Cancer screening in public health clinics: the importance of clinic utilization.

OBJECTIVES: To determine how screening for breast and cervical cancer in public health clinics was associated with overall clinic utilization. METHODS: Evidence of screening and clinic visits between June 1989 and May 1992 was obtained by medical record audit for a random sample of 1825 women aged 40 to 75 attending eight public health clinics in the San Francisco Bay Area. RESULTS: With an average number of visits (4 per year), women who did not receive a physical examination were much less likely than those who did to obtain a clinical breast examination (OR = 0.03), mammography referral (OR = 0.1), or a mammogram (OR = 0.4) within 2 years, or a Papanicolaou smear (OR = 0.1) within 3 years. Without a physical examination, the odds of screening or referral increased with the first visit (OR = 1.2 for referral, breast examination, and Pap; 1.3 for mammography), but with a decreasing marginal effect of each additional visit (ratio of successive one-visit OR values = 0.992 for referral and breast examination; 0.995 for Pap; 0.98 for mammography). With a physical exam, visits were associated with mammography only (first visit OR = 1.2; OR ratio = 0.992). CONCLUSIONS: In public health clinics, screening is associated either with receipt of routine care or repeated visits for treatment. Women who fall through the cracks are those who come to the clinic with a medical problem but otherwise receive few services. Interventions in public health clinics need to facilitate the provider's ability to use medically related visits as opportunities to increase adherence to screening recommendations.

Sources of support and the physical and mental well-being of young women with breast cancer.

Women following the stress resulting from the diagnosis and treatment for breast cancer draw resources from their network of friends and relatives. These resources include both emotional support and instrumental resources such as getting a ride to a medical appointment. Emotional support buffers the effects of the stresses they face and improves their mental well-being while the existence, rather than the use, of instrumental supports is positively related to physical well-being. These hypotheses are tested on a population-based cohort of 336 women in the United States, diagnosed and treated for breast cancer when aged 50 or less. Most are married (65%), work (75%), have dependent children (63%), are white (70%), and had a mastectomy (51%). Results of the multi-variate analyses indicate that consistent with predictions, controlling for socio-demographic and treatment-related variables, the size of the social network was related to greater emotional and instrumental support, and greater emotional support was related to better mental well-being. Contrary to predictions, greater use of instrumental resources was related to poorer physical well-being. The results indicate the importance of social resources on well-being following life-threatening illness.

Diagnosis and endovascular treatment of iliocaval compression syndrome.

PURPOSE: The purpose of this study was to evaluate the clinical presentation, diagnosis, and endovascular treatment of iliocaval compression syndrome (ICS). PATIENTS AND METHODS: During a 3-year period, 18 patients (17 women, 1 man; mean age, 42 years) presented with clinical and imaging findings consistent with ICS. All patients were evaluated with venography and Doppler ultrasound (DUS), 13 of 18 with intravascular pressure measurements, 12 of 18 with intravascular ultrasound, 9 of 18 with air plethysmography (APG), and 4 of 18 with magnetic resonance venography. Seventeen patients were treated with endovascular stenting, one was treated with angioplasty alone, and six received adjunct thrombolysis. RESULTS: Despite the presence of stenosis or occlusion in all cases, APG indicated no iliac vein obstruction (outflow fraction > or = 40%) in nine patients. DUS revealed acute (6) or chronic (7) unilateral iliofemoral deep venous thrombosis in 13 of 18 patients, whereas the results of five of 18 DUS studies were normal. Recanalization and stent placement (n = 17) or angioplasty (n = 1) was achieved in all patients. The average pressure gradient was 5.6 mm Hg preprocedure and 0.6 mm Hg postprocedure. The primary patency rate demonstrated with DUS (n = 17) and venography (n = 7) at 6 months was 89%. The primary patency rate at 12 months was 79%. CONCLUSIONS: ICS often presents as sudden unilateral left lower extremity pain and swelling in young to middle-aged female patients after pregnancy, surgery, or a period of inactivity. Venography, intravascular ultrasound, and magnetic resonance venography demonstrate high sensitivity, whereas APG-outflow fraction demonstrates low sensitivity in the diagnosis of ICS. Endovascular stenting and angioplasty provide safe and effective early and intermediate-term treatment of symptomatic ICS.

Implementing capitation of Medicaid mental health services in Colorado: is "readiness" a necessary condition?

Two consortia of community mental health centers in Colorado varied in their administrative readiness for changing to a capitated system and, ultimately, implemented capitation using different organizational arrangements. The objective was to assess the impact of this natural experiment on administrative change, costs, and utilization of services during the first two years postcapitation. Prior to capitation, one was rated as having greater "readiness" than the other and received a capitation contract from the state, while the other did not. A private, for-profit managed behavioral health organization was awarded a contract and formed a joint venture with the less "ready" consortium, providing managed care expertise to complement the consortium's expertise in delivering mental health services. Two years later, these consortia do not look different either administratively or in their patterns of service utilization and costs. These findings suggest alternative ways of successfully implementing a capitated public mental health system.

The impact of risk shifting and contracting on mental health service costs in California.

This paper identifies the impact of "program realignment," a 1991 California state policy that significantly enhanced local governments' financial risk and programmatic authority for public mental health services, on treatment costs per user, and on the mix of inpatient and outpatient service costs. The study employs a natural pre-realignment and post-realignment design using the 59 California local mental health authorities (LMHAs) as the unit of analysis over a seven-year period spanning policy implementation. Total treatment and inpatient cost per user decreases and outpatient cost per user increases after program realignment. Higher levels of contracting with private providers tend to enhance this trend, while risk for institutional services reduces user costs uniformly. Financial and programmatic decentralization can enhance cost efficiency in treatment, while promoting substitution of outpatient services for inpatient services. Local conditions such as risk and contracting determine the extent of the policy response.

Managed care and service capacity development in a public mental health system.

Developing a continuum of care is considered to be one of the first steps in the process of implementing managed care strategies. This study summarizes the results of a final survey that focused on the ability of Colorado community mental health centers (CMHCs) to build service capacity and create new programs as a result of Medicaid capitation financing. Capitated agencies, compared to those that remained fee-for-service during the study period, reported a much greater ability to develop services as a result of capitation. Decreases in services were minimal for all agencies. Some differences in managed care organizational models were noted, as were differences in the speed of implementation. Gaps in some services still remain. These findings point to important program implementation issues for publicly funded managed care.

Intrusiveness of illness and quality of life in young women with breast cancer.

Our objective was to test a theoretical model that explains quality of life as a function of the intrusiveness of illness encroaching on the different domains of one's life. The intrusiveness of illness is explained not only by disease and treatment related factors, but also by one's psychological and social resources (Devins, 1994). To investigate this issue, a sample of 336 women aged 50 and under, recently diagnosed with breast cancer were interviewed in their homes. Consistent with Devins' model, intrusiveness of illness mediated the effect of disease and treatment factors on quality of life. Contrary to his model, some treatment factors also had direct effects while social and psychological factors had only direct effects on quality of life. Neither time post-diagnosis nor type of treatment affected the psychological component of quality of life.

Nurse staffing patterns and hospital efficiency in the United States.

The objective of this exploratory study was to assess the effects of four nurse staffing patterns on the efficiency of patient care delivery in the hospital: registered nurses (RNs) from temporary agencies; part-time career RNs; RN rich skill mix; and organizationally experienced RNs. Using Transaction Cost Analysis, four regression models were specified to consider the effect of these staffing plans on personnel and benefit costs and on non-personnel operating costs. A number of additional variables were also included in the models to control for the effect of other organization and environmental determinants of hospital costs. Use of career part-time RNs and experienced staff reduced both personnel and benefit costs, as well as total non-personnel operating costs, while the use of temporary agencies for RNs increased non-personnel operating costs. An RN rich skill mix was not related to either measure of hospital costs. These findings provide partial support of the theory. Implications of our findings for future research on hospital management are discussed.

Early detection of cancer. Psychologic and social dimensions.

Major strides in early detection research can be attributed to social and behavioral research. Social scientists have been involved in research determining the epidemiologic basis of and the cost-effectiveness of screening for asymptomatic disease. The availability of well accepted screening tests has been a barrier to early detection research, especially in the area of men's health. Early detection research has focused on the individual and system levels. Theoretical models are being adapted for early detection from smoking research and are a strength of current work. These models explain why people participate in early detection and how behavior change can occur. In studying system barriers to early detection, intervention efforts have been focused in the community and in the medical care delivery system. Methodologic issues are beginning to emerge, including measuring of program outcomes, and the appropriate research designs for community studies. Except for immigrant populations, initial screening rates are high, and the periodicity of screening becomes the outcome of choice. Some of these problems are the direct result of the success of research and public education efforts to increase cancer screening. The following are priorities for the next decade: theory driven research on behavior change and on interventions; the social determinants of physicians' participation in screening; process evaluation to relate community efforts to outcomes; and reductions in the stage at which cancer is diagnosed as an outcome measure.

Emotional support following cancer: a test of the stigma and social activity hypotheses.

Reports of changes in emotional support following surgery for breast cancer can be attributed to one of two factors: (1) the stigma associated with cancer, or (2) illness-imposed restrictions in one's activities. These explanations were assessed using data from a longitudinal study of women, following their surgical treatment for early breast cancer (N = 145), gallbladder disease (N = 90), benign breast disease (N = 87), or no surgery (N = 90). Multiple regression analysis was used to test the two models. Contrary to the cancer stigma hypothesis, women with breast cancer initially perceived themselves to have more emotional support, rather than less. Type of surgery did not explain the level of emotional support as post-surgery time increased. Instead, support for the social activity hypothesis was found. The results are interpreted as indicating that breast cancer no longer carries with it a stigma, at least not to the extent of reducing the level of women's emotional support.

Cancer screening among African-American women: their use of tests and social support.

This study examined associations between social ties (as measured by the Social Network Index), instrumental and emotional support, and the use of three female cancer screening tests: mammography, cervical smear, and clinical breast examination. Data were taken from a household survey of 670 African-American women living in northern California in 1986. In multiple logistic regression models, Berkman's index was associated with increased use of mammography but not with the use of cervical smear or clinical breast examination. Instrumental and emotional support measures were not significant. These results suggest that social networks may have a role in early cancer detection.

Popliteal vein entrapment presenting as deep venous thrombosis and chronic venous insufficiency.

PURPOSE: This report describes popliteal vein entrapment in three patients and demonstrates that it may present with manifestations of typical venous disease. METHODS: This report was compiled from a review of inpatient and outpatient records. RESULTS: In the first case, a 28-year-old woman was seen with left leg popliteal and calf deep vein thrombosis without obvious cause. She described long-standing calf discomfort, and passive dorsiflexion of the left foot caused disappearance of arterial pulsations at the pedal level. She was given the anticoagulants heparin and sodium warfarin (Coumadin) followed by surgical exploration. The popliteal vein and artery were entrapped by a fibrous extension of the medial head of the gastrocnemius muscle attaching to the lateral femoral condyle. After band lysis, the patient has been symptom free for 6 years. The second patient, a 37-year-old man, was seen with bilateral chronic venous insufficiency (CVI). Passive dorsiflexion and active plantar flexion of the feet did not diminish the pedal pulses; impedance plethysmography suggested mild outflow obstruction. Ascending venography demonstrated entrapment at the midportion of duplicated popliteal veins with no postthrombotic changes. He was treated with compression stockings and has done well during an 18-month follow-up. The third patient, a 17-year-old male, was seen with severe symptoms of right leg CVI and venous obstruction since 3 years of age. Air plethysmography revealed ambulatory venous hypertension, whereas venography demonstrated reflux down to the knee with an extrinsic narrowing at the midpopliteal vein. During operation, an abnormal origin of the lesser saphenous vein (LSV) from the popliteal vein was found; the LSV took a medial route, compressed the tibial nerve, and caused severe distortion and narrowing of the popliteal vein. Division of the LSV resulted in release of popliteal venous compression and immediate relief of symptoms. CONCLUSIONS: The three cases presented demonstrate that popliteal venous entrapment may begin with symptoms of deep vein thrombosis and CVI. Popliteal venous entrapment must be considered in the differential diagnosis of venous disease in younger patients in whom common predisposing factors are absent.

Social support and cancer screening among older black Americans.

BACKGROUND: Age-adjusted cancer mortality is 27% higher for Black Americans than for the general U.S. population, which may result from inappropriate use of cancer detection tests. Social support has been shown to affect adjustment to breast cancer and survival, but it has not been studied as a predictor of use of preventive health care services in the older population. Our hypothesis is that larger social networks are associated with greater utilization of cancer-screening tests in the older population. PURPOSE: The objective of this study was to examine the relationship between social support and use of cancer-screening tests among older Black Americans. METHODS: Data for this study were obtained from a 1986 baseline survey evaluation of a community intervention program to increase cancer awareness and a 1991 end-point survey of use of cancer detection tests. Our study sample consisted of 617 Black Americans aged 55 years or older who lived in San Francisco (Calif.), the control community, and in Oakland (Calif.), the target community for intervention. The survey included measures of 1) social network characteristics, as determined by a modified version of Berkman and Syme's Social Network Index; 2) demographic characteristics; and 3) use of six cancer-screening tests--mammography, occult blood stool examination, cervical smear, clinical breast examination, digital rectal examination, and sigmoidoscopy. RESULTS: Multiple logistic regression analysis of the Social Network Index results indicated statistically significant positive associations of social support with the use of mammography and occult blood stool examination but not with the other cancer-screening tests. There were statistically significant associations between having HMO (Health Maintenance Organization) insurance and increased use of mammography and occult blood stool examination, compared with having Medi-Cal or other insurance. The interval between the surveys had a statistically significant positive association with use of mammography. These significant associations were not explained by differences in the other variables, which included health status, age, gender, education, type of health insurance, interval between the surveys, and a regular source of care. CONCLUSIONS: Social support seems to be associated with increased use of mammography and occult blood stool examinations among older Black Americans. IMPLICATIONS: Interventions designed to increase utilization of social networks may be an effective way to increase use of cancer screening, which may ultimately lead to reduced mortality from cancer.

Psychosocial outcomes of cancer: a comparative analysis of Hodgkin's disease and testicular cancer.

PURPOSE: The psychosocial outcomes of testicular cancer and Hodgkin's disease were compared to test our hypotheses that more specific dysfunction and less hiding of symptoms would be found in the former group, as cancer visibly affects a sexual organ. Since those with Hodgkin's disease could more easily deny the disease, poorer psychosocial adjustment was predicted. PATIENTS AND METHODS: The sample consists of 85 men with Hodgkin's disease and 88 men with testicular cancer (seminomatous, n = 39; or nonseminomatous, n = 49). They were interviewed once, at least 1 year following the end of treatment. Measures of sociodemographic characteristics, physical functioning, psychologic distress, and social outcomes were collected. Treatment data were collected from medical records. RESULTS: Men with testicular cancer report more focused symptoms: less sexual enjoyment and poor health habits. Men with Hodgkin's disease report more generalized symptoms: fatigue, energy loss, and work impairment. Multivariate analysis indicates that most of these differences are site-related; independent effects of treatment on outcomes were found for more generalized symptoms. Contrary to expectations, both groups reported similar levels of infertility and erectile dysfunction. CONCLUSION: The response to testicular cancer is site-specific, while the response to Hodgkin's disease is related to both site and treatment (stage-related).

Dynamic assessment of quality of life after autologous bone marrow transplantation.

To determine the quality of life in adult patients after autologous bone marrow transplantation (BMT), we administered a questionnaire to a cohort of patients seen at a single referral-based center. The sample included adults 18 years and older during the 1 year following an autologous BMT. Both disease-free patients and those who relapsed with 1-year of follow-up data available were included. Of 59 eligible patients, 58 (98%) responded to the questionnaire. Patients completed a telephone questionnaire administered by a nurse specialist in the field of BMT approximately every 90 days. At the time of initial contact on day +90, the mean quality of life was 7.8 (range, 1 to 10) on a scale of 1 to 10, with 10 being the best. By the end of the first year of follow-up, the mean quality of life was 8.9 (range, 3 to 10). Seventy-eight percent of the patients were employed. Twenty-one percent lost weight during the first year, with the majority reporting voluntary weight loss. Fourteen percent reported difficulties with sexual activity. Only 5% reported difficulty with sleeping or with frequent colds. One patient felt that her appearance was worse, and none of the patients reported a poor appetite. Eighty-eight percent of surviving adult patients reported an above-average to excellent quality of life 1 year following autologous BMT. This outcome is encouraging and suggests that this procedure is not associated with long-term morbidity in the surviving adult patient.

The effect of the social organization of work on the voluntary turnover rate of hospital nurses in the United States.

In light of current concerns over nursing shortages and productivity, voluntary turnover among hospital nurses in the United States has assumed renewed importance as a managerial issue. This study examines the thesis that the social organization of work in hospitals is an important determinant of the voluntary turnover rate among registered nurses. This perspective differs from previous work in this area in that both turnover and its determinants are conceptualized at the organizational rather than individual level, thus opening the way for administrative intervention to reduce turnover. The conceptual model is tested using multiple regression techniques on a sample of 435 hospitals. Results suggest that organizational characteristics and environmental conditions are important contributors to turnover. Organizational characteristics are stronger predictors of turnover than are economic factors.

Factors affecting the use of screening mammography among African American women.

Our objective was to determine the influence of health consciousness in the utilization of mammography in asymptomatic African American women. The sample consisted of 670 women who participated in a household interview in two cities. Logistic regression was used to determine the independent effects of health consciousness, holding constant other factors believed to be related to mammography utilization. Health insurance, income below the poverty line, and an annual physical were not significant predictors. The single most important predictor of having a mammogram was the regular practice of breast self-examination; the group of women who practiced self-examination was almost twice as likely to have a mammogram.