Self-reported desire to improve colposcopic impressions.

BACKGROUND: Women who participate in cervical cancer screening programs must have access to high quality colposcopy services when their cytology test are abnormal. The purpose of this project is to evaluate colposcopic services currently available in New Hampshire and whether colposcopy providers are willing to network to maintain and improve their colposcopic pattern recognition skills in order to improve their colposcopic correlations. METHODS: A survey was mailed to 1314 providers throughout New Hampshire. The survey ascertained the extent of current colposcopic services in New Hampshire through practitioner and practice demographics, the cervical procedures performed, the self-reported colposcopy skill level, and the self-reported quality of past colposcopic education. It also measured interest in networking with others to improve their colposcopic pattern recognition skills. RESULTS: The survey response rate was 62%. 145 of the 810 respondents (18%) are currently performing colposcopies, indicating a statewide potential colposcopy accommodation rate of 3.5 to 7 women per month per colposcopist. 57% of the physician assistants, 59% of the family physicians, 75% of the gynecologists and 100% of the nurse practitioners were interested in enhancing their colposcopic pattern recognition skills by networking through quarterly meetings. CONCLUSIONS: The crude accommodation rate for colposcopy appears sufficient for the women of New Hampshire although the geographic distribution of the colposcopists is unknown. A majority of the colposcopists were interested in networking to improve their colposcopic pattern recognition skills, which could improve patient care.

The technical performance and clinical feasibility of telecolposcopy.

BACKGROUND: The purpose of our study was to demonstrate the technical performance and clinical feasibility of a telecolposcopic system through assessment of image transmission veracity, ease of office system implementation, and the patient's acceptance of the electronic image transmission. METHODS: We used a telecolposcopic system incorporating a custom software package that integrated patient history, current gynecologic status, epidemiologic risk factors, and colposcopic images for local medical documentation and transmission. Satisfaction questionnaires were developed to measure ease of implementation at the remote sites and the patients' acceptance of telecolposcopy. RESULTS: Seventy-nine women participated in our trial. From 3 to 20 images were captured for each woman, documenting cervical squamous intraepithelial lesions and vaginal and vulvar diseases. All images were received without distortions in color, size, or orientation. With complete visualization of the squamocolumnar junction there was an 86% agreement between the remote and review sites (kappa=.533, P=.019). The interobserver agreement for colposcopic impressions was 86% (kappa=.684, P <.001), and for colposcopic impressions with histology within one level of disease severity, 86% (kappa=.78, P <.001). Colposcopists' and patients' satisfaction with telecolposcopy was excellent. More than 95% of the women stated that they would rather have their colposcopy locally with electronic transmission if an experienced colposcopist were more than 25 miles away. CONCLUSIONS: The telecolposcopic system described in our study is technically feasible, can be implemented in an office system with limited technical support, and is preferred by women who have to travel many miles to receive referral health care.

Measuring health state preferences in women with breast hypertrophy.

The purpose of this article is to introduce the measurement of utilities, or patient preferences, to the plastic surgery community. Specifically, the study demonstrated the development and validation of a utility measure for estimating the health-related quality of life in women with breast hypertrophy. Two self-administered instruments were developed, a Wheel and a Table. All subjects completed the utility assessments for their "current health" and again for "breast-related symptoms." The reliability of the instruments was assessed in repeat (test-retest) interviews of 47 women within 10 to 18 days. Utilities obtained with the new instruments were also compared with the performance of other validated utility assessment instruments, including a visual analogue scale, a computer-based instrument (U-Titer), and a preference classification system (EuroQol). Of the 47 women in the test-retest reliability study, 21 had experienced breast hypertrophy (13 had not had reduction surgery and 8 had undergone reduction mammaplasty). Mean utility values for breast-related symptoms among women with breast hypertrophy (n = 13) were: Table, 0.85; Wheel, 0.90; and U-Titer, 0.66. Current health utility scores were significantly lower for women with breast hypertrophy (n = 13), as measured by all instruments except the Wheel. The Table had good reliability and distinguished women with breast hypertrophy from those without. Although the Table provided higher utility values for the same health state compared with the computer-based interview (U-Titer), it is much less costly to implement. The Table is recommended as a reasonable alternative for use in multicenter studies of women with breast hypertrophy. The reported utility value for breast hypertrophy of 0.86 is much lower than predicted. It is comparable with the reported burden of living with other health conditions, such as moderate angina (0.90) and a kidney transplant (0.84).

Has the impact of hormone replacement therapy on health-related quality of life been undervalued?

Previous economic evaluations of hormone replacement therapy (HRT) have restricted positive effects to alleviation of postmenopausal symptoms and negative effects to drug side effects. We studied the association between HRT use and postmenopausal women's valuation of both health-related quality of life and potential treatment side effects. Postmenopausal women with either a documented first vertebral fracture within the past 5 years or no history of osteoporotic fractures were recruited from Olmsted County, Minnesota, and from Dartmouth-Hitchcock Medical Center in New Hampshire to participate in a study to assess quality of life and women's attitudes toward osteoporosis prevention. Women's valuations of their current health and potential HRT-related side effects were quantified as quality-adjusted life years (QALYs) assessed by an automated utility assessment instrument (U-Titer) and the time tradeoff technique, by a vertical rating scale, and by estimated quality of well-being (QWB) scores. Health status was measured using the Medical Outcomes Study SF-36. Regression methods were used to assess the impact of current HRT use on health-related quality of life and valuation of side effects. There were 106 women with vertebral fracture and 180 with no history of hip, wrist, or vertebral fractures. Altogether, 116 (40.6%) women were currently taking HRT, 64 (22.2%) had taken HRT in the past, and 106 (37.1%) women had never taken HRT. Current HRT users had higher time tradeoff QALYs than never and past HRT users, with gains ranging from 15.0 to 83.7 days per year for current users relative to the others. Benefits were largest for women with a vertebral fracture and limitations in activities. The secondary QALY measures also showed significantly higher values for current HRT users compared with other women, as did SF-36 subscales for general health, physical function, role-emotional function, and vitality. There was substantial variability in women's perceptions of HRT side effects. Overall, the proportion of women willing to trade time to avoid bleeding was largest, at 95.5%, followed by breast tenderness, weight gain, and endometrial biopsy at 90.4%, 87.4%, and 82.7%, respectively. Current HRT users had higher health-related quality of life than past or never users according to all measures studied. Women's perceptions of potential side effects were highly variable and should be considered by physicians when prescribing an HRT regimen. If, as our results suggest, postmenopausal therapy has positive effects beyond the immediate postmenopausal years, previous economic studies may have underestimated the value of HRT.