PSA surveillance following radical prostatectomy: what we know and why it matters

Disease recurrence is common after initial therapy for prostate cancer, but little is known about how well men receive follow-up surveillance after initial treatment or how patterns of follow-up care may influence choice of initial treatment. The overall objectives of this dissertation were (1): to examine patterns of prostate-specific antigen (PSA) test receipt among elderly men treated with radical prostatectomy for non-metastatic prostate cancer, (2): to validate the radiation therapy variable in Surveillance, Epidemiology, and End Result (SEER) data by comparing treatment receipt with Medicare claims, and (3): to compare through a decision model a wait and see approach to radiation therapy in which radiation therapy is initiated only after evidence of disease recurrence to an approach of treating all qualifying men with radiation therapy adjuvant to surgery. This dissertation used population-based SEER-Medicare data to examine the first two aims. The decision model was constructed as a Markov cohort model and populated with data from clinical trials, retrospective studies, surveys, and Medicare fee schedules. Time from treatment was the dominant factor in predicting whether a man received a PSA surveillance test in a given year following surgery. In all men, test receipt decreased as time from surgery increased. I also found some evidence of racial/ethnic disparities in test receipt as well as evidence that test receipt is influenced by access to care and social support. I found that although there is some disagreement across SEER and Medicare in terms of documentation of adjuvant radiation therapy (ART) receipt, overall agreement is very high. This lends support to previous studies using SEER alone to study ART. The results from the decision model suggest that most men will benefit more from a wait and see approach to radiation therapy than ART. However, if men do not receive appropriate PSA surveillance testing, ART may be a better option. This research highlights the need for long-term follow-up care plans for men treated with radical prostatectomy for prostate cancer.Doctor of Philosoph

Valuing a Homeland Security Policy: Countermeasures for the Threats from Shoulder Mounted Missiles

This paper reports estimates for the ex ante tradeoffs for three specific homeland security policies that all address a terrorist attack on commercial aircraft with shoulder mounted missiles. Our analysis focuses on the willingness to pay for anti-missile laser jamming countermeasures mounted on commercial aircraft compared with two other policies as well as the prospect of remaining with the status quo. Our findings are based a stated preference conjoint survey conducted in 2006 and administered to a sample from Knowledge Networks' national internet panel. The estimates range from $100 to$220 annually per household. Von Winterfeldt and O'Sullivan's [2006] analysis of the same laser jamming plan suggests that the countermeasures would be preferred if economic losses are above $74 billion, the probability of attack is larger than 0.37 in ten years, and if the cost of the measures is less than about$14 billion. Our results imply that, using the most conservative of our estimates, a program with a cost consistent with their thresholds would yield significant aggregate net benefits. More generally, this research grows out of a need to measure the benefits of an iconic public good -- national defense -- to assess the economic efficiency of Department of Homeland Security policies.

Effectiveness of implementing a dyadic psychoeducational intervention for cancer patients and family caregivers

PURPOSE: This study examined the effectiveness, feasibility, and satisfaction with implementation of the FOCUS program in two US Cancer Support Community affiliates in Ohio and California as well as the cost to deliver the program. FOCUS is an evidence-based psychoeducational intervention for dyads (cancer patients and caregivers). METHODS: A pre-post-intervention design was employed. Eleven, five-session Focus programs were delivered by licensed professionals in a small group format (three-four dyads/group) to 36 patient-caregiver dyads. An Implementation Training Manual, a FOCUS Intervention Protocol Manual, and weekly conference calls were used to foster implementation. Participants completed questionnaires prior to and following completion of each five-session FOCUS program to measure primary (emotional distress, quality of life) and secondary outcomes (benefits of illness, self-efficacy, and dyadic communication). Enrollment and retention rates and fidelity to FOCUS were used to measure feasibility. Cost estimates were based on time and median hourly wages. Repeated analysis of variance was used to analyze the effect of FOCUS on outcomes for dyads. Descriptive statistics were used to examine feasibility, satisfaction, and cost estimates. RESULTS: FOCUS had positive effects on QOL (p = .014), emotional (p = .012), and functional (p = .049) well-being, emotional distress (p = .002), benefits of illness (p = .013), and self-efficacy (p = .001). Intervention fidelity was 85% with enrollment and retention rates of 71.4 and 90%, respectively. Participants were highly satisfied. Cost for oversight and delivery of the five-session FOCUS program was $168.00 per dyad. CONCLUSIONS: FOCUS is an economic and effective intervention to decrease distress and improve the quality of life for dyads

Managed Care and the Diffusion of Endoscopy in Fee-for-Service Medicare

To determine whether Medicare managed care penetration impacted the diffusion of endoscopy services (sigmoidoscopy, colonoscopy) among the fee-for-service (FFS) Medicare population during 2001–2006

AgBioData consortium recommendations for sustainable genomics and genetics databases for agriculture

The future of agricultural research depends on data. The sheer volume of agricultural biological data being produced today makes excellent data management essential. Governmental agencies, publishers and science funders require datamanagement plans for publicly funded research. Furthermore, the value of data increases exponentially when they are properly stored, described, integrated and shared, so that they can be easily utilized in future analyses. AgBioData (https://www.agbiodata.org) is a consortium of people working at agricultural biological databases, data archives and knowledgbases who strive to identify common issues in database development, curation and management, with the goal of creating database products that are more Findable, Accessible, Interoperable and Reusable. We strive to promote authentic, detailed, accurate and explicit communication between all parties involved in scientific data. As a step toward this goal, we present the current state of biocuration, ontologies, metadata and persistence, database platforms, programmatic (machine) access to data, communication and sustainability with regard to data curation. Each section describes challenges and opportunities for these topics, along with recommendations and best practices

Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.

BACKGROUND: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months. METHODS: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed. FINDINGS: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed. INTERPRETATION: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. FUNDING: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden

PSA surveillance following radical prostatectomy: What we know and why it matters

Disease recurrence is common after initial therapy for prostate cancer, but little is known about how well men receive follow-up surveillance after initial treatment or how patterns of follow-up care may influence choice of initial treatment. The overall objectives of this dissertation were (1): to examine patterns of prostate-specific antigen (PSA) test receipt among elderly men treated with radical prostatectomy for non-metastatic prostate cancer, (2): to validate the radiation therapy variable in Surveillance, Epidemiology, and End Result (SEER) data by comparing treatment receipt with Medicare claims, and (3): to compare through a decision model a "wait and see" approach to radiation therapy in which radiation therapy is initiated only after evidence of disease recurrence to an approach of treating all qualifying men with radiation therapy adjuvant to surgery. This dissertation used population-based SEER-Medicare data to examine the first two aims. The decision model was constructed as a Markov cohort model and populated with data from clinical trials, retrospective studies, surveys, and Medicare fee schedules. Time from treatment was the dominant factor in predicting whether a man received a PSA surveillance test in a given year following surgery. In all men, test receipt decreased as time from surgery increased. I also found some evidence of racial/ethnic disparities in test receipt as well as evidence that test receipt is influenced by access to care and social support. I found that although there is some disagreement across SEER and Medicare in terms of documentation of adjuvant radiation therapy (ART) receipt, overall agreement is very high. This lends support to previous studies using SEER alone to study ART. The results from the decision model suggest that most men will benefit more from a wait and see approach to radiation therapy than ART. However, if men do not receive appropriate PSA surveillance testing, ART may be a better option. This research highlights the need for long-term follow-up care plans for men treated with radical prostatectomy for prostate cancer

Heterogeneity in mammography use across the nation: separating evidence of disparities from the disproportionate effects of geography

Abstract Background Mammography is essential for early detection of breast cancer and both reduced morbidity and increased survival among breast cancer victims. Utilization is lower than national guidelines, and evidence of a recent decline in mammography use has sparked concern. We demonstrate that regression models estimated over pooled samples of heterogeneous states may provide misleading information regarding predictors of health care utilization and that comprehensive cancer control efforts should focus on understanding these differences and underlying causal factors. Our study population includes all women over age 64 with breast cancer in the Surveillance Epidemiology and End Results (SEER) cancer registries, linked to a nationally representative 5% reference sample of Medicare-eligible women located in 11 states that span all census regions and are heterogeneous in racial and ethnic mix. Combining women with and without cancer in the sample allows assessment of previous cancer diagnosis on propensity to use mammography. Our conceptual model recognizes the interplay between individual, social, cultural, and physical environments along the pathways to health care utilization, while delineating local and more distant levels of influence among contextual variables. In regression modeling, we assess individual-level effects, direct effects of contextual factors, and interaction effects between individual and contextual factors. Results Pooling all women across states leads to quite different conclusions than state-specific models. Commuter intensity, community acculturation, and community elderly impoverishment have significant direct impacts on mammography use which vary across states. Minorities living in isolated enclaves with others of the same race/ethnicity may be either advantaged or disadvantaged, depending upon the place studied. Conclusion Careful analysis of place-specific context is essential for understanding differences across communities stemming from different causal factors. Optimal policy interventions to change behavior (improve screening rates) will be as heterogeneous as local community characteristics, so no "one size fits all" policy can improve population health. Probability modeling with correction for clustering of individuals within multilevel contexts can reveal important differences from place to place and identify key factors to inform targeting of specific communities for further study.</p