Improving cancer incidence estimates for American Indians in Minnesota.

OBJECTIVES: The purpose of this study was to estimate cancer incidence for American Indians in Minnesota. METHODS: Indian Health Service enrollment data were linked to the Minnesota tumor registry to identify cancers among American Indians in Minnesota. Incidence rates for the 5 most common cancers in this population, estimated after the linkage, were compared with rates estimated before the linkage and with rates for the total population of Minnesota. RESULTS: The linkage identified 302 cancer cases not previously identified as occurring among American Indians in Minnesota. Postlinkage estimates suggested that incidence rates for prostate and colorectal cancer are similar to those for the total population of Minnesota, but that rates of lung and cervical cancer are significantly higher. Breast cancer rates are slightly lower than those for the total population of Minnesota but more than twice as high as previous estimates for American Indians. CONCLUSIONS: The postlinkage estimates suggest different priorities for cancer education, prevention, and control than might be assumed from either prelinkage estimates or previously published data, and underscore the importance of using accurate and specific data for setting these priorities.

Medical records as an alternative to self-report for measuring mammography utilization.

A pilot study assessed whether medical records were a viable alternative to self-report for measuring mammography use in a population-based sample. Of 98 women contacted by telephone, 62 (63.3%) ultimately provided written consent to obtain their mammogram reports. Although all physicians complied with requests for records, an average of three physician contacts per woman were required and 87 percent of mammogram reports were located; therefore, records were available for only 56 percent of women contacted initially. This, coupled with the effort associated with obtaining the records, does not support the use of medical records as an alternative to self-report to measure mammography utilization in the general population.

Measuring mammography compliance: lessons learned from a survival analysis of screening behavior.

Data from a telephone survey of women participating in a federally funded screening program were used to demonstrate the sensitivity of mammography compliance estimates to varying definitions of the time interval within which women are considered compliant with screening guidelines and what constitutes a true screening (as opposed to diagnostic) mammogram. The survival analysis approach used reveals patterns concealed by other approaches to measuring mammography behavior and provides a means for quantifying the impact of various definitional choices on compliance estimates. The results suggest that, although variations in defining and excluding potential diagnostic mammograms lead to differences in compliance measures no greater than 6%, differences as small as 1 month in the screening interval definition used can produce differences in compliance estimates as large as 27%. These results call into question the comparability of estimates across studies and suggest that standard measures would greatly facilitate future efforts in understanding how to promote compliance with mammography screening guidelines.

Questionable data and preconceptions: reconsidering the value of mammography for American Indian Women.

Although the benefits of mammography are well established, many remain skeptical of the value of mammography for American Indian women. This skepticism stems in part from a belief that breast cancer is too rare an event among American Indians to warrant widespread screening. The validity of this assumption for Northern Plains Indians is challenged by a discussion of the limitations of available data on breast cancer in American Indian populations (including lack of generalizability, underestimation, and an overreliance on relative rather than absolute measures of cancer incidence) and by findings from the Minnesota Breast and Cervical Cancer Control Program, a federally funded program providing free breast and cervical cancer screening to American Indian and other women in Minnesota. In light of this information, the authors recommend that the low priority of mammography for American Indian women be reconsidered.

Impact of the Mammography Quality Standards Act on access in Minnesota.

OBJECTIVES: The Minnesota Department of Health surveyed registered mammography facilities to assess their accreditation status prior to full implementation of the Federal Mammography Quality Standards Act (MQSA), which mandated accreditation of all mammography facilities by October 1994; to strategize on the steps that might be taken to avoid closure of facilities; and to evaluate the ultimate impact of the law on the availability of mammography in Minnesota. METHODS: Mammography facilities registered with the Radiation Control Section of the state health department were surveyed five months prior to and four months after the October 1994 deadline. Data collected included accreditation status, plans for continuing service, number of mammograms performed, and areas in which technical assistance was needed. In October 1995, the number and distribution of facilities were determined from the Radiation Control Section registration database. RESULTS: The pre-MQSA survey of 182 respondents found that 96% planned to continue mammography services but only 49% were accredited. The remaining 51% had applications in progress. In the post-MQSA survey, 70% of 182 facilities were found to be accredited, and 30% were operating under provisional certification. As of October 1995, although six facilities had closed, there was a net gain of four mammography facilities providing on-site service. CONCLUSIONS: Despite fears to the contrary, access to mammography in the state of Minnesota was not adversely affected by full implementation of the Mammography Quality Standards Act.

Preventing cervical cancer.

Primary physicians should be sure their women patients of all ages are being screened for cervical cancer. Underinsured women with low incomes may be referred to the Minnesota Breast and Cervical Cancer Control Program for free exams.

Estimation of outpatient risk characteristics and influenza vaccination status: validation of a self-administered questionnaire.

As part of an effort to evaluate the effectiveness of a multifaceted, institution-wide influenza vaccination program, we mailed a self-administered postcard questionnaire to 500 randomly selected outpatients following both the 1987-1988 and 1988-1989 immunization seasons. The postcard asked if the patients received influenza vaccine, where they were immunized, whether they had any high-risk medical illnesses, their age at their last birthday, and their name. To assess the validity of the questionnaire, following the 1988 survey, we selected a 25% systematic sample of respondents and compared survey responses with medical record documentation. Response rates for the surveys were 77.6% for the 1988 survey (two mailings) and 86.5% for the 1989 survey (three mailings). Ninety-four percent (n = 89) of charts selected for audit were successfully reviewed. Agreement between questionnaire responses and medical records was excellent, with greater than 90% agreement and kappas of .8 to .9 for classifying patients as high-risk and receipt of vaccine at the Department of Veterans' Affairs Medical Center. For other data, agreement ranged from 84% to 96% with kappas of .6 to .75. Responses to the 1989 survey also demonstrated the importance of sample frame definition and response wave on estimates of risk characteristics and vaccination rates. A self-administered postcard questionnaire is a valid tool for estimating outpatient risk characteristics and influenza vaccination rates.

Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program.

PURPOSE: To enhance influenza vaccination rates for high-risk outpatients at the Department of Veterans Affairs Medical Center (VAMC) in Minneapolis, Minnesota, an institution-wide immunization program was implemented during 1987. PATIENTS AND METHODS: The program consisted of: (1) a hospital policy allowing nurses to vaccinate without a signed physician's order; (2) stamped reminders on all clinic progress notes; (3) a 2-week walk-in flu shot clinic; (4) influenza vaccination "stations" in the busiest clinic areas; and (5) a mailing to all outpatients. Risk characteristics and vaccination rates for patients were estimated from a validated self-administered postcard questionnaire mailed to 500 randomly selected outpatients. For comparison, 500 patients were surveyed from each of three other Midwestern VAMCs without similar programs. RESULTS: Overall, 70.6% of Minneapolis patients were high-risk and 58.3% of them were vaccinated. In contrast, 69.9% of patients at the comparison medical centers were high-risk, but only 29.9% of them were vaccinated. CONCLUSION: The Minneapolis VAMC influenza vaccination program was highly successful and may serve as a useful model for achieving the national health objective for influenza immunization.

Beneficial effects of treatment of nicotine dependence during an inpatient substance abuse treatment program.

The Minneapolis Department of Veterans Affairs Medical Center began an intervention for tobacco use in its inpatient substance dependency treatment program on June 19, 1988, including an institutional smoke-free policy and a smoking cessation program. Sequential substance-dependent patients admitted before institution of the policy (n = 455) were compared with patients admitted after institution of the policy (n = 457). Patients completed self-administered questionnaires regarding smoking practices and attitudes. Seventy-six percent of patients were current cigarette smokers. Fifty-eight percent of patients after institution of the policy described themselves as "not smoking regularly," compared with 19% of patients admitted before the institution of the policy. Similar proportions of patients admitted before and after the institution of the policy believed that quitting smoking would threaten recovery. Forty-one percent of patients hospitalized after institution of the policy abstained from smoking for more than 1 week during their hospital stay. Rates of early termination of treatment did not change. We conclude that concurrent intervention for nicotine addiction during inpatient treatment of substance dependence is associated with a temporary reduction in smoking and increased motivation to quit smoking.

Frequency of adverse reactions after influenza vaccination.

PURPOSE: Although concern about side effects constitutes a major deterrent to patient compliance with recommendations for influenza vaccination, there is a paucity of data about the frequency of adverse reactions to newer trivalent vaccines. Our aim was to determine the frequency of adverse reactions to influenza vaccine in older, chronically ill persons, many of whom are at high risk for influenza-related morbidity. PATIENTS AND METHODS: We conducted a telephone survey of 40% of the patients who were vaccinated at a walk-in flu shot clinic. The subjects were randomly assigned to two groups. To determine postvaccine symptom rates, Group I was interviewed seven days after vaccination. Group II was interviewed 21 days after vaccination in order to control for baseline symptom rates. Both groups were queried about fever, disability, and flu-like illness in the week preceding the interview. RESULTS: Of 816 patients selected, 650 (79.6%) completed the interview. The mean age of the subjects was 63, and more than two thirds were at risk for influenza-related morbidity. The frequencies of self-reported fever (5.3% versus 5.1%, p = 0.91) and disability (10.4% versus 9.3%, p = 0.65) were similar in the two groups. However, a significantly higher proportion of Group I subjects reported a flu-like illness compared to the Group II subjects (14.2% versus 8.7%, p = 0.03). Although Group I subjects were more likely to report flu-like illness within two days of vaccination compared to a similar time interval for Group II subjects, there was no corresponding clustering of disability after vaccination. CONCLUSION: We conclude that the overall frequency of symptoms in both groups was low; however, the absolute risk of a flu-like illness was 5.5% higher during the first week following influenza vaccination when compared with the third week after the injection. These symptoms did not result in a decreased ability to perform usual daily activities.

Adult immunization.

Although often overlooked in adults, vaccination is an inexpensive, cost-effective means of preventing serious morbidity and mortality from infectious diseases. Primary care physicians have a unique opportunity to implement systems to ensure that their patients are adequately immunized. Recommendations are included for eight vaccines to consider for use in adult primary care.

Organizational strategies to improve influenza vaccine delivery. A standing order in a general medicine clinic.

Educational programs designed to modify physician compliance with influenza vaccination guidelines have yielded only modest improvement. We examined the impact of a standing order on the influenza vaccination rate in a general medicine clinic (GMC). The standing order gave GMC nurses the responsibility to identify and vaccinate high-risk elderly patients. The vaccine order rate in GMC patients seen during the one-month study period in 1986 (n = 97) was compared with the rate in GMC patients from a similar period in 1984 (n = 77) and with the rate in patients seen in three subspecialty clinics during the 1986 study period (n = 106). Comparison patients were vaccinated only by specific physician order. Following the intervention, 79 (81%) of 1986 GMC study patients had vaccination orders, vs 20 (28%) of the 1984 GMC comparison group and 31 (29%) of the 1986 subspecialty clinic comparison group. A simple organizational change consisting of a standing order profoundly improved compliance with vaccination guidelines.

Improved preventive care following an intervention during an ambulatory care rotation: carryover to a second setting.

Recent studies have shown that physician compliance with recommended preventive care guidelines can be improved. Little is known, however, about whether a successful intervention aimed at improving performance applied in one setting will carry over to another. To explore this issue, the authors examined the impact of an intervention involving lecture, feedback, and checklists introduced during an ambulatory care rotation at one hospital (SPR) on resident performance of six preventive care measures at a second outpatient clinic (VA). The performance of 15 residents who had been exposed to the program was compared with that of 13 who had not been exposed to the program. The mean proportion of indicated measures performed by the exposed residents was significantly higher than that of the residents without exposure to the program (0.49 vs. 0.36, p less than 0.05). Improvement was found for all measures but was statistically significant only for influenza vaccination (0.28 vs. 0.07, p = 0.03). Post-intervention performance at SPR was also significantly improved (0.53 vs. 0.36, p less than 0.001). The authors conclude not only that the intervention improved resident performance of preventive care but also that the improvement was carried over to practice in a second outpatient setting.