Preventable cancer mortality in American Indian and Alaska Native women.

This report describes a series of six studies on cancer in American Indian and Alaska Native (AI/AN) women, with a particular emphasis on cancer of the breast and cervix. Data from the Indian Health Service (IHS) inpatient data system was used to generate estimates of incidence of cancer among AI/AN populations. Additionally, breast cancer rates among Indian women in Arizona and New Mexico were compiled from extensive chart review of the New Mexico Tumor Registry and the IHS Inpatient Data System. Study of the performance of the health care system for cancer screening in women suggest that the major deficiency lies not in a failure to bring women in for screening, but rather to complete the screening after contact has been made and the need for screening recognized. The studies indicate that cancer is generally diagnosed in American Indian women at a more advanced stage and survival experience of Indian cancer patients is worse than non-Indian, even when corrected for later stage at diagnosis. Several of the studies suggest that failure to diagnose cancer in its very early stages appears to be in large part dependent on patient behavior. An alarming number of women do not keep follow-up appointments, even after multiple referrals and rescheduling of appointments. These findings suggest the need for intervention strategies that encourage women to become knowledgeable about cancer and to accept responsibility for their screening. The studies suggest that the relative difficulty in improving screening rates are traced to an inadequate understanding of cancer and its prevention on the part of women in the community

Studies in Ambulatory Care Quality Assessment in the Indian Health Service Volume 3: Comparison of Rural Private Practice, Health Maintenance Organizations, and the Indian Health Service

This report describes a method designed to assess the quality of ambulatory health care in the Indian Health Service. The first part of the evaluation was a description of the design phase of the quality assurance methodology. The second report describes a pilot study in six IHS Service Units, three private practices, and two large Health Maintenance Organizations. This third volume compares the three different types of health care units. The primary purpose of this report is to determine if there is any significant difference in the performance of the different health care providers of ambulatory health care.Seven tracer conditions were selected on the basis of severity of impact on the patient. The tracer conditions included: severe lacerations, iron deficiency anemia, urinary tract infection, prenatal care, infant care, streptococcal infection, and hypertension. Specific patient cohorts were identified by tracer condition and monitored by criteria indicators. These indicators describe the continuity, distribution, and appropriateness of provider care. The indicators are aggregated into three major types: population based, provider based, and health status indicators. The results were tabulated in frequency tables. Comparisons of tracer cohorts were then made for all three types of health care providers.This comparative phase of the study found that there was no substantial or consistent difference in the performance of the care providers across units. Most of the differences observed were attributable to the provider\u27s ability or inability to recognize the patient\u27s needs, and the patient\u27s ability to articulate their needs. It appeared that IHS units did a more comprehensive job of consumer education. That may be attributable to the multidisciplinary health care teams, and extensive field operations of IHS. Conversely, the recognition of patient needs tends to be higher with private practitioners and HMOs.The study suggests four major methodological areas of concern in the application of quality assurance techniques. First, the evaluation of provider performance alone does not necessarily reflect the adequacy of care provided. Second, the study indicates a continuing need to improve the continuity of care provision. Health status indicators were the weakest part of the quality assessment methodology and require further research and development. Finally, one must use tracer conditions with caution. The adequacy of care resulting from the assessment of one condition may not always be generalizable to insure adequacy of care for similar conditions. Focusing on specific conditions may serve to blind the care provider to other symptomatically similar conditions

Studies in Ambulatory Care Quality Assessment in the Indian Health Service

This report describes a method designed to assess the quality of ambulatory health care in the Indian Health Service. This evaluation approaches the issue of quality assurance for ambulatory care through three basic performance criteria: 1) the method must be easily and economically incorporated into the existing system; 2) the method must identify areas of deficiency in health care and suggest adaptive programs to correct deficiencies; and 3) the method must view health care from the community perspective and examine the quality of the care actually received.This study design was developed around six methodological design questions: 1) what mode of health care delivery is assessed; 2) what aspect of quality is measured; 3) what is the content of the evaluation; 4) how is quality assessed; 5) from what perspective are the measurements taken; and 6) how are the results analyzed? The results of the above design decisions are then used to develop criteria-based indicators and instruments. The project product is a set of flow charts or process maps and tables which outline in detail, the performance and process criteria, and forms to be used to connect data and index the progress and effectiveness of actual patient status and health care performance. The final stage in the process is to propose a design for field testing the established methodology. The evaluation instrument was successfully completed, and implemented at the field test study sites.For the purpose of improving the pilot study and subsequent evaluations, the designers of this methodology strongly suggest that: 1) audit specific data should include all usual patient status data, complete patient history data, including negative as well as positive progress, and educational counseling plans and outcomes; 2) validity of proposed criteria ought to be supported by controlled clinical studies; and 3) only those elements of care which can actually be changed should be subjected to compliance with performance criteria

Get screened: a pragmatic randomized controlled trial to increase mammography and colorectal cancer screening in a large, safety net practice

Abstract Background Most randomized controlled trials of interventions designed to promote cancer screening, particularly those targeting poor and minority patients, enroll selected patients. Relatively little is known about the benefits of these interventions among unselected patients. Methods/Design "Get Screened" is an American Cancer Society-sponsored randomized controlled trial designed to promote mammography and colorectal cancer screening in a primary care practice serving low-income patients. Eligible patients who are past due for mammography or colorectal cancer screening are entered into a tracking registry and randomly assigned to early or delayed intervention. This 6-month intervention is multimodal, involving patient prompts, clinician prompts, and outreach. At the time of the patient visit, eligible patients receive a low-literacy patient education tool. At the same time, clinicians receive a prompt to remind them to order the test and, when appropriate, a tool designed to simplify colorectal cancer screening decision-making. Patient outreach consists of personalized letters, automated telephone reminders, assistance with scheduling, and linkage of uninsured patients to the local National Breast and Cervical Cancer Early Detection program. Interventions are repeated for patients who fail to respond to early interventions. We will compare rates of screening between randomized groups, as well as planned secondary analyses of minority patients and uninsured patients. Data from the pilot phase show that this multimodal intervention triples rates of cancer screening (adjusted odds ratio 3.63; 95% CI 2.35 - 5.61). Discussion This study protocol is designed to assess a multimodal approach to promotion of breast and colorectal cancer screening among underserved patients. We hypothesize that a multimodal approach will significantly improve cancer screening rates. The trial was registered at Clinical Trials.gov NCT00818857http://deepblue.lib.umich.edu/bitstream/2027.42/78264/1/1472-6963-10-280.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78264/2/1472-6963-10-280.pdfPeer Reviewe

Recent advances in radiotherapy

Radiation therapy has come a long way from treatment planning based on orthogonal radiographs with large margins around tumours. Advances in imaging and radiation planning software have led to three-dimensional conformal radiotherapy and, further, to intensity modulated radiotherapy (IMRT). IMRT permits sparing of normal tissues and hence dose-escalation to tumours. IMRT is the current standard in treatment of head and prostate cancer and is being investigated in other tumour sites. Exquisitely sculpted dose distributions (increased geographical miss) with IMRT, plus tumour motion and anatomical changes during radiotherapy make image guided radiotherapy an essential part of modern radiation delivery. Various hardware and software tools are under investigation for optimal IGRT

Reengineering the clinical research enterprise to involve more community clinicians

<p>Abstract</p> <p>Background</p> <p>The National Institutes of Health has called for expansion of practice-based research to improve the clinical research enterprise.</p> <p>Methods</p> <p>This paper presents a model for the reorganization of clinical research to foster long-term participation by community clinicians.</p> <p>Based on the literature and interviews with clinicians and other stakeholders, we posited a model, conducted further interviews to test the viability of the model, and further adapted it.</p> <p>Results</p> <p>We propose a three-dimensional system of checks and balances to support community clinicians using research support organizations, community outreach, a web-based registry of clinicians and studies, web-based training services, quality audits, and a feedback mechanism for clinicians engaged in research.</p> <p>Conclusions</p> <p>The proposed model is designed to offer a systemic mechanism to address current barriers that prevent clinicians from participation in research. Transparent mechanisms to guarantee the safety of patients and the integrity of the research enterprise paired with efficiencies and economies of scale are maintained by centralizing some of the functions. Assigning other responsibilities to more local levels assures flexibility with respect to the size of the clinician networks and the changing needs of researchers.</p

The chronic care model: Congruency and predictors among patients with cardiovascular diseases and chronic obstructive pulmonary disease in the Netherlands

Objective: The Chronic Care Model (CCM) achieved widespread acceptance and reflects the core elements of patient-centred care in chronic diseases such as CVD and COPD. Our aim is to assess the extent to which current care for CVD and COPD patients aligns with the CCM in Dutch healthcare practices in the early stages of implementing disease-management programs, thereby revealing possible predictors that tell us whether certain patients are more likel

Physicians’ Perspectives on Prescribing Benzodiazepines for Older Adults: A Qualitative Study

BACKGROUND: There is a continued high prevalence of benzodiazepine use by older community-residing adults and of their continued prescription by practitioners, despite well known adverse effects and the availability of safer, effective alternatives. OBJECTIVES: To understand factors influencing chronic use of benzodiazepines in older adults. DESIGN: Qualitative study, semistructured interviews with physicians. PARTICIPANTS: Thirty-three practicing primary care physicians around Philadelphia. APPROACH: Qualitative interviews were audiotaped, transcribed, and entered into a qualitative software program. A multidisciplinary team coded transcripts and developed themes. RESULTS: Physicians generally endorsed benzodiazepines as effective treatment for anxiety, citing quick action and strong patient satisfaction. The use of benzodiazepines in older adults was not seen to be problematic because they did not show drug-seeking or escalating dose behavior suggesting addiction. Physicians minimized other risks of benzodiazepines and did not view monitoring or restricting renewal of prescriptions as an important clinical focus relative to higher-priority medical issues. Many physicians expressed skepticism about risks of continued use and considerable pessimism in the successful taper/discontinuation in older patients with long-term use and prior failed attempts. Physicians also anticipated patient resistance to any such efforts, including switching physicians. CONCLUSIONS: Primary care physicians are averse to addressing the public health problem of benzodiazepine overuse in the elderly. Their attitudes generally conflict with practice guidelines and they complain of a lack of training in constructive strategies to address this problem. A 2-pronged effort should focus on increasing skill level and preventing new cases of benzodiazepine dependency through improved patient education and vigilant monitoring of prescription renewal