The Emerging Leaders in Public Health Initiative: Leadership Development to Advance Public Health Practice

CONTEXT

Effective leadership is essential for governmental public health agencies to promote and protect the health of their communities.

OBJECTIVE

The Emerging Leaders in Public Health Initiative, a program of The Kresge Foundation, was implemented to strengthen leadership in governmental public health. We seek to examine lessons from the initiative to contribute to the field a better understanding of leadership development practices.

DESIGN

An external evaluator conducted a retrospective analysis of participant responses postinitiative to assess the overall impact of the initiative and explore which components were most valuable.

SETTING

United States.

PARTICIPANTS

Directors and other staff from governmental public health agencies were recruited in 2-person teams to participate in 3 successive cohorts.

INTERVENTION

Drawn from adaptive leadership principles, a framework was developed to guide the selection and implementation of educational and experiential activities. Participants were challenged to develop a new role for their public health agency, which provided a learning laboratory to practice individual and team leadership skills. The Kresge Foundation provided participants with a resource grant and a National Program Office offered convenings, webinars, coaching, and technical assistance over the 18 months of the developmental experience.

MAIN OUTCOME MEASURES

Satisfaction, perceived value of components, and future intentions were assessed from participants in cohorts II and III (n = 70). The overall response rate was 93%.

RESULTS

One hundred four diverse leaders from 52 agencies, representing 30 states participated in the initiative. Participants were extremely satisfied with the program (94%) and indicated a strong likelihood of recommending it to a colleague (96%). Unrestricted grant funding, peer learning, and in-person learning sessions were the program components rated most highly valuable.

CONCLUSIONS

This initiative offers insights into principles and processes to be considered for future public health leadership development.

The Emerging Leaders in Public Health Initiative: Individual Leadership Transformation

The Emerging Leaders in Public Health (ELPH) Initiative, sponsored by The Kresge Foundation, provided leadership development to local governmental public health leaders. An adaptive leadership framework was used to shape the curriculum. The coleads attended multiday convenings and webinars over a 16- to 18-month period. Key components of the initiative included using applied learning to solidify their leadership skills as they worked to develop a new role for their agencies provision of a resource grant from The Kresge Foundation to support agency transformation and technical assistance and consultation provided by a National Program Office. An external evaluator conducted a multicomponent evaluation of individual leadership skill change. Graduates assessed change in their own leadership and change in their colead. Colleagues of ELPH participants were surveyed about their observed changes in the leadership actions of the program graduates. One hundred four leaders from 30 states participated in the initiative in 3 successive cohorts. Leaders demonstrated improvement as shown by self-report and external observation. Improved ability to communicate in a way that inspires others was one of the most significant changes in leadership behaviors. Additional leadership actions were strengthened including the ability to create and maintain high-performing teams, the ability to ask transformational questions, and the ability to actively listen to understand. The pandemic has shown the importance of developing the field, starting with leadership. Leadership development and agency transformation are synergistic; they depend on each other and support each other.

Building diverse leadership in an academic medical center: The ACCLAIM program

As healthcare systems become more complex, medical education needs to adapt in many ways. There is a growing need for more formal leadership learning for healthcare providers, including greater attention to health disparities. An important challenge in addressing health disparities is ensuring inclusive excellence in the leadership of healthcare systems and medical education. Women and those who are underrepresented in medicine (URMs) have historically had fewer opportunities for leadership development and are less likely to hold leadership roles and receive promotions. One successful initiative for improved learning of medical leadership-presented as a case example here-is the Academic Career Leadership Academy in Medicine (ACCLAIM) at the University of North Carolina at Chapel Hill School of Medicine. ACCLAIM is uniquely designed for faculty identified as having emerging leadership potential, with an emphasis on women and URMs. Using a leadership learning system approach, annual cohorts of participants (Scholars) interactively participate in a multi-faceted nine-month long learning experience, including group (e.g., guest-speaker weekly presentations and exercises) and individual learning components (e.g., an individual leadership project). Since its initiation in 2012 and through 2021, 111 Scholars have participated in ACCLAIM; included were 57% women and 27% URMs. Two important outcomes described are: short-term impact as illustrated by consistent improvements in quantitively measured leadership knowledge and capabilities; and long-term leadership growth, whereby half of the ACCLAIM graduates have received academic rank promotions and almost two-thirds have achieved new leadership opportunities, with even higher percentages observed for women and URMs; for example, 87% of URMs were either promoted or achieved new leadership positions. Also consistently noted, through qualitative assessments, are broader healthcare system knowledge and shared tactics for addressing common challenges among Scholars. This case example shows that the promotion of leadership equity may jointly enhance professional development while creating opportunities for systems change within academic medical centers. Such an approach can be a potential model for academic medical institutions and other healthcare schools seeking to promote leadership equity and inclusion.

Frequency of Animal Leptospirosis in the Southern United States and the Implications for Human Health

Leptospirosis is a zoonotic disease with symptoms in humans and animals, ranging from subclinical to serious and fatal. The disease occurs worldwide, but there is limited recognition of the public and animal health risks it poses in the southern United States. A systematic review of the frequency of animal leptospirosis in 17 states and jurisdictions covering the southern continental United States was performed to advance our understanding of the pathogen's distribution and identify transmission patterns that could be targeted for prevention efforts. Fifty-two articles, spanning >100 years, met the analysis criteria. A wide range of techniques were used to measure seroprevalence and isolate the bacteria. The assessment identified exposure to Leptospira spp and Leptospira spp infection among a diverse range of species, spanning 22 animal families within 14 states, suggesting that the pathogen is distributed throughout the southern region. Disease frequency trends were assessed among animals in various habitats (all habitats, nonwild habitats, and wild habitats). The frequency of Leptospira spp detection in animals in wild habitats increased slightly over time (<0.2%/year). We identified reports of 11 human leptospirosis illness clusters and outbreaks in the southern United States. Exposure to potentially contaminated surface waters were documented for at least seven of the events, and interactions with infected or likely infected animals were documented for at least six of the events. This analysis highlights the need for stronger partnerships across the public and animal health fields to enhance diagnostics, surveillance, and reporting. The early identification of leptospirosis in animals may serve as an indicator of environmental contamination and trigger prevention measures, such as vaccinating companion animals and livestock, use of potable water, and the wearing of waterproof protective clothing near water that may be contaminated.

Building capacity for Public Health 3.0: introducing implementation science into an MPH curriculum

Background

Many public health programs fail because of an inability to implement tested interventions in diverse, complex settings. The field of implementation science is engaged in developing strategies for successful implementation, but current training is primarily researcher-focused. To tackle the challenges of the twenty-first century, public health leaders are promoting a new model titled Public Health 3.0 where public health practitioners become “chief health strategists” and develop interdisciplinary skills for multisector engagement to achieve impact. This requires broad training for public health practitioners in implementation science that includes the allied fields of systems and design thinking, quality improvement, and innovative evaluation methods. At UNC Chapel Hill’s Gillings School of Global Public Health, we created an interdisciplinary set of courses in applied implementation science for Master of Public Health (MPH) students and public health practitioners. We describe our rationale, conceptual approach, pedagogy, courses, and initial results to assist other schools contemplating similar programs.

Methods

Our conceptual approach recognized the vital relationship between implementation research and practice. We conducted a literature review of thought leaders in public health to identify skill areas related to implementation science that are priorities for the future workforce. We also reviewed currently available training programs in implementation science to understand their scope and objectives and to assess whether any of these would be a fit for these priorities. We used a design focused implementation framework to create four linked courses drawing from multiple fields such as engineering, management, and the social sciences and emphasizing application through case studies. We validated the course content by mapping them to implementation science competencies in the literature.

Results

To date, there is no other program that provides comprehensive interdisciplinary skills in applied implementation science for MPH students. As of April 2018, we have offered a total of eleven sections of the four courses, with a total enrollment of 142, of whom 127 have been master’s-level students in the school of public health. Using Kirkpatrick’s Model, we found positive student reaction, learning, and behavior. Many students have completed applied implementation science focused practicums, master’s papers, and special studies.

Conclusions

A systematically designed interdisciplinary curriculum in applied implementation science for MPH students has been found by students to be a useful set of skills. Students have demonstrated the capability to master this material and incorporate it into their practicums and master’s papers.

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0866-6) contains supplementary material, which is available to authorized users.

Senior PharmAssist: Less Hospital Use with Enrollment in an Innovative Community-Based Program

OBJECTIVES

To evaluate changes in acute health services use of Senior PharmAssist participants.

DESIGN

Retrospective analysis.

SETTING

Community-based, nonprofit program in Durham County, North Carolina.

PARTICIPANTS

Adults aged 60 and older with income of 200% of the federal poverty level or less who enrolled in the Senior PharmAssist program (N = 191) between August 1, 2011, and March 15, 2017.

INTERVENTION

Medication therapy management (MTM), customized community referrals, Medicare insurance counseling, and medication copayment assistance provided by Senior PharmAssist.

MEASUREMENTS

Primary outcomes were self-reported emergency department (ED) visits and hospital admissions in the previous year, assessed at baseline and every 6 months for up to 2 years.

RESULTS

Mean number of ED visits declined over time (0.83 visits per year at baseline to 0.53 visits per year at 24 months, P = .002), as did the percentage of participants reporting an ED visit in the past year (49% at baseline to 31% at 24 months, P = .003). Mean hospital admissions also decreased (0.56 admissions per year at baseline to 0.4 admissions per year at 24 months, P = .02). There was no significant change in percentage of participants reporting a hospital admission in the past year (33% at baseline to 25% at 24 months, P = .23).

CONCLUSION

Older adults who enrolled in a community-based program that helps them manage medications, connect with community resources, and overcome barriers to medication access experienced reductions in acute health services use. J Am Geriatr Soc 66:2394-2400, 2018.

National Institutes of Health Pathways to Prevention Workshop: Advancing Research to Prevent Youth Suicide

The National Institutes of Health (NIH) Pathways to Prevention Workshop "Advancing Research to Prevent Youth Suicide" was cosponsored by the NIH Office of Disease Prevention, National Institute of Mental Health, National Institute on Drug Abuse, and National Center for Complementary and Integrative Health. A multidisciplinary working group developed the agenda, and an evidence-based practice center prepared an evidence report that addressed data systems relevant to suicide prevention efforts through a contract with the Agency for Healthcare Research and Quality. During the workshop, experts discussed the evidence and participants commented during open forums. After considering the data from the evidence report, expert presentations, and public comments, an independent panel prepared a draft report that was posted on the NIH Office of Disease Prevention Web site for 5 weeks for public comment. This abridged version of the final report provides a road map for optimizing youth suicide prevention efforts by highlighting strategies for guiding the next decade of research in this area. These strategies include recommendations for improving data systems, enhancing data collection and analysis methods, and strengthening the research and practice community.

Building the evidence for decision-making: the relationship between local public health capacity and community mortality

OBJECTIVES

We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina.

METHODS

We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality.

RESULTS

Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and children's services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05).

CONCLUSIONS

Our findings, in the context of other studies, provide support for investment in local public health services to improve community health.

Effects of performance improvement programs on preparedness capacities

OBJECTIVE

In response to public health systems and services research priorities, we examined the extent to which participation in accreditation and performance improvement programs can be expected to enhance preparedness capacities.

METHODS

Using data collected by the Local Health Department Preparedness Capacities Assessment Survey, we applied a series of weighted least-squares models to examine the effect of program participation on each of the eight preparedness domain scores. Participation was differentiated across four groups: North Carolina (NC) accredited local health departments (LHDs), NC non-accredited LHDs, national comparison LHDs that participated in performance or preparedness programs, and national comparison LHDs that did not participate in any program.

RESULTS

Domain scores varied among the four groups. Statistically significant positive participation effects were observed on six of eight preparedness domains for NC accreditation programs, on seven domains for national comparison group LHDs that participated in performance programs, and on four domains for NC non-accredited LHDs.

CONCLUSIONS

Overall, accreditation and other performance improvement programs have a significant and positive effect on preparedness capacities. While we found no differences among accredited and non-accredited NC LHDs, this lack of significant difference in preparedness scores among NC LHDs is attributed to NC's robust statewide preparedness program, as well as a likely exposure effect among non-accredited NC LHDs to the accreditation program.

Declining trends in local health department preparedness capacities

OBJECTIVES

We examined local health department (LHD) preparedness capacities in the context of participation in accreditation and other performance improvement efforts. MetHODS: We analyzed preparedness in 8 domains among LHDs responding to a preparedness capacity instrument from 2010 through 2012. Study groups included LHDs that (1) were exposed to a North Carolina state-based accreditation program, (2) participated in 1 or more performance improvement programs, and (3) had not participated in any performance improvement programs. We analyzed mean domain preparedness scores and applied a series of nonparametric Mann-Whitney Wilcoxon tests to determine whether preparedness domain scores differed significantly between study groups from 2010 to 2012.

RESULTS

Preparedness capacity scores fluctuated and decreased significantly for all study groups for 2 domains: surveillance and investigation and legal preparedness. Significant decreases also occurred among participants for plans and protocols, communication, and incident command. Declines in capacity scores were not as great and less likely to be significant among North Carolina LHDs.

CONCLUSIONS

Decreases in preparedness capacities over the 3 survey years may reflect multiple years of funding cuts and job losses, specifically for preparedness. An accreditation program may have a protective effect against such contextual factors.

Comparative effectiveness of follow-up imaging approaches in pancreatic cancer

AIM

Although PET imaging is sometimes used in follow-up of pancreatic cancer, evidence regarding comparative effectiveness of PET and older imaging modalities is limited.

PATIENTS & METHODS

Linked cancer registry and Medicare claims data were analyzed to examine patterns of imaging and effects on treatment patterns and survival among newly diagnosed pancreatic cancer patients from 2003 to 2007.

RESULTS

12% of patients received PET during follow-up. In a time-varying exposure model, computed tomography/MRI was associated with lower mortality risk relative to PET in surgical patients (HR: 0.66; 95% CI: 0.52-0.83). In a subset analysis, type of follow-up imaging before 180 days was not associated with mortality after 180 days (computed tomography/MRI vs PET; hazard ratio: 0.98; 95% CI: 0.84-1.16).

CONCLUSION

Follow-up PET is uncommon among Medicare beneficiaries with pancreatic cancer, and is generally used late in the disease course. This pattern of PET use was not associated with decreased mortality risk compared with conventional imaging.

Quality measures for hospice and palliative care: piloting the PEACE measures

BACKGROUND

The Carolinas Center for Medical Excellence launched the PEACE project in 2006, under contract with the Centers for Medicare & Medicaid Services (CMS), to identify, develop, and pilot test quality measures for hospice and palliative care programs.

OBJECTIVES

The project collected pilot data to test the usability and feasibility of potential quality measures and data collection processes for hospice and palliative care programs. Settings/subjects: Twenty-two hospices participating in a national Quality Improvement Collaborative (QIC) submitted data from 367 chart reviews for pain care and 45 chart reviews for nausea care. Fourteen additional hospices completed a one-time data submission of 126 chart reviews on 60 potential patient-level quality measures across eight domains of care and an organizational assessment evaluating structure and processes of care.

DESIGN

Usability was assessed by examining the range, variability and size of the populations targeted by each quality measure. Feasibility was assessed during the second pilot study by surveying data abstractors about the abstraction process and examining the rates of missing data. The impact of data collection processes was assessed by comparing results obtained using different processes.

RESULTS

Measures shown to be both usable and feasible included: screening for physical symptoms on admission and documentation of treatment preferences. Methods of data collection and measure construction appear to influence observed rates of quality of care.

CONCLUSIONS

We successfully identified quality measures with potential for use in hospices and palliative care programs. Future research is needed to understand whether these measures are sensitive to quality improvement interventions.

Use of electronic documentation for quality improvement in hospice

Little evidence exists about the use of electronic documentation (ED) in hospice and its relationship to quality improvement (QI) practices. The purposes of this study were to (1) estimate the prevalence of ED use in hospice, (2) identify organizational characteristics associated with use of ED, and (3) determine whether quality measurement practices differed based on documentation format (electronic vs nonelectronic). Surveys concerning the use of ED for QI practices and the monitoring of quality-related care and outcomes were collected from 653 hospices. Users of ED were able to monitor a wider range of quality-related data than users of non-ED. Quality components such as advanced care planning, cultural needs, experience during care of the actively dying, and the number/types of care being delivered were more likely to be documented by users of ED. Use of ED may help hospices monitor quality and compliance.

Impact of distance to a urologist on early diagnosis of prostate cancer among black and white patients

PURPOSE

We examined whether an increased distance to a urologist is associated with a delayed diagnosis of prostate cancer among black and white patients, as manifested by higher risk disease at diagnosis.

MATERIALS AND METHODS

North Carolina Central Cancer Registry data were linked to Medicare claims for patients with incident prostate cancer diagnosed in 2004 to 2005. Straight-line distances were calculated from the patient home to the nearest urologist. Race stratified multivariate ordinal logistic regression was used to examine the association between distance to a urologist and prostate cancer risk group (low, intermediate, high or very high/metastasis) at diagnosis for black and white patients while accounting for age, comorbidity, marital status and diagnosis year. An overall model was then used to examine the distance × race interaction effect.

RESULTS

Included in analysis were 1,720 white and 531 black men. In the overall cohort the high risk cancer rate increased monotonically with distance to a urologist, including 40% for 0 to 10, 45% for 11 to 20 and 57% for greater than 20 miles. Correspondingly the low risk cancer rate decreased with longer distance. On race stratified multivariate analysis longer distance was associated with higher risk prostate cancer for white and black patients (p = 0.04 and <0.01, respectively) but the effect was larger in the latter group. The distance × race interaction term was significant in the overall model (p = 0.03).

CONCLUSIONS

Longer distance to a urologist may disproportionally impact black patients. Decreasing modifiable barriers to health care access, such as distance to care, may decrease racial disparities in prostate cancer.

Abstract PL04-02: Efficacy of PSA screening for prostate cancer: A case-control study of Caucasian and African American Medicare beneficiaries

Background: PSA screening has become standard practice in the US although mortality data from controlled trials is lacking to assess the efficacy of screening of African American men. We investigated whether PSA screening efficacy is similar among elderly Caucasian and African American men.

Methods: This case-control study compared PSA exposure history of Surveillance, Epidemiology, and End Results (SEER) dataset-derived cases deceased from prostate cancer to that of control subjects from a linked Medicare dataset. The prostate cancer cases include males diagnosed with prostate cancer between 1992 and 2005 that subsequently died from the disease (matched with 3:1 on race, age, and SEER region).

Results: We identified 8,846 cases deceased from prostate cancer, and 23,538 age-, race-, and SEER site-matched controls. African Americans comprised about 10% of both the cases (779) and controls (2,337). Conditional logistic regression analyses were used to calculate prostate cancer-specific mortality among African American (1.09 [95% CI 0.917–1.303]) and Caucasian subjects (1.14 [95% CI 1.076–1.201]) who were asymptomatic at the time of their PSA screening test.

Conclusions: The results of this large, claims-based, case-control study suggest that the efficacy of PSA screening among elderly African American men is not dissimilar to that of elderly Caucasian men, and that neither group benefitted from reduced mortality attributable to screening.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):PL04-02.

Physician visits and colorectal cancer testing among Medicare enrollees in North Carolina and South Carolina, 2005

INTRODUCTION

Many Medicare enrollees do not receive colorectal cancer tests at recommended intervals despite having Medicare screening coverage. Little is known about the physician visits of Medicare enrollees who are untested. Our study objective was to evaluate physician visits of enrollees who lack appropriate testing to identify opportunities to increase colorectal cancer testing.

METHODS

We used North Carolina and South Carolina Medicare data to compare type and frequency of physician visits for Medicare enrollees with and without a colorectal cancer test in 2005. Type of physician visit was defined by the physician specialty as primary care, mixed specialty (more than 1 specialty, 1 of which was primary care), and nonprimary care. We used multivariate modeling to assess the influence of type and frequency of physician visits on colorectal cancer testing.

RESULTS

Approximately half (46.5%) of enrollees lacked appropriate colorectal cancer testing. Among the untested group, 19.8% had no physician visits in 2005. Enrollees with primary care visits were more likely to be tested than those without a primary care visit. Many enrollees who had primary care visits remained untested. Enrollees with visits to all physician types had a greater likelihood of having colorectal cancer testing.

CONCLUSION

We identified 3 categories of Medicare enrollees without appropriate colorectal cancer testing: those with no visits, those who see primary care physicians only, and those with multiple visits to physicians with primary and nonprimary care specialties. Different strategies are needed for each category to increase colorectal cancer testing in the Medicare population.

Predictors of timing of adjuvant chemotherapy in older women with hormone receptor-negative, stages II-III breast cancer

Adherence to consensus guidelines for cancer care may vary widely across health care settings and contribute to differences in cancer outcomes. For some women with breast cancer, omission of adjuvant chemotherapy or delays in its initiation may contribute to differences in cancer recurrence and mortality. We studied adjuvant chemotherapy use among women with stage II or stage III, hormone receptor-negative breast cancer to understand health system and socio-demographic correlates of underuse and delayed adjuvant chemotherapy. We used Surveillance Epidemiology and End Results (SEER)-Medicare linked data to examine the patterns of care for 6,678 women aged 65 and older diagnosed with stage II or stage III hormone receptor-negative breast cancer in 1994-2002, with claims data through 2007. Age-stratified logistic regression was employed to examine the potential role of socio-demographic and structural/organizational health services characteristics in explaining differences in adjuvant chemotherapy initiation. Overall utilization of guideline-recommended adjuvant chemotherapy peaked at 43% in this population. Increasing age, higher co-morbidity burden, and low-income status were associated with lower odds of chemotherapy initiation within 4 months, whereas having positive lymph nodes, more advanced disease, and being married were associated with higher odds (P < 0.05). Health system-related structural/organizational characteristics and race/ethnicity offered little explanatory insight. Timely initiation of guideline-recommended adjuvant chemotherapy was low, with significant variation by age, income, and co-morbidity status. Based on these findings, future studies should seek to explore the more nuanced reasons why older women do not receive chemotherapy and why delays in care occur.

Quality improvement in hospice: adding a big job to an already big job?

Hospice organizations are adopting quality measurement and quality improvement (QI) practices to comply with the Medicare Conditions of Participation effective January 31, 2009. However, little is known about organizational best practices or specific needs during implementation. This study identified and described the barriers and facilitators to QI implementation in hospice. Using semistructured interviews with a national sample of key informants (n = 52) concerning facilitators and barriers to QI in hospice, 4 major themes emerged from the data regarding participants' experiences and perceptions: (1) external factors constrain QI implementation; (2) internal factors limit capacity for QI; (3) research on best practices is limited; and (4) traditional QI may not be a good fit for hospice. Though challenging, participants provided recommendations that they believed would facilitate QI in hospice. Categorizing barriers and facilitators as within or outside an organization's control may help organizations assess their capabilities and locate resources to address areas for improvement.

The PEACE project review of clinical instruments for hospice and palliative care

BACKGROUND

Hospice and palliative care organizations are expanding their use of standardized instruments and other approaches to measure quality. We undertook a systematic review and evaluation of published patient-level instruments for potential application in hospice and palliative care clinical quality measurement.

METHODS

We searched prior reviews and computerized reference databases from 1990 through February 2007 for studies of instruments relevant to physical, psychological, social, cultural, spiritual, or ethical aspects of palliative care, or measuring prognosis, function or continuity of care. Publications were selected for full review if they provided evidence of psychometric properties or practical application of an instrument tested in or appropriate for a hospice or palliative care population. Selected instruments were evaluated and scored for scientific soundness and potential application in clinical quality measurement.

RESULTS

The search found 1427 publications, with 229 selected for full manuscript review. Manuscripts provided information on 129 instruments which were evaluated using a structured scoring guide for psychometric properties. Thirty-nine instruments scoring near or above the 75th percentile were recommended. Most instruments covered multiple domains or focused on care for physical symptoms, psychological or social aspects of care. Few instruments were available to measure cultural aspects of care, structure and process of care, and continuity of care.

CONCLUSION

Numerous patient-level instruments are available to measure physical, psychological and social aspects of palliative care with adequate evidence for scientific soundness and practical clinical use for quality improvement and research. Other aspects of palliative care may benefit from further instrument development research.

Trends and racial differences in the use of androgen deprivation therapy for metastatic prostate cancer

CONTEXT

Androgen deprivation therapy (ADT) is widely used to manage the symptoms of advanced prostate cancer and has been shown to slow the progression of the disease. Previous research investigating racial differences in the use of ADT has reported inconsistent findings.

OBJECTIVES

The purpose of this study was to assess use trends for ADT overall and by type (orchiectomy and luteinizing hormone-releasing hormone [LHRH] agonists) and the factors associated with time to receipt for metastatic prostate cancer.

METHODS

Data from the Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims database were obtained for 5,273 men, aged 65 years and older and diagnosed with Stage IV prostate cancer during 1991-1999 from seven SEER regions. An accelerated failure time regression model with log-normal distribution was used to examine factors associated with mean time to receipt of ADT.

RESULTS

African-American men were less likely than white men to receive any ADT after diagnosis (P<0.001). Differences were noted in the time to receipt of ADT, with African-American men having a longer mean time to receipt of orchiectomy (time ratio [TR]=1.50; 95% confidence interval [CI]=1.03, 2.17) or LHRH agonist (TR=1.42; 95% CI=1.06, 1.89) than white men.

CONCLUSION

African-American men with metastatic prostate cancer were significantly less likely to receive ADT and, when treated, had a slightly longer time to receipt than white men, which has implications for patients and physicians involved in the palliative management of metastatic prostate cancer.

Hospices' preparation and practices for quality measurement

CONTEXT

Hospice and palliative care organizations need to measure and analyze quality of care, in response to national palliative care practice guidelines and new hospice regulatory requirements. Little is known about hospices' readiness to meet this new mandate.

OBJECTIVES

We analyzed data from a national survey of hospices to describe preparation and practices for quality measurement and research and to examine associated organizational characteristics.

METHODS

Web-based survey of hospice staff responsible for quality of care.

RESULTS

Survey respondents represented 652 National Hospice and Palliative Care Organization (NHPCO) member hospice organizations; 52% were participating in the NHPCO Quality Partners program. Most of these hospices involve clinical providers in decisions to change care practices (69%) and participate in quality improvement projects (64%), but research participation is uncommon (16%). Many hospices collect data about staff certification and training (76%) and use family surveys to measure care quality (70%). A minority of hospices have clinical data in electronic format (13%-29%). Large size, multiple sites, government ownership, and presence of a change leader in the organization were the characteristics associated with greater preparation for quality improvement and research.

CONCLUSION

Current organizational activities, data collection rates, and use of electronic data systems may limit hospices' preparation and practices related to quality improvement and research participation; larger size and designation of a change leader are associated with greater capacity. Hospices may need technical assistance and training to provide for meaningful measurement of quality of care.

Trends in colorectal cancer test use in the medicare population, 1998-2005

BACKGROUND

Colorectal cancer (CRC) screening has been covered under the Medicare program since 1998. No prior study has addressed the question of the completeness of CRC screening in the entire Medicare cohort.

METHODS

In 2008, CRC test-use rates were analyzed for the national fee-for-service Medicare population using Medicare enrollment and claims data from 1998 through 2005. Annual test-use rates were calculated for fecal occult blood testing, sigmoidoscopy, barium enema, and colonoscopy for each year by the demographic characteristics of enrollees. A current-in-Medicare rate was calculated to assess the percentage of enrollees with CRC testing according to recommended intervals.

RESULTS

Colonoscopy rates have increased every year since the introduction of CRC screening coverage. Test-use rates for all other test modalities have steadily decreased. The percentage of Medicare enrollees receiving appropriate tests has slowly increased. In 2005, 47% of enrollees aged >or=65 years and 33% of enrollees aged 50-64 years had claims indicating that they had been tested according to recommended intervals.

CONCLUSIONS

CRC test-use rates in the Medicare population are low. Disparities are apparent by age, race/ethnicity, gender, disability, income, and geographic residence. Much work remains to be done to increase testing to acceptable levels.

The potential use of autopsy for continuous quality improvement in hospice and palliative care

CONTEXT

In 2006, the Centers for Medicare & Medicaid Services (CMS) contracted with The Carolinas Center for Medical Excellence (CCME), the Quality Improvement Organization (QIO) for North and South Carolina, to develop an instrument package and procedures for hospice and palliative care programs to assess and monitor the quality of the care that they provide. As part of our work, we investigated the potential uses of autopsy for continuous quality improvement purposes.

OBJECTIVE

Our objective is to understand (1) the potential benefits and uses of autopsy for various constituents, (2) the reasons for the decline in the use of autopsy despite these potential benefits, (3) the practical aspects of autopsy in the hospice setting, and (4) current hospice practices in regard to autopsy.

DESIGN

To achieve these goals, we reviewed the existing literature and interviewed stakeholders, including hospice and palliative care providers, professional organizations and advocacy groups, quality improvement and measurement experts, and pathologists.

RESULTS

Important barriers limit the use of autopsy to understand and improve quality of care in hospice, including costs, unintended consequences, and the limited ability to systematically use autopsy information to improve care. Some themes were more predominant among providers, whereas others emerged primarily from interviews with nonproviders.

CONCLUSIONS

On the basis of existing research and stakeholder interviews, autopsy is currently not a feasible mechanism to improve quality of care in hospice. If financial and attitudinal barriers are reduced, a systematic sampling of deaths for autopsy may provide evidence for the value of this information source.

Hip and other osteoporotic fractures increase the risk of subsequent fractures in nursing home residents

Nursing home residents with a history of hip fractures or prior osteoporotic fractures were found to have an increased risk of another osteoporotic fracture over the ensuing two years when compared to nursing home residents with no fracture history.

INTRODUCTION

Because of the high prevalence of osteoporosis and fall risk factors in nursing home residents, it is possible that the importance of previous fracture as a marker for subsequent fracture risk may be diminished. We tested whether a history of prior osteoporotic fractures would identify residents at increased risk of additional fractures after nursing home admission.

METHODS

We identified all Medicare enrollees aged 50 and older who were in a nursing home in North Carolina in 2000 (n=30,655). We examined Medicare hospitalization claims to determine which enrollees had been hospitalized in the preceding 4 years for a hip fracture (n=7,257) or other fracture (n=663). We followed participants from nursing home entry until the end of 2002 using Medicare hospital claims to determine which participants were hospitalized with a subsequent fracture (n=3,381).

RESULTS

Among residents with no recent fracture history, 6.8% had a hospital claim for a subsequent fracture, while 15.1% of those with a prior non-hip fracture and 23.9% of participants with a prior hip fracture sustained subsequent fractures. Multivariate proportional hazards models of time to fracture indicated that persons with prior hip fractures are at three times higher risk (HR=2.99, 95% CI: 2.78, 3.21) and those hospitalized with other non-hip fractures are at 1.8 times higher risk of subsequent fractures (HR=1.84, 95% CI: 1.50, 2.25).

CONCLUSION

Nursing home residents hospitalized with a prior osteoporotic fracture are at increased risk of a fracture.

Evaluation of claims, medical records, and self-report for measuring fecal occult blood testing among medicare enrollees in fee for service

BACKGROUND

There is no agreement on the best data source for measuring colorectal cancer (CRC) screening. Medicare claims have been used to measure CRC testing but the validity of using claims to measure fecal occult blood tests (FOBT) has not been established.

METHODS

We compared ascertainment of FOBT among three data sources: self-reports, Medicare claims, and medical records. Data were collected on FOBT use during the study window (1/1/1998 - 12/31/2002). Our study was conducted with North Carolina Medicare enrollees (N = 561) who had previously responded to a telephone survey on CRC tests. FOBT information was abstracted from respondents' physician office medical records and compared with self-reported FOBT use and Medicare claims for FOBT. Data sources were assessed for accuracy and completeness of FOBT reporting using sensitivity, specificity, positive predictive value, negative predictive value, and agreement.

RESULTS

Reporting of FOBT use in the prior year in medical records and Medicare claims agreed 82% of the time [95% confidence interval (95% CI), 79-85%]. FOBT 1-year use rates from self-report agreed with test use found in medical records 70% of the time (95% CI, 66-74%). The lowest agreement was between self-reported 1-year FOBT use and Medicare claims, which agreed 67% of the time (95% CI, 63-71%).

CONCLUSIONS

No data source could be established as providing complete and valid information about FOBT use among Medicare enrollees, showing the difficulty of ascertaining test use rates for noninvasive, low-cost procedures conducted in multiple settings. Caution should be used when attempting to measure FOBT use with self-report, Medicare claims, or medical records.

Data sources for measuring colorectal endoscopy use among Medicare enrollees

BACKGROUND

Estimates of colorectal cancer test use vary widely by data source. Medicare claims offer one source for monitoring test use, but their utility has not been validated. We compared ascertainment of sigmoidoscopy and colonoscopy between three data sources: self reports, Medicare claims, and medical records.

MATERIALS AND METHODS

The study population included Medicare enrollees residing in North Carolina (n = 561) who had participated in a telephone survey on colorectal cancer tests. Medicare claims were obtained for the 5 years preceding the survey (January 1, 1998 to December 31, 2002). Information about sigmoidoscopy and colonoscopy procedures conducted in physician offices were abstracted from medical records. Sensitivity, specificity, positive predictive value, negative predictive value, agreement, and kappa statistics were calculated using the medical record as the gold standard. Agreement on specific procedure type and purpose was also assessed.

RESULTS

Agreement between claim and medical record regarding whether an endoscopic procedure had been done was high (over 90%). Agreement between self report and medical record and between self report and claim was good (79% and 74%, respectively). All three data sources adequately distinguished the type of procedure done. None of the data sources showed reliable levels of agreement regarding procedure purpose (screening or diagnostic).

CONCLUSION

Medicare claims can provide accurate information on whether a patient has undergone colorectal endoscopy and may be more complete than physician medical records. Medicare claims cannot be used to distinguish screening from diagnostic tests. Recognizing this limitation, researchers who use Medicare claims to assess rates of colorectal testing should include both screening and diagnostic endoscopy procedures in their analyses.

Randomized trial to improve fracture prevention in nursing home residents

BACKGROUND

Interventions to improve the fracture prevention in nursing homes are needed.

METHODS

Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n=67) with > or =10 residents with a diagnosis of osteoporosis or recent hip fracture (n=606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering.

RESULTS

No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P=.72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models.

CONCLUSIONS

Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities.

Racial differences in clinical progression among Medicare recipients after treatment for localized prostate cancer (United States)

OBJECTIVE

Prostate cancer recurrence impacts patient quality of life and risk of prostate-cancer specific death following definitive treatment. We investigate differences in disease-free survival among white, black, Hispanic, and Asian patients in a large, population-based database.

METHODS

Merged Surveillance, Epidemiology, and End Results Program (SEER) and Medicare files provided data on 23,353 white patients, 2,814 black patients, 480 Hispanic patients, and 566 Asian patients diagnosed at age 65-84 years with clinically localized prostate cancer between 1986 and 1996 in five SEER sites. Patients were followed through 1998. Racial differences in disease-free survival were assessed using Kaplan-Meier survival curves and Cox regression models.

RESULTS

The 75th percentile disease-free survival time for black patients was 13 months less than that for white patients (95% confidence interval [CI]: 6.2-19.8 months), 29.7 months less than that for Hispanic patients (95% CI: 4.4-55.0 months), and 39.1 months less than that for Asian patients (95% CI: 12.1-66.1 months). In multivariate analysis, black race predicted shorter disease-free survival among surgery patients, but not among radiation patients.

CONCLUSIONS

Black patients experienced shorter disease-free survival compared to white, Hispanic, and Asian patients, and the disease-free survival of white, Hispanic, and Asian patients were not statistically different. Earlier recurrence of prostate cancer may help explain black patients' increased risk of mortality from prostate cancer.

Barriers to colorectal cancer screening among Medicare consumers

BACKGROUND

Few studies have examined lack of physician recommendation and other reasons for under-utilization of colorectal cancer (CRC) screening in the Medicare population.

METHODS

Data from a telephone survey conducted in 2001 in a random sample of Medicare consumers residing in North and South Carolina were used to examine barriers to CRC screening, focusing on consumers' reports of receiving a physician's recommendation to obtain CRC screening and reasons for not being screened. Analyses were restricted to respondents with no history of CRC (n = 1901). Descriptive statistics were used to characterize respondents' CRC screening status, receipt of a physician's recommendation for screening, and reasons for not being screened. Logistic regression modeling was used to examine factors associated with receiving a physician recommendation for fecal occult blood test, sigmoidoscopy, colonoscopy, any endoscopy, and any CRC test.

RESULTS

Thirty-one percent of Medicare consumers had never been tested for CRC, and 18% had been tested but were not current with Medicare-covered intervals. Overall, 28% reported not receiving a physician recommendation for screening. Predictors of receiving a physician recommendation included sociodemographic (younger age, white race, more education), health status (increased CRC risk, comorbidity), and healthcare access (had a routine/preventive care visit in the past 12 months) factors. Lack of knowledge/awareness and the physician not ordering the test were commonly cited reasons for not having CRC tests.

CONCLUSIONS

Colorectal cancer screening was under-utilized by Medicare consumers in two states, and lack of physician recommendation was an important contributing factor. Providing a benefit under the Medicare program does not ensure its widespread use by consumers or their physicians.

Racial differences in colorectal cancer test use by Medicare consumers

BACKGROUND

Lower use of colorectal cancer (CRC) screening has been suggested as a factor in higher rates of CRC incidence and mortality among African Americans. Racial differences in colorectal cancer test use are not well understood.

METHODS

The study sample included respondents aged 50 to 80 to a 2001 telephone survey of Medicare consumers from two states. The analyses, initiated in 2004, were limited to respondents with no history of CRC (n = 1901). Three CRC tests were examined: fecal occult blood tests (FOBTs), sigmoidoscopy, and colonoscopy. Type of testing and testing according to Medicare coverage intervals by race were compared. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from unadjusted and adjusted models to assess the independent associations between race and test use.

RESULTS

Adherence to the Medicare-covered intervals for CRC tests was low (56.8% for whites, 39.1% for African Americans), and did not significantly differ by race after adjustment. African Americans were, however, significantly less likely to have ever been tested (OR = 0.48, 95% CI = 0.33-0.70) and more likely to have had an endoscopic test than an FOBT (OR = 3.06, 95% CI = 1.70-5.51).

CONCLUSIONS

The type of test used to screen for colorectal cancer has important implications for compliance with recommended screening intervals. Understanding reasons for racial differences in CRC test use may help identify approaches to increasing test use in the Medicare population.

Increasing colorectal cancer testing: translating physician interventions into population-based practice

Colorectal cancer (CRC) screening in the Medicare population remains low despite Medicare coverage. We describe a population-based effort to increase CRC testing of Medicare enrollees in two States through promotion and distribution of office-based tools to primary care physicians and gastroenterologists. Small increases in colonoscopy test use by primary care physicians were observed, but the differences were not statistically significant. Results in one State were stronger than the other, and two components of the intervention appeared more promising than others. Use of CRC tests can be increased, but additional approaches are needed.

Inpatient smoking-cessation counseling and all-cause mortality among the elderly

BACKGROUND

Although smoking cessation is essential to the management of acute myocardial infarction (AMI), prevalence and benefits of smoking-cessation counseling in the inpatient setting are not well described among older adults. The objective of this study was to evaluate associations between inpatient smoking-cessation counseling and 5-year all-cause mortality among older adults hospitalized with AMI.

METHODS

The Cooperative Cardiovascular Project (January 1994-July 1995) included 788 Medicare beneficiaries aged >/=65 years who were current smokers, admitted to acute care facilities in North Carolina with confirmed AMI, and discharged alive. Information on smoking-cessation advice or counseling prior to discharge was abstracted from medical records. Associations of counseling with 5-year risk of death were assessed with multivariate Cox proportional hazards regression.

RESULTS

Smoking-cessation counseling was provided to 40% of AMI patients before discharge. Women (p =0.06) and blacks (p =0.02) were less likely to receive counseling. Counseling was associated with a history of chronic obstructive pulmonary disease (p =0.01). Increasing age, discharge to a skilled nursing facility, and histories of hypertension, heart failure, or stroke were associated with no counseling (p <0.05, all cause). Age-adjusted mortality rates (per 1000 enrollees) at 5 years were 488.3 for patients who were given counseling compared to 579.3 for patients without counseling. After adjustment for age, race, gender, prior histories of hypertension, cardiovascular diseases, diabetes, and chronic obstructive pulmonary disease, Killip class III or IV, and discharge to a skilled nursing facility; inpatient counseling remained associated with improved survival (relative hazard, 0.78; 95% confidence interval, 0.63-0.97).

CONCLUSIONS

Inpatient counseling on smoking cessation is suboptimal among older smokers hospitalized with AMI. Even without confirmation of actual cessation, these data suggest that provision of smoking-cessation advice or counseling has a major impact on survival of older adults.

Racial differences in mortality among Medicare recipients after treatment for localized prostate cancer

BACKGROUND

Prostate cancer mortality is higher among black American men than among white American men. We investigated whether racial disparities in outcomes of clinically localized prostate cancer vary by treatment (surgery, radiation therapy, or nonaggressive treatment).

METHODS

Merged Surveillance, Epidemiology, and End Results Program (SEER) and Medicare files provided data (on treatment modality, age, race, cancer stage, tumor grade, census tract socioeconomic status, and date of death) on 5747 black and 38 242 white patients diagnosed at age 65-84 years with clinically localized prostate cancer between 1986 and 1996 in five SEER sites. Patients were followed through 1998. Racial differences in survival outcomes were assessed using Kaplan-Meier survival curves and Cox regression models.

RESULTS

The median survival time for black patients was 1.7 years (95% confidence interval [CI] = 1.6 to 1.9 years) less than that for white patients. Median survival in black patients relative to white patients was 1.8 years (95% CI = 1.5 to 2.0 years) less among those who had surgery, 0.7 years (95% CI = 0.5 to 1.0 years) less among those who had radiation therapy, and 1.0 years (95% CI = 0.7 to 1.1 years) less among those who had nonaggressive treatment. Racial disparities were evident both in overall survival and in prostate cancer-specific survival, before and after statistical adjustment for covariates.

CONCLUSIONS

Black patients' poorer overall survival from localized prostate cancer varies by initial treatment, with the survival gap being largest among patients undergoing surgery. Investigating these treatment-specific differences may clarify the mechanisms underlying worse outcomes for black patients in the health care system.

Risk factors for hip fracture in skilled nursing facilities: who should be evaluated?

This paper aims to identify risk factors for hip fracture in Medicare skilled nursing facility (SNF) residents and to develop a predictive model based on routinely collected administrative data (the Minimum Data Set, MDS) to identify high-risk residents. Prospective cohort study of 28,807 North Carolina Medicare SNF residents aged >65 years with a complete MDS assessment in 1999. Demographic, historical, physical, cognitive, behavioral, activities of daily living, and medication variables were obtained from the MDS. Hip fracture occurring after the first MDS assessment identified by ICD-9 code was the outcome measure. Variables significantly associated with hip fracture by chi-square test in a randomly selected derivation sample were combined in a multivariable logistic model and in models stratified by gender. The models were validated in the remaining subjects. Variables significantly related to subsequent hip fracture in the full cohort include: female sex (odds ratio 1.3, 95% confidence interval 1.0-1.7), white race (2.3, 1.6-3.5), age (1.03 per year, 1.01-1.04), cognitive impairment (1.4, 1.8-1.8), incontinence (0.68, 0.5-0.9), prior fractures (1.6, 1.2-2.1), and prior falls (1.4, 1.2-1.8). In ambulatory non-Hispanic white women, anxiety (1.5, 1.0-2.1), anxiolytic use (1.4, 1.1-1.9), wandering (1.4, 1.0-2.2), and training in community skills (1.4, 1.1-1.8) were new significant variables. For ambulatory non-Hispanic white men, education level (2.0, 1.2-3.2), weight loss (0.5, 0.2-1.0), history of osteoporosis (3.0, 1.3-6.7), pathologic bone fracture (9.7, 2.2-42.6), COPD (2.1, 1.3-3.5), glaucoma (2.6, 1.0-6.2), and standing balance impairment (1.8, 1.0-3.3) were also significant. All models were highly correlated with subsequent hip fracture, but the discriminative ability was limited (c statistic 0.678). Risk factors explained more of hip fracture risk in non-Hispanic white men (c statistic 0.793) than non-Hispanic white women (0.658). Risk factors for hip fracture in Medicare SNF residents have similarities and differences from those previously identified in community-dwelling older adults. Osteoporosis screening and intervention should focus on the healthiest, most independent subset of residents who have the greatest fracture risk.

Lipid testing among patients with diabetes who receive diabetes care from primary care physicians

OBJECTIVE

To identify factors related to lipid testing among patients with diabetes who receive diabetes care from primary care physicians.

RESEARCH DESIGN AND METHODS

North Carolina Medicare claims were used to identify individuals with diabetes who received diabetes care from primary care physicians. Lipid testing was related to sociodemographic characteristics, comorbid conditions, physician specialty, and mortality.

RESULTS

Based on Medicare claims from July 1997 through June 1999, 13,660 diabetic North Carolina residents with Medicare, 65-75 years of age, had received HbA(1c) testing from a single primary care physician during at least three of four consecutive 6-month time intervals. During these 2 years, 31% had no lipid profile and 24% had only one lipid profile. Caucasians were 1.6 times more likely than African Americans to receive lipid profiles. Patients not receiving state Medicare assistance were 1.4 times more likely to have a lipid profile than the presumably lower-income patients receiving assistance. Patients with stroke and heart failure were less likely to receive lipid profiles. Those with no lipid profile were almost twice as likely to die from cardiovascular disease than those with at least two lipid profiles.

CONCLUSIONS

Adherence to lipid testing recommendations by primary care physicians for elderly patients with diabetes has much room for improvement. The most vulnerable patients (African Americans, the economically disadvantaged, and the medically complex) are the least likely to receive lipid testing.

Identifying and characterizing one-time and never users of mammography screening services among medicare eligible women

BACKGROUND

Despite eligibility for a screening mammogram once every 2 years from 1991 to 1997, only a small percentage of Medicare women utilized this benefit. We examined mammography use among 388,707 North Carolina Medicare women from 1994 to 1997 to identify characteristics of one-time and never users of mammography.

METHODS

Data were obtained from North Carolina Medicare mammography claims and enrollment files from 1994 to 1997. Women ages 65+ as of 01/01/1994, continuously enrolled in Medicare from 1994 to 1997, and alive as of 12/31/1997 were included in the sample (n = 388,707). Mammogram use was categorized as never, once, or at least twice during 1994/1995 and 1996/1997. Women with at least one mammography claim during 1994/1995 and at least one mammography claim during 1996/1997 were called repeat users, women with one mammography claim during the 4 years were labeled one-time users, and women with zero mammography claims during the 4 years were termed never users. Multivariate logistic regression analyses were conducted to determine associations between characteristics and mammography frequency.

RESULTS

Biennial mammography claims data rates were 35.3% in 1994/1995 and 41.8% in 1996/1997. Compared with all other users, one-time users (n = 108,899) were more likely to be ages 65-74 (vs 75-84 and 85+), live in an urban versus rural county, and be eligible for Medicare only versus Medicare and Medicaid. Never users (n = 184,545) were more likely to be ages 85+, be non-Caucasian, live in a rural county, and be eligible for both Medicare and Medicaid versus Medicare.

CONCLUSIONS

These results demonstrate different demographic characteristics for one-time and never mammography users. This approach of using multiple years of claims data to segment the targeted population provides the opportunity to tailor interventions to subgroups.

Cancer mortality among electric utility workers exposed to polychlorinated biphenyls

OBJECTIVES

To assess whether excess mortality from cancer, malignant melanoma of the skin, and cancers of the brain and liver in particular, is associated with long term occupational exposure to polychlorinated biphenyls (PCBs).

METHODS

An epidemiological study of mortality was conducted among 138,905 men employed for at least six months between 1950 and 1986 at five electrical power companies in the United States. Exposures were assessed by panels composed of workers, hygienists, and managers at each company, who considered tasks performed by workers in 28 job categories and estimated weekly exposures in hours for each job. Poisson regression was used to examine mortality in relation to exposure to electrical insulating fluids containing PCBs, controlling for demographic and occupational factors.

RESULTS

Neither all cause nor total cancer mortality was related to cumulative exposure to PCB insulating fluids. Mortality from malignant melanoma increased with exposure; rate ratios (RRs) relative to unexposed men for melanoma were 1.23 (95% confidence interval (95% CI) 0.56 to 2.52), 1.71 (0.68 to 4.28) and 1.93 (0.52 to 7.14) for men with < 2000, > 2000-10,000, and > 10,000 hours of cumulative exposure to PCB insulating fluids, respectively, without consideration of latency. Lagging exposure by 20 years yielded RRs of 1.29 (0.76 to 2.18), 2.56 (1.09 to 5.97), and 4.81 (1.49 to 15.50) for the same exposure levels. Mortality from brain cancer was modestly increased among men with < 2000 hours (RR 1.61, 95% CI 0.86 to 3.01) and > 2000-10,000 hours exposure (RR 1.79, 95% CI 0.81 to 3.95), but there were no deaths from brain cancer among the most highly exposed men. A lag of five years yielded slightly increased RRs. Mortality from liver cancer was not associated with exposure to PCB insulating fluids.

CONCLUSIONS

This study was larger and provided more detailed information on exposure than past investigations of workers exposed to PCBs. The results suggest that PCBs cause cancer, with malignant melanoma being of particular concern in this industry.

Previous cesarean birth. A risk factor for placenta previa?

OBJECTIVE

To study the risk of placenta previa following a previous cesarean birth.

STUDY DESIGN

We conducted a population-based, case-control study using 1990 North Carolina state birth certificate data. The study population included 342 women with a pregnancy complicated by placenta previa and 1,082 randomly selected controls. Analysis was restricted to women who reported one or more previous live births and delivered a singleton, live neonate. Adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated using logistic regression, controlling for maternal age, race, prior spontaneous or induced abortions and cigarette use.

RESULTS

When the data were adjusted for maternal age, race, prior spontaneous or induced abortions, and cigarette use, women who had a previous cesarean birth and had a parity of 3 were 1.7 times more likely (OR 1.7, 95% CI 0.7, 4.2) and women of parity > or = 4 were 5.5 times more likely (OR 5.5, 95% CI 1.0, 30.1) to have placenta previa than women of parity 1 who had a previous cesarean birth.

CONCLUSION

Women with a history of a previous cesarean birth and parity > or = 3 were at increased risk of having a pregnancy complicated by placenta previa.

Seat belt use laws: the influence of data on public opinion

Motor vehicle crashes are a major public health problem. Mandatory seat belt use laws capable of lessening the highway death and injury toll have recently received a great deal of public attention. Public opinions toward such laws were assessed in a representative sample of 410 North Carolina drivers. In our experimental design, subjects were randomly assigned to receive one of six types of data expressing the effectiveness of the proposed mandatory and the current voluntary policies. A comparison group received no data. Exposure to data about the effectiveness of the proposed seat belt law was strongly predictive of policy preferences, though the specific type of data did not appear to have an influence. Additional characteristics predictive of policy preferences included attitudes toward other government regulations, beliefs about the effectiveness of seat belts, and personal seat belt use. The findings suggest that health educators need to continue to provide the public with data about potential safety regulations. Furthermore, health educators, to be more effective, should target information toward certain critical beliefs such as those about the relative effectiveness of a particular policy.