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.     

Clinical pathway for peritoneal carcinomatosis from colon and rectal cancer: guidelines for current practice

Peritoneal carcinomatosis from colon and rectal cancer was in the past a terminal condition without curative treatment options. Recently, an aggressive treatment strategy has resulted in long-term survival in a select group of patients with this condition. The sequence of diagnostic tests and treatments for these patients are presented in a chronological order as a clinical pathway. This exposition is to provide a standardized management plan that will allow critical evaluation of the morbidity, mortality, outcomes and cost of this protracted plan of patient care. The discipline that the clinical pathway process demands may facilitate the continued optimization of this treatment strategy.     

The dietitian''s role in developing and implementing the first federal obesity guidelines

OBJECTIVE: To determine possible indications for tracheotomy in the burned child based on bronchoscopic and laryngoscopic findings. DESIGN AND SETTING: A retrospective case study of all patients admitted to a tertiary children's burn center. PARTICIPANTS: All children admitted with burn inhalation injury between 1990 and 1995 (n = 211). INTERVENTION: All patients underwent laryngoscopy and bronchoscopy and 19 underwent tracheotomy, with 5 tracheotomy tubes placed emergently. MAIN OUTCOME MEASURES: Observations during laryngoscopy and bronchoscopy included erythema, edema, carbonaceous material, ulcerations, and bronchial mucous casts. The supraglottis, glottis, and subglottis were analyzed separately, when possible. Any sepsis resulting from tracheotomy was determined. Complications, such as glottic webs, subglottic stenosis, and tracheomalacia, were noted. RESULTS: Indications for tracheotomy included 6 for airway obstruction, 6 for prolonged intubation, 6 for pulmonary cleansing, and 1 for endotracheal tube complications (subglottic stenosis). When examined by bronchoscopy and laryngoscopy, 17 of 19 children had significant airway edema, 10 had carbonaceous material in the airway, and 3 had ulcerations in the airway. CONCLUSIONS: Tracheotomy is indicated in the burned child when significant airway edema is present. Failure to place a tracheotomy tube in these cases leads to a high incidence of immediate tracheotomies (26%). There was no evidence of clinically significant infection attributable to tracheotomy. The number of airway complications due to tracheotomy was no higher than from endotracheal intubation.     

Applying current research to influence clinical practice

The benefits of anti-hypertensive drug treatment have been established by clinical trials demonstrating significant reductions in cardiovascular morbidity and mortality. Thiazide diuretics predominated in these trials but it is reasonable to conclude that the benefits were attributable to the blood pressure (BP) reduction per se and not to specific pharmacological characteristics. Furthermore, it can be calculated that even greater benefits would probably have accrued if the magnitude of the BP reduction had been greater. On first principles, therefore, the basic requirement for any anti-hypertensive drug is confirmation of its ability to reduce BP. The angiotensin II antagonists constitute an important new class of drug, with a low incidence of adverse effects, but early studies with the prototype, losartan, have raised some doubts about its anti-hypertensive 'potency' in the clinical setting. For example, in several different comparative studies there were consistently lesser BP reductions with losartan compared to enalapril. This applied to both the trough and peak BP reductions. Furthermore, dose-response relationships have not always been clearly defined: for example, in one study diastolic BP reductions (trough) fell in the range 4.1 to 4.8 mm Hg with 50, 100 and 150 mg losartan. Although the preliminary results with newer angiotensin II antagonists suggest that they may have greater efficacy, there is only limited information about the definitive identification of the clinically relevant dose ranges for many of these drugs.     

Enhancing the early detection of melanoma within current guidelines

Queensland has the highest reported incidence of malignant melanoma in the world, and early detection offers the possibility of reducing the burden of this cancer in the short term. We report on a survey of 995 residents of the Gold Coast, Queensland, regarding behavioural aspects of the early detection of skin cancer. Survey results suggest that although many people report some form of skin examination behaviour, by either checking their own skin, having another nonmedical person check their skin, or by going to their general practitioner for a skin check, much of this activity may be inadequate. They indicate that current early detection could be enhanced by encouraging individuals and general practitioners to extend the coverage of the examinations they already conduct.     

An introduction to colposcopy. Concepts, controversies and guidelines for practice

Colposcopy is a clinical procedure used to investigate the health of the cervix and lower genital tract. This article is limited to an overview of the colposcopic examination. Colposcopy consists of four sequential steps visualization, assessment, sampling, and documentation and correlation. Since most women are dependent on their primary care providers for information and guidance, a post-colposcopic appointment will aid in the discussion of treatment options and help alleviate any fears or unanswered questions. Regardless of the treatment, stress the need for frequent follow-up exams for Pap smears or repeat colposcopy.     

Cost-effectiveness of extending screening mammography guidelines to include women 40 to 49 years of age

BACKGROUND: Screening mammography is recommended for women 50 to 69 years of age because of its proven efficacy and reasonable cost-effectiveness. Extending screening recommendations to include women 40 to 49 years of age remains controversial. OBJECTIVE: To compare the cost-effectiveness of screening mammography in women of different age groups. DESIGN: Cost-effectiveness analysis done using Markov and Monte Carlo models. PATIENTS: General population of women 40 years of age and older. INTERVENTIONS: Biennial screening from 50 to 69 years of age was compared with no screening. Screening done every 18 months from ages 40 to 49 years, followed by biennial screening from ages 50 to 69 years, was compared with biennial screening from ages 50 to 69 years. MEASUREMENTS: Life-expectancy, costs, and incremental cost-effectiveness. RESULTS: Screening women from 50 to 69 years of age improved life expectancy by 12 days at a cost of $704 per woman, resulting in a cost-effectiveness ratio of $21,400 per year of life saved. Extending screening to include women 40 to 49 years of age improved life expectancy by 2.5 days at a cost of $676 per woman. The incremental cost-effectiveness of screening women 40 to 49 years of age was $105,000 per year of life saved. On the basis of a multiway sensitivity analysis, there is a 75% chance that screening mammography in women 50 to 69 years of age costs less than $50,000 per year of life saved, compared with a 7% chance in women 40 to 49 years of age. CONCLUSION: The cost-effectiveness of screening mammography in women 40 to 49 years of age is almost five times that in older women. When breast cancer screening policies are being set, the incremental cost-effectiveness of extending mammographic screening to younger women should be considered.     

Adherence to breast cancer screening guidelines among African-American women of differing employment status

The purpose of this study was to identify and compare the adherence to breast cancer screening guidelines [monthly breast self-examination (BSE), age-related mammography, yearly professional breast examination (PBE)] among African-American women (AAW) of differing employment status. The Breast Cancer Screening Model served as the organizing framework for this study. One hundred fifty-four subjects were quota sampled according to age and employment group status. Findings showed that 63% of all subjects practiced monthly BSE and 76% had undergone a yearly PBE. Only 20% of all subjects had undergone a mammogram according to the age-related guidelines. Overall, breast cancer screening rates were lower than recommended across all employment groups. Variables that uniquely explained 74% of the variance in monthly BSE included level of education, marital status, social influence, knowledge of BSE, and intention to do BSE in the future. Age group, previous instruction on mammography, income, and perceived barriers related to mammography explained 15% of the variance in age-related mammography. Finally, marital status, previous information on PBE, and intrinsic motivation explained 42% of the variance in yearly PBE. Together, these findings highlight the need for (a) the development of strategies that will promote long-term adherence to all three screening guidelines, and (b) the design of qualitative studies using a representative sample of AAW of differing socioeconomic backgrounds.     

Educating APNs for implementing the guidelines for adolescents in Bright futures: guidelines of health supervision of infants, children, and adolescents

As the scope of what constitutes health and the range of determinants of health-promoting and compromising behaviors among adolescents are expanded, APNs must be well prepared to be powerful influences in the lives of all adolescents. The guidelines offered by Bright Futures challenge nurse educators to prepare APNs who possess the core competencies to knowledgeably address the health issues and concerns of all adolescents in multiple settings. The American Academy of Nursing Expert Panel's recommendations contained herein, if implemented, will further enhance the capabilities of graduate programs to prepare APNs to provide developmentally and culturally relevant disease prevention and health promotion care to adolescents and their families.     

Tonometry in optometric practice -- the current status

The past two decades have seen enhanced optometric interest in tonometry and in other techniques to assess the ocular and/or general health status. This probably reflects several factors; an increasing role of the optometrist as a primary health care practitioner, the availability of better instrumentation for tonometry, and a far better understanding of the relationship between intraocular pressure and diseases from the group known as the glaucomas. This paper represents an attempt to provide information which may be helpful to the practitioner in determining what tonometer to use and how to utilize tonometric data most effectively.     

Incorporating the service accomplishments into pre-registration curriculum to enhance reflective practice

Much emphasis is being placed on the importance of reflective practice as a means to ensure that practitioners are competent in their practice. It is therefore important to ensure that student nurses acquire these reflective skills as part of their development throughout pre-registration curricula. Although reflective practice is seen as a major part of curricula activity, the style in which reflection is advocated takes many different formats. Strategies for developing reflection which focus on outcomes for students can become subjective and fail to place healthcare practice within the context of social structures and values. This paper offers a framework for reflection that promotes an outlook which is both objective and subjective, based on Mezirow's six levels of reflection (as adapted by Powell 1989) and O'Brien's (1987) five service accomplishments. Focus of reflection within the wider context of society and healthcare policy should enable development of a practitioner who is both competent in practice and can analyse and evaluate their practice.     

Gender and the transition into practice

Since 1990, over half the enrollees in advanced education pediatric dentistry programs have been women. The higher proportion of women in pediatric dentistry should permit examination of the practice patterns of groups of men and women at similar stages in their careers. In 1991 the American Academy of Pediatric Dentistry surveyed 4,950 dentists about a variety of issues related to practice patterns and demographics, obtaining 2,362 responses. This study conducted a secondary analysis of the survey data by developing three age-matched graduation cohorts based on gender and years since graduation: 1 to 5 years, 6 to 10 years, and over 10 years. Four areas were investigated: practice patterns, practice arrangements, distribution of time, and income. The overall differences in practice patterns between males and females were statistically significant for the Early Career Group (1 to 5 years). More males were in private practice and a higher proportion of them were practice owners. More women were dental school faculty or in private practice as an employee or contractor. The differences in practice patterns for males and females were not statistically significant for the Intermediate Career Group (6 to 10 years). In the Established Career group (over 10 years), the differences were again statistically significant, with more males as practice owners and shareholders and more women in solo practices. Analysis of time distribution showed that, in the two earlier career groups, women spend about twice as much time as men in child care. These findings may help to explain why many women in the early stages of their careers might prefer the flexibility of working for someone else. When the effects of gender and employment status on income were tested, significant differences were found for the Intermediate and Established groups, with males and practice owners having higher income levels.(ABSTRACT TRUNCATED AT 250 WORDS)