Effect of a Decision Aid on Agreement Between Patient Preferences and Repair Type for Abdominal Aortic Aneurysm: A Randomized Clinical Trial

Importance

Patients with abdominal aortic aneurysm (AAA) can choose open repair or endovascular repair (EVAR). While EVAR is less invasive, it requires lifelong surveillance and more frequent aneurysm-related reinterventions than open repair. A decision aid may help patients receive their preferred type of AAA repair.

Objective

To determine the effect of a decision aid on agreement between patient preference for AAA repair type and the repair type they receive.

Design, Setting, and Participants

In this cluster randomized trial, 235 patients were randomized at 22 VA vascular surgery clinics. All patients had AAAs greater than 5.0 cm in diameter and were candidates for both open repair and EVAR. Data were collected from August 2017 to December 2020, and data were analyzed from December 2020 to June 2021.

Interventions

Presurgical consultation using a decision aid vs usual care.

Main Outcomes and Measures

The primary outcome was the proportion of patients who had agreement between their preference and their repair type, measured using χ2 analyses, κ statistics, and adjusted odds ratios.

Results

Of 235 included patients, 234 (99.6%) were male, and the mean (SD) age was 73 (5.9) years. A total of 126 patients were enrolled in the decision aid group, and 109 were enrolled in the control group. Within 2 years after enrollment, 192 (81.7%) underwent repair. Patients were similar between the decision aid and control groups by age, sex, aneurysm size, iliac artery involvement, and Charlson Comorbidity Index score. Patients preferred EVAR over open repair in both groups (96 of 122 [79%] in the decision aid group; 81 of 106 [76%] in the control group; P = .60). Patients in the decision aid group were more likely to receive their preferred repair type than patients in the control group (95% agreement [93 of 98] vs 86% agreement [81 of 94]; P = .03), and κ statistics were higher in the decision aid group (κ = 0.78; 95% CI, 0.60-0.95) compared with the control group (κ = 0.53; 95% CI, 0.32-0.74). Adjusted models confirmed this association (odds ratio of agreement in the decision aid group relative to control group, 2.93; 95% CI, 1.10-7.70).

Conclusions and Relevance

Patients exposed to a decision aid were more likely to receive their preferred AAA repair type, suggesting that decision aids can help better align patient preferences and treatments in major cardiovascular procedures.

Trial Registration

ClinicalTrials.gov Identifier: NCT03115346.

Discharge-ready volume status in acute decompensated heart failure: a survey of hospitalists

Acute decompensated heart failure is the leading cause of hospitalization in older adults. Clinical practice guidelines recommend patients should be euvolemic at hospital discharge – yet accurate assessment of volume status is recognized to be exceptionally challenging. This conundrum led us to investigate how hospitalists are assessing volume status and discharge- readiness of patients hospitalized with heart failure. We collected audience response data during a didactic heart failure presentation at the 2019 Society of Hospital Medicine annual meeting. Respondents (n = 216), 76% of whom were practicing physician hospitalists caring for more than 20 acute heart failure patients per year, were presented six questions. Eighteen percent of respondents reported not being able to determine the completeness of decongestion on discharge and 32% reported that complete decongestion was not a treatment target. These findings suggest important differences between guideline recommendations and how hospitalists treat heart failure in current clinical practice.

Association of Regional Practice Environment Intensity and the Ability of Internists to Practice High-Value Care After Residency

IMPORTANCE

Use of health care services and physician practice patterns have been shown to vary widely across the United States. Although practice patterns-in particular, physicians' ability to provide high-quality, high-value care-develop during training, the association of a physician's regional practice environment with that ability is less well understood.

OBJECTIVE

To examine the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians whose practice environment changed due to relocation after residency.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included a national sample of 3896 internal medicine physicians who took the 2002 American Board of Internal Medicine initial certification examination followed approximately 1 decade (April 21, 2011, to May 7, 2015) later by the Maintenance of Certification (MOC) examination. At the time of the MOC examination, 2714 of these internists were practicing in a new region. Data were analyzed from March 6, 2016, to May 21, 2018.

EXPOSURES

Intensity of care in the Dartmouth Atlas hospital referral region (HRR), measured by per-enrollee end-of-life physician visits (primary) and current practice type (secondary).

MAIN OUTCOMES AND MEASURES

The outcome, a physician's ability to practice high-value care, was assessed using the Appropriately Conservative Management (ACM) score on the MOC examination, measuring performance across all questions for which the correct answer was the most conservative option. The exposure, regional health care intensity, was measured as per-enrollee end-of-life physician visits in the Dartmouth Atlas HRR of the physician's practice.

RESULTS

Among the 3860 participating internists included in the analysis (2030 men [52.6%]; mean [SD] age, 45.6 [4.5] years), those who moved to regions in the quintile of highest health care intensity had an ACM score 0.22 SD lower (95% CI, -0.32 to -0.12) than internists who moved to regions in the quintile of lowest intensity, controlling for postresidency ACM scores. This difference reflected scoring in the 44th compared with the 53rd percentile of all examinees. This association was mildly attenuated (0.18 SD less; 95% CI, -0.28 to -0.09) after adjustment for physician and practice characteristics.

CONCLUSIONS AND RELEVANCE

This study found that practice patterns of internists who relocate after residency training appear to migrate toward norms of the new region. The demands of practicing in high-intensity regions may erode the ability to practice high-value conservative care.

The Burden of Cystoscopic Bladder Cancer Surveillance: Anxiety, Discomfort, and Patient Preferences for Decision Making

OBJECTIVE

To examine discomfort, anxiety, and preferences for decision making in patients undergoing surveillance cystoscopy for non-muscle-invasive bladder cancer (NMIBC).

METHODS

Veterans with a prior diagnosis of NMIBC completed validated survey instruments assessing procedural discomfort, worry, and satisfaction, and were invited to participate in semistructured focus groups about their experience and desire to be involved in surveillance decision making. Focus group transcripts were analyzed qualitatively, using (1) systematic iterative coding, (2) triangulation involving multiple perspectives from urologists and an implementation scientist, and (3) searching and accounting for disconfirming evidence.

RESULTS

Twelve patients participated in 3 focus groups. Median number of lifetime cystoscopy procedures was 6.5 (interquartile range 4-10). Based on survey responses, two-thirds of participants (64%) experienced some degree of procedural discomfort or worry, and all participants reported improvement in at least 2 dimensions of overall well-being following cystoscopy. Qualitative analysis of the focus groups indicated that participants experience preprocedural anxiety and worry about their disease. Although many participants did not perceive themselves as having a defined role in decision making surrounding their surveillance care, their preferences to be involved in decision making varied widely, ranging from acceptance of the physician's recommendation, to uncertainty, to dissatisfaction with not being involved more in determining the intensity of surveillance care.

CONCLUSION

Many patients with NMIBC experience discomfort, anxiety, and worry related to disease progression and not only cystoscopy. Although some patients are content to defer surveillance decisions to their physicians, others prefer to be more involved. Future work should focus on defining patient-centered approaches to surveillance decision making.

Association between apple consumption and physician visits: appealing the conventional wisdom that an apple a day keeps the doctor away

IMPORTANCE

Fruit consumption is believed to have beneficial health effects, and some claim, "An apple a day keeps the doctor away."

OBJECTIVE

To examine the relationship between eating an apple a day and keeping the doctor away.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study of a nationally representative sample of the noninstitutionalized US adult population. A total of 8728 adults 18 years and older from the 2007-2008 and 2009-2010 National Health and Nutrition Examination Survey completed a 24-hour dietary recall questionnaire and reported that the quantity of food they ate was reflective of their usual daily diet.

EXPOSURES

Daily apple eaters (consuming the equivalent of at least 1 small apple daily, or 149 g of raw apple) vs non-apple eaters, based on the reported quantity of whole apple consumed during the 24-hour dietary recall period.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was success at "keeping the doctor away," measured as no more than 1 visit (self-reported) to a physician during the past year; secondary outcomes included successful avoidance of other health care services (ie, no overnight hospital stays, visits to a mental health professional, or prescription medications).

RESULTS

Of 8399 eligible study participants who completed the dietary recall questionnaire, we identified 753 adult apple eaters (9.0%)--those who typically consume at least 1 small apple per day. Compared with the 7646 non-apple eaters (91.0%), apple eaters had higher educational attainment, were more likely to be from a racial or ethnic minority, and were less likely to smoke (P<.001 for each comparison). Apple eaters were more likely, in the crude analysis, to keep the doctor (and prescription medications) away: 39.0% of apple eaters avoided physician visits vs 33.9% of non-apple eaters (P=.03). After adjusting for sociodemographic and health-related characteristics, however, the association was no longer statistically significant (OR, 1.19; 95% CI, 0.93-1.53; P=.15). In the adjusted analysis, apple eaters also remained marginally more successful at avoiding prescription medications (odds ratio, 1.27; 95% CI, 1.00-1.63). There were no differences seen in overnight hospital stay or mental health visits.

CONCLUSIONS AND RELEVANCE

Evidence does not support that an apple a day keeps the doctor away; however, the small fraction of US adults who eat an apple a day do appear to use fewer prescription medications.

The association between residency training and internists' ability to practice conservatively

IMPORTANCE

Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians' ability to minimize the provision of unnecessary care.

OBJECTIVE

To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients' care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357).

EXPOSURES

Intensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program's hospital referral region.

MAIN OUTCOMES AND MEASURES

The mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM (or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier.

RESULTS

Within each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (P < .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores ranged from the 75th to the 48th percentile in regions from lowest to highest intensity. Graduates of programs in low-intensity regions tended, more weakly, to score better on the AAM subscale (in 3 of 4 knowledge tiers).

CONCLUSIONS AND RELEVANCE

Regardless of overall medical knowledge, internists trained at programs in hospital referral regions with lower-intensity medical practice are more likely to recognize when conservative management is appropriate. These internists remain capable of choosing an aggressive approach when indicated.

Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis

BACKGROUND

Hip fracture surgery and lower extremity arthroplasty are associated with increased risk of both venous thromboembolism and bleeding. The best pharmacologic strategy for reducing these opposing risks is uncertain.

PURPOSE

To compare venous thromboembolism (VTE) and bleeding rates in adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery.

DATA SOURCES

Medline, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library through June 2013; reference lists, ClinicalTrials.gov, and scientific meeting abstracts.

STUDY SELECTION

Randomized trials comparing aspirin to anticoagulants for prevention of VTE following major lower extremity orthopedic surgery.

DATA EXTRACTION

Two reviewers independently extracted data on rates of VTE, bleeding, and mortality.

DATA SYNTHESIS

Of 298 studies screened, 8 trials including 1408 participants met inclusion criteria; all trials screened participants for deep venous thrombosis (DVT). Overall rates of DVT did not differ statistically between aspirin and anticoagulants (relative risk [RR]: 1.15 [95% confidence interval {CI}: 0.68-1.96]). Subgrouped by type of surgery, there was a nonsignificant trend favoring anticoagulation following hip fracture repair but not knee or hip arthroplasty (hip fracture RR: 1.60 [95% CI: 0.80-3.20], 2 trials; arthroplasty RR: 1.00 [95% CI: 0.49-2.05], 5 trials). The risk of bleeding was lower with aspirin than anticoagulants following hip fracture repair (RR: 0.32 [95% CI: 0.13-0.77], 2 trials), with a nonsignificant trend favoring aspirin after arthroplasty (RR: 0.63 [95% CI: 0.33-1.21], 5 trials). Rates of pulmonary embolism were too low to provide reliable estimates.

CONCLUSION

Compared with anticoagulation, aspirin may be associated with higher risk of DVT following hip fracture repair, although bleeding rates were substantially lower. Aspirin was similarly effective after lower extremity arthroplasty and may be associated with lower bleeding risk. Journal of Hospital Medicine 2014;9:579-585. © 2014 Society of Hospital Medicine.

Did you hear the one about the doctor? An examination of doctor jokes posted on Facebook

BACKGROUND

Social networking sites such as Facebook have become immensely popular in recent years and present a unique opportunity for researchers to eavesdrop on the collective conversation of current societal issues.

OBJECTIVE

We sought to explore doctor-related humor by examining doctor jokes posted on Facebook.

METHODS

We performed a cross-sectional study of 33,326 monitored Facebook users, 263 (0.79%) of whom posted a joke that referenced doctors on their Facebook wall during a 6-month observation period (December 15, 2010 to June 16, 2011). We compared characteristics of so-called jokers to nonjokers and identified the characteristics of jokes that predicted joke success measured by having elicited at least one electronic laugh (eg, an LOL or "laughing out loud") as well as the total number of Facebook "likes" the joke received.

RESULTS

Jokers told 156 unique doctor jokes and were the same age as nonjokers but had larger social networks (median Facebook friends 227 vs 132, P<.001) and were more likely to be divorced, separated, or widowed (P<.01). In 39.7% (62/156) of unique jokes, the joke was at the expense of doctors. Jokes at the expense of doctors compared to jokes not at the expense of doctors tended to be more successful in eliciting an electronic laugh (46.5% vs 37.3%), although the association was statistically insignificant. In our adjusted models, jokes that were based on current events received considerably more Facebook likes (rate ratio [RR] 2.36, 95% CI 0.97-5.74).

CONCLUSIONS

This study provides insight into the use of social networking sites for research pertaining to health and medicine, including the world of doctor-related humor.

Too Little? Too Much? Primary care physicians' views on US health care: a brief report

BACKGROUND

Some believe that a substantial amount of US health care is unnecessary, suggesting that it would be possible to control costs without rationing effective services. The views of primary care physicians-the frontline of health care delivery-are not known.

METHODS

Between June and December 2009, we conducted a nationally representative mail survey of US primary care physicians (general internal medicine and family practice) randomly selected from the American Medical Association Physician Masterfile (response rate, 70%; n=627).

RESULTS

Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians). Almost all physicians (95%) believe that physicians vary in what they would do for identical patients; 76% are interested in learning how aggressive or conservative their own practice style is compared with that of other physicians in their community.

CONCLUSIONS

Many US primary care physicians believe that their own patients are receiving too much medical care. Malpractice reform, realignment of financial incentives, and more time with patients could remove pressure on physicians to do more than they feel is needed. Physicians are interested in feedback on their practice style, suggesting they may be receptive to change.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00853918.

Health behaviors and utilization among users of complementary and alternative medicine for treatment versus health promotion

OBJECTIVE

To compare the characteristics, health behaviors, and health services utilization of U.S. adults who use complementary and alternative medicine (CAM) to treat illness to those who use CAM for health promotion.

DATA SOURCE

The 2007 National Health Interview Survey (NHIS).

STUDY DESIGN

We compared adult (age ≥18 years) NHIS respondents based on whether they used CAM in the prior year to treat an illness (n=973), for health promotion (n=3,281), or for both purposes (n=3,031). We used complex survey design methods to make national estimates and examine respondents' self-reported health status, health behaviors, and conventional health services utilization.

PRINCIPAL FINDINGS

Adults who used CAM for health promotion reported significantly better health status and healthier behaviors overall (higher rates of physical activity and lower rates of obesity) than those who used CAM as treatment. While CAM Users in general had higher rates of conventional health services utilization than those who did not use CAM; adults who used CAM as treatment consumed considerably more conventional health services than those who used it for health promotion.

CONCLUSION

This study suggests that there are two distinct types of CAM User that must be considered in future health services research and policy decisions.

Regional variations in palliative care: do cardiologists follow guidelines?

OBJECTIVES

Regional variation in health care use in the last 6 months of life is well documented. Our objective was to examine whether an association exists between cardiologists' tendencies to discuss palliative care for patients with advanced heart failure and the regional use of health care in the last 6 months of life.

METHODS

We performed a national mail survey of a random sample of 994 eligible Cardiologists from the American Medical Association Masterfile. Hypothetical patient scenarios were used to explore physician management of patient scenarios.

RESULTS

We received 614 responses (response rate: 62%). In a 75-year-old with symptomatic chronic heart failure and asymptomatic nonsustained ventricular tachycardia, cardiologists in regions with high use in the last 6 months of life were less likely to have discussions about palliative care (23% versus 32% for comparisons between the highest and lowest quintiles, p = 0.04). Similarly, in an 85 year-old with symptomatic chronic heart failure and an acute exacerbation, cardiologists in high use regions were less likely to have discussions about palliative care (35% versus 47%, p = 0.0008).

CONCLUSIONS

Despite professional guidelines suggesting that cardiologists discuss palliative care with patients with late stage heart failure, less than half of cardiologists would discuss palliative care in two elderly patients with late-stage heart failure and this guideline discordance was worse in the regions with more health care use in the last 6 months of life.

Utilization and expenditures on chiropractic care in the United States from 1997 to 2006

OBJECTIVE

To investigate national utilization and expenditures on chiropractic care between 1997 and 2006.

DATA SOURCE

The nationally representative Medical Expenditure Panel Survey (MEPS).

STUDY DESIGN

We performed descriptive analyses and generated national estimates from data obtained from U.S. adult (>or=18 years) MEPS respondents who reported having visited a chiropractor (annual sample size between 789 and 1,082). For each year, we examined the estimated total national expenditure, the total number of U.S. adults who received chiropractic care, the total number of ambulatory visits to U.S. chiropractors, and the inflation-adjusted charges and expenditures per U.S. adult chiropractic patient.

PRINCIPAL FINDINGS

The total number of U.S. adults who visited a chiropractor increased 57 percent from 7.7 million in 2000 to 12.1 million in 2003. From 1997 to 2006, the inflation-adjusted national expenditures on chiropractic care increased 56 percent from U.S.$3.8 billion to U.S.$5.9 billion. Inflation-adjusted total mean expenditures per patient and expenditures per office visit remained unchanged.

CONCLUSION

The large increase in U.S. adult expenditures on chiropractic care between 1997 and 2006 was due to a 57 percent increase in the total number of U.S. adult chiropractic patients that occurred from 2000 to 2003. From 2003 to 2006, the total number of U.S. adult chiropractic patients has remained stable.

Regional variations in health care intensity and physician perceptions of quality of care

BACKGROUND

Research has documented dramatic differences in health care utilization and spending across U.S. regions with similar levels of patient illness. Although patient outcomes and quality of care have been found to be no better in regions of high health care intensity, it is unknown whether physicians in these regions feel more capable of providing good patient care than those in low-intensity regions.

OBJECTIVE

To determine whether physicians in high-intensity regions feel better able to care for patients than physicians in low-intensity regions.

DESIGN

Physician telephone survey.

SETTING

51 metropolitan and 9 nonmetropolitan areas of the United States and a supplemental national sample.

PARTICIPANTS

10,577 physicians who provided care to adults in 1998 or 1999 were surveyed for the Community Tracking Study (response rate, 61%).

MEASUREMENTS

The End-of-Life Expenditure Index, a measure of spending that reflects differences in the overall quantity of medical services provided rather than differences in illness or price, was used to determine health care intensity in the physicians' community. Outcomes included physicians' perceived availability of clinical services, ability to provide high-quality care to patients, and career satisfaction.

RESULTS

Although the highest-intensity regions have substantially more hospital beds and specialists per capita, physicians in these regions reported more difficulty obtaining needed services for their patients. The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50% in high-intensity regions to 64% in the lowest-intensity region (P < 0.001 for the relationship between intensity and perceived ability to obtain hospital admissions); the proportion of physicians who felt able to obtain high-quality specialist referrals ranged from 64% in high-intensity regions to 79% in low-intensity regions (P < 0.001). Compared with low-intensity regions, fewer physicians in high-intensity regions felt able to maintain good ongoing patient relationships (range, 62% to 70%; P < 0.001) or able to provide high-quality care (range, 72% to 77%; P = 0.009). In most cases, differences persisted but were attenuated in magnitude after adjustment for physician attributes, practice characteristics, and local market factors (for example, managed care penetration); the difference in perceived ability to provide high-quality care was no longer statistically significant (P = 0.099).

LIMITATIONS

The cross-sectional design prevented demonstration of a causal relationship between intensity and physician perceptions of quality.

CONCLUSION

Despite more resources, physicians in regions of high health care intensity did not report greater ease in obtaining needed services or greater ability to provide high-quality care.

Current Antibiotic Therapy for Isolated Urinary Tract Infections in Women

BACKGROUND

Sulfa antibiotics, such as a combination product of trimethoprim and sulfamethoxazole, have traditionally been the drugs of choice for urinary tract infections (UTIs) and remained the most common treatment as recently as a decade ago. However, increasing sulfa resistance among Escherichia coli may have led to changes in prescribing practices.

METHODS

We used the 2000-2002 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey to obtain nationally representative data on antibiotics prescribed for women with isolated outpatient UTIs following visits to physicians' offices, hospital clinics, and emergency departments (n = 2638). Logistic regression was used to determine predictors of quinolone use.

RESULTS

Quinolones were more commonly prescribed than sulfa antibiotics in each year evaluated. In the most recent year of data, quinolones were prescribed in 48% and sulfas in 33% of UTI visits (P<.04). Quinolones were significantly more likely to be prescribed to older patients and in visits occurring in the Northeast; however, no difference in quinolone prescribing was seen when evaluating insurance status, setting, race, ethnicity, health care provider type, and year. Approximately one third of the quinolones used were broader-spectrum agents.

CONCLUSIONS

Quinolones have surpassed sulfas as the most common class of antibiotic prescribed for isolated outpatient UTI in women. Few significant predictors of quinolone use exist, suggesting that the increase is not confined to a certain subset of patients. This pervasive growth in quinolone use raises concerns about increases in resistance to this important class of antibiotics.

Variation in the tendency of primary care physicians to intervene

BACKGROUND

Research has documented dramatic variation in health care spending across the United States that has little relationship to health outcomes. Although high-spending areas have more physicians per capita, it is not known whether this disparity fully explains the differences in spending or whether individual physicians in high-spending regions have a greater tendency to intervene for their patients. We sought to measure the tendency of primary care physicians to intervene across regions that differ in their levels of local health care spending.

METHODS

We used data from the Community Tracking Study Physician Survey, a telephone survey of a nationally representative sample of 5490 primary care physicians who provided care to adults in 1998-1999 (response rate 59%). Local health care spending in physicians' communities was determined by assigning each participating physician to 1 of 306 US hospital referral regions. The tendency of physicians to intervene was measured by evaluating their responses to 6 clinical vignettes in which they were asked how often they would order a test, referral, or treatment for the patient described.

RESULTS

In 5 of the 6 vignettes, physicians in high-spending regions were more likely to recommend interventions than those practicing in low-spending regions. For example, for a 35-year-old man with back pain and foot drop, physicians in high-spending regions would recommend magnetic resonance imaging 82% of the time, compared with 69% for physicians in low-spending regions (P<.001). For a 60-year-old man somewhat bothered by symptoms of benign prostatic hypertrophy, physicians in high-spending regions would make a urology referral 32% of the time, while those in low-spending regions would do so only 23% of the time (P<.001). Our findings that physicians in high-spending regions have a greater tendency to intervene persisted in analyses stratified by physician specialty (family/general practice vs internal medicine).

CONCLUSION

Varying rates of health care spending across the United States reflect the underlying tendency of local physicians to recommend interventions for their patients.

Screening for cervical cancer: will women accept less?

BACKGROUND

U.S. professional organizations increasingly agree that most women require Papanicolaou smear screening every 2 to 3 years rather than annually and that most elderly women may stop screening. We sought to describe the attitudes of women in the United States toward less intense screening, specifically, less frequent screening and eventual cessation of screening.

METHODS

We conducted a random-digit-dialing telephone survey of women in 2002 (response rate of 75% among eligible women reached by telephone). A nationally representative sample of 360 women aged 40 years or older with no history of cancer was surveyed about their acceptance of less intense screening.

RESULTS

Almost all women aged 40 years or older (99%) had had at least one Pap smear; most (59%) were screened annually. When women were asked to choose their preferred frequency for screening, 75% preferred screening at least annually (12% chose screening every 6 months). Less than half (43%) had heard of recommendations advocating less frequent screening. When advised of such recommendations, half of all women believed that they were based on cost. Sixty-nine percent said that they would try to continue being screened annually even if their doctors recommended less frequent screening and advised them of comparable benefits. Only 35% of women thought that there might come a time when they would stop getting Pap smears; of these, almost half would not stop until after age 80 years. The strongest predictor of reluctance to reduce the frequency of screening was a belief that cost was the basis of current screening frequency recommendations.

CONCLUSION

Most women in the United States prefer annual Pap smears and are resistant to the idea of less intense screening. Concern that cost considerations rather than evidence form the basis of screening recommendations may partly explain women's reluctance to accept less intense screening.

The burden of prevention: downstream consequences of Pap smear testing in the elderly

CONTEXT

Although cervical cancer is an unusual cause of death among women 65 and older, most elderly women in the US report continuing to undergo periodic Pap smear screening.

OBJECTIVE

To describe the incidence of Pap smears and downstream testing among elderly women.

SETTING

Claims-based analysis of female Medicare enrollees age 65 and older.

METHODS

Using three years of Medicare Part B 5% Files (1995-1997), we differentiated between women undergoing screening Pap smears and those undergoing Pap smears for surveillance of previous abnormalities or Pap smear follow-up. We determined the proportion of elderly women undergoing Pap smear testing and rates of downstream testing and procedures after an initial Pap smear.

RESULTS

Four million female Medicare beneficiaries over 65 years underwent Pap smear testing between 1995 and 1997, representing 25% of the eligible population. After adjusting for underbilling for Pap smears under Medicare, 43% of women over 65 are estimated to have undergone Pap smear testing during the 3-year period. The large majority (90%) of Pap smears were for screening, while 10% were done for surveillance or follow-up. For every 1000 women with a screening Pap smear, 39 had at least one downstream intervention within eight months of the initial Pap smear, including seven women who underwent colposcopy and two women who had other surgical procedures. Rates of downstream interventions were considerably higher for women undergoing Pap smear follow-up (302 per 1000 with at least one downstream intervention), and surveillance of previous abnormalities (209 per 1000 with a downstream intervention).

CONCLUSION

Cervical cancer screening is widespread among elderly American women, and follow-up testing is not uncommon, particularly among the ten percent of women who appear to be in a cycle of repeated testing. This substantial volume of testing occurs despite the rarity of cervical cancer deaths and unknown benefits of screening in this age group.

Cervical cancer screening among women without a cervix

CONTEXT

Most US women who have undergone hysterectomy are not at risk of cervical cancer-they underwent the procedure for benign disease and they no longer have a cervix. In 1996, the US Preventive Services Task Force recommended that routine Papanicolaou (Pap) smear screening is unnecessary for these women.

OBJECTIVE

To determine whether Pap smear screening among women who have undergone hysterectomy has decreased following the recommendation.

DESIGN

We used data from the Behavioral Risk Factor Surveillance System (1992-2002), an annual, population-based telephone survey of US adults conducted by the Centers for Disease Control and Prevention. Data about timing, type, and indication for hysterectomies were obtained from the Nationwide Inpatient Sample and other sources.

STUDY PARTICIPANTS

In each year of the survey, a representative sample of US women 18 years and older who had undergone hysterectomy (combined n = 188,390) was studied.

MAIN OUTCOME MEASURE

The main outcome was the proportion of women with a history of hysterectomy who reported a current Pap smear (within 3 years). Overall proportions are age adjusted to the 2002 US female population.

RESULTS

Twenty-two million US women 18 years and older have undergone hysterectomy, representing 21% of the population. The proportion of these women who reported a current Pap smear did not change during the 10-year study period. In 1992 (before the US Preventive Services Task Force recommendations), 68.5% of women who had undergone hysterectomy reported having had a Pap smear in the past 3 years; in 2002 (6 years after the recommendation), 69.1% had had a Pap smear during the same period (P value for the comparison =.22). After accounting for Pap smears that may have preceded a recent hysterectomy and hysterectomies that spared the cervix or were performed for cervical neoplasia, we estimate that almost 10 million women, or half of all women who have undergone hysterectomy, are being screened unnecessarily.

CONCLUSIONS

Many US women are undergoing Pap smear screening even though they are not at risk of cervical cancer. The US Preventive Services Task Force recommendations either have not been heard or have been ignored.

The frequency of Pap smear screening in the United States

BACKGROUND

U.S. professional medical societies and the national health systems of all other industrialized nations recommend that most women need not undergo Papanicolaou (Pap) smear screening annually. There are no data, however, regarding the frequency at which women actually undergo screening.

OBJECTIVE

To describe the frequency of cervical cancer screening in the United States.

DESIGN

National Health Interview Survey, a cross-sectional population-based telephone survey conducted by the National Center for Health Statistics.

PARTICIPANTS

Representative sample of U.S. women age 21 and older who denied a history of cancer (N = 16,467).

MEASUREMENTS

Pap smear screening frequency, categorized as no regular screening or screening at 1 of 3 discrete screening intervals (every year, every 2 years, or every 3 years) based on each woman's reported number of Pap smears in the previous 6 years.

RESULTS

The vast majority (93%) of American women report having had at least one Pap smear in their lifetime. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, 17% report a 2-year screening interval, 16% report being screened every 3 years, and 11% are not being screened regularly. Even the very elderly report frequent screening-38% of women age 75 to 84 and 20% of women age 85 and older reported annual Pap smears. Overall, 20% of women reported having had at least one abnormal Pap smear. Among these women, rates of frequent Pap smear screening are considerably higher-80% undergo annual screening, with only a modest decline in screening frequency with increasing age.

CONCLUSIONS

The majority of American women report being screened for cervical cancer more frequently than recommended. Lengthening the screening interval would not only reduce the volume of specimens that cytotechnologists are required to read, but would also reduce the follow-up testing after abnormal smears.

Screening men for prostate and colorectal cancer in the United States: does practice reflect the evidence?

CONTEXT

The debate about the efficacy of prostate-specific antigen (PSA) screening for prostate cancer has received substantial attention in the medical literature and the media, but the extent to which men are actually screened is unknown. If practice were evidence-based, PSA screening would be less common among men than colorectal cancer screening, a preventive service of broad acceptance and proven efficacy.

OBJECTIVE

To compare the prevalences of PSA and colorectal cancer screening among US men.

DESIGN, SETTING, AND POPULATION

The 2001 Behavioral Risk Factor Surveillance System, an annual population-based telephone survey of US adults conducted by the Centers for Disease Control and Prevention, was used to gather data on a representative sample of men aged 40 years or older from all 50 states and the District of Columbia (n = 49 315).

MAIN OUTCOME MEASURES

Proportions of men ever screened and up to date on screening for prostate cancer (with PSA testing) and colorectal cancer (with fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy).

RESULTS

Overall, men are more likely to report having ever been screened for prostate cancer than for colorectal cancer; 75% of those aged 50 years or older have had a PSA test vs 63% for any colorectal cancer test (risk ratio [RR], 1.20; 95% confidence interval [CI], 1.18-1.21). Up-to-date PSA screening is also more common than colorectal cancer screening for men of all ages. Among men aged 50 to 69 years (those for whom there is the greatest consensus in favor of screening), 54% reported an up-to-date PSA screen, while 45% reported up-to-date testing for colorectal cancer (RR, 1.19; 95% CI, 1.16-1.21). In state-level analyses of this age group, men were significantly more likely to be up to date on prostate cancer screening compared with colorectal cancer screening in 27 states, while up-to-date colorectal cancer screening was more common in only 1 state.

CONCLUSION

Among men in the United States, prostate cancer screening is more common than colorectal cancer screening. Physicians should ensure that men who choose to be screened for cancer are aware of the known mortality benefit of colorectal cancer screening and the uncertain benefits of screening for prostate cancer.

Breast cancer screening

Randomized controlled trials involving nearly 500,000 women on two continents have confirmed the early promise that screening mammography can reduce breast cancer mortality. The observed benefits of mammographic screening, however, are not the same in all women. The mortality reduction in women over age 70 is unknown, and women aged 40 to 49 do not appear to benefit from mammographic screening to the same extent as those over age 50. The reasons for this disparity are incompletely understood, but it depends in part upon differing tumor biology and mammographic test characteristics in younger women. Even if relative survival benefits were equal for women under and over age 50, absolute reduction in risk would remain considerably lower for younger women, a disparity that would not be corrected by improved screening technology or adjustment of interscreening intervals. The authors' review of the evidence leads them to strongly support mammographic screening of women aged 50 to 69 at an interval not longer than 2 years. The authors also feel it is reasonable to screen women over age 70 who have a favorable life expectancy. They conclude, however, that the evidence does not support a blanket recommendation in favor of screening women aged 40 to 49. Instead, they advocate a well-informed conversation between physician and patient regarding the present knowledge and the risks and benefits of screening for each individual woman. Definitive answers await the results of ongoing RCTs designed to study the survival benefit conferred by screening women aged 40 to 49. Disagreement will undoubtedly persist regarding which recommendations should determine private practice and public policy.