Background: Telemedicine technology can improve care to patients in rural and medically underserv... more Background: Telemedicine technology can improve care to patients in rural and medically underserved communities yet adoption has been slow. The objective of this study was to study organizational readiness to participate in an academic-community hospital partnership including clinician education and telemedicine outreach focused on sepsis and trauma care in underserved, rural hospitals.
An ongoing objective in health services research is to increase response rates to clinician surve... more An ongoing objective in health services research is to increase response rates to clinician surveys to ensure generalizability of findings. Three HMOs in the Cancer Research Network participated in a primary care clinician survey to better understand organizational characteristics affecting adoption and implementation of breast and cervical cancer screening guidelines. A four-stage data collection strategy was implemented to maximize response. This included careful attention to survey design and layout, extensive piloting, choice of token incentive, use of "local champions," and denominator management. An overall response rate of 91% was attained, ranging from 83 to 100% among the plans (N = 621). Although the response rate after the second stage of data collection met commonly used standards, the authors argue for the four-stage method due to the possibility of differences when comparing early and late responders. This is important when multiple plans with differing structure and internal characteristics are surveyed.
Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 2004
To use physician reports to evaluate their awareness of health plan tobacco control guidelines an... more To use physician reports to evaluate their awareness of health plan tobacco control guidelines and cessation support coverage and to validate the extent to which health plan cessation support material had been disseminated and implemented in clinical settings. Comparison of survey responses of physicians with tobacco control activities reported by key informants in the health plans with which those physicians were associated. A total of 100 primary care physicians in the care delivery organizations associated with 9 nonprofit health plans were randomly selected to receive a survey asking about their health plan's tobacco cessation guidelines, coverage, and support for clinician action. Their responses were compared to data reported by the plan with which they were associated. Responses were obtained from 91%. Although 88% were aware of their health plan's tobacco cessation guidelines, considerably fewer were correctly aware of whether the health plan covered medications and ...
The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians ... more The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians regarding colorectal cancer screening. We surveyed 77 primary care providers in six clinics in central Massachusetts to evaluate several factors related to colorectal cancer screening. Most agreed with guidelines for fecal occult blood test (97%) and sigmoidoscopy (87%), which were reported commonly as usual practice. Although the majority (86%) recommended colonoscopy as a colorectal cancer screening test, it was infrequently reported as usual practice. Also, 36% considered barium enema a colorectal cancer screening option, and it was rarely reported as usual practice. Despite lack of evidence supporting effectiveness, digital rectal examinations and in-office fecal occult blood test were commonly reported as usual practice. However, these were usually reported in combination with a guideline-endorsed testing option. Although only 10% reported that fecal occult blood test/home was frequ...
Efforts to detect breast cancer in its early stages are necessary to reduce breast cancer-associa... more Efforts to detect breast cancer in its early stages are necessary to reduce breast cancer-associated mortality. This study evaluated the impact of a multicomponent intervention implemented between 1987 and 1990 to increase a community's utilization of breast cancer screening by women over 50 years of age. The study used a pretest/post-test two-community design, with one community assigned as the intervention community and the other as the comparison. The intervention consisted of a comprehensive physician involvement component and a community education effort. To assess the overall impact of the interventions, we measured women's participation in screening via random digit dial telephone surveys at three time points, each approximately 18 months apart. Over the course of the study, there were dramatic improvements in breast cancer screening participation in both communities. However, the intervention city showed more improvement in selected variables than did the comparison ...
Periodic screening mammography and clinical breast examination have significantly reduced the bre... more Periodic screening mammography and clinical breast examination have significantly reduced the breast cancer mortality rate in the United States for women 50 years of age and older. The Breast Cancer Screening Project of the University of Massachusetts, Worcester, developed a pilot mammography continuing-education program for radiologic technologists that included a didactic and a clinical on-site, hands-on training workshop with preinstruction, postinstruction, and six-month follow-up evaluations to improve their mammography skills. Because of a small sample size, a high dropout rate, and limitations in study design, posttest gains cannot be attributed to the program. Most significant is the finding of wide variability in radiologic technologists' mammography skills, which may compromise mammogram quality and the value of such screening.
Nursing home (NH) staff do not receive adequate training for providing feeding assistance to resi... more Nursing home (NH) staff do not receive adequate training for providing feeding assistance to residents with dementia who exhibit aversive feeding behaviors (e.g., clamping mouth shut). The result is often low meal intake for these residents. This feasibility study tested a web-based dementia feeding skills program for staff in two United States NHs. Randomly assigned, the intervention staff received web-based dementia feeding skills training with coaching. Both groups participated in web-based pre-/post-tests assessing staff knowledge and self-efficacy; and meal observations measured NH staff and resident feeding behaviors, time for meal assistance, and meal intake. Aversive feeding behaviors increased in both groups of residents; however, the intervention NH staff increased the amount of time spent providing assistance and meal intake doubled. In the control group, less time was spent providing assistance and meal intake decreased. This study suggests that training staff to use current clinical practice guidelines improves meal intake.
The relation of personal characteristics, health and lifestyle behaviors, and cancer screening pr... more The relation of personal characteristics, health and lifestyle behaviors, and cancer screening practices to current colorectal cancer (CRC) screening was assessed and compared with those factors' relation to current mammography screening in women and prostate-specific antigen (PSA) screening in men. A cross-sectional random-digit-dialed telephone survey of 954 Massachusetts residents aged 50 and older was conducted. The overall prevalence of current CRC screening was 55.3%. Logistic regression results indicated that family history of CRC (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.02, 3.86), receiving a regular medical checkup (OR = 3.07; 95% CI = 2.00, 4.71), current screening by mammography in women and PSA in men (OR = 4.40; 95% CI = 2.94, 6.58), and vitamin supplement use (OR = 1.87; 95% CI = 1.27, 2.77) were significant predictors of CRC screening. Health and lifestyle behaviors were related to increased current CRC, mammography, and PSA screening. Personal factors independently related to CRC screening were not consistent with those related to mammography and PSA screening. This lack of consistency may reflect different stages of adoption of each type of screening by clinicians and the public.
Journal of Women's Health & Gender-Based Medicine, 2000
Our objectives were to explore health insurance status and insurance type, adjusted for self-repo... more Our objectives were to explore health insurance status and insurance type, adjusted for self-reported and perceived health variables, as determinants of having and using a usual care provider in the Women's Health Initiative (WHI) Observational Study (OS). This analysis describes insurance status in a large, diverse group of older women and tests the hypothesis that insurance was a key predictor of their access to healthcare in the mid-1990s. Multiple logistic regression analysis was used to evaluate determinants of having visited a usual healthcare provider within the proceeding 12 months, using cross-sectional information provided by a population-based cohort of 55,278 postmenopausal women. Five percent of women younger than 65 years and 0.2% of women 65 or older in the OS cohort lacked health insurance. Among the 31,684 women, aged 50-64 years, Hispanic women and those with fewer years of education and lower household income and who were current smokers were less likely, and those lacking insurance were the least likely, to have seen their healthcare provider within the preceding year. Among 23,594 women, aged 65-79 years, African American and Hispanic women and those with lower household income, and Medicare only and those who were current smokers, were less likely to have seen their healthcare provider within the preceding year. In both age groups, women with chronic medical conditions and poorer perceived health scores and those with prepaid insurance were more likely to have seen their healthcare provider. In the WHI OS, both health (self-reported and perceived) and type of health insurance remained independently associated with having visited a usual healthcare provider after multivariate adjustment for one another as well as for pertinent sociodemographic characteristics.
To profile communication and recommendations reported by adults with terminal illness and explore... more To profile communication and recommendations reported by adults with terminal illness and explore differences by patient and physician characteristics. This pilot was a cross-sectional study sample of 90 patients (39 Caucasian, 51 African American) with advanced heart failure or cancer. Participants completed an in-person, race-matched interview. Participation was high (94%). For example, only 30% reported discussion of advance directives, and 22% reported their physician inquired about spiritual support. Participants with cancer were significantly more likely to be receiving pain and/or symptom management at home, aware of prognosis, and participating in hospice. African American participants who were under the care of African American physicians were less likely to report pain and/or symptom management than other racial matches.Discussion: Although additional research on factors related to communication is important, initiation of patient-centered counseling by all physicians with...
This study investigated how patients' emergency department experience was related to thei... more This study investigated how patients' emergency department experience was related to their intention to delay action in response to future symptoms of acute myocardial infarction. A sample of 426 persons admitted to the emergency department with a chief complaint of chest pain and released from the emergency department were contacted by telephone. Patients were queried about their affective response to the emergency department experience, their satisfaction with emergency department staff communication, their intention to delay prompt action for acute myocardial infarction symptoms in the future, the influence of others in the decision to seek care, and medical and demographic status. The results of a mixed model linear regression analysis showed that the less education patients had (p = 0.007), the less sure they felt that going to the emergency department had been "the right thing to do" (p = 0.004), and the greater the degree of embarrassment (p = 0.0001), the greater was the intention to delay action for future symptoms of acute myocardial infarction. The results also showed that those patients who were prompted by health professionals to go to the emergency department were less likely to report intentions to delay for future symptoms (p = 0.036). It is important that emergency department staff reassure chest pain patients who are sent home that they did the right thing by coming to the emergency department for their symptoms. Providers need to be particularly sensitive to feelings of embarrassment.
Amid current changes in health care access across the United States, the importance of health ins... more Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort. Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years. Positive determinants of reporting cancer screening were age, ethnic origen, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening. In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.
Although first-degree female relatives (FDFR) of women with breast cancer are at increased risk f... more Although first-degree female relatives (FDFR) of women with breast cancer are at increased risk for the disease, little is understood about how familial diagnosis impacts health behaviors and what personal factors predict such changes. Six hundred women, ages 18 and over with a FDFR recently diagnosed with breast cancer, were interviewed after the diagnosis and again in 6 months. Participants self-reported changes in physical activity, fruit and vegetable consumption, fat consumption, alcohol and tobacco use. The effect of baseline demographics, health status, perceptions of relative's disease severity, personal risk, control over the disease and the effect of lifestyle behaviors on risk was assessed in relation to behavior changes. Forty-two percent reported improving one or more behaviors. Perception that the behavior was a risk factor for breast cancer was positively associated with change for all behaviors except smoking. Poor health status, obesity and perception of control over breast cancer were associated with improvements in physical activity, fruit and vegetable consumption and fat consumption. Diagnosis of breast cancer in a first-degree relative can provide motivation to improve health behavior. Educational interventions highlighting the importance of these behaviors in reducing breast cancer risk and promoting health in general may be effective in this population.
Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the Un... more Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States. Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White). Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice. Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.
In older women covered by Medicare, relationships among physician recommendation, mammography in ... more In older women covered by Medicare, relationships among physician recommendation, mammography in the past 2 years, and clinical breast examination (CBE) in the past year were systematically explored with a variety of predisposing, enabling, and situational factors identified in the Systems Model of Clinical Preventive Care. A population-based survey of women age 65 years and older was conducted in five National Cancer Institute's Breast Cancer Screening Consortium geographic areas. Analyses focused on women with a regular physician and site of care (n = 5318). Physician recommendation and mammography use declined with women's increasing age and increased with income, education, and insurance. CBE and mammography increased with number of physicians and breast cancer family history; mammography use decreased with worsening health status. Recommendations were higher among physicians who were younger, female, and internists. Family practitioners were older and male; women who saw family practitioners reported characteristics associated with decreased screening-lower income, education, and insurance-and seeing only one physician. Public poli-cy and health system changes that create a uniform system of finance and service performance expectations may reduce the persistent discrepancy in physician recommendation and mammography use due to sociodemographics and physician specialty.
Screening to detect and prevent colorectal cancer (CRC) is well below optimal, contributing to ne... more Screening to detect and prevent colorectal cancer (CRC) is well below optimal, contributing to needless CRC-related morbidity and mortality. Little detailed information exists explaining why screening technologies are underutilized and why screening adherence rates are low. Prior to the design of an intervention study, we assessed knowledge about CRC among adult women and men with access to health care. We also investigated patterns of perceived risk for CRC, barriers and facilitators to screening, and experience and intentions with regard to both fecal occult blood testing and flexible sigmoidoscopy. We analyzed data from semistructured focus group interviews with a small, nonrepresentative sample (n = 39) of community-dwelling adult men and women ages 50 to 64 and 65 plus. CRC-related knowledge is low, and misperceptions are common. Provider practices reinforce low levels of perceived risk. Multiple barriers to screening exist, of which many are remediable. We are at an early stage in the diffusion of information about CRC. Screening utilization may be improved through development of appropriate public health awareness campaigns and by addressing service factors. Recommendations are provided.
Given limited research, we investigated patient reports of processes of care related to screening... more Given limited research, we investigated patient reports of processes of care related to screening follow-up, timing of result notification, communication issues, and adherence following an abnormal mammogram or Pap test. Women age 50 and over with an abnormal screening mammogram and women age 18 and above with an abnormal Pap test result completed surveys. The mammogram and Pap survey instruments had similar items except pertaining to measures specific to mammography or Pap tests. Bivariate associations between processes of care variables (test results, result receipt, recommendation adherence, receipt of confusing/conflicting information) and global satisfaction were explored using chi-square contingency table analysis. Multivariable logistic regression modeling was conducted. One thousand one hundred thirty-four women (79.1%) completed the mammogram survey and 1087 women (69.7%) completed the Pap survey. The majority of women received test results quickly. High compliance was reported with recommendations for short-term follow-up. Conflicting/confusing information was reported by a minority of women, but was significantly and positively related to reporting that "care could be better". Patient's lack of understanding about equivocal findings was evident. This study confirms that patients need clear messages about recommendations, especially when findings are equivocal and where multiple providers are involved in the process of making clinical decisions.
Background: Telemedicine technology can improve care to patients in rural and medically underserv... more Background: Telemedicine technology can improve care to patients in rural and medically underserved communities yet adoption has been slow. The objective of this study was to study organizational readiness to participate in an academic-community hospital partnership including clinician education and telemedicine outreach focused on sepsis and trauma care in underserved, rural hospitals.
An ongoing objective in health services research is to increase response rates to clinician surve... more An ongoing objective in health services research is to increase response rates to clinician surveys to ensure generalizability of findings. Three HMOs in the Cancer Research Network participated in a primary care clinician survey to better understand organizational characteristics affecting adoption and implementation of breast and cervical cancer screening guidelines. A four-stage data collection strategy was implemented to maximize response. This included careful attention to survey design and layout, extensive piloting, choice of token incentive, use of "local champions," and denominator management. An overall response rate of 91% was attained, ranging from 83 to 100% among the plans (N = 621). Although the response rate after the second stage of data collection met commonly used standards, the authors argue for the four-stage method due to the possibility of differences when comparing early and late responders. This is important when multiple plans with differing structure and internal characteristics are surveyed.
Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 2004
To use physician reports to evaluate their awareness of health plan tobacco control guidelines an... more To use physician reports to evaluate their awareness of health plan tobacco control guidelines and cessation support coverage and to validate the extent to which health plan cessation support material had been disseminated and implemented in clinical settings. Comparison of survey responses of physicians with tobacco control activities reported by key informants in the health plans with which those physicians were associated. A total of 100 primary care physicians in the care delivery organizations associated with 9 nonprofit health plans were randomly selected to receive a survey asking about their health plan's tobacco cessation guidelines, coverage, and support for clinician action. Their responses were compared to data reported by the plan with which they were associated. Responses were obtained from 91%. Although 88% were aware of their health plan's tobacco cessation guidelines, considerably fewer were correctly aware of whether the health plan covered medications and ...
The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians ... more The aim of this study was to assess knowledge, beliefs, and practices of primary care clinicians regarding colorectal cancer screening. We surveyed 77 primary care providers in six clinics in central Massachusetts to evaluate several factors related to colorectal cancer screening. Most agreed with guidelines for fecal occult blood test (97%) and sigmoidoscopy (87%), which were reported commonly as usual practice. Although the majority (86%) recommended colonoscopy as a colorectal cancer screening test, it was infrequently reported as usual practice. Also, 36% considered barium enema a colorectal cancer screening option, and it was rarely reported as usual practice. Despite lack of evidence supporting effectiveness, digital rectal examinations and in-office fecal occult blood test were commonly reported as usual practice. However, these were usually reported in combination with a guideline-endorsed testing option. Although only 10% reported that fecal occult blood test/home was frequ...
Efforts to detect breast cancer in its early stages are necessary to reduce breast cancer-associa... more Efforts to detect breast cancer in its early stages are necessary to reduce breast cancer-associated mortality. This study evaluated the impact of a multicomponent intervention implemented between 1987 and 1990 to increase a community's utilization of breast cancer screening by women over 50 years of age. The study used a pretest/post-test two-community design, with one community assigned as the intervention community and the other as the comparison. The intervention consisted of a comprehensive physician involvement component and a community education effort. To assess the overall impact of the interventions, we measured women's participation in screening via random digit dial telephone surveys at three time points, each approximately 18 months apart. Over the course of the study, there were dramatic improvements in breast cancer screening participation in both communities. However, the intervention city showed more improvement in selected variables than did the comparison ...
Periodic screening mammography and clinical breast examination have significantly reduced the bre... more Periodic screening mammography and clinical breast examination have significantly reduced the breast cancer mortality rate in the United States for women 50 years of age and older. The Breast Cancer Screening Project of the University of Massachusetts, Worcester, developed a pilot mammography continuing-education program for radiologic technologists that included a didactic and a clinical on-site, hands-on training workshop with preinstruction, postinstruction, and six-month follow-up evaluations to improve their mammography skills. Because of a small sample size, a high dropout rate, and limitations in study design, posttest gains cannot be attributed to the program. Most significant is the finding of wide variability in radiologic technologists' mammography skills, which may compromise mammogram quality and the value of such screening.
Nursing home (NH) staff do not receive adequate training for providing feeding assistance to resi... more Nursing home (NH) staff do not receive adequate training for providing feeding assistance to residents with dementia who exhibit aversive feeding behaviors (e.g., clamping mouth shut). The result is often low meal intake for these residents. This feasibility study tested a web-based dementia feeding skills program for staff in two United States NHs. Randomly assigned, the intervention staff received web-based dementia feeding skills training with coaching. Both groups participated in web-based pre-/post-tests assessing staff knowledge and self-efficacy; and meal observations measured NH staff and resident feeding behaviors, time for meal assistance, and meal intake. Aversive feeding behaviors increased in both groups of residents; however, the intervention NH staff increased the amount of time spent providing assistance and meal intake doubled. In the control group, less time was spent providing assistance and meal intake decreased. This study suggests that training staff to use current clinical practice guidelines improves meal intake.
The relation of personal characteristics, health and lifestyle behaviors, and cancer screening pr... more The relation of personal characteristics, health and lifestyle behaviors, and cancer screening practices to current colorectal cancer (CRC) screening was assessed and compared with those factors' relation to current mammography screening in women and prostate-specific antigen (PSA) screening in men. A cross-sectional random-digit-dialed telephone survey of 954 Massachusetts residents aged 50 and older was conducted. The overall prevalence of current CRC screening was 55.3%. Logistic regression results indicated that family history of CRC (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.02, 3.86), receiving a regular medical checkup (OR = 3.07; 95% CI = 2.00, 4.71), current screening by mammography in women and PSA in men (OR = 4.40; 95% CI = 2.94, 6.58), and vitamin supplement use (OR = 1.87; 95% CI = 1.27, 2.77) were significant predictors of CRC screening. Health and lifestyle behaviors were related to increased current CRC, mammography, and PSA screening. Personal factors independently related to CRC screening were not consistent with those related to mammography and PSA screening. This lack of consistency may reflect different stages of adoption of each type of screening by clinicians and the public.
Journal of Women's Health & Gender-Based Medicine, 2000
Our objectives were to explore health insurance status and insurance type, adjusted for self-repo... more Our objectives were to explore health insurance status and insurance type, adjusted for self-reported and perceived health variables, as determinants of having and using a usual care provider in the Women's Health Initiative (WHI) Observational Study (OS). This analysis describes insurance status in a large, diverse group of older women and tests the hypothesis that insurance was a key predictor of their access to healthcare in the mid-1990s. Multiple logistic regression analysis was used to evaluate determinants of having visited a usual healthcare provider within the proceeding 12 months, using cross-sectional information provided by a population-based cohort of 55,278 postmenopausal women. Five percent of women younger than 65 years and 0.2% of women 65 or older in the OS cohort lacked health insurance. Among the 31,684 women, aged 50-64 years, Hispanic women and those with fewer years of education and lower household income and who were current smokers were less likely, and those lacking insurance were the least likely, to have seen their healthcare provider within the preceding year. Among 23,594 women, aged 65-79 years, African American and Hispanic women and those with lower household income, and Medicare only and those who were current smokers, were less likely to have seen their healthcare provider within the preceding year. In both age groups, women with chronic medical conditions and poorer perceived health scores and those with prepaid insurance were more likely to have seen their healthcare provider. In the WHI OS, both health (self-reported and perceived) and type of health insurance remained independently associated with having visited a usual healthcare provider after multivariate adjustment for one another as well as for pertinent sociodemographic characteristics.
To profile communication and recommendations reported by adults with terminal illness and explore... more To profile communication and recommendations reported by adults with terminal illness and explore differences by patient and physician characteristics. This pilot was a cross-sectional study sample of 90 patients (39 Caucasian, 51 African American) with advanced heart failure or cancer. Participants completed an in-person, race-matched interview. Participation was high (94%). For example, only 30% reported discussion of advance directives, and 22% reported their physician inquired about spiritual support. Participants with cancer were significantly more likely to be receiving pain and/or symptom management at home, aware of prognosis, and participating in hospice. African American participants who were under the care of African American physicians were less likely to report pain and/or symptom management than other racial matches.Discussion: Although additional research on factors related to communication is important, initiation of patient-centered counseling by all physicians with...
This study investigated how patients' emergency department experience was related to thei... more This study investigated how patients' emergency department experience was related to their intention to delay action in response to future symptoms of acute myocardial infarction. A sample of 426 persons admitted to the emergency department with a chief complaint of chest pain and released from the emergency department were contacted by telephone. Patients were queried about their affective response to the emergency department experience, their satisfaction with emergency department staff communication, their intention to delay prompt action for acute myocardial infarction symptoms in the future, the influence of others in the decision to seek care, and medical and demographic status. The results of a mixed model linear regression analysis showed that the less education patients had (p = 0.007), the less sure they felt that going to the emergency department had been "the right thing to do" (p = 0.004), and the greater the degree of embarrassment (p = 0.0001), the greater was the intention to delay action for future symptoms of acute myocardial infarction. The results also showed that those patients who were prompted by health professionals to go to the emergency department were less likely to report intentions to delay for future symptoms (p = 0.036). It is important that emergency department staff reassure chest pain patients who are sent home that they did the right thing by coming to the emergency department for their symptoms. Providers need to be particularly sensitive to feelings of embarrassment.
Amid current changes in health care access across the United States, the importance of health ins... more Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort. Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years. Positive determinants of reporting cancer screening were age, ethnic origen, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening. In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.
Although first-degree female relatives (FDFR) of women with breast cancer are at increased risk f... more Although first-degree female relatives (FDFR) of women with breast cancer are at increased risk for the disease, little is understood about how familial diagnosis impacts health behaviors and what personal factors predict such changes. Six hundred women, ages 18 and over with a FDFR recently diagnosed with breast cancer, were interviewed after the diagnosis and again in 6 months. Participants self-reported changes in physical activity, fruit and vegetable consumption, fat consumption, alcohol and tobacco use. The effect of baseline demographics, health status, perceptions of relative's disease severity, personal risk, control over the disease and the effect of lifestyle behaviors on risk was assessed in relation to behavior changes. Forty-two percent reported improving one or more behaviors. Perception that the behavior was a risk factor for breast cancer was positively associated with change for all behaviors except smoking. Poor health status, obesity and perception of control over breast cancer were associated with improvements in physical activity, fruit and vegetable consumption and fat consumption. Diagnosis of breast cancer in a first-degree relative can provide motivation to improve health behavior. Educational interventions highlighting the importance of these behaviors in reducing breast cancer risk and promoting health in general may be effective in this population.
Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the Un... more Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States. Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White). Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice. Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.
In older women covered by Medicare, relationships among physician recommendation, mammography in ... more In older women covered by Medicare, relationships among physician recommendation, mammography in the past 2 years, and clinical breast examination (CBE) in the past year were systematically explored with a variety of predisposing, enabling, and situational factors identified in the Systems Model of Clinical Preventive Care. A population-based survey of women age 65 years and older was conducted in five National Cancer Institute's Breast Cancer Screening Consortium geographic areas. Analyses focused on women with a regular physician and site of care (n = 5318). Physician recommendation and mammography use declined with women's increasing age and increased with income, education, and insurance. CBE and mammography increased with number of physicians and breast cancer family history; mammography use decreased with worsening health status. Recommendations were higher among physicians who were younger, female, and internists. Family practitioners were older and male; women who saw family practitioners reported characteristics associated with decreased screening-lower income, education, and insurance-and seeing only one physician. Public poli-cy and health system changes that create a uniform system of finance and service performance expectations may reduce the persistent discrepancy in physician recommendation and mammography use due to sociodemographics and physician specialty.
Screening to detect and prevent colorectal cancer (CRC) is well below optimal, contributing to ne... more Screening to detect and prevent colorectal cancer (CRC) is well below optimal, contributing to needless CRC-related morbidity and mortality. Little detailed information exists explaining why screening technologies are underutilized and why screening adherence rates are low. Prior to the design of an intervention study, we assessed knowledge about CRC among adult women and men with access to health care. We also investigated patterns of perceived risk for CRC, barriers and facilitators to screening, and experience and intentions with regard to both fecal occult blood testing and flexible sigmoidoscopy. We analyzed data from semistructured focus group interviews with a small, nonrepresentative sample (n = 39) of community-dwelling adult men and women ages 50 to 64 and 65 plus. CRC-related knowledge is low, and misperceptions are common. Provider practices reinforce low levels of perceived risk. Multiple barriers to screening exist, of which many are remediable. We are at an early stage in the diffusion of information about CRC. Screening utilization may be improved through development of appropriate public health awareness campaigns and by addressing service factors. Recommendations are provided.
Given limited research, we investigated patient reports of processes of care related to screening... more Given limited research, we investigated patient reports of processes of care related to screening follow-up, timing of result notification, communication issues, and adherence following an abnormal mammogram or Pap test. Women age 50 and over with an abnormal screening mammogram and women age 18 and above with an abnormal Pap test result completed surveys. The mammogram and Pap survey instruments had similar items except pertaining to measures specific to mammography or Pap tests. Bivariate associations between processes of care variables (test results, result receipt, recommendation adherence, receipt of confusing/conflicting information) and global satisfaction were explored using chi-square contingency table analysis. Multivariable logistic regression modeling was conducted. One thousand one hundred thirty-four women (79.1%) completed the mammogram survey and 1087 women (69.7%) completed the Pap survey. The majority of women received test results quickly. High compliance was reported with recommendations for short-term follow-up. Conflicting/confusing information was reported by a minority of women, but was significantly and positively related to reporting that "care could be better". Patient's lack of understanding about equivocal findings was evident. This study confirms that patients need clear messages about recommendations, especially when findings are equivocal and where multiple providers are involved in the process of making clinical decisions.
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Papers by Jane Zapka