Evaluation of a candidate breast cancer associated SNP in ERCC4 as a risk modifier in BRCA1 and BRCA2 mutation carriers. Results from the Consortium of Investigators of Modifiers of BRCA1/BRCA2 (CIMBA)

Background: In this study we aimed to evaluate the role of a SNP in intron 1 of the ERCC4 gene (rs744154), previously reported to be associated with a reduced risk of breast cancer in the general population, as a breast cancer risk modifier in BRCA1 and BRCA2 mutation carriers. Methods: We have genotyped rs744154 in 9408 BRCA1 and 5632 BRCA2 mutation carriers from the Consortium of Investigators of Modifiers of BRCA1/2 (CIMBA) and assessed its association with breast cancer risk using a retrospective weighted cohort approach. Results: We found no evidence of association with breast cancer risk for BRCA1 (per-allele HR: 0.98, 95% CI: 0.93–1.04, P=0.5) or BRCA2 (per-allele HR: 0.97, 95% CI: 0.89–1.06, P=0.5) mutation carriers. Conclusion: This SNP is not a significant modifier of breast cancer risk for mutation carriers, though weak associations cannot be ruled out. A Osorio1, R L Milne2, G Pita3, P Peterlongo4,5, T Heikkinen6, J Simard7, G Chenevix-Trench8, A B Spurdle8, J Beesley8, X Chen8, S Healey8, KConFab9, S L Neuhausen10, Y C Ding10, F J Couch11,12, X Wang11, N Lindor13, S Manoukian4, M Barile14, A Viel15, L Tizzoni5,16, C I Szabo17, L Foretova18, M Zikan19, K Claes20, M H Greene21, P Mai21, G Rennert22, F Lejbkowicz22, O Barnett-Griness22, I L Andrulis23,24, H Ozcelik24, N Weerasooriya23, OCGN23, A-M Gerdes25, M Thomassen25, D G Cruger26, M A Caligo27, E Friedman28,29, B Kaufman28,29, Y Laitman28, S Cohen28, T Kontorovich28, R Gershoni-Baruch30, E Dagan31,32, H Jernström33, M S Askmalm34, B Arver35, B Malmer36, SWE-BRCA37, S M Domchek38, K L Nathanson38, J Brunet39, T Ramón y Cajal40, D Yannoukakos41, U Hamann42, HEBON37, F B L Hogervorst43, S Verhoef43, EB Gómez García44,45, J T Wijnen46,47, A van den Ouweland48, EMBRACE37, D F Easton49, S Peock49, M Cook49, C T Oliver49, D Frost49, C Luccarini50, D G Evans51, F Lalloo51, R Eeles52, G Pichert53, J Cook54, S Hodgson55, P J Morrison56, F Douglas57, A K Godwin58, GEMO59,60,61, O M Sinilnikova59,60, L Barjhoux59,60, D Stoppa-Lyonnet61, V Moncoutier61, S Giraud59, C Cassini62,63, L Olivier-Faivre62,63, F Révillion64, J-P Peyrat64, D Muller65, J-P Fricker65, H T Lynch66, E M John67, S Buys68, M Daly69, J L Hopper70, M B Terry71, A Miron72, Y Yassin72, D Goldgar73, Breast Cancer Family Registry37, C F Singer74, D Gschwantler-Kaulich74, G Pfeiler74, A-C Spiess74, Thomas v O Hansen75, O T Johannsson76, T Kirchhoff77, K Offit77, K Kosarin77, M Piedmonte78, G C Rodriguez79, K Wakeley80, J F Boggess81, J Basil82, P E Schwartz83, S V Blank84, A E Toland85, M Montagna86, C Casella87, E N Imyanitov88, A Allavena89, R K Schmutzler90, B Versmold90, C Engel91, A Meindl92, N Ditsch93, N Arnold94, D Niederacher95, H Deißler96, B Fiebig97, R Varon-Mateeva98, D Schaefer99, U G Froster100, T Caldes101, M de la Hoya101, L McGuffog49, A C Antoniou49, H Nevanlinna6, P Radice4,5 and J Benítez1,3 on behalf of CIMB

Do list size and remuneration affect GPs' decisions about how they provide consultations?

Background: Doctors' professional behaviour is influenced by the way they are paid. When GPs are paid per item, i.e., on a fee-for-service basis (FFS), there is a clear relationship between workload and income: more work means more money. In the case of capitation based payment, workload is not directly linked to income since the fees per patient are fixed. In this study list size was considered as an indicator for workload and we investigated how list size and remuneration affect GP decisions about how they provide consultations. The main objectives of this study were to investigate a) how list size is related to consultation length, waiting time to get an appointment, and the likelihood that GPs conduct home visits and b) to what extent the relationships between list size and these three variables are affected by remuneration. Methods: List size was used because this is an important determinant of objective workload. List size was corrected for number of older patients and patients who lived in deprived areas. We focussed on three dependent variables that we expected to be related to remuneration and list size: consultation length; waiting time to get an appointment; and home visits. Data were derived from the second Dutch National Survey of General Practice (DNSGP-2), carried out between 2000 and 2002. The data were collected using electronic medical records, videotaped consultations and postal surveys. Multilevel regression analyses were performed to assess the hypothesized relationships. Results: Our results indicate that list size is negatively related to consultation length, especially among GPs with relatively large lists. A correlation between list size and waiting time to get an appointment, and a correlation between list size and the likelihood of a home visit were only found for GPs with small practices. These correlations are modified by the proportion of patients for whom GPs receive capitation fees. Waiting times to get an appointment tend to become shorter with increasing patient lists when there is a larger capitation percentage. The likelihood that GPs will conduct home visit rises with increasing patient lists when the capitation percentage is small. Conclusion: Remuneration appears to affect GPs' decisions about how they provide consultations, especially among GPs with relatively small patient lists. This role is, however, small compared to other factors such as patient characteristics.

Metodologias utilizadas para detectar distúrbios emocionais em clínicas de assistência primária à saúde: revisão de literatura

A series of studies in the field of Epidemiological Psychiatry have been performed over the last two decades, and these have focused on the ability of primary care physicians to detect emotional disorders in the patients that attend their practices. The scientific methodology utilized in these studies is the subject of this review, which contains a discussion concerning: a) interviewer awareness bias; b) accuracy of the instruments and c) medical and psychological concepts involved in defining minor emotional disorders. Suggestions for change in the methodology are made in each of the sections of the review.Na área de epidemiologia psiquiátrica vêm sendo realizados, nos últimos vinte anos, estudos que têm como finalidade medir a habilidade que clínicos gerais possuem em detectar distúrbios emocionais nos pacientes que procuram atendimento na rede básica de saúde. A metodologia utilizada nesses estudos é o tema central da atual revisão, que contém a) viés do entrevistador; b) acuidade dos instrumentos; e c) conceitos médicos e psicológicos envolvidos na definição de distúrbio psiquiátrico menor. São também apresentadas sugestões para mudanças de metodologia

Swiss residents' arguments for and against a career in medicine

BACKGROUND: In some Western countries, the medical profession is continuously losing prestige, doctors are claiming of high demands, low rewards, and difficult structural working conditions. This study aimed to investigate the arguments given by Swiss residents for and against a career in medicine. METHODS: As part of a prospective cohort study of Swiss medical school graduates on career development, 567 fourth-year residents were asked to answer the free-response item of what arguments there still were in favour of or against a career in medicine. They also indicated whether they would choose the medical profession all over again (yes/no). The statements were transcribed, content categories inductively formulated, and their descriptions written down in a code manual. Arguments were encoded according to the code manual and assigned to eight content categories (Mayring's content analysis). Frequency distributions were given for categories and tested with Chi(2)-tests for differences in gender, speciality fields, and whether or not the respondent would again choose a career in medicine. RESULTS: The 567 participants made 1,640 statements in favour of and 1,703 statements against a career in medicine. The content analysis of the residents' answers yielded eight categories with arguments both for and against a career in medicine. Of all "statements for" responses, 70% fell into the two top-ranking categories of Personal experiences in day-to-day working life (41.2%) and Interpersonal experiences in professional relationships (28.8%). The top-ranking category of the "statements against" arguments was General work-related structural conditions (32%), followed by Social prestige and health-policy aspects (21%). Main arguments in favour of a career in medicine were interdisciplinary challenge, combination of basic sciences and interpersonal concerns, helping suffering people, guarantee of a secure job; arguments against comprised high workload, time pressure, emotional stress, poorly structured continuing education, increasing bureaucracy, work-life imbalance, low income, and decreasing social prestige. The statements revealed few differences depending on gender, medical field, and attitude towards choosing the medical profession again; one out of five young doctors would not do so. CONCLUSION: Residents' chief complaint is deteriorating structural working conditions, including unfavourable work-life balance. Making medicine an attractive profession again will require sustainable changes in health-policy framework and social reward

Patient Complexity: More Than Comorbidity. The Vector Model of Complexity

BACKGROUND: The conceptualization of patient complexity is just beginning in clinical medicine. OBJECTIVES: This study aims (1) to propose a conceptual approach to complex patients; (2) to demonstrate how this approach promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans; and (3) to examine availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients. METHODS/RESULTS: The Vector Model of Complexity portrays interactions between biological, socioeconomic, cultural, environmental and behavioral forces as health determinants. These forces are not easily discerned but exert profound influences on processes and outcomes of care for chronic medical conditions. Achieving congruence between patient, physician, and healthcare system is essential for effective, patient-centered care; requires assessment of all axes of the Vector Model; and, frequently, requires trade-off decisions to develop a tailored treatment plan. Most evidence-based guidelines rarely provide guidance for trade-off decisions. Quality measures often exclude complex patients and are not designed explicitly to assess their overall healthcare. CONCLUSIONS/RECOMMENDATIONS: We urgently need to expand the evidence base to inform the care of complex patients of all kinds, especially for the clinical trade-off decisions that are central to tailoring care. We offer long- and short-term strategies to begin to incorporate complexity into quality measurement and performance profiling, guided by the Vector Model. Interdisciplinary research should lay the foundation for a deeper understanding of the multiple sources of patient complexity and their interactions, and how provision of healthcare should be harmonized with complexity to optimize health

Quality improvement in small office settings: an examination of successful practices

<p>Abstract</p> <p>Background</p> <p>Physicians in small to moderate primary care practices in the United States (U.S.) (<25 physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives.</p> <p>Methods</p> <p>We undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities.</p> <p>Results</p> <p>Physicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers.</p> <p>Conclusion</p> <p>These findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.</p

Professional quality of life and organizational changes: a five-year observational study in Primary Care

<p>Abstract</p> <p>Background</p> <p>The satisfaction and the quality of life perceived by professionals have implications for the performance of health organizations. We have assessed the variations in professional quality of life (PQL) and their explanatory factors during a services management decentralization process.</p> <p>Methods</p> <p>It was designed as a longitudinal analytical observational study in a Health Area in Madrid, Spain. Three surveys were sent out during an ongoing management decentralization process between 2001 and 2005. The professionals surveyed were divided into three groups: Group I (97.3% physicians), group II (92.5% nurses) and group III (auxiliary personnel). Analysis of the tendency and elaboration of an explanatory multivariate model was made. The PQL -35 questionnaire, based on Karasek's demand-control theory, was used to measure PQL. This questionnaire recognizes three PQL dimensions: management support (MS), workload (WL) and intrinsic motivation (IM).</p> <p>Results</p> <p>1444 responses were analyzed. PQL increased 0.16 (CI 95% 0.04 – 0.28) points in each survey. Group II presents over time a higher PQL score than group I of 0.38 (IC 95% 0.18 – 0.59) points. There is no difference between groups I and III.</p> <p>For each point that MS increases, PQL increases between 0.44 and 0.59 points. PQL decreases an average of between 0.35 and 0.49 point, for each point that WL increases.</p> <p>Age appears to have a marginal association with PQL (CI 95% 0.00 – 0.02), as it occurs with being single or not having a stable relationship (CI 95% 0.01 – 0.41). Performing management tasks currently or in the past is related to poorer PQL perception (CI 95% -0.45 – -0.06), and the same occurs with working other than morning shifts (CI 95% -0.03 – -0.40 points).</p> <p>PQL is not related to sex, location of the centre (rural/urban), time spent working in the organization or contractual situation.</p> <p>Conclusion</p> <p>With the improvement in work control and avoiding increases in workloads, PQL perception can be maintained despite deep organizational changes at the macro-management level. Different professional groups experience different perceptions depending on how the changes impact their position in the organization.</p

Factors associated with self-rated health status in university students: a cross-sectional study in three European countries

Mikolajczyk RT, Brzoska P, Maier C, et al. Factors associated with self-rated health status in university students: a cross-sectional study in three European countries. BMC Public Health. 2008;8(1): 215.Background: Self-rated health status (SRHS) is a reliable and valid measure for assessing the subjective and objective health of individuals. Previous studies have either focused predominantly on the elderly or investigated only a narrow range of factors potentially associated with SRHS. In examining student populations, these past studies were limited to single countries. The objectives of this study were to assess which candidate variables were independently associated with SRHS in university students, to compare these variables by country and by gender, and to investigate which of the variables was most important as a rating frame for SRHS. Methods: The data is from the Cross-National Student Health Survey, conducted in 2005 in universities in Germany, Bulgaria, and Poland (n = 2103; mean age = 20.7 years). SRHS was assessed with a single question using a five-point scale ranging from "excellent" to "poor". The study also measured a wide range of variables including: physical and psychological health, studying, social contacts/social support, and socio-demographic status. Results: Psychosomatic complaints (considered an aspect of physical health and, adjusted for psychological health) were the most important indicators in forming a rating frame for students' SRHS. There were few differences in the effects of variables associated with SRHS by gender (well-being: a measure of psychological health) and the variables associated with SRHS by country (well-being and self-efficacy). The remaining variables showed homogenous effects for both genders and for all three countries. Conclusion: The results suggest that SRHS can be reasonably used to compare students' health across countries. SRHS is affected by different physical, psychological and psychosomatic aspects of health; however, its strongest association is with psychosomatic complaints

Assessing the evolution of primary healthcare organizations and their performance (2005-2010) in two regions of Québec province: Montréal and Montérégie

<p>Abstract</p> <p>Background</p> <p>The Canadian healthcare system is currently experiencing important organizational transformations through the reform of primary healthcare (PHC). These reforms vary in scope but share a common feature of proposing the transformation of PHC organizations by implementing new models of PHC organization. These models vary in their performance with respect to client affiliation, utilization of services, experience of care and perceived outcomes of care.</p> <p>Objectives</p> <p>In early 2005 we conducted a study in the two most populous regions of Quebec province (Montreal and Montérégie) which assessed the association between prevailing models of primary healthcare (PHC) and population-level experience of care. The <b>goal </b>of the present research project is to track the <it>evolution </it>of PHC organizational models and their relative performance through the reform process (from 2005 until 2010) and to assess factors at the organizational and contextual levels that are associated with the transformation of PHC organizations and their performance.</p> <p>Methods/Design</p> <p>This study will consist of three interrelated surveys, hierarchically nested. The first survey is a population-based survey of randomly-selected adults from two populous regions in the province of Quebec. This survey will assess the current affiliation of people with PHC organizations, their level of utilization of healthcare services, attributes of their experience of care, reception of preventive and curative services and perception of unmet needs for care. The second survey is an organizational survey of PHC organizations assessing aspects related to their vision, organizational structure, level of resources, and clinical practice characteristics. This information will serve to develop a taxonomy of organizations using a mixed methods approach of factorial analysis and principal component analysis. The third survey is an assessment of the organizational context in which PHC organizations are evolving. The five year prospective period will serve as a natural experiment to assess contextual and organizational factors (in 2005) associated with migration of PHC organizational models into new forms or models (in 2010) and assess the impact of this evolution on the performance of PHC.</p> <p>Discussion</p> <p>The results of this study will shed light on changes brought about in the organization of PHC and on factors associated with these changes.</p