Distress, personality, and mammography utilization among women with a family history of breast cancer.

The authors examined the impact of psychological distress and the personality construct of conscientiousness (as measured by the Neuroticism, Extraversion, and Openness—Five Factor Inventory) on mammography utilization among women who were at increased risk for breast cancer. Participants were 200 women who had at least 1 first degree relative with breast cancer. Overall, 80% of the participants had obtained a mammogram in the previous year. Analyses controlling for potential confounders (perceived risk, decisional balance, and physician recommendation for mammography), revealed that distress was negatively associated with mammography utilization among participants who were low in conscientiousness. Distress was not significantly related to mammography utilization among highly conscientious women. The results are discussed in terms of their implications regarding interventions designed to increase mammography utilization in this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Quantitative evaluation of local drug delivery using the InfusaSleeve catheter

BACKGROUND: Rural women are less likely to receive screening mammography at recommended intervals. This study evaluated efforts to promote screening mammography among women in rural communities through community education interventions and low-cost mobile mammography van services. METHODS: Two matched sets of communities were identified in an isolated rural region. One area received community education programs in addition to the mammography van for 2 years; the second area received only the van services. The educational programs were designed using diagnostic research methods; they included recruitment of opinion leaders to organize small group breast screening education sessions, an information campaign using direct mail, and primary health care provider education. RESULTS: A household telephone survey conducted 6 months after completion of these programs indicated that mammography utilization and perceived mammography norms were higher among women in the Program area than among women in the Comparison area. Process data were consistent with these findings. Clinical examination and self-examination behaviors were not influenced by the programs. CONCLUSIONS: This study showed that well-focused educational interventions for rural women can increase utilization of screening mammography when access and cost barriers also are reduced.     

Factors associated with women's adherence to mammography screening guidelines

OBJECTIVE: To examine individual and environmental factors associated with adherence to mammography screening guidelines. DATA SOURCES: A unique data set that combines a national probability sample (1992 National Health Interview Survey); a national probability sample of mammography facility characteristics (1992 National Survey of Mammography Facilities); county-level data on 1990 HMO market share; and county-level data on the supply of primary care providers (1991 Area Resource File). STUDY DESIGN: The design was cross-sectional. DATA EXTRACTION/ANALYSIS: Data sets were linked to create an individual-level sample of women ages 50-74 (weighted n = 2,026). We used multipart, sequential logistic regression models to examine the predictors of having ever had mammography, having had recent mammography, and adherence to guidelines. We categorized women as adherent if they reported a lifetime number of exams appropriate for their age (based on screening every two years) and they reported having had an exam in the past two years. PRINCIPAL FINDINGS: Only 27 percent of women had the age-appropriate number of screening exams (range 16 percent-37 percent), while 59 percent of women had been screened within two years. Women were significantly more likely to adhere to screening guidelines if they reported participating with their doctor in the decision to be screened; were younger; had smaller families, higher education and income, and a recent Pap smear; reported breast problems; and lived in an area with a higher percentage of mammography facilities with reminder systems, no shortage of primary care providers, higher HMO market share, and higher screening charges. CONCLUSIONS: A small percentage of women adhere to screening guidelines, suggesting that adherence needs to become a focus of clinical, programmatic, and policy efforts.     

A strategic approach to occupational injuries

The development of an integrated risk management approach to occupational injuries at Conrail had an enormously positive impact on injury incidence, lost work days, and company costs. Dr. Comstock describes managed care techniques that facilitate interface between quality assurance and risk management.     

Technology transfer in digital mammography. Report of the Joint National Cancer Institute-National Aeronautics and Space Administration workshop of May 19-20, 1993

Digital mammography is one of the most promising novel technologies for further improvement of early detection of breast cancer, offering important potential advantages: 1) improved image quality; 2) digital image processing for improved lesion contrast; 3) computer-aided diagnosis for enhanced radiologic interpretation; and 4) teleradiology for facilitated radiologic consultation. The Diagnostic Imaging Research Branch of the National Cancer Institute (NCI) recently funded an international, multidisciplinary, multi-institutional Digital Mammography Development Group for collaborations between NCI, the academic community, and industry to facilitate the integrated development and implementation of digital mammographic systems. Currently, however, digital mammography faces a number of fundamental technological roadblocks: 1) cost-effective digital detectors and displays for imaging systems; 2) the need for novel algorithms for image processing and computer-aided diagnosis; and 3) high performance, low cost digital networks to provide an "information superhighway" for teleradiology. To solve some of these technological problems, the Diagnostic Imaging Research Branch of NCI joined efforts with the Technology Transfer Division of the National Aeronautics and Space Administration to pursue a federal technology transfer program in digital mammography. The authors discuss the findings and recommendations of the workshop entitled "Technology Transfer in Digital Mammography," which was organized and held jointly by the NCI and the National Aeronautics and Space Administration in May, 1993. Numerous innovative technologies of varying degree of promise for digital mammography were presented at the conference. In this article, specific technologies presented at the workshop by the federal and federally-supported laboratories are described, and critiques of these technologies by the leaders of the medical imaging community are presented.     

Resist and redirect: physicians respond to breast cancer informed consent legislation

During the 1980s, former breast cancer patients initiated efforts to introduce Breast Cancer Informed Consent legislation in twenty-two state legislatures. Their general intent in proposing this legislation was to insure that women patients were included in the decision-making process regarding their breast cancer treatment. A qualitative analysis of the reactions of medical professional organizations to these efforts revealed a pattern of change over time. Because professionals were not aware of early efforts for Breast Cancer Informed Consent, these met little or no resistance. Subsequent efforts in the early 1980s were met with organized resistance; physicians' organizations responded to the legislation as if it were a threat to their professional autonomy. By the middle of the decade, professionals had co-opted the efforts, shaping the legislation to their benefit. The challenge to physician authority that former breast cancer patients mounted had mixed results, but ultimately illustrated that professions are quite effective at retaining power.     

Trends in breast cancer screening in Missouri from 1987 to 1995, and predictions for the years 2000 and 2010

BACKGROUND: Breast cancer is a major cause of morbidity and mortality in the United States (U.S.) and Missouri. In 1992, 3,915 new breast cancer cases were diagnosed and in 1995, 1,006 deaths from breast cancer were reported in Missouri. Although breast cancer incidence has increased in Missouri in the past 20 years, there are indications that early detection has also increased during the same period. Knowledge about which segments of the population have experienced the greatest increase in mammography screening rates helps in planning and implementation of breast cancer control programs at the state level. OBJECTIVES: Examine the prevalence and trends of lifetime mammography and 2-year mammography compliance in Missouri by age, race, and education from 1987 to 1995 and make predictions for the years 2000 and 2010. METHODS: We used data from the Missouri Behavioral Risk Factor Surveillance System (BRFSS), 1987 to 1995, to estimate the prevalence of ever having had a mammogram and compliance with mammography screening guidelines within two years by race, age, and education status among Missouri women over age 18. Using linear models, we regressed breast cancer screening prevalence estimates on time to obtain trends and predictions. RESULTS: Overall, African-American women were more likely to have had a lifetime mammogram than white women. However, we found a steady increase in the prevalence of ever having had a mammogram for all groups of women defined by age and education status, except among African Americans. Increase in the prevalence of ever having had a mammogram was much higher in women age 50 and older and slightly higher among women with a high school education or less. The average prevalence of 2-year mammography screening compliance was about 60% for all groups, a rate which did not significantly change between 1987 and 1995. By the year 2000, white women will have mammography rates equal to or higher than African-American women, and the majority of all women age 50 and older (98.3% to 100%) will have had a lifetime mammogram. CONCLUSION: Missouri target populations are predicted to attain Year 2000 National Health Objectives concerning lifetime mammography. Current efforts should be continued in order to maintain levels of mammography, particularly among African-American women.     

Peer review: A view from within.

Presents examples of exploitative and abusive practices by psychologists, as observed by the author during his years as consultant to Blue Shield of California. Although the practices are not unique to psychology, the profession is urged to continue its efforts in quality assurance and utilization review to ensure that the quality of services delivered to the public does not interfere with the development of the discipline. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A bimetal anode with tungsten or rhodium? Comparative studies on image quality and dosage requirement in mammography

PURPOSE: The impact of different anode materials (tungsten and rhodium) on spatial resolution, image contrast and radiation exposure was studied. MATERIALS AND METHODS: Two mammographic systems providing bimetal x-ray tubes (Mo/W and Mo/Rh) were compared by imaging a breast radiography phantom with additional acrylic plates from 3 to 8 cm thickness. Spatial resolution was evaluated using a line bar pattern. Image contrast was assessed by measuring the ratio of optical densities in a acrylic step-wedge. The entrance dose was measured with a low energy ionisation chamber. RESULTS: The spatial resolution was about 13 lp/mm regardless of the beam quality. The image contrast depended substantially on the thickness. A similar image contrast was found with Mo/Mo, Mo/Rh and Rh/Rh for simulated breast thicknesses of 4 to 6 cm and with Rh/Rh and W/Rh for 7 cm. In comparison to Mo/Mo the dose reduction was significant for Mo/Rh (35%), Rh/Rh (50%) and W/Rh (60%). CONCLUSIONS: Bimetal x-ray tubes provide optimal conditions for screen film mammography of both normal and dense breasts, allowing good contrast and dose reduction by using the adequate anode/filter-combination.     

Data recording of problems during anaesthesia: presentation of a well-functioning and simple system

BACKGROUND: As quality assurance, risk analysis and documentation become more important, rapid access to accurate information of departmental activity is needed. In this paper we describe a system for routine data recording of anaesthesia-related information, and we give examples of how this information can be used. METHODS: For each anaesthesia procedure we record 20 variables in a database. The variables are related to the patient, the procedure, and the anaesthesia. Both the type and severity of intraoperative problems are recorded. All information is routinely written on the standard anaesthetic chart, and later entered into a database. All charts are quality checked before data entry. RESULTS: With small modifications, we have used this system for 10 years, and it is well integrated as part of our departmental routine. From 1985 to 1995 we have recorded an increased incidence of 'minor' intraoperative problems, while the increase in 'severe' problems has been small. During the period 1993-95 the total problem incidence has been stable at around 14%. We have found the incidence of problems related to technical equipment to be 0.14%, and of 'minor' severity, and therefore equipment failure has not warranted extensive quality assurance efforts. We also investigated the impact of our routines for gastric emptying of non-fasting patients, and found an incidence of pulmonary aspiration of 0.03%. Our results made us conclude that our recommendations concerning anaesthetic technique and gastric emptying are safe. The system has proven to be simple enough to be practicable, and yet detailed enough to be informative for educational, quality assurance, research and administrative purposes. CONCLUSION: A simple database for information related to anaesthetic care and problems can be a useful tool for anaesthesiology departments. We have used the system for a variety of quality assurance efforts, for educational and administrative purposes and in research. To get reliable data it is important to keep the system simple, with the information recorded kept to a minimum. The software chosen must make it possible for people within the department to write and modify reports. A constant focus on data quality is important, and motivated nurses and doctors as well as leadership enthusiasm are necessary to make the system work properly. The atmosphere of problem recording should be one of 'openness and confidence', rather than 'inspection and control'.     

Political aspects of peer review.

Discusses professional psychology's increasing recognition in federal health-care legislation. Whether psychology is eventually included in a national health insurance bill will be primarily determined by political considerations, including psychology's relationship with organized medicine, its credibility within the federal bureaucracy, and its performance in the development of standards for care and assurance of quality. It is concluded that psychology's success in developing a workable system of quality assurance through peer review may be the profession's most important asset in determining its role in future legislation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Accreditation and associated quality assurance efforts.

Discusses accreditation programs and the quality assurance efforts associated with them. The demands of consumers and purchasers of services, expressed in governmental action, have forced more direct and systematic efforts to assess and assure service quality. Time- and cost-efficient methods for assessing quality are available, but their use is resisted by organized medicine, which controls most accreditation and quality assurance activities in health care. The involvement of psychologists in the programs is discussed. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effects of health beliefs on screening mammography utilization among a diverse sample of older women

Screening mammography is particularly effective in detecting breast cancer in elderly women. Yet, although half of all breast cancers are diagnosed in older women, statistics show that women aged 65 and over tend to underutilize screening mammography. Prior research has used the constructs of the Health Belief Model to explore attitudes and beliefs relative to breast cancer screening. Prior studies have also identified health beliefs and concerns relative to screening mammography and race/ethnicity as some of the patient-related predictors of screening mammography utilization among younger women. This study uses the theoretical framework of the Health Belief Model to explore the effects of these variables on utilization in a multiracial, multiethnic, random sample of 1011 women, aged 65 and over. Race/ethnicity, belief that mammograms detect cancer, ease the mind, and provide accurate results; concern over the radiation, pain, and cost associated with receiving a mammogram; and other independent variables were tested as predictors of screening mammography utilization. Regression analysis identified that the belief that having a mammogram eases recipients minds was the most significant predictor of screening mammography utilization. None of the other health beliefs or health concerns were significant predictors. Race/ethnicity had no direct effects on utilization nor was it a confounder in the relationship between health beliefs, concerns and utilization. These results indicate that, along with emphasizing the importance of mammograms in early detection of breast cancer, stressing the reassurance that mammography brings recipients may be an effective health education strategy for elderly women of different racial/ethnic backgrounds.     

Quality management in medical specialties: the use of channels and dikes in improving health care in The Netherlands

BACKGROUND: In 1989 a Dutch national policy was instituted to ensure that quality management is the responsibility of both health care professionals and management, with input from insurers and patients. In turn, quality management of medical specialists remained to a large extent self-regulatory, with accountability toward third-party payers and patients. Three programs for quality management-peer review, guidelines, and visitation-have sufficiently persuaded patient organizations and care insurers about medical specialists' ability to ensure the quality of the care they provide. PEER REVIEW: Operational since 1976, the national program for peer review in hospitals has stressed the need for explicit evaluative mechanisms. This program led to the foundation of the National Organization for Quality Assurance in Hospitals (CBO), which conducts peer review activities but also support efforts aimed at quality assurance in hospitals. Once it is linked with the other two quality management programs, peer review will realize its full potential as a profession-based method for standardizing and rationalizing medical specialty practice. PRACTICE GUIDELINES: Since 1982, more than 60 consensus guidelines have been developed for and by medical professionals, with input from patient organizations and third-party payers. Medical specialty associations have also created their own guidelines. Although the guidelines' impact has not been evaluated systematically, studies have shown effects on behavioral change and health outcomes. Solid, credible guidelines continue to be developed, although the successful implementation of these guidelines needs to be studied. VISITATION PROGRAM: Visitation, or onsite assessment of specialty practice sites (in training and non-training hospitals), has been a hot issue in Dutch medical quality assurance. All 28 scientific societies have visitation programs, focusing on areas for improvement such as process management, use of guidelines, and evaluation of patient satisfaction and treatment outcomes. Closely linked to other medical quality assurance activities, visitation programs also incorporate clinical guidelines into evaluations. CONCLUSIONS: Profession-driven peer review, practice guidelines, and visitation programs have been effective support tools for quality management in The Netherlands. Future challenges involve creating more synergy among these programs and between the profession-based quality management approaches and recently introduced hospital-based quality systems and maintaining the trust between third-party payers and patients.     

Optimal atrioventricular (AV) pacing interval during temporary AV sequential pacing after cardiac surgery

This paper deals with quality assurance in health care and its relation to quality assurance in trade and industry. We present the service quality model--a model of quality from marketing research--and discuss how it can be applied to health care. Traditional quality assurance appears to have serious flaws. It lacks a general theory of the sources of hazards in the complex process of patient care and tends to stagnate, for no real improvement takes place. Departing from this criticism, modern quality assurance in health care is marked by: defining quality in a preferential sense as "fitness for use"; the use of theories and models of trade and industry (process-control); an emphasis on analyzing the process, instead of merely inspecting it; use of the Deming problem solving technique (plan, do, check, act); improvement of the process of care by altering perceptions of parties involved. We present an experience of application and utilization of this method in the University Hospital Maastricht, The Netherlands. The successful application of this model requires a favorable corporate culture and motivation of the health care workers. This model provides a useful framework to uplift the traditional approach to quality assurance in health care.     

Preemption or prevention?: lessons from efforts to control firearms, alcohol, and tobacco

The judicial doctrine of preemption allows federal or state governments to restrict the ability of state or local governments, respectively, to regulate in a given area. Industries whose products create substantial public health risks have begun to promote preemptive legislation which prevents the lower levels of government from adopting strong public health protections. This article discusses the implications of preemptive legislation concerning three of the most harmful products available in America: tobacco, firearms and alcohol. These examples illustrate the potential danger that preemptive legislation poses to efforts to prevent illness, injury and death caused by these products.     

National survey of mammographic facilities in 1985, 1988, and 1992

PURPOSE: To determine trends in mammography in the United States. MATERIALS AND METHODS: A sample of mammographic facilities was selected for each year of the Nationwide Evaluation of X-ray Trends. The same protocol was followed for the 1985, 1988, and 1992 surveys. Data were collected with use of the same imaging phantom for all three surveys and also with a different phantom in the 1988 and 1992 surveys. RESULTS: Of the 356 facilities surveyed in 1992, 59% claimed to be in compliance with the Health Care Financing Administration (HCFA) mammography requirements, 42% were accredited by the American College of Radiology (ACR), and 23% did not hold credentials from either the HCFA or the ACR. Since 1985, there has been a 34% improvement in acceptable phantom image quality score and a 20% decrease in the mean glandular dose. CONCLUSION: Mammography as practiced today is essentially a screen-film technique. Mammographic phantom image quality has improved considerably. The overall mean glandular dose has decreased primarily because of the elimination of xeroradiography.     

A review of methods used for medical quality assurance in hospitals: advantages and disadvantages

This paper reviews the advantages and disadvantages of medical quality assurance methods commonly used in hospitals. A computer-based literature search up to April 1993 was done using the terms quality assurance, quality control, audit, utilization review, accreditation, occurrence screening and total quality management. In addition, a manual search was undertaken of references of papers obtained by the computer search and of the contents of the following journals: Quality Review Bulletin, Australian Clinical Review and the British Medical Journal. An assessment of the advantages and disadvantages of 15 quality assurance methods used in hospitals was made. Many quality assurance methods used in hospitals have significant disadvantages. A systematic method that provides meaningful and useful information to clinicians and improves patient care is urgently required. New methods such as occurrence screening and total quality management are slowly emerging and have much potential.     

Automatic grain size determination and classification of iron carbides with neural nets

Under the aspect of quality assurance material testing is getting more and more important. As a consequence there is a strong demand for automation and objective procedures. This article concentrates on the inspection of polished steel specimens using image processing and intelligent software techniques. Nowadays computer aided image processing of microstructures is widely used, but final analysis and quality grading are based on the experience of the testing personnel. Using intelligent software techniques (soft computing), especially neural nets, allows complex decision processes to be done on a computer in a reproducible manner. Of course there are certain premises: suitable restriction of the application domain, careful image preprocessing and feature extraction, critical surveillance of the training process. The article focuses on two neural net applications: grain size determination and classification of iron carbides. To learn the ability to do complex decisions in a reproducible manner from a suitable example data set – at least in a restricted domain – is the main advantage of a neural net solution.