High-impact chronic pain in sickle cell disease: insights from the Pain in Sickle Cell Epidemiology Study (PiSCES)

ABSTRACT

The US National Pain Strategy recommends identifying individuals with chronic pain (CP) who experience substantial restriction in work, social, or self-care activities as having high-impact chronic pain (HICP). High-impact chronic pain has not been examined among individuals with CP and sickle cell disease (SCD). We analyzed data from 63 individuals with SCD and CP who completed at least 5 months of pain diaries in the Pain in Sickle Cell Epidemiology Study (PiSCES). Forty-eight individuals met the definition for HICP, which was operationalized in this study as reporting pain interference on more than half of diary days. Compared with individuals without HICP, individuals with HICP experienced higher mean daily pain intensity, particularly on days without crises. They also experienced a greater proportion of days with pain, days with healthcare utilization, and days with home opioid use and higher levels of stress. They did not have a statistically significantly higher proportion of days with crises or experience higher mean daily pain intensity on days with crises. Individuals with HICP experienced worse physical functioning and worse physical health compared with those without HICP, controlling for mean pain intensity, age, sex, and education. The results of this study support that HICP is a severely affected subgroup of those with CP in SCD and is associated with greater pain burden and worse health outcomes. The findings from this study should be confirmed prospectively in a contemporary cohort of individuals with SCD.

Vaso-occlusive crisis pain intensity, frequency, and duration: which best correlates with health-related quality of life in adolescents and adults with sickle cell disease?

ABSTRACT

In a cross-sectional analysis of baseline data from a randomized clinical trial, we studied 198 adolescents and adults aged 15+ with sickle cell disease. Interest was in assessing the relative strengths of the relationship of vaso-occlusive crisis (VOC) pain domains of intensity, frequency, and duration, with health-related quality of life (HRQOL). Variation in psychosocial, physical function, and pain expression domains of HRQOL was partially explained by frequency, intensity, and duration of VOC pain, separately and together, over and above differences in age, sex, genotype, and organ system damage. However, no single domain measure accounted for more than an additional partial R2 of 12.5% alone. Vaso-occlusive crisis pain frequency explained the most variation, when simultaneously considering VOC intensity and duration, except for stiffness , where duration was most predictive. Yet VOC pain intensity, and even VOC duration, also contributed to variability in HRQOL. We recommend that for most purposes, because all 3 VOC pain domains contribute to variability in HRQOL, all 3 domains should be assessed and interventions should be targeted to improve all 3 domains to maximize HRQOL outcomes (Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02197845 ).

Intraindividual pain variability and phenotypes of pain in sickle cell disease: a secondary analysis from the Pain in Sickle Cell Epidemiology Study

ABSTRACT

Mean pain intensity alone is insufficient to describe pain phenotypes in sickle cell disease (SCD). The objective of this study was to determine impact of day-to-day intraindividual pain variability on patient outcomes in SCD. We calculated metrics of pain variability and pain intensity for 139 participants with <10% missing data in the first 28 days of the Pain in Sickle Cell Epidemiology Study. We performed Spearman rank correlations between measures of intraindividual pain variability and outcomes. We then used k-means clustering to identify phenotypes of pain in SCD. We found that pain variability was inversely correlated with health-related quality of life, except in those with daily or near-daily pain. Pain variability was positively correlated with affective coping, catastrophizing, somatic symptom burden, sickle cell stress, health care utilization, and opioid use. We found 3 subgroups or clusters of pain phenotypes in SCD. Cluster 1 included individuals with the lowest mean pain, lowest temporal instability and dependency, lowest proportion of days with pain and opioid use, and highest physical function. Cluster 2 included individuals with the highest mean pain, highest temporal dependency, highest proportion of days with pain and opioid use, and lowest physical function. Cluster 3 included individuals with high levels of mean pain, highest temporal instability, but with lower temporal dependency, proportion of days with pain and opioid use, and physical function compared with cluster 2. We conclude that intraindividual pain variability is associated with patient outcomes and psychological characteristics in SCD and is useful in delineating phenotypes of pain in SCD.

Cardiometabolic genomics and pharmacogenomics investigations in Filipino Americans: Steps towards precision health and reducing health disparities

Background

Filipino Americans (FAs) are the third-largest Asian American subgroup in the United States (US). Some studies showed that FAs experience more cardiometabolic diseases (CMDs) than other Asian subgroups and non-Hispanic Whites. The increased prevalence of CMD observed in FAs could be due to genetics and social/dietary lifestyles. While FAs are ascribed as an Asian group, they have higher burdens of CMD, and adverse social determinants of health compared to other Asian subgroups. Therefore, studies to elucidate how FAs might develop CMD and respond to medications used to manage CMD are warranted. The ultimate goals of this study are to identify potential mechanisms for reducing CMD burden in FAs and to optimize therapeutic drug selection. Collectively, these investigations could reduce the cardiovascular health disparities among FAs.

Rationale and design

This is a cross-sectional epidemiological design to enroll 300 self-identified Filipino age 18 yrs. or older without a history of cancer and/or organ transplant from Virginia, Washington DC, and Maryland. Once consented, a health questionnaire and disease checklist are administered to participants, and anthropometric data and other vital signs are collected. When accessible, we collect blood samples to measure basic blood biochemistry, lipids, kidney, and liver functions. We also extract DNA from the blood or saliva for genetic and pharmacogenetic analyses. CMD prevalence in FAs will be compared to the US population. Finally, we will conduct multivariate analyses to ascertain the role of genetic and non-genetic factors in developing CMD in FAs. Virginia Commonwealth University IRB approved all study materials (Protocol HM20018500).

Summary

This is the first community-based study to involve FAs in genomics research. The study is actively recruiting participants. Participant enrollment is ongoing. At the time of this publication, the study has enrolled 97 participants. This ongoing study is expected to inform future research to reduce cardiovascular health disparities among FAs.

Nonalcoholic fatty liver disease is specifically related to the risk of hepatocellular cancer but not extrahepatic malignancies

OBJECTIVE

We performed a matched cohort study among individuals with and without nonalcoholic fatty liver disease (NAFLD) to determine: 1) the incidence of cancers (extrahepatic and liver) and their spectrum and 2) if NAFLD increases the risk of extrahepatic cancers.

METHODS

The NAFLD and non-NAFLD (control) cohorts were identified from electronic medical records via International Classification of Diseases (ICD) codes from a single center and followed from 2010 to 2019. Cohorts were matched 1:2 for age, sex, race, body mass index (BMI), and type 2 diabetes.

RESULTS

A total of 1,412 subjects were included in the analyses. There were 477 individuals with NAFLD and 935 controls (median age, 52 years; women, 54%; white vs. black: 59% vs. 38%; median BMI, 30.4 kg/m²; type 2 diabetes, 34%). The cancer incidence (per 100,000 person-years) was 535 vs. 1,513 (NAFLD vs. control). Liver cancer incidence (per 100,000 person-years) was 89 in the NAFLD group vs. 0 in the control group, whereas the incidence of malignancy was higher across other types of cancer in the control group vs. in the NAFLD group.

CONCLUSIONS

The overall extrahepatic cancer risk in NAFLD is not increased above and beyond the risk from background risk factors such as age, race, sex, BMI, and type 2 diabetes.

Effect of weight, obesity, and other co-morbidities on mortality of colon cancer patients

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Background: There have been reports implicating underweight status as well as obesity with lower survival in colorectal cancer patients, but data has been inconsistent. Methods: In this retrospective observational study, we gathered pre-treatment data on BMI and other co-morbidities from 423 colon cancer patients who underwent surgical resection (stages I to III) or were metastatic at diagnosis (stage IV) at VCU Medical Center from 2005 to 2018 and analyzed their survival outcomes. Results: Compared to patients with a normal BMI, patients with underweight status (BMI < 18.5) have a trend towards higher all-cause mortality (HR 1.66, 95% CI 0.67-4.12). Patients with overweight BMI (25-29.9) and obese BMI ( > 30) have a trend towards improved mortality (HR 0.67, 95% CI 0.46-0.98) (HR 0.75, 95% CI 0.53-1.07) respectively. The p-value was 0.0675. We also found that pre-existing diabetes mellitus is associated with increased all-cause mortality (HR 1.43, CI 1.03 to 1.98, p < 0.05), as well as the use of aspirin at diagnosis (HR 1.60, CI 1.16 to 2.21, p < 0.05). Conclusions: Our results are similar to previous findings that patients with underweight status have worse mortality outcome, suggesting the importance of nutritional status prior to starting treatment. We also found that overweight and obese patients have trends towards improved survival compared to normal weight patients. Future focus can be directed to see whether overweight or obesity status past diagnosis affect survival trends. Aspirin use at diagnosis in our study population is associated with worse mortality outcome; literature is conflicting with outcomes and pre-diagnosis aspirin use. Our findings are similar for both locoregional colon cancers as well as metastatic disease. Research should be directed at seeing what kind of interventions such as nutrition or rehabilitation can be used to ameliorate the increased mortality trend in the underweight status group of patients.

Effects of an entertaining, culturally targeted narrative and an appealing expert interview on the colorectal screening intentions of African American women

Universal screening for colorectal cancer (CRC) is recommended for individuals 50-75 years of age, but screening uptake is suboptimal and African Americans have suffered persistent racial disparities in CRC incidence and deaths. We compared a culturally tailored fictional narrative and an engaging expert interview on the ability to increase intentions to be screened for CRC among African American women. In a post-only experiment, women (N = 442) in face-to-face listening groups in African American churches heard audio recordings of either a narrative or an expert interview. Questionnaires were completed immediately afterward and 30 days later. Women who heard narratives reported stronger intentions to be screened with a home stool blood test than women who heard the interview; the effect lasted at least 30 days. Culturally tailored, fictional narratives appear to be an effective persuasive strategy for reducing racial disparities in CRC outcomes.

The KinFact intervention - a randomized controlled trial to increase family communication about cancer history

BACKGROUND

Knowing family history is important for understanding cancer risk, yet communication within families is suboptimal. Providing strategies to enhance communication may be useful.

METHODS

Four hundred ninety women were recruited from urban, safety-net, hospital-based primary care women's health clinics. Participants were randomized to receive the KinFact intervention or the control handout on lowering risks for breast/colon cancer and screening recommendations. Cancer family history was reviewed with all participants. The 20-minute KinFact intervention, based in communication and behavior theory, included reviewing individualized breast/colon cancer risks and an interactive presentation about cancer and communication. Study outcomes included whether participants reported collecting family history, shared cancer risk information with relatives, and the frequency of communication with relatives. Data were collected at baseline, 1, 6, and 14 months.

RESULTS

Overall, intervention participants were significantly more likely to gather family cancer information at follow-up (odds ratio [OR]: 2.73; 95% confidence interval [CI]: 2.01, 3.71) and to share familial cancer information with relatives (OR: 1.85; 95% CI: 1.37, 2.48). Communication frequency (1=not at all; 4=a lot) was significantly increased at follow-up (1.67 vs. 1.54). Differences were not modified by age, race, education, or family history. However, effects were modified by pregnancy status and genetic literacy. Intervention effects for information gathering and frequency were observed for nonpregnant women but not for pregnant women. Additionally, intervention effects were observed for information gathering in women with high genetic literacy, but not in women with low genetic literacy.

CONCLUSIONS

The KinFact intervention successfully promoted family communication about cancer risk. Educating women to enhance their communication skills surrounding family history may allow them to partner more effectively with their families and ultimately their providers in discussing risks and prevention.

Differences in response to a dietary intervention between the general population and first-degree relatives of colorectal cancer patients

OBJECTIVE

To determine whether response to a dietary intervention is greater among people with family history of colorectal cancer (CRC) compared with a general population.

DESIGN

Cohort study examining participants from 2 related studies.

SETTING

Rural Virginia.

PARTICIPANTS

Seventy people with first-degree relatives with CRC and 113 participants from the intervention arm of a trial in the general population.

INTERVENTION

Both studies implemented a low-intensity intervention delivered via telephone and mail, including low-literacy self-help booklets and personalized dietary feedback.

MAIN OUTCOME MEASURES

Fat, fiber, and fruit and vegetable behavior.

ANALYSIS

Propensity score matching controlled for confounders. Mixed-model ANOVAs compared samples; mediation by perceived cancer risk was assessed.

RESULTS

Participants in both groups significantly improved fat, fiber, and fruit and vegetable behavior at 1-month follow-up; there was significantly greater improvement in the general population sample. Cancer risk perception did not mediate the relationship between study sample and dietary change.

CONCLUSIONS AND IMPLICATIONS

Contrary to expectations, first-degree relatives of CRC patients did not respond better to a dietary intervention than the general population, nor was risk perception related to dietary change. Given the role of diet in CRC risk, additional research should investigate targeted strategies to improve dietary intakes of people at higher cancer risk.

The value of billing data from oncology practice to supplement treatment information for cancer surveillance

BACKGROUND

Cancer treatment information is often underreported in cancer registries due to the shift in cancer care to ambulatory settings. Incomplete treatment information for central registries limits the usefulness of these data for understanding disparities in outcomes. The objective of this study was to evaluate the added value and validity of medical billing data to supplement treatment for incident cases within a central cancer registry.

METHODS

Billing data using standardized structure and nomenclature as submitted by all practices was evaluated using an automated software (MDoffice, MDO) process that captures and processes these data and submits the information in a standardized format. A validation of the billing reported treatment was performed using data from 3 community oncology practices.

RESULTS

The accuracy of treatment data captured was 100 percent for both chemotherapy and radiation therapy among the 313 cases validated. Chemotherapy (36 percent and 5 percent respectively for solid tumors and hematologic cancers) and radiation therapy (46 percent and 20 percent respectively for solid tumors and hematologic cancers) information was added to 738 known incident cases using billing data.

CONCLUSION

Automated reporting based on billing data from community specialty providers is likely to markedly enhance the completeness of treatment data among known cancer cases as these community providers render significant amounts of treatment for cancer patients.

IMPROVE trial: a randomized controlled trial of patient-controlled analgesia for sickle cell painful episodes: rationale, design challenges, initial experience, and recommendations for future studies

BACKGROUND

The hallmark of sickle cell disease (SCD) is pain from a vaso-occlusive crisis. Although ambulatory pain accounts for most days in pain, pain is also the most common cause of hospitalization and is typically treated with parenteral opioids. The evidence base is lacking for most analgesic practice in SCD, particularly for the optimal opioid dosing for patient-controlled analgesia (PCA), in part because of the challenges of the trial design and conduct for this rare disease.

PURPOSE

The purpose of this report is to describe our Network's experiences with protocol development, implementation, and analysis, including overall study design, the value of pain assessments rather than 'crisis' resolution as trial endpoints, and alternative statistical analysis strategies.

METHODS

The Improving Pain Management and Outcomes with Various Strategies (IMPROVE) PCA trial was a multisite inpatient randomized controlled trial comparing two PCA-dosing strategies in adults and children with SCD and acute pain conducted by the SCD Clinical Research Network. The specified primary endpoint was a 25-mm change in a daily average pain intensity using a Visual Analogue Scale, and a number of related pain intensity and pain interference measures were selected as secondary efficacy outcomes. A time-to-event analysis strategy was planned for the primary endpoint.

RESULTS

Of 1116 individuals admitted for pain at 31 participating sites over a 6-month period, 38 were randomized and 4 withdrawn. The trial was closed early due to poor accrual, reflecting a substantial number of challenges encountered during trial implementation.

LIMITATIONS

While some of the design issues were unique to SCD or analgesic studies, many of the trial implementation challenges reflected the increasing complexity of conducting clinical trials in the inpatient setting with multiple care providers and evolving electronic medical record systems, particularly in the context of large urban academic medical centers.

LESSONS LEARNED

Complicated clinical organization of many sites likely slowed study initiation. More extensive involvement of research staff and site principal investigator in the clinical care operations improved site performance. During the subsequent data analysis, alternative statistical approaches were considered, the results of which should inform future efficacy assessments and increase future trial recruitment success by allowing substantial reductions in target sample size.

CONCLUSIONS

A complex randomized analgesic trial was initiated within a multisite disease network seeking to provide an evidence base for clinical care. A number of design considerations were shown to be feasible in this setting, and several pain intensity and pain interference measures were shown to be sensitive to time- and treatment-related improvements. While the premature closure and small sample size precluded definitive conclusions regarding treatment efficacy, this trial furnishes a template for design and implementation considerations that should improve future SCD analgesic trials.

Bedside shift-to-shift nursing report: implementation and outcomes

One unit's staff developed and evaluated an intervention to relocate shift-to-shift nursing report to the patient's bedside. Despite challenges related to privacy, distractions, and integration of nursing technicians to the change, bedside shift report reduced shift report times and improved nursing satisfaction.

Risk perception and knowledge of breast and colon cancers in a diverse population

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Background: The accuracy of cancer risk perception has implications for preventive behaviors. Studies show that despite receiving personalized breast and colon cancer risk information, people continue to overestimate their numeric risks. It is still not fully understood why this occurs. Breast cancer, especially, is highly visible in the media so an individual may hear more about breast cancer, increasing general knowledge but potentially inflating risk perceptions. This study explores relationships between general knowledge and numeric risk perceptions for breast cancer (BC) and colon cancer (CC) among women. We hypothesize that general knowledge of BC will be high relative to CC, but risk perception for BC will be less accurate. Methods: Data was obtained from the first 369 (final N=490) patients recruited for the Kin Fact study from a Women’s Health Clinic. Kin Fact is a randomized controlled trial examining effects of an intervention to increase cancer risk communication in families. Women complete baseline surveys including knowledge and numeric risk perception measures for BC and CC. We use CA Gene software to calculate actual lifetime risk for BC and CC. Correlations, t-tests and linear regressions were used for the analysis. Results: Women averaged 33 years old, and 58% were African American. Average lifetime risk was 3% for CC and 11% for BC. Women overestimated their numeric risk for both BC and CC, but the mean overestimation for BC (24%) was significantly larger than for CC (19%) (p<0.001). Average scores for BC knowledge were also significantly higher than for CC (p<0.001). Compared to knowledge about CC, women who had greater knowledge of BC also were more inaccurate in terms of their perceived numeric risk (r= -0.131, p=0.016). This finding remained significant controlling for age, race and genetic literacy. Conclusions: Results endorse an apparently paradoxical effect that compared with CC, women with increased knowledge of BC have less accurate risk perception for BC. Inaccuracies in perceived risk can affect psychosocial well-being and adherence to screening and prevention recommendations. Findings reveal a need for increasing knowledge about cancer without adversely impacting the accuracy of risk perceptions.

Fruit and vegetable intake among rural youth following a school-based randomized controlled trial

OBJECTIVE

We implemented a theory-based randomized controlled trial (Living Free of Tobacco, Plus (LIFT+) in ten rural middle schools and assessed impact on tobacco use and fruit/vegetable (F/V) intake in 2008-2010. Data on F/V intake at baseline, immediate post intervention, and 1-year follow-up are presented.

METHODS

Schools were randomized to intervention or control groups. Goal setting, peer leaders, and class workshops with parent involvement, were intervention features; community partners were supportive. Seventh graders filled out surveys on health behaviors, psycho-social variables, and demographic characteristics. Adjusted models comparing intervention and control conditions were analyzed.

RESULTS

Sample (n=1119) was 48.5% female, 50% White, with a mean age of 12.7 years. Mean F/V servings were significantly higher in intervention schools at immediate post (3.19 servings) and at 1-year (3.02 servings) compared to controls (2.90, 2.69 respectively). Knowledge of 5-a-day recommendation was significantly higher in intervention schools at immediate post test (75.0%) versus controls (53.8%) but not at 1-year follow-up.

CONCLUSIONS

Intervention schools reported significantly higher mean F/V servings at post intervention and 1-year, and for knowledge of F/V recommendations at immediate post compared to controls. Higher levels of parent and community involvement may further increase F/V intake in future interventions. ClinicalTrials.gov Identifier: NCT01412697.

Opioid patient controlled analgesia use during the initial experience with the IMPROVE PCA trial: a phase III analgesic trial for hospitalized sickle cell patients with painful episodes

Opioid analgesics administered by patient-controlled analgesia (PCA)are frequently used for pain relief in children and adults with sickle cell disease (SCD) hospitalized for persistent vaso-occlusive pain, but optimum opioid dosing is not known. To better define PCA dosing recommendations,a multi-center phase III clinical trial was conducted comparing two alternative opioid PCA dosing strategies (HDLI—higher demand dose with low constant infusion or LDHI—lower demand dose and higher constant infusion) in 38 subjects who completed randomization prior to trial closure. Total opioid utilization (morphine equivalents,mg/kg) in 22 adults was 11.6 ± 2.6 and 4.7 ± 0.9 in the HDLI andin the LDHI arms, respectively, and in 12 children it was 3.7 ± 1.0 and 5.8 ± 2.2, respectively. Opioid-related symptoms were mild and similar in both PCA arms (mean daily opioid symptom intensity score: HDLI0.9 ± 0.1, LDHI 0.9 ± 0.2). The slow enrollment and early study termination limited conclusions regarding superiority of either treatment regimen. This study adds to our understanding of opioid PCA usage in SCD. Future clinical trial protocol designs for opioid PCA may need to consider potential differences between adults and children in PCA usage.

Comparing screening and preventive health behaviors in two study populations: daughters of mothers with breast cancer and women responding to the behavioral risk factor surveillance system survey

BACKGROUND

Studies show that daughters of mothers with breast cancer may be at increased risk for developing the disease. However, daughters' adherence to health behavior and screening recommendations, compared to the general population, is unknown.

METHODS

Telephone interviews explored characteristics of adult daughters (n=147), including primary and secondary preventive behaviors, body mass index (BMI, kg/m(2)), physical activity, fruit/vegetable intake, alcohol intake, smoking, and mammography. Daughters of mothers with breast cancer were recruited from the community and were compared with Virginia women (n=2528) from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) survey. Differences were examined using logistic regression, adjusting for demographic covariates.

RESULTS

Daughters were younger (p<0.001), more highly educated (p<0.001), and more likely to never have been married (p<0.001) than BRFSS participants, but groups were similar by race. In adjusted analyses, daughters were significantly more likely to have ever had a mammogram (p<0.001) and to have had one recently (p=0.001). Daughters also were significantly less likely to consume>3 fruit/vegetable servings daily (p=0.032) compared to BRFSS results. There were no differences in BMI, smoking rates, alcohol consumption, or level of physical activity at work.

CONCLUSIONS

Daughters with familial breast cancer risk were more likely to receive mammography screening than BRFSS participants, but they were no different in BMI, physical activity at work, exercise, or smoking than BRFSS participants and were less likely to consume more fruits and vegetables. More research is needed to explore group differences in screening practices compared to modifiable health behaviors in daughters of mothers with breast cancer.

Genetic risk, perceived risk, and cancer worry in daughters of breast cancer patients

This study explored relationships between worry, perceived risk for breast cancer, consulting a genetic counselor, having genetic testing, and genetic risk for women whose mothers had breast cancer. Analyses involved data from a community-based phone survey of women whose mothers had breast cancer. Participants were categorized as having low, intermediate, or high genetic risk based on their reported family history, in accordance with an accepted classification scheme. The Lerman Breast Cancer Worry Scale measured worry, and participants reported their perceived lifetime likelihood of breast cancer, risk compared to others, and chance from 1 to 100. ANOVA, chi-square, and multiple regression analyses were conducted as appropriate. One hundred-fifty women participated. Mean age was 38 years, and 81% were Caucasian. Fifty-two women had low, 74 had intermediate, and 24 had high genetic risk for breast cancer. There were no significant differences in worry or perceived risk by hereditary risk category. Most high-risk women (91%) had not spoken with a genetic counselor, and no one had previous genetic testing. These findings suggest perceived risk, worry about breast cancer, and use of expert consultation do not match the genetic contribution to risk. There is a need for effectively stratifying and communicating risk in the community and providing tailored reassurance or referral for high-risk assessment.

Impact of automated data collection from urology offices: improving incidence and treatment reporting in urologic cancers

BACKGROUND

Urologic cancers represent a substantial proportion of the total cancer burden, yet the true burden of these cancers is unknown due to gaps in current cancer surveillance systems. Prostate and bladder cancers in particular may be underreported due to increased availability of outpatient care. Thus, there is a critical need to develop systems to completely and accurately capture longitudinal data to understand the true patterns of care and outcomes for these cancers.

METHODS

We determined the accuracy and impact of automated software to capture and process billing data to supplement reporting of cancers diagnosed and treated in a large community urology practice. From these data, we estimated numbers of unreported cancers for an actively reporting and for a non-reporting practice and the associated impact for a central cancer registry.

RESULTS

The software automatically processed billing data representing 26,133 visits for 15,495 patients in the 3.5-month study period. Of these, 2,275 patients had a cancer diagnosis and 87.2% of these matched with a central registry case. The estimated annual number of prostate and bladder cancers remaining unreported from this practice was 158. If the practice were not actively reporting, the unreported cases were estimated at 1,111, representing an increase of 12% to the registry. Treatments added from billing varied by treatment type with the largest proportion of added treatments for biologic response modifiers (BRMs) (127%-166%) and chemotherapy (22%).

CONCLUSION

Automated processing of billing data from community urology practices offers an opportunity to enhance capture of missing prostate and bladder cancer surveillance data with minimal effort to a urology practice.

IMPACT

Broader implementation of automated reporting could have a major impact nationally considering the more than 12,000 practicing urologists listed as members of the American Urological Association.

Mammography screening after risk-tailored messages: the women improving screening through education and risk assessment (WISER) randomized, controlled trial

AIMS

A randomized trial investigated the impact of risk-tailored messages on mammography in diverse women in the Virginia Commonwealth University Health System's gynecology clinics.

METHODS

From 2003 to 2005, 899 patients > or =40 years of age were randomized to receive risk-tailored information or general information about breast health. Multiple logistic regression analyses summarize their breast health practices at 18 months.

RESULTS

At baseline, 576 (64%) women reported having a mammogram in the past year. At 18-month follow-up, mammography rates were 72.6% in the intervention group and 74.2% in the control group (N.S.). Women (n = 123) who reported worrying about breast cancer "often" or "all the time" had significantly higher mammography rates with the intervention (85.0%) vs. the controls (63.5%). No significant differences existed in clinical breast examination, self-examination, or mammography intentions between the two study arms. However, intervention women with lower education reported significantly fewer clinical breast examinations at follow-up.

CONCLUSIONS

The brief intervention with a risk-tailored message did not have a significant effect overall on screening at 18 months. However, among those who worried, mammography rates in the intervention group were higher. Individual characteristics, such as worry about breast cancer and education status, may impact interventions to improve breast cancer prevention practices.

Fruit and vegetable dietary behavior in response to a low-intensity dietary intervention: the rural physician cancer prevention project

CONTEXT

Increased fruit and vegetable intake can reduce cancer risk. Information from this study contributes to research exploring health disparities in high-risk dietary behavior.

PURPOSE

Changes in fruit and vegetable behavior were evaluated to assess the effects of a low-intensity, physician-endorsed dietary intervention in a rural population.

METHODS

The study was a randomized trial of 754 patients from 3 physician practices in rural Virginia. Low-literacy nutrition education materials and personalized dietary feedback were administered by mail and telephone. Mixed model analysis of variance was used to determine the effect of the intervention on fruit and vegetable intake behavior, knowledge, intentions, and self-efficacy at 1, 6, and 12 months.

FINDINGS

The intervention effect was moderated by age, race, sex, and education. Intake at 1 and 6 months was increased for older and younger participants and those with some college, and further maintained at 12 months by those who did not complete high school. African Americans in the intervention group displayed significantly greater intentions to increase fruit/vegetable intake than whites/others. Knowledge of fruit/vegetable recommendations significantly increased in the intervention group at 12 months, particularly for men.

CONCLUSIONS

For the rural population, a low-intensity physician-endorsed self-help dietary intervention was successful in initiating fruit and vegetable dietary changes at 1 and 6 months post-intervention, and increasing intentions to change in African Americans. The relationship of the moderating effects of age, race, sex and education need to be further explored in relation to dietary intervention and dietary behavior change for the rural population.

Recruiting diverse patients to a breast cancer risk communication trial--waiting rooms can improve access

Low participation among underserved populations in health research constrains progress in public health practices. From 2003 to 2005, Women's Health Clinic patients at the VCU Health System were recruited to a trial investigating breast cancer risk communication. In secondary analyses, we examined dimensions of the recruitment of these diverse women. The sample characteristics (age, insurance, race and previous mammograms) were compared to the overall clinic. Of recruitment attempts for eligible women, 45% consented; of those who declined, the top cited reasons were lack of time (40%) and lack of interest (18%). Of 899 participants, 35% qualified for the indigent care program, compared to 31% of the overall clinic (P<0.001). Forty-five percent of participants were African American, compared to 54% of overall clinic patients (P<0.001). Participants were younger (50 vs. 53 years, P<0.001) than the overall clinic population. Nonrepresentative enrollment of patients in clinical trials is common and could lead to suboptimal applicability of findings. Although there were statistically significant race and age differences between the study sample and the overall population, we demonstrate that waiting room recruitment can engage diverse women in a clinical trial and cancer risk communication.

The added value of claims for cancer surveillance: results of varying case definitions

OBJECTIVE

As cancer diagnosis and treatment has moved to the outpatient healthcare setting, traditional cancer surveillance tools are less effective for complete and unbiased capture of incident cases. This study evaluates the potential for Medicare data to supplement cancer surveillance in a unique manner by using a standard that is independent of a central cancer registry.

DESIGN

State cancer registry records were matched with Medicare data. Case validation included inpatient record abstraction combined with a mail/telephone survey of treating physicians. The positive predictive value (PPV), sensitivity (capture rate), and potential additional cases were calculated for 6 Medicare claims-based case definitions.

RESULTS

The PPV varied according to cancer site and definition, ranging from 70%-97% (prostate) to 87%-98% (breast). Sensitivity varied inversely with PPV, ranging from 51%-94% (breast) to 10%-88% (lung). The most important factors that predicted being missed by the registry were having no admission to an ACOS-certified hospital and no surgical treatment.

CONCLUSION

Medicare data represent a valid resource for supplementing state cancer registries in surveillance efforts. This potential is especially applicable to cancers predominantly diagnosed and treated outside the hospital setting.

Randomized trial of a low-intensity dietary intervention in rural residents: the Rural Physician Cancer Prevention Project

BACKGROUND

Dietary behavior, specifically a low-fat, high-fiber diet, plays a role in the primary prevention of chronic diseases including cancer.

DESIGN

A community-based randomized trial to assess the impact of a low-intensity, physician-endorsed, self-help dietary intervention that provided tailored dietary feedback, and was designed to promote improved fat and fiber behavior in a rural, low-education/low-literacy, partly minority population. The data were collected from 1999 to 2003.

SETTING/PARTICIPANTS

A total of 754 patients from three physician practices in rural Virginia completed a baseline telephone survey assessing dietary and psychosocial information, and were then randomly assigned to the intervention or control condition. Follow-up telephone evaluation was based on 522 participants at 1 month, 470 at 6 months, and 516 participants at 12 months.

INTERVENTION

A series of tailored feedback, followed by brief telephone counseling and theory-based nutritional education booklets, provided by staggered delivery to the home.

MAIN OUTCOME MEASURES

Dietary fat and fiber behavior, dietary intentions to change, self-efficacy for dietary change, and fat and fiber knowledge.

RESULTS

The intervention group demonstrated significant improvement in dietary fat and fiber behaviors and intentions to change fat and fiber intake (p <0.05) at 1, 6, and 12 months.

CONCLUSIONS

The Rural Physician Cancer Prevention Project provides an effective model for achieving public health-level dietary health behavior changes among a rural, minority, and low-literacy/low-education population.

Using Medicare Data to Estimate the Number of Cases Missed by a Cancer Registry

BACKGROUND

Cancer surveillance is essential for assessing patterns of cancer occurrence. State cancer registries do not capture all available cases potentially biasing results. Secondary data may be useful in identifying new cases and estimating the number of cases missed.

OBJECTIVE

We sought to create 2 distinct data sources from Medicare claims to use in combination with registry data as 3 sources for a capture-recapture analysis to estimate the capture rate and bias in capture of a statewide cancer registry.

METHODS

Data from the Virginia cancer registry (Registry) were merged with Medicare inpatient (Part A) as well as Medicare outpatient and physician claims (Part B) to provide 3 sources to estimate missing cases. A 3-source loglinear model was used to estimate the number of missing cancer cases for breast, lung, colorectal, and prostate cancer. Models included main effects and interactions. Additional analysis looked at the effect of demographic and comorbidity variables.

RESULTS

Loglinear models demonstrated mostly positive dependence between the 3 sources, implying that 2-source models would underestimate missing cases and overestimate capture rates. Using capture-recapture estimates of total number of cancer cases as the denominator, capture rates for Registry ranged from 59% (colorectal) to 74% (lung). When the aggregate of cases found by either Medicare or Registry were used the capture rates ranged from 74% (prostate) to 89% (breast). Further analysis indicated that capture rates differed by demographic characteristics.

CONCLUSION

We conclude that Medicare claims are useful to supplement a Registry, estimate the number of missing cases, and assess bias in capture.

A systematic review of the effects of estrogens for symptoms suggestive of overactive bladder

OBJECTIVE

To perform a systematic review of the effects of estrogen therapy on symptoms suggestive of overactive bladder (OAB) in postmenopausal women.

MATERIALS AND METHODS

This analysis involved a literature review of Medline, Excerpta Medica, and the Science Citation Index and a manual search of popular urology, gynecology, gerontology, and primary care medicine journals from January 1969 to December 1999. Articles had to include estrogen and placebo treatment groups, published or original data presented at a scientific meeting and report symptoms suggestive of OAB. This search identified 11 randomized trials and included a total of 430 subjects. Thirty-six subjects who participated in two crossover studies received both estrogen and placebo and thus are counted twice, therefore 236 received estrogen therapy and 230 were placebo controls. Estrogen was administered systemically or locally as estriol, estradiol, conjugated estrogen, or estradiol and estriol. A meta-analysis of these studies was performed for all estrogen therapies and then separately for systemic and local therapies.

RESULTS

Overall, estrogen therapies were associated with statistically significant improvements in all outcome variables: diurnal frequency (P = 0.0011), nocturnal frequency (P = 0.0371), urgency (P = 0.0425), number of incontinence episodes (P = 0.0002), first sensation to void (P = 0.0001), and bladder capacity (P = 0.0018). Local therapies had statistically significant beneficial effects on all outcome variables. However, systemic therapies were only associated with significant improvements in incontinence episodes and first sensation to void while nocturnal frequency actually worsened.

CONCLUSION

Estrogen therapy may be effective in alleviating the symptoms suggestive of OAB. Local administration may be the most beneficial route of administration.

Gail model risk assessment and risk perceptions

Patients can benefit from accessible breast cancer risk information. The Gail model is a well-known means of providing risk information to patients and for guiding clinical decisions. Risk presentation often includes 5-year and life-time percent chances for a woman to develop breast cancer. How do women perceive their risks after Gail model risk assessment? This exploratory study used a randomized clinical trial design to address this question among women not previously selected for breast cancer risk. Results suggest a brief risk assessment intervention changes quantitative and comparative risk perceptions and improves accuracy. This study improves our understanding of risk perceptions by evaluating an intervention in a population not previously selected for high-risk status and measuring perceptions in a variety of formats.

Predicting hospital rates of fluoroquinolone-resistant Pseudomonas aeruginosa from fluoroquinolone use in US hospitals and their surrounding communities

Rates of fluoroquinolone resistance among Pseudomonas aeruginosa in hospitals are increasing, but interhospital variability is great. We sought to determine whether this variability correlated to fluoroquinolone use in hospitals and in the surrounding community. Hospital quinolone use in 1999 (24 hospitals) through 2001 (35 hospitals) was determined from billing records. The number of fluoroquinolone prescriptions within a 10-mile (approximately 16-km) radius of each hospital was determined for 1999 and 2000. Hospital fluoroquinolone use increased from 1999 through 2001, from 137 to 163 defined daily doses (DDD)/1000 patient-days (P=.01). The rate of community fluoroquinolone use also increased, from 2.3 to 2.8 DDD/1000 inhabitant-days (P<.001). Rates of fluoroquinolone-resistant P. aeruginosa increased from 29% in 1999 to 36% in 2001 (P=.003). Both community and hospital fluoroquinolone use were predictive of rates of fluoroquinolone-resistant P. aeruginosa. Levofloxacin was associated with resistance, but ciprofloxacin was not. Most of the variability in resistance rates is explained by volume of fluoroquinolone use, both in the hospital and the surrounding community.

Using Medicare claims to identify second primary cancers and recurrences in order to supplement a cancer registry

BACKGROUND AND OBJECTIVE

The purpose of this study was to use Medicare claims to develop models to assist cancer registries in identifying cancer patients with second primaries or recurrences (an "event").

METHODS

Medicare inpatient and Part B data were merged with a cancer registry for patients first diagnosed in 1993-1994. Logistic regression was used to model the occurrence of an event at least 1 year after initial diagnosis, and to identify factors that could discriminate between recurrences and second primaries.

RESULTS

Predictors of an event included an inpatient cancer diagnosis, cancer diagnosis different from the initial diagnosis from any source, and radiation or surgery claims in Part B. The ROC curve area was 0.90 with all Medicare data; 0.84 when restricted to inpatient data. A cancer diagnosis different from the initial diagnosis or having surgery predicted a second primary; regional or distant stage disease, diagnosis of secondary malignancy, or an inpatient diagnosis of primary cancer in a position other than principal predicted recurrence.

CONCLUSIONS

Although Medicare claims have not been evaluated as a stand-alone system to identify second primaries and recurrences, Medicare claims may be useful tools for Cancer Registries in case ascertainment and follow-up.

Using hospital discharge files to enhance cancer surveillance

Use of the traditional mechanism for cancer surveillance, hospital-based registries, may limit ascertainment of incident cases. In this study, the authors evaluated the ability of a statewide hospital discharge file (HDF) to enhance central cancer registry reporting. Incident cancers from a Virginia cancer registry were linked with an HDF for 1995. Medical record abstractions for over 2,000 cancers verified HDF and registry data. There were 19,740 unique cases ascertained from the two combined data sources. The registry captured approximately 83% of cases, while the HDF captured 62%. Although the HDF missed a substantial number of registry cases, the HDF positive predictive value for identifying the correct cancer site was 94%. Logistic regression was used to identify significant characteristics of cases likely to be captured only by the HDF; these characteristics included hospital cancer program certification, the position of the cancer diagnosis on the claim, and cancer surgery. This study represents the evaluation of a novel approach to enhancing registry completeness and accuracy using statewide HDFs. The results strongly suggest that neither a central cancer registry nor an HDF is a sufficient source for complete capture of cases. Using HDFs to supplement a central cancer registry may be a valuable and efficient method for improving registry completeness of reporting.

A systematic review of estrogens for recurrent urinary tract infections: third report of the hormones and urogenital therapy (HUT) committee

Our objective was to apply a meta-analysis to the available data to evaluate the effect of estrogen supplementation in the prevention of recurrent urinary tract infections in postmenopausal women. The literature review incorporated articles based on a search of Excerpta Medica, Medline, Science Citation Index and a manual search of commonly read journals in the fields of urology, gynecology, gerontology and primary healthcare, from January 1969 to December 1998. The search was not limited to English-language publications. Inclusion criteria were peer-reviewed articles containing original data with a primary outcome of symptomatic urinary tract infections and an estrogen-treated group. Articles were categorized into randomized controlled trials, case-control studies and self-controlled series. Of the articles reviewed, five were randomized controlled trials, two were case-control studies and three were self-control series. Meta-analysis of data from 334 subjects revealed a significant benefit from estrogen over placebo (odds ratio = 2.51, 95% confidence interval = 1.48 4.25). The most convincing results were obtained using the vaginal route of administration. A variety of different estrogen preparations have been employed in the few published reports, making comparison of the data difficult. However, vaginal administration seems to be effective in the prevention of recurrent urinary tract infections in postmenopausal women.

Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal women: second report of the Hormones and Urogenital Therapy Committee

OBJECTIVE

To evaluate the efficacy of estrogen therapy in the treatment of postmenopausal women with symptoms and signs associated with urogenital atrophy, by meta-analysis of available data.

METHODS

We searched the literature (Excerpta Medica, Biosis, MEDLINE, and hand search) for studies published between January 1969 and April 1995. Criteria for inclusion were English-language articles, peer-reviewed original publications, and urogenital atrophy assessed by at least one of the following outcomes: patient symptoms, physician report, pH, or cytologic change. Data had to allow comparison between treated and control groups in controlled trials or an estimated change from baseline in uncontrolled series. Meta-analytic methods were applied separately to controlled clinical trials and uncontrolled studies.

RESULTS

Of the 77 relevant articles reviewed, nine contained ten randomized controlled trials. Meta-analysis of these using the Stouffer method revealed a statistically significant benefit of estrogen therapy for all outcomes studied. In 54 uncontrolled case series, the patient symptoms were treated by 24 different treatment modalities. All routes of administration appeared to be effective and maximum benefit was obtained between 1 and 3 months after the start of treatment. As expected, the least systemic absorption of estrogen was seen with estriol (administered orally or vaginally), then vaginal estradiol as measured by pretherapy and posttherapy serum estradiol and estrone.

CONCLUSION

Estrogen is efficacious in the treatment of urogenital atrophy and low-dose vaginal estradiol preparations are as effective as systemic estrogen therapy in the treatment of urogenital atrophy in postmenopausal women.

Immediate reproducibility of upper limit of vulnerability measurements in patients undergoing transvenous implantable cardioverter defibrillator implantation

INTRODUCTION

Measurement of the upper limit of vulnerability (ULV) with monophasic T wave shocks has been proposed as a patient-specific measurement of defibrillation efficacy that results in fewer episodes of ventricular fibrillation (VF) than measurement of a defibrillation efficacy curve.

METHODS AND RESULTS

We sought to determine the magnitude of variance in ULV in 63 consecutive patients undergoing implantation of an implantable cardioverter defibrillator (ICD). We measured ULV as the strength at or above which VF is not induced when a stimulus is delivered at 310 msec after an 8-beat ventricular pacing drive at 400 msec. Defibrillation threshold (DFT) was measured in patients with an active can device using a biphasic waveform and the binary search method beginning at 12 J. Sixty-three patients were studied; they had a mean age of 62 +/- 12 years and a mean ejection fraction of 35% +/- 15%. Three quarters of patients had an ischemic cardiomyopathy. Each patient underwent 4.5 +/- 0.8 measurements of ULV. Monophasic ULV correlated poorly with biphasic DFT (R between 0.19 and 0.28, P = 0.04 to 0.17). There was no change in ULV between second to third, third to fourth, and first to last measurement in 22% to 41% of patients. The reliability coefficient was 0.87. A ULV > or = 20 J was found in eight patients. The only predictor of high ULV was a high DFT.

CONCLUSION

Monophasic ULVs do not closely predict biphasic active can DFTs using a standard protocol. High DFTs were predicted by high ULVs. There was little variation in the acute measurement of ULV between trials. These findings have important implications for using ULV measurements to determine changes in DFTs after interventions. The methodology of determining ULV is critical to its use for predicting DFTs and programming ICDs.

Factors that determine the treatment for local and regional prostate cancer

This article assesses the significance of comorbid and nonclinical factors in type of treatment received by elderly male patients with local-regional stage prostate cancer. Multivariate analysis of data from the Virginia Cancer Registry was linked to Medicare claim files, the Area Resource File, and 1990 Census Data. The type of initial treatment received was studied in 3117 men with local-regional staged prostate cancer diagnosed from 1985 to 1989. The frequency of surgical and radiation therapy for prostate cancer rose between 1985 and 1989 (12.5% to 18.5% for surgery, P < 0.001; 25% to 32% for radiation, P < 0.001). Age was the most important predictor of therapeutic choice; no therapy was given to 26% of men 65 to 69 years old versus 63% of men 85 years or older P < 0.001). Race, residence (rural versus urban), and comorbidity were also strong factors in predicting initial therapy. Using logistic regression, three treatment alternatives were evaluated. Age (odds ratio [OR] .51; 99% confidence interval [CI] = .43, .60), comorbidity (OR .72; 99% CI .63, .82), income (OR 1.14; 99% CI 1.01, 1.28), residence (OR .65; 99% CI .48, .87), diagnosis year (OR 1.15; 99% CI 1.07, 1.23) all were associated independently with treatment versus no treatment. For surgery versus radiation, age (OR .40; 99% CI .27, .57), race (OR 2.92; 99% CI 1.65, 5.15) and education (OR 1.75; 99% CI 1.31, 2.34) were significant factors. For hormonal/orchiectomy versus surgery/radiation, age (OR 5.19; 99% CI 3.84, 7.01), comorbidity (OR 1.28; 99% CI 1.03, 1.58), distance to radiation oncologist (OR .89; 99% CI .80, .99), and diagnosis year (OR .89; 99% CI .79, 1.00) were significant. The number of men receiving surgical and radiation treatments for prostate cancer increased between 1985 and 1989. During that period, age consistently played a significant role in all therapeutic decisions. Other factors, such as comorbidity, race, socioeconomic status, and distance, also were important considerations, depending on the treatment alternative.

Differences in initial treatment patterns and outcomes of lung cancer in the elderly

BACKGROUND

Non-small cell lung cancer (NSCLC) accounts for substantial deaths and costs in the elderly greater than 65 years old. The current practice of NSCLC treatment in a Medicare population was examined to ascertain important areas of practice variation, and differences in clinical outcome and costs.

METHODS

Data from incident cases of NSCLC from the Virginia Cancer Registry (VCR), 1985-89, were matched with claims from Medicare Part A and B, census tract data and the Area Resource File. Multivariate models were created to include clinical data, demographics, and access information.

RESULTS

For patients with locoregional disease, increasing age was associated with lower likelihood of therapy (odds ratio (OR) 0.35; confidence intervals (CI) 0.29, 0.43), thoracotomy (OR 0.27; CI 0.21, 0.34), and more use of radiation therapy compared to surgery (OR 1.69; CI 1.39, 2.03). Low education levels were associated with less likelihood of treatment (OR 0.78; CI 0.66, 0.94), or radiation instead of surgery (OR 1.22; CI 1.05, 1.47). Patients in urban areas were less likely to receive therapy (OR 0.67; CI 0.49, 0.92). For distant disease, increasing age was also associated with lower likelihood of treatment (OR 0.48; CI 0.41, 0.56), as was increasing co-morbidity (OR 0.84; CI 0.75, 0.93). Distance to radiation oncologists made no difference in radiotherapy utilization. Two year survival according to therapy was surgery 66%, radiation 15%, no therapy 17%.

CONCLUSIONS

Patterns of care, and survival according to therapy, vary widely for elderly NSCLC patients. Age, low education, higher co-morbidity and urban residence all decrease the likelihood of surgical therapy for locoregional NSCLC. Despite the availability of coverage through the Medicare program, use of therapies and survival is not uniform for all beneficiaries. Possible discrimination by age, co-morbid illnesses not recorded in the Medicare files, or patient and provider choice could all be involved; administrative billing files cannot resolve these important differences.

Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program in Women (CPW) Research Group

Urinary incontinence (UI) is a relatively common condition in middle-aged and older women. Traditional measures of symptoms do not adequately capture the impact that UI has on individuals' lives. Further, severe morbidity and mortality are not associated with this condition. Rather, UI's impact is primarily on the health status and health-related quality of life (HRQOL) of women. Generic measures of HRQOL inadequately address the impact of the condition on the day-to-day lives of women with UI. The current paper presents data on two new condition-specific instruments designed to assess the HRQOL of UI in women: the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). Used in conjunction with one another, these two measures provide detailed information on how UI affects the lives of women. The measures provide data on the more traditional view of HRQOL by assessing the impact of UI on various activities, roles and emotional states (IIQ), as well as data on the less traditional but critical issue of the degree to which symptoms associated with UI are troubling to women (UDI). Data on the reliability, validity and sensitivity to change of these measures demonstrate that they are psychometrically strong. Further, they have been developed for simple, self-administration.

Clinical characteristics and resource utilization of ICU patients: implications for organization of intensive care

We reviewed the clinical characteristics and resource utilization of 391 medical (M) and 315 surgical (S) ICU patients. In general, MICU patients had more physiologic derangement, as determined by the admission, maximal, and average acute physiology scores (APS). SICU patients had more frequent therapeutic interventions as measured by admission, maximal, and average therapeutic intervention scoring system values. Notably, 40% of MICU and 30% of SICU patients never received any active interventions and were admitted strictly for monitoring purposes. Patients on admission with APS less than or equal to 10 had markedly shorter ICU stays, with almost 50% less treatment than patients with APS over 10. Fifty-six percent of patients with APS less than or equal to 10 did not require any active intervention. In contrast, 83% of patients with APS greater than 10 had considerable intensive interventions. These patients required mechanical ventilation, invasive monitoring, and vasoactive drugs more than twice as often as patients with lower APS scores. Consideration should be given, therefore, to the organization of ICUs according to the patient's severity of illness.

Implications of DRG payments for medical intensive care

Patients in the most prevalent DRGs in a Medical Intensive Care Unit (MICU) were compared with their counterparts who received only routine hospital care on adjusted total hospital costs and length of stay. Costs for both groups were compared with estimated DRG payments under an all-payer system. For patients in three DRGs, measures of severity of illness were examined as predictors of costs. Significant differences between MICU and routine care patients were found in 10 of 13 DRGs studied; intensive care costs were substantially above overall payment rates. The severity of illness measures varied widely in their correlation with costs, depending on DRG and whether the patients were MICU or routine care. These apparent differences in accounting costs may result in hospital decisions to restrict the number of MICU beds. Severity of illness adjustments to DRGs might produce more equitable payments. The most useful measure of severity may differ, however, depending on DRG.

Improving estimates of prevalence by repeated testing

Suppose a screening or diagnostic test with unknown properties is to be used, not primarily for classifying individuals, but for estimating the prevalence of disease. Its sensitivity and specificity may be enhanced by applying it repeatedly to the same individuals, thus bringing the proportion of individuals with overall positive results closer to the true prevalence. Repeated testing also makes it possible to estimate the prevalence by maximum likelihood. Some simple designs for estimation are evaluated in terms of their accuracy and cost.

Nutrient intake in Jerusalem--consumption in 17-year-olds

The food intake of 17-yr-old Jerusalem residents was assessed in a random sample, including 627 males and 551 females, by a 24-h dietary recall method. The intake of energy in boys and girls was lower than the recommended energy intake for this age, but the intake relative to body weight was low only in girls. In boys and girls, the intakes of fat relative to energy were 32.4 and 33.7%, respectively; those of saturated fatty acids (SFA) (9.8 and 10.5%) were lower and those of carbohydrates (53.9 and 52.5%) were higher than intakes found in other Western countries. The P:S (polyunsaturated to saturated fatty acids) ratio of their diets was high and ranged from 0.79 to 1.29 in various sex and origin groups. Intake of cholesterol per 1,000 kcal was similar to that in Western countries. There were marked differences in nutrient intake of subjects whose fathers had immigrated from different countries. Boys whose fathers were born in Israel or Europe had higher intakes of fat and cholesterol, and both boys and girls had a higher intake of SFA and a lower intake of carbohydrates and starch as well as a lower P:S ratio than did their counterparts whose fathers were born in Asia and North Africa. Thus, the nutrient intake of youngsters in Jerusalem differs markedly from that of populations in other Western countries.

Nutrient intake in Jerusalem--consumption in adults

During 1976-80, nutrient intake was assessed in a cross-sectional sample of 1,589 middle-aged Jerusalem residents (1,028 males and 561 females) using the protocols and methods of the North American Lipid Research Clinics (LRCs) Prevalence Studies. All subjects were parents of 17-yr-old youngsters studied previously. Energy intake in both males and females was lower than the recommended energy intake for this age-group. Intake of fat relative to energy in males and females was 32.1 and 34.0%, of saturated fatty acids (SFA) 10.0 and 11.0%, and of total carbohydrates 50.2 and 49.9%, respectively. Cholesterol consumption was 210 and 238 mg/1,000 kcal in males and females, respectively. The mean polyunsaturated to saturated fatty acids (P:S) ratio of the diet was 0.95 in males and 0.84 in females. There were marked differences in the nutrient intake of subjects of different ethnic origin. Subjects from Israel and Europe consumed more total fat and SFA and less total carbohydrates than did their counterparts from Asia and North Africa. Consumption of polyunsaturated fatty acids (PFA) was highest in subjects from Israel. The P:S ratio of the diet was highest in the North African group, followed by the Israeli group, and lowest in subjects from Europe. The highest sucrose intake was found in subjects from North Africa and the highest cholesterol intake in immigrants from Europe. Nutrient intake of Jerusalem adults differed markedly from that of populations in other Western countries.

Nutrient intake in Jerusalem--effects of origin, social class and education

The independent association of ethnic group, social class and education with nutrient intake was studied in a sample of 1,294 adults in the Jerusalem Lipid Research Clinic (LRC) population. By univariate analysis, intake of fat and saturated fatty acids (SFA) was higher (P less than or equal to 0.05) in males and females of the upper social classes (classified by the occupation of the head of the family) than in the lower classes, while the opposite trend was found for the consumption of carbohydrates and starch. In men, an association between social class and the intakes of protein and other carbohydrates (i.e., other than sucrose and starch) and the ratio of polyunsaturated fatty acids (PFA) to SFA (P:S ratio) was also found. In both sexes, the mean intakes of SFA and other carbohydrates were higher and that of starch lower in subjects with a higher level of education (P less than or equal to 0.05). Education was also associated with the consumption of protein and fat in males and with that of carbohydrates and sucrose in females. Country of origin was related (P less than or equal to 0.05) to the intake of fat, SFA and other carbohydrates in both sexes, to that of protein and cholesterol in males and to that of carbohydrates, sucrose and starch in females. The P:S ratio of the diet of male subjects was also associated with origin. Using various models of analysis of variance, it was shown that origin was associated with nutrient intake (P less than or equal to 0.10), independent of the effect of social class and education for protein, fat, SFA, cholesterol, sucrose and other carbohydrates in males, and for fat, SFA, PFA and other carbohydrates in females. The P:S ratio of the male diet was also associated with origin. The level of education was independently related (P less than or equal to 0.10) to the intake of fat, SFA, starch and other carbohydrates in males and to that of sucrose in females, while social class was associated independently with carbohydrate consumption in males only. After prior adjustment for origin, education had a stronger residual effect than did social class in males, while in females the associations of social class and education with nutrient intake were almost identical.