Patient involvement in surgery treatment decisions for breast cancer

PURPOSE

High rates of mastectomy and marked regional variations have motivated lingering concerns about overtreatment and failure to involve women in treatment decisions. We examined the relationship between patient involvement in decision making and type of surgical treatment for women with breast cancer.

METHODS

All women with ductal carcinoma-in-situ and a 20% random sample of women with invasive breast cancer aged 79 years and younger who were diagnosed in 2002 and reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries were identified and surveyed shortly after receipt of surgical treatment (response rate, 77.4%; n = 1,844).

RESULTS

Mean age was 60.1 years; 70.2% of the women were white, 18.0% were African American, and 11.8% were from other ethnic groups. Overall, 30.2% of women received mastectomy as initial treatment. Most women reported that they made the surgical decision (41.0%) or that the decision was shared (37.1%); 21.9% of patients reported that their surgeon made the decision with or without their input. Among white women, only 5.3% of patients whose surgeon made the decision received mastectomy compared with 16.8% of women who shared the decision and 27.0% of women who made the decision (P < .001, adjusted for clinical factors, predisposing factors, and number of surgeons visited). However, this association was not observed for African American women (Wald test 10.0, P = .041).

CONCLUSION

Most women reported that they made or shared the decision about surgical treatment. More patient involvement in decision making was associated with greater use of mastectomy. Racial differences in the association of involvement with receipt of treatment suggest that the decision-making process varies by racial groups.

Patterns and correlates of local therapy for women with ductal carcinoma-in-situ

PURPOSE

Concerns have been raised about the quality of treatment for women with ductal carcinoma-in-situ (DCIS) because persistent high rates of mastectomy suggest overtreatment, whereas lower than expected rates of radiation therapy after breast-conserving surgery (BCS) suggest undertreatment.

PATIENTS AND METHODS

All women with DCIS diagnosed in 2002 and who reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries were identified and surveyed shortly after receipt of surgery (response rate, 79.7%; n = 817). Analyses were restricted to patients with DCIS (n = 659) indicated by SEER stage data.

RESULTS

Only 14.0% of patients at lowest risk of recurrence (based on tumor size and histologic grade) received a mastectomy compared with 22.8% and 52.6% of patients at intermediate and highest risk (P < .001). Only 13.1% of patients who were not influenced or slightly influenced by concerns about recurrence received mastectomy compared with 48.8% of women who were greatly influenced by this concern (P < .001). A between-geographic site difference in receipt of radiation after BCS was observed for the lowest risk group (38.9% in Los Angeles v 70.5% in Detroit) but not for the highest risk group (80.2% in Los Angeles v 85.9% in Detroit, P = .006 for site and risk group differences). Between-site differences in receipt of radiation after BCS were consistent with patient recall of surgeon discussions about treatment.

CONCLUSION

Surgeons are tailoring their recommendations for local therapy options for DCIS based on important clinical factors. Patient attitudes also play an important role in treatment decisions. The substantial influence of both surgeon opinion and patient attitudes should temper concerns about the quality of treatment for women with DCIS.

Satisfaction with surgery outcomes and the decision process in a population-based sample of women with breast cancer

OBJECTIVE

To better understand medical decision making in the context of "preference sensitive care," we investigated factors associated with breast cancer patients' satisfaction with the type of surgery received and with the decision process.

DATA SOURCES/DATA COLLECTION

For a population-based sample of recently diagnosed breast cancer patients in the Detroit and Los Angeles metropolitan areas (N=1,633), demographic and clinical data were obtained from the Surveillance, Epidemiology, and End Results tumor registry, and self-reported psychosocial and satisfaction data were obtained through a mailed survey (78.4 percent response rate).

STUDY DESIGN

Cross-sectional design in which multivariable logistic regression was used to identify sociodemographic and clinical factors associated with three satisfaction measures: low satisfaction with surgery type, low satisfaction with the decision process, and decision regret.

PRINCIPAL FINDINGS

Overall, there were high levels of satisfaction with both surgery and the decision process, and low rates of decision regret. Ethnic minority women and those with low incomes were more likely to have low satisfaction or decision regret. In addition, the match between patient preferences regarding decision involvement and their actual level of involvement was a strong indicator of satisfaction and decision regret/ambivalence. While having less involvement than preferred was a significant indicator of low satisfaction and regret, having more involvement than preferred was also a risk factor. Women who received mastectomy without reconstruction were more likely to report low satisfaction with surgery (odds ratio [OR]=1.54, p<.05), low satisfaction with the process (OR=1.37, p<.05), and decision regret (OR=1.55, p<.05) compared with those receiving breast conserving surgery (BCS). An additional finding was that as patients' level of involvement in the decision process increased, the rate of mastectomy also increased (p<.001).

CONCLUSIONS

A significant proportion of breast cancer patients experience a decision process that matches their preferences for participation, and report satisfaction with both the process and the outcome. However, women who report more involvement in the decision process are significantly less likely to receive a lumpectomy. Thus, increasing patient involvement in the decision process will not necessarily increase use of BCS or lead to greater satisfaction. The most salient aspect for satisfaction with the decision making process is the match between patients' preferences and experiences regarding participation.

Familial seropositive rheumatoid arthritis in North American Native families: effects of shared epitope and cytokine genotypes

OBJECTIVE

A number of North American native (NAN) populations have high prevalence rates of both rheumatoid arthritis (RA) and the shared epitope (SE). We examined the phenotype and familial incidence of RA in a NAN population, and investigated how the SE and cytokine genes may affect disease risk within affected families.

METHODS

NAN patients with seropositive RA or polyarthritis rheumatoid factor (RF) positive juvenile idiopathic arthritis (JIA) were identified from clinical databases. Patients were recruited consecutively as they presented for clinic visits. Family pedigrees were constructed and consenting relatives were interviewed and examined. The risk of RA within families was calculated by multiple logistic regression. Input variables were the SE and cytokine genotypes. Probands and affected relatives were entered as the affected group, and unaffected relatives within families as the unaffected group. Results were confirmed among unrelated subjects, i.e., unrelated patients and unaffected relatives of other probands.

RESULTS

The familial prevalence of RA was 0.50 (95% confidence intervals 0.30, 0.70) among 28 families studied. The interleukin 10 (IL-10) promoter -1082 G/A genotype decreased the odds of RA relative to the A/A genotype in affected families (OR 0.247, 95% CI 0.081, 0.751; p = 0.014) and among unrelated subjects (OR 0.203, 95% CI 0.064, 0.640; p = 0.006). The G/G genotype yielded an OR of 0.093 (95% 0.013, 0.676; p = 0.019) among unrelated subjects. The SE had no effect in these calculations.

CONCLUSION

There was a high familial prevalence of RA in this NAN cohort. In susceptible NAN families, the risk of RA was reduced by IL-10 genotypes, whereas the SE did not affect risk. Study of healthy NAN controls is required to determine if these conclusions apply to this NAN population as a whole.

Disability and quality of life impact of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

This manuscript examines the impact of mental health state and specific mental and physical disorders on work role disability and quality of life in six European countries.

METHOD

The ESEMeD study was conducted in: Belgium, France, Germany, Italy, the Netherlands and Spain. Individuals aged 18 years and over who were not institutionalized were eligible for an in-home computer-assisted interview. Common mental disorders, work loss days (WLD) in the past month and quality of life (QoL) were assessed, using the WMH-2000 version of the CIDI, the WHODAS-II, and the mental and physical component scores (MCS, PCS) of the 12-item short form, respectively. The presence of five chronic physical disorders: arthritis, heart disease, lung disease, diabetes and neurological disease was also assessed. Multivariate regression techniques were used to identify the independent association of mental and physical disorders while controlling for gender, age and country.

RESULTS

In each country, WLD and loss of QoL increased with the number of disorders. Most mental disorders had approximately 1.0 SD-unit lower mean MCS and lost three to four times more work days, compared with people without any 12-month mental disorder. The 10 disorders with the highest independent impact on WLD were: neurological disease, panic disorder, PTSD, major depressive episode, dysthymia, specific phobia, social phobia, arthritis, agoraphobia and heart disease. The impact of mental vs. physical disorders on QoL was specific, with mental disorders impacting more on MCS and physical disorders more on PCS. Compared to physical disorders, mental disorders had generally stronger 'cross-domain' effects.

CONCLUSION

The results suggest that mental disorders are important determinants of work role disability and quality of life, often outnumbering the impact of common chronic physical disorders.

Use of mental health services in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

Comprehensive information about access and patterns of use of mental health services in Europe is lacking. We present the first results of the use of health services for mental disorders in six European countries as part of the ESEMeD project.

METHOD

The study was conducted in: Belgium, France, Germany, Italy, the Netherlands and Spain. Individuals aged 18 years and over who were not institutionalized were eligible for an computer-assisted interview done at home. The 21 425 participants were asked to report how frequently they consulted formal health services due to their emotions or mental health, the type of professional they consulted and the treatment they received as a result of their consultation in the previous year.

RESULTS

An average of 6.4% of the total sample had consulted formal health services in the previous 12 months. Of the participants with a 12-month mental disorder, 25.7% had consulted a formal health service during that period. This proportion was higher for individuals with a mood disorder (36.5%, 95% CI 32.5-40.5) than for those with anxiety disorders (26.1%, 95% CI 23.1-29.1). Among individuals with a 12-month mental disorder who had contacted the health services 12 months previously, approximately two-thirds had contacted a mental health professional. Among those with a 12-month mental disorder consulting formal health services, 21.2% received no treatment.

CONCLUSION

The ESEMeD results suggest that the use of health services is limited among individuals with mental disorders in the European countries studied. The factors associated with this limited access and their implications deserve further research.

Crossing the digital divide: evaluating online communication between patients and their providers

OBJECTIVE

To address provider, payer, and patient concerns about the use of online communication in healthcare settings by performing a randomized controlled trial of a Web-based patient-provider communication tool in primary care.

SUBJECTS AND METHODS

Forty-one staff physicians and 91 residents in 4 primary care centers were randomized to a Web-based online communication system. Patients of intervention physicians were encouraged to communicate via the system about health issues, scheduling, prescription renewals, referrals, and billing. Data collected included patient Web use, e-mail use, telephone calls, visit distribution, and physician and patient attitudes toward and satisfaction with communication.

RESULTS

One thousand thirty-eight patients sent 2238 messages during the 40-week study. Half of the messages were directly related to a patient's health; half were administrative. Patient Web use peaked at 8.5 weekly messages per 100 scheduled visits. Patient e-mail and telephone volume remained similar across groups. Intervention physicians reported more positive attitudes toward Web-based communication than control physicians (mean Web benefits scale score, 4.0 vs 1.1; P = .008), but there were no between-group differences in attitudes toward communication in general. Patients and physicians reported differential preferences for the use of online communication based on problem complexity and sensitivity.

CONCLUSIONS

Web-based messaging was lower than expected because of patient-related factors and limitations of the technology. Patients, physicians, and staff had positive attitudes toward online communication. There was no detectable difference in communication volume between study groups, but more sensitive measures of work burden need to be developed and evaluated.

The emerging role of online communication between patients and their providers

Despite the explosion of online communication in the community, its use between patients and their health care providers remains low. However, rapidly growing patient and provider interest in using online communication has motivated organizations to consider options for deploying these new tools in clinical practice. In this paper, we describe the barriers and challenges health care providers and their organizations must address in developing and deploying these new tools. We formulate lessons from early experiences with e-mail and web-based communication in clinical settings. Finally, we provide a roadmap for developing and deploying these new tools in clinical practice. Health care providers and their organizations will need to consider issues related to technology, data management, operations, communication management, and financial support in order to successfully deploy online services and communication for patients in clinical settings.

A content analysis of e-mail communication between patients and their providers: patients get the message

OBJECTIVE

E-mail use in the clinical setting has been slow to diffuse for several reasons, including providers' concerns about patients' inappropriate and inefficient use of the technology. This study examined the content of a random sample of patient-physician e-mail messages to determine the validity of those concerns.

DESIGN

A qualitative analysis of patient-physician e-mail messages was performed.

MEASUREMENTS

A total of 3,007 patient-physician e-mail messages were collected over 11 months as part of a randomized, controlled trial of a triage-based e-mail system in two primary care centers (including 98 physicians); 10% of messages were randomly selected for review. Messages were coded across such domains as message type, number of requests per e-mail, inclusion of sensitive content, necessity of a physician response, and message tone.

RESULTS

The majority (82.8%) of messages addressed a single issue. The most common message types included information updates to the physicians (41.4%), prescription renewals (24.2%), health questions (13.2%), questions about test results (10.9%), referrals (8.8%), "other" (including thank yous, apologies) (8.8%), appointments (5.4%), requests for non-health-related information (4.8%), and billing questions (0.3%). Overall, messages were concise, formal, and medically relevant. Very few (5.1%) included sensitive content, and none included urgent messages. Less than half (43.2%) required a physician response.

CONCLUSION

A triage-based e-mail system promoted e-mail exchanges appropriate for primary care. Most patients adhered to guidelines aimed at focusing content, limiting the number of requests per message, and avoiding urgent requests or highly sensitive content. Thus, physicians' concerns about the content of patients' e-mails may be unwarranted.

Psychotropic drug utilization in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

To assess psychotropic drug utilization in the general population of six European countries, and the pattern of use in individuals with different DSM-IV diagnoses of 12-month mental disorders.

METHOD

Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000), a cross-sectional psychiatric epidemiological study in a representative sample of 21 425 adults aged 18 or older from six European countries (e.g. Belgium, France, Germany, Italy, the Netherlands and Spain). Individuals were asked about any psychotropic drug use in the past 12 months, even if they used the drug(s) just once. A colour booklet containing high-quality pictures of psychotropic drugs commonly used to treat mental disorders was provided to help respondents recall drug use.

RESULTS

Psychotropic drug utilization is generally low in individuals with any 12-month mental disorder (32.6%). The extent of psychotropic drug utilization varied according to the specific DSM-IV diagnosis. Among individuals with a 12-month diagnosis of pure major depression, only 21.2% had received any antidepressants within the same period; the exclusive use of antidepressants was even lower (4.6%), while more individuals took only anxiolytics (18.4%).

CONCLUSION

These data question the appropriateness of current pharmacological treatments, particularly for major depression, in which under-treatment is coupled with the high use of non-specific medications, such as anxiolytics.

Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

To describe the 12-month and lifetime prevalence rates of mood, anxiety and alcohol disorders in six European countries.

METHOD

A representative random sample of non-institutionalized inhabitants from Belgium, France, Germany, Italy, the Netherlands and Spain aged 18 or older (n = 21425) were interviewed between January 2001 and August 2003. DSM-IV disorders were assessed by lay interviewers using a revised version of the Composite International Diagnostic Interview (WMH-CIDI).

RESULTS

Fourteen per cent reported a lifetime history of any mood disorder, 13.6% any anxiety disorder and 5.2% a lifetime history of any alcohol disorder. More than 6% reported any anxiety disorder, 4.2% any mood disorder, and 1.0% any alcohol disorder in the last year. Major depression and specific phobia were the most common single mental disorders. Women were twice as likely to suffer 12-month mood and anxiety disorders as men, while men were more likely to suffer alcohol abuse disorders.

CONCLUSION

ESEMeD is the first study to highlight the magnitude of mental disorders in the six European countries studied. Mental disorders were frequent, more common in female, unemployed, disabled persons, or persons who were never married or previously married. Younger persons were also more likely to have mental disorders, indicating an early age of onset for mood, anxiety and alcohol disorders.

Sampling and methods of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

The European Study of Epidemiology of Mental Disorders (ESEMeD) project was designed to evaluate the prevalence, the impact and the treatment patterns in Europe. This paper presents an overview of the methods implemented in the project.

METHOD

ESEMeD is a cross-sectional study in a representative sample of 21 425 adults, 18 or older, from the general population of Belgium, France, Germany, Italy, the Netherlands and Spain. The Composite International Diagnostic Interview (WMH-CIDI) was administered by home interviews from January 2001 to August 2003 using Computer Assisted Personal Interview (CAPI) technology. Data quality was controlled to ensure reliability and validity of the information obtained.

RESULTS

Response rate varied from 78.6% in Spain to 45.9% in France. Less than 4% of the individuals had errors in the checking procedures performed.

CONCLUSION

The sampling methodologies, comprehensive psychiatric instruments and quality control procedures used have rendered the ESEMeD database a unique and important source of information about the prevalence, the disability burden and unmet medical needs of mental disorders within Europe.

12-Month comorbidity patterns and associated factors in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

Comorbidity patterns of 12-month mood, anxiety and alcohol disorders and socio-demographic factors associated with comorbidity were studied among the general population of six European countries.

METHOD

Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD), a cross-sectional psychiatric epidemiological study in a representative sample of adults aged 18 years or older in Belgium, France, Germany, Italy, the Netherlands and Spain. The diagnostic instrument used was the Composite International Diagnostic Interview (WMH-CIDI). Data are based on 21 425 completed interviews.

RESULTS

In general, high associations were found within the separate anxiety disorders and between mood and anxiety disorders. Lowest comorbidity associations were found for specific phobia and alcohol abuse-the disorders with the least functional disabilities. Comorbidity patterns were consistent cross-nationally. Associated factors for comorbidity of mood and anxiety disorders were female gender, younger age, lower educational level, higher degree of urbanicity, not living with a partner and unemployment. Only younger people were at greater risk for comorbidity of alcohol disorder with mood, anxiety disorders or both.

CONCLUSION

High levels of comorbidity are found in the general population. Comorbidity is more common in specific groups. To reduce psychiatric burden, early intervention in populations with a primary disorder is important to prevent comorbidity.

Effect of a triage-based E-mail system on clinic resource use and patient and physician satisfaction in primary care: a randomized controlled trial

OBJECTIVES

E-mail communication between patients and their providers has diffused slowly in clinical practice. To address concerns about the use of this technology, we performed a randomized controlled trial of a triage-based e-mail system in primary care. DESIGN AND PATIENTS/PARTICIPANTS: Physicians in 2 university-affiliated primary care centers were randomized to a triage-based e-mail system promoted to their patients. E-mails from patients of intervention physicians were routed to a central account and parsed to the appropriate staff for response. Control group physicians and their patients did not have access to the system. We collected information on patient e-mail use, phone calls, and visit distribution by physician over the 10 months and performed physician and patient surveys to examine attitudes about communication.

RESULTS

E-mail volume was greater for intervention versus control physicians (46 weekly e-mails per 100 scheduled visits vs 9 in the control group at the study midpoint; P <.01) but there were no between-group differences in phone volume (67 weekly phone calls per 100 scheduled visits vs 55 in the control group; P =.45) or rates of patient no-shows (5% in both groups; P =.77). Intervention physicians reported more favorable attitudes toward electronic communication than did control physicians but there were no differences in attitudes toward patient or staff communication in general. There were few between-group differences in patient attitudes toward electronic communication or communication in general.

CONCLUSIONS

E-mail generated through a triage-based system did not appear to substitute for phone communication or to reduce visit no-shows in a primary care setting. Physicians' attitudes toward electronic communication were improved, but physicians' and patients' attitudes toward general communication did not change. Growth of e-mail communication in primary care settings may not improve the efficiency of clinical care.

A national study of the quantity and cost of informal caregiving for the elderly with stroke

BACKGROUND

As the US population ages, increased stroke incidence will result in higher stroke-associated costs. Although estimates of direct costs exist, little information is available regarding informal caregiving costs for stroke patients.

OBJECTIVE

To determine a nationally representative estimate of the quantity and cost of informal caregiving for stroke.

METHODS

The authors used data from the first wave of the Asset and Health Dynamics (AHEAD) Study, a longitudinal study of people over 70, to determine average weekly hours of informal caregiving. Two-part multivariable regression analyses were used to determine the likelihood of receiving informal care and the quantity of caregiving hours for those with stroke, after adjusting for important covariates. Average annual cost for informal caregiving was calculated.

RESULTS

Of 7,443 respondents, 656 (8.8%) reported a history of stroke. Of those, 375 (57%) reported stroke-related health problems (SRHP). After adjusting for cormorbid conditions, potential caregiver networks, and sociodemographics, the proportion of persons receiving informal care increased with stroke severity, and there was an association of weekly caregiving hours with stroke +/- SRHP (p < 0.01). Using the median 1999 home health aide wage (8.20 dollars/hour) as the value for family caregiver time, the expected yearly caregiving cost per stroke ranged from 3,500 dollars to 8,200 dollars. Using conservative prevalence estimates from the AHEAD sample (750,000 US elderly patients with stroke but no SRHP and 1 million with stroke and SRHP), this would result in an annual cost of up to 6.1 billion dollars for stroke-related informal caregiving in the United States.

CONCLUSIONS

Informal caregiving-associated costs are substantial and should be considered when estimating the cost of stroke treatment.

Informal caregiving for diabetes and diabetic complications among elderly americans

OBJECTIVES

Little is known regarding the amount of time spent by unpaid caregivers providing help to elderly individuals for disabilities associated with diabetes mellitus (DM). We sought to obtain nationally representative estimates of the time, and associated cost, of informal caregiving provided to elderly individuals with diabetes, and to determine the complications of DM that contribute most significantly to the subsequent need for informal care.

METHODS

We estimated multivariable regression models using data from the 1993 Asset and Health Dynamics Among the Oldest Old Study, a nationally representative survey of people aged 70 or older (N = 7,443), to determine the weekly hours of informal caregiving and imputed cost of caregiver time for community-dwelling elderly individuals with and without a diagnosis of DM.

RESULTS

Those without DM received an average of 6.1 hr per week of informal care, those with DM taking no medications received 10.5 hr, those with DM taking oral medications received 10.1 hr, and those with DM taking insulin received 14.4 hr of care (p <.01). Disabilities related to heart disease, stroke, and visual impairment were important predictors of diabetes-related informal care. The total cost of informal caregiving for elderly individuals with diabetes in the United States was between $3 and $6 billion per year, similar to previous estimates of the annual paid long-term care costs attributable to DM.

DISCUSSION

Diabetes imposes a substantial burden on elderly individuals, their families, and society, both through increased rates of disability and the significant time that informal caregivers must spend helping address the associated functional limitations. Future evaluations of the costs of diabetes, and the cost-effectiveness of diabetes interventions, should consider the significant informal caregiving costs associated with the disease.

Bridging the electronic divide: patient and provider perspectives on e-mail communication in primary care

OBJECTIVE

To determine e-mail utilization patterns and attitudes toward e-mail use among primary care physicians and their ambulatory outpatient clinic patients.

STUDY DESIGN

Cross-sectional baseline survey.

PARTICIPANTS AND METHODS

Participants included 476 consecutive outpatient clinic patients, 126 general medical and family practice physicians, and 16 clinical and office staff from 2 large primary care centers within an academic teaching system. They completed a survey about e-mail usage patterns and their attitudes toward using e-mail for patient-provider communication.

RESULTS

More than half of patients (52.1%) were self-defined e-mail users, yet only 10.5% of those users had ever used e-mail to communicate with their doctors. Seventy percent of all patients said they would be willing to use e-mail to communicate with their doctors. Overall, patients were concerned about logistics, such as whether the message would get to the right person and how long it would take to get a response. Physicians and staff were more optimistic than patients about the potential for e-mail to improve the doctor-patient relationship. Patient e-mail users, patient e-mail nonusers, physicians, and staff reported low levels of concern about the security and privacy of e-mail.

CONCLUSIONS

Patient-provider e-mail may diffuse slowly into the primary care clinical practice setting because of patient concerns about efficiency and effectiveness and whether e-mail use will improve their relationship with providers. Managed care organizations that plan to build e-mail and Web-based patient portals will need to promote these technologies in a way that educates both patient and providers about their appropriate use.

Phantoms in the snow: Canadians' use of health care services in the United States

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians' use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994-1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

A method for the parallel synthesis of multiply substituted oxazolidinones

There are many examples of both naturally occurring and synthetic molecules containing a 2-oxazolidinone ring that have significant biological activity. The oxazolidinone ring potentially has three sites for attachment of diversity elements. A synthesis that can provide for inclusion of diversity elements at all three positions should be a powerful method for the preparation of oxazolidinone libraries. In this paper we present the preparation of a 3 x 3 x 3 array yielding 27 different products with minimal workup, high yields, and, most importantly, high purity. Using an intramolecular acylnitrene-mediated aziridination reaction, we have prepared (triphenylmethoxymethyl)-3-oxa-1-azabicyclo[3.1.0]hexan-2-one as a starting material for library generation. The first substitution involves opening the aziridine ring of the azabicyclo[3.1.0]hexane ring system using a Grignard reagent. The nitrogen of the oxazolidinone is now ready for substitution via alkylation or arylation. Removing the trityl protecting group via esterification under mildly acidic conditions accomplishes the final substitution.

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) project: rationale and methods

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) is a new cross-sectional study investigating the prevalence and the associated factors of mental disorders, as well as their effect on health-related quality of life and the use of services in six European countries. This paper describes the rationale, methods and the plan for the analysis of the project. A total of 22,000 individuals representative of the non-institutionalized population aged 18 and over from Belgium, France, Germany, Italy, the Netherlands and Spain are being interviewed in their homes. Trained interviewers use a computer-assisted personal interview (CAPI) including the most recent version of the Composite International Diagnostic Interview (CIDI, 2000), a well-established epidemiological survey for assessing mental disorders. This is the first international study using the standardized up-to-date methodology for epidemiological assessment. Sizeable differences in prevalence, impact and level of need that is met by the health services are expected. The analysis of these differences should facilitate the monitoring of ongoing mental health reform initiatives in Europe and provide new research hypotheses.

A randomized controlled trial comparing three invitation strategies in a breast cancer screening program

BACKGROUND

The objective of this study was to compare the response received by a population-based breast cancer screening program, according to three different invitation strategies: letters sent by mail from the program (program group), letters sent by mail from the Primary Health Care Team (PHT group), and direct contact through a trained professional (direct contact group).

METHODS

We used a cluster-randomized controlled trial with assignment to invitation group using home address. Nine hundred eighty-six women of Barcelona (Spain), ages 50 to 64 years, were invited to participate in the program. The main outcome used was the response rate after the first invitation.

RESULTS

Five hundred sixty-four women accepted the invitation (57.2%). The highest response rate was achieved in the direct contact group (63.5%), followed by the PHT group (55.6%), the program group being the one that attained the lowest response rate (52.1%). The direct contact group had a higher probability of participating than the PHT group (RR = 1.14, P = 0.037) or the program group (RR = 1.22, P = 0.003). The response rate in the direct contact group was 72.1% when the letter was received by the subject herself. The increase in response occurred particularly among women of lower educational level.

CONCLUSIONS

Inviting women to participate in a breast cancer screening program through direct contact by trained personnel increased participation rate compared with mailed-letter methods. The positive effect appeared restricted to women with lower educational levels.

Correlates of surgical treatment type for women with noninvasive and invasive breast cancer

There is concern that breast-conserving surgery is underused in some breast cancer patient subpopulations, including women with ductal carcinoma in situ (DCIS), an early-stage form of the disease. We conducted a population-based study to identify correlates of surgical treatment type and patient satisfaction, comparing women with DCIS and those with invasive disease. We used telephone interview and mailed survey of 183 women recently diagnosed with breast cancer (oversampling for women with DCIS), identified from the Metropolitan Detroit Cancer Surveillance System (response rate 71.2%). Overall, 52.5% of study subjects received a mastectomy (48.9%, 45.8%, and 73.5% of women with DCIS, local disease, and regional disease, respectively, p < 0.05). One third of women did not perceive that they were given a choice between surgical types, and an additional one third of women received a surgeon recommendation, most of whom received the treatment recommended. Patient attitudes, such as concerns about the clinical benefits and risks of specific surgery options, were important correlates of treatment choice but did not vary by stage of disease. Knowledge about differences in clinical benefits and risks between surgery options was low. Finally, satisfaction with the decision-making process was significantly lower in women who did not perceive a choice between surgery options. Correlates of breast cancer surgery type appeared to be similar for women with DCIS and invasive breast cancer, with surgeons playing a dominant role in the process. Results also suggested that the decision-making process may be as important for patient satisfaction as the treatment chosen.