.70], respectively). Women over age 65 and those with incompletely staged cancer had the lowest odds for receiving radiation therapy after breast-conserving surgery (0.29 [95% CI = 0.09-0.99] and 0.14 [95% CI = 0.03-0.72], respectively). Women diagnosed through the screening programs had odds of undergoing breast-conserving surgery similar to those of all women in the regions (1.11 [95% CI= 0.89-1.39]).

CONCLUSIONS

Treatment patterns for women diagnosed with early-stage breast cancer through three state-based screening programs appear to have been similar to those reported in the literature. In addition, their treatment appears to have been similar to that of other women during the same time period.

Risk factors for infection with HBV and HCV in a largecohort of hemophiliac males

BACKGROUND

Before the implementation of donor screening and the development of effective virus-inactivation procedures, persons with hemophilia (PWHs) were at risk of infection with HBV and HCV transmitted through clotting factor concentrates.

STUDY DESIGN AND METHODS

Data collected from the medical records of a cohort of 2,772 males with hemophilia who resided in six states of the United States were used to examine relations between demographic and clinical characteristics and laboratory markers of past or present infection with HBV and HCV using logistic regression.

RESULTS

Test results were available for 60 percent of the cohort. Among those tested, 30 percent were positive for markers of HBV infection and 64 percent for HCV infection. Factors associated with increased odds of positive HBV markers and HCV infection were greater severity of hemophilia, larger amounts of factor use, and HIV infection. Markers of HBV infection persisted in birth cohorts as late as 1992 and those of HCV infections in birth cohorts through 1991. Compared to same-age US males, PWHs born between 1987 and 1989 were more likely to have markers of HBV and HCV infection.

CONCLUSION

PWHs who received clotting factor concentrates before 1990 may be at risk for infection with hepatitis B or hepatitis C and should be tested.

Mammography and breast cancer detection by race and Hispanic ethnicity: results from a national program (United States)

OBJECTIVE

Some of the racial and ethnic variation in breast cancer incidence rates may reflect differential use of mammography. We report breast cancer rates using mammography and diagnostic data from five race/ethnicity groups.

METHODS

Mammography data were analyzed for 573,751 women who received breast cancer screening between July 1991 and March 1998 from the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Abnormal mammography rates, breast cancer detection rates, and cancer stage distribution data are presented by race/ethnicity and screening round (first or subsequent).

RESULTS

For the first screening round, percentages of abnormal mammographies ranged from 7.3% among black women to 9.3% among Asian/Pacific Islander women. Cancer detection rates ranged from 4.9 cancers per 1000 mammograms for Hispanic and American Indian/Alaska Native (AI/AN) women to 7.7 per 1000 for white women. Subsequent round rates were lower but varied similarly. AI/AN women had the highest percentage (68%) of first-round cancers detected in the early stage (range for the other groups: 52-63%).

CONCLUSIONS

Breast cancer detection rates for racial and ethnic groups in this program varied less than published population-based incidence rates. Differential use of mammography among these groups may account for some of the variation reported for breast cancer incidence.

Mass screening in low-income populations: the challenges of securing diagnostic and treatment services in a national cancer screening program

Funding for many mass screening programs for low-income and uninsured populations provides resources for screening tests, yet only rarely does it provide coverage for necessary follow-up diagnostic and treatment services. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), a federally funded initiative that provides cancer screening to low-income uninsured and underinsured women, covers some diagnostic follow-up tests and no treatment services. We conducted in-depth case studies of seven state programs participating in the NBCCEDP to investigate the strategies and approaches being used to secure diagnostic and treatment services. The results suggest that the program relies on a patchwork of resources--at state and local levels--to provide diagnostic and treatment services. This includes a number of components of local safety nets, all of which are unstable and have uncertain futures. Public health disease-screening initiatives need to reconsider the feasibility of continued reliance on case-by-case appeals to the local safety net for diagnostic follow-up and treatment services.

Time to diagnosis and treatment of breast cancer: results from the National Breast and Cervical Cancer Early Detection Program, 1991-1995

OBJECTIVES

This study examined times to diagnosis and treatment for medically underserved women screened for breast cancer.

METHODS

Intervals from first positive screening test to diagnosis to initiation of treatment were determined for 1659 women 40 years and older diagnosed with breast cancer.

RESULTS

Women with abnormal mammograms had shorter diagnostic intervals than women with abnormal clinical breast examinations and normal mammograms. Women with self-reported breast symptoms had shorter diagnostic intervals than asymptomatic women. Diagnostic intervals were less than 60 days in 78% of cases. Treatment intervals were generally 2 weeks or less.

CONCLUSIONS

Most women diagnosed with breast cancer were followed up in a timely manner after screening. Further investigation is needed to identify and then address factors associated with longer diagnostic and treatment intervals to maximize the benefits of early detection.

Strategies for follow-up and treatment services in state breast and cervical cancer screening programs

This report describes strategies used to provide diagnostic follow-up and treatment services to low-income women screened through the National Breast and Cervical Cancer Early Detection Program.

Effect of oxygen concentration and redox potential on recovery of sublethally heat-damaged cells of Escherichia coli O157:H7, Salmonella enteritidis and Listeria monocytogenes

The measured heat resistance of cells of Escherichia coli O157:H7, Salmonella enteritidis and Listeria monocytogenes was up to eightfold greater when they were grown, heated and recovered anaerobically rather than aerobically. Measured heat resistance was highest when anaerobic gas mixtures were used (time at 59 degrees C for a 6-decimal (6-D) reduction of E. coli O157:H7, 19-24 min); moderate when low concentrations of oxygen (0.5-1%) were included (time for a 6-D reduction, 5-17 min); and lowest when higher concentrations of oxygen (2-40%) were used (time for a 6-D reduction, 3 min). This effect was principally attributed to the recovery conditions, and a greater effect was noted at lower heating temperatures. The use of reduced oxygen concentration (< 2% O2), e.g. packing under an anaerobic gas mixture or a vacuum, might therefore increase the risk of these pathogens surviving heat treatments applied to food. It is also possible that foods that are packed in air but with a low redox potential might allow the survival of heated cells, and thus the anticipated level of safety might not be achieved.

Predictive models of the effect of temperature, pH and acetic and lactic acids on the growth of Listeria monocytogenes

The combined effect of temperature (1-20 degrees C), pH (4.5-7.2) and acetic acid (0-10,000 mg/l; model 1) or lactic acid (0-20,000 mg/l; model 2) on growth of Listeria monocytogenes in laboratory media was studied. Growth curves at various combinations of temperature, pH and acid concentration were fitted by the model of Baranyi and Roberts (1994), and specific growth rates derived from the curve fit were modelled. Predictions of growth from the models were compared with data in the literature, and this showed the models to be suitable for use in predicting growth of L. monocytogenes in a range of foods including meat, poultry, fish, egg and milk and dairy products. The two models are compatible, i.e. they give similar predictions for cases when no acid is present.

Acute effects of amiodarone on membrane properties, refractoriness, and conduction in guinea pig papillary muscles

Amiodarone has potent and complex antiarrhythmic effects associated with a rare incidence of proarrhythmia. For a comprehensive understanding of its antiarrhythmic mechanisms in the same preparations, amiodarone (50 microM) was employed as it would be in the clinical setting and applied to guinea pig papillary muscles impaled by microelectrodes, paced at different rates, and superfused with various concentrations of potassium ([K]e). Amiodarone exerted complex actions, as follows: (1) The maximum rate of rise (Vmax) of the fast action potential (i.e., [K]e = 5.4-9.0 mM) as well as that of the slow action potential (i.e., [K]e = 15.0 mM in the presence of 1.0 microM isoproterenol) was suppressed in a rate-dependent manner. (2) Amiodarone exhibited a rate- and [K]e-dependent increase in the ratio of effective refractory period vs action potential duration at 90% repolarization (ERP/APD90), disclosing post-repolarization refractoriness. (3) Amiodarone had no effect on passive cable factors, such as threshold current and tissue resistance, during propagation. These versatile electrophysiological effects of amiodarone may contribute to its unique antiarrhythmic effects, as well as the low incidence of proarrhythmia with this drug.