RESUMEN
CONTEXT: Persons with lower-extremity peripheral arterial disease (PAD) are often asymptomatic or have leg symptoms other than intermittent claudication (IC). OBJECTIVE: To identify clinical characteristics and functional limitations associated with a broad range of leg symptoms identified among patients with PAD. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 460 men and women with PAD and 130 without PAD, who were identified consecutively, conducted between October 1998 and January 2000 at 3 Chicago-area medical centers. MAIN OUTCOME MEASURES: Ankle-brachial index score of less than 0.90; scores from 6-minute walk, accelerometer-measured physical activity over 7 days, repeated chair raises, standing balance (full tandem stand), 4-m walking velocity, San Diego claudication questionnaire, Geriatric Depression Score Short-Form, and the Walking Impairment Questionnaire. RESULTS: All groups with PAD had poorer functioning than participants without PAD. The following values are for patients without IC vs those with IC. Participants in the group with leg pain on exertion and rest (n = 88) had a higher (poorer) score for neuropathy (5.6 vs 3.5; P<.001), prevalence of diabetes mellitus (48.9% vs 26.7%; P<.001), and spinal stenosis (20.8% vs 7.2%; P =.002). The atypical exertional leg pain/carry on group (exertional leg pain other than IC associated with walking through leg pain [n = 41]) and the atypical exertional leg pain/stop group (exertional leg pain other than IC that causes one to stop walking [n = 90]) had better functioning than the IC group. The group without exertional leg pain/inactive (no exertional leg pain in individual who walks =6 blocks per week [n = 28]) and the leg pain on exertion and rest group had poorer functioning than those with IC. Adjusting for age, sex, race, and comorbidities and compared with IC, participants with atypical exertional leg pain/carry on achieved a greater distance on the 6-minute walk (404.3 vs 328.5 m; P<.001) and were less likely to stop during the 6-minute walk (6.8% vs 36%; P =.002). The group with pain on exertion and rest had a slower time for completing 5 chair raises (13.5 vs 11.9 seconds; P =.009), completed the tandem stand less frequently (37.5% vs 60.0%; P =.004), and had a slower 4-m walking velocity (0.80 vs 0.90 m/s; P<.001). CONCLUSIONS: There is a wide range of leg symptoms in persons with PAD beyond that of classic IC. Comorbid disease may contribute to these symptoms in PAD. Functional impairments are found in every PAD symptom group, and the degree of functional limitation varies depending on the type of leg symptom.
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Arteriopatías Oclusivas/fisiopatología , Pierna/irrigación sanguínea , Enfermedades Vasculares Periféricas/fisiopatología , Anciano , Arteriopatías Oclusivas/epidemiología , Presión Sanguínea , Arteria Braquial , Comorbilidad , Estudios Transversales , Depresión , Femenino , Humanos , Claudicación Intermitente/epidemiología , Claudicación Intermitente/fisiopatología , Masculino , Dolor , Enfermedades Vasculares Periféricas/epidemiología , Esfuerzo Físico , Descanso , Índice de Severidad de la Enfermedad , Arterias Tibiales , CaminataRESUMEN
Colorectal cancer is ideally suited for early detection strategies that are likely to improve survival rates. Screening with either a fecal occult blood test (FOBT) or flexible sigmoidoscopy has been shown to identify precancerous polyps or cancers in early stages. However, persons with limited education and of lower socioeconomic status infrequently participate in screening programs in general and have very low rates of colorectal screening. Low literacy, which is common among persons with limited education and low income, may be an overlooked factor in understanding patients' decision making about colorectal cancer screening. This article provides information from focus groups about colorectal cancer screening, which we examine in the context of relevant literature on cancer screening and literacy. Using the health belief model, we examine the association between inadequate health literacy skills and low rates of colorectal cancer screening. The theoretical model also provides insights into strategies for improving knowledge, attitudes, and beliefs and screening rates for this challenging patient population.
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Neoplasias Colorrectales/prevención & control , Escolaridad , Educación en Salud , Tamizaje Masivo , Educación del Paciente como Asunto , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/mortalidad , Humanos , Sangre Oculta , Tasa de SupervivenciaRESUMEN
OBJECTIVE: To assess factors associated with patient satisfaction with communication of mammography results and their understanding and ability to recall these results. DESIGN: Cross-sectional telephone survey. SETTING: Academic breast imaging center. PATIENTS: Two hundred ninety-eight patients who had either a screening or diagnostic mammogram. MEASUREMENTS AND MAIN RESULTS: Survey items assessed waiting time for results, anxiety about results, satisfaction with several components of results reporting, and patients' understanding of results and recommendations. Women undergoing screening exams were more likely to be dissatisfied with the way the results were communicated than those who underwent diagnostic exams and received immediate results (20% vs 11%, P =.05). For these screening patients, waiting for more than two weeks for notification of results, difficulty getting in touch with someone to answer questions, low ratings of how clearly results were explained, and considerable or extreme anxiety about the results were all independently associated with dissatisfaction with the way the results were reported, while age and actual exam result were not. CONCLUSIONS: Patients undergoing screening mammograms were more likely to be dissatisfied with the way the results were communicated than were those who underwent diagnostic mammograms. Interventions to reduce the wait time for results, reduce patients' anxiety, and improve the clarity with which the results and recommendations are given may help improve overall satisfaction with mammography result reporting.
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Comunicación , Mamografía/psicología , Satisfacción del Paciente/estadística & datos numéricos , Anciano , Ansiedad/etiología , Neoplasias de la Mama/diagnóstico , Femenino , Humanos , Modelos Logísticos , Mamografía/normas , Persona de Mediana Edad , Oportunidad Relativa , Factores de TiempoAsunto(s)
Salud , Mujeres , Neoplasias de la Mama/prevención & control , Anticonceptivos Orales , Enfermedad Coronaria/mortalidad , Violencia Doméstica/prevención & control , Femenino , Terapia de Reemplazo de Hormonas , Humanos , Masculino , Obesidad/prevención & control , Osteoporosis Posmenopáusica/tratamiento farmacológico , Disfunciones Sexuales Fisiológicas/epidemiología , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: We conducted a prospective controlled clinical trial in an urban academic general medicine practice to test the effect of same-day mammography availability on adherence to physicians' screening mammography recommendations. PATIENTS AND METHODS: Participants were a consecutive sample of 920 female patients aged 50 years or older who had received a physician's recommendation for screening mammography at an office visit and had no active breast symptoms, history of breast cancer, or a mammogram within the previous 12 months. Women were assigned to same-day screening mammography availability (intervention group) or usual screening mammography scheduling (control group). MAIN OUTCOME MEASURES: Three-, 6-, and 12-month rates of adherence to physicians' recommendations for screening mammography. RESULT: Twenty-six percent of women in the intervention group obtained a same-day screening mammogram. At 3 months, 58% of the women in the intervention group underwent the recommended screening mammography compared with 43% of the women in the control group (P<.001), increasing to 61% and 49% at 6 months (P<.001), and 268 (66%) of 408 vs 287 (56%) of 512 at 12 months (P = .003). The difference between the intervention and control groups 3-month adherence rates was most marked among women aged 65 years or older (58% vs 34%; P<.001), women who were not employed (54% vs 36%; P<.001), and women with a history of having had either no mammograms (39% vs 20%; P = .02) or only 1 to 2 mammograms (57% vs 38%; P<.001) within the last 5 years. CONCLUSIONS: Same-day mammography availability increased 3-, 6-, and 12-month screening mammography adherence rates in this urban academic general medicine practice. The effect was most marked among women aged 65 years or older, women who were not employed, and those who had had fewer than 3 mammograms in the last 5 years. The efficacy of this intervention in other settings still needs to be demonstrated.
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Mamografía/métodos , Tamizaje Masivo/métodos , Visita a Consultorio Médico , Centros Médicos Académicos , Anciano , Femenino , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Factores de Tiempo , Salud UrbanaRESUMEN
PURPOSE: To assess the effects of stage of training, gender, and specialty interest on medical students' breast cancer knowledge, attitudes, and clinical breast examination (CBE) skills as a case study of the progression of physical examination skills during medical education. METHOD: In 1996, questionnaires assessing breast cancer knowledge and attitudes were administered to 493 premedical and first-, second-, and third-year medical students at Northwestern University Medical School. Silicone breast models were used to evaluate the CBE proficiency of a subset of 151 students. RESULTS: Breast cancer knowledge was positively correlated with stage of training (r = .62), with significant differences between all levels (p < .001). In contrast, first-year medical students attained the highest mean lump-detection sensitivity (61.5%), followed by second-year (53.9%) and third-year (43.5%) students (p < .001, first- vs third-year students; p < .10, second- vs third-year students). There was no significant difference in specificity among the four stages. CONCLUSIONS: The results suggest that breast cancer knowledge and attitudes are not related to CBE proficiency, which is a practiced tactile skill. The decline in lump-detection sensitivity with increased stage of training may demonstrate the need for increased attention to palpation skills during the clinical years. These findings are consistent with those of earlier reports that suggest the need for the reinforcement of physical examination skills during clinical education.
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Neoplasias de la Mama/diagnóstico , Competencia Clínica/normas , Palpación/normas , Estudiantes de Medicina , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Modelos Anatómicos , Sensibilidad y Especificidad , Encuestas y CuestionariosRESUMEN
OBJECTIVES: To evaluate the effects of a brief educational program on beliefs, knowledge, and behaviors related to skin cancer control among internal medicine housestaff and attending physicians. DESIGN: Randomised controlled trial. SETTING: Urban academic general medicine practice. PARTICIPANTS: Internal medicine housestaff and attending physicians with continuity clinics at the practice site. INTERVENTION: Two 1-hour educational seminars on skin cancer control conducted jointly by a general internist and a dermatologist. MEASUREMENTS AND MAIN RESULTS: Self-reported attitudes and beliefs about skin cancer control, ability to identify and make treatment decisions on 18 skin lesions, and knowledge of skin cancer risk factors were measured by a questionnaire before and after the teaching intervention. Exit surveys of patients at moderate to high risk of skin cancer were conducted 1 month before and 1 month after the intervention to measure physician skin cancer control practices reported by patients. Eighty-two physicians completed baseline questionnaires and were enrolled in the study, 46 in the intervention group and 36 in the control group. Twenty-five physicians attended both sessions, 11 attended one, and 10 attended neither. Postintervention, the percentage of physicians feeling adequately trained increased from 35% to 47% in the control group (p = .34) and from 37% to 57% in the intervention group (p = .06). Intervention physicians had an absolute mean improvement in their risk factor identification score of 6.7%, while control physicians' mean score was unchanged (p = .06). Intervention and control physicians had similar increases in their postintervention lesion identification and management scores. Postintervention, the mean proportion of patients per physician stating they were advised to watch their moles increased more among intervention physicians than control physicians (absolute difference of 19% vs -8%, p = .04). Other changes in behavior were not significant. CONCLUSIONS: Although we observed a few modest intervention effects, overall this brief skin cancer education intervention did not significantly affect primary care physicians' skin cancer control attitudes, beliefs, knowledge, or behaviors. A more intensive intervention with greater participation may be necessary to show a stronger impact on attitudes and knowledge about skin cancer control among primary care physicians.
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Competencia Clínica , Medicina Interna/educación , Internado y Residencia , Cuerpo Médico de Hospitales , Neoplasias Cutáneas/prevención & control , HumanosRESUMEN
BACKGROUND: This study assessed whether age-related differences in breast carcinoma knowledge and perceived risk exist among women in a primary care setting and whether these women's beliefs about the best age to begin screening mammography reflect those of their physicians. METHODS: Consecutive women ages 30-70 years who visited an academic general medicine practice were asked to complete a questionnaire assessing breast carcinoma knowledge, beliefs, and perceived risk. Women's risk estimates were compared with individual risk probabilities derived from the Gail model. Women's beliefs about when to begin screening mammography were compared with the beliefs of the attending physicians in the practice. Questionnaire results were compared across age groups. RESULTS: Six hundred seventy-four women completed the survey. Overall, knowledge scores were negatively correlated with age (correlation coefficient = -0.30, P = 0.001). The level of knowledge about the benefits of mammography was high across all age groups. In contrast, knowledge that breast carcinoma incidence increases with age was poor. Only 28% of all women recognized that breast carcinoma is more common among women age 65 years than among women age 40 years. Among all women, 26% underestimated their risk of developing breast carcinoma in the next 10 years, 32% correctly estimated their risk, and 42% overestimated their risk. Fifty-five percent thought that mammography should begin when a woman is age 30-35 years. In contrast, all surveyed physicians recommended that a woman start undergoing mammography at age 40 years or older. CONCLUSIONS: In this primary care setting, older women had poorer breast carcinoma knowledge than younger women but were equally likely to appreciate the benefits of mammography. Most women were unaware that age is a risk factor for breast carcinoma. Improved education of females by their physicians may resolve some of the observed discrepancies regarding the optimal age to begin screening mammography.
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Neoplasias de la Mama/prevención & control , Medicina Familiar y Comunitaria , Conocimientos, Actitudes y Práctica en Salud , Mamografía , Adulto , Factores de Edad , Anciano , Neoplasias de la Mama/psicología , Femenino , Humanos , Tamizaje Masivo , Persona de Mediana Edad , Educación del Paciente como Asunto , Pautas de la Práctica en Medicina , Riesgo , Encuestas y CuestionariosRESUMEN
PURPOSE: To compare the effects of clinical breast examination (CBE) training on lump-detection rates in simulated premenopausal and postmenopausal breast tissue. METHOD: Two sets of six silicone models were made with background breast tissue simulating premenopausal tissue (most nodular, least soft) and postmenopausal breast tissue (least nodular, most soft) respectively. Eighteen lumps were located in each set of models. In September 1994, 82 housestaff and attending physicians with outpatient practices in the Division of General Internal Medicine at Northwestern University Medical School were randomized to a CBE-teaching intervention or a control group. Lump-detection rates for the two sets of models were measured before and after the teaching intervention. Analysis of covariance was used to analyze the effect of CBE training on examination sensitivity and specificity, controlling for baseline rates. RESULTS: CBE training increased lump-detection rates similarly and significantly in models simulating premenopausal and postmenopausal tissue, respectively. Specificity declined after training in models simulating postmenopausal tissue (p = 0.02) but was unchanged in models simulating premenopausal tissue (p = 0.54). CBE training had greater influence on sensitivity among house-staff than among attending physicians (p = 0.02). CONCLUSION: CBE training similarly affects lump detection in simulated premenopausal and postmenopausal breast tissue, but adversely affects specificity in simulated postmenopausal tissue only.
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Enfermedades de la Mama/diagnóstico , Educación Médica Continua , Análisis de Varianza , Femenino , Humanos , Maniquíes , Cuerpo Médico de Hospitales , Posmenopausia , Premenopausia , Sensibilidad y EspecificidadRESUMEN
We varied the softness and nodularity of silicone breast models to assess the effects of age-related breast tissue characteristics on lump detection. In two sets of six silicone breast models manufactured to simulate premenopausal and postmenopausal breast tissue, respectively, 82 internal medicine attending and housestaff physicians more readily detected lumps among models simulating older breast tissue. The proportion of models with one or more false-positive findings was higher among models simulating postmenopausal breast tissue. We conclude that age-related changes in breast tissue most likely contribute to the higher sensitivity of clinical breast examination in older women.
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Neoplasias de la Mama/diagnóstico , Prótesis e Implantes , Adulto , Reacciones Falso Positivas , Femenino , Humanos , Posmenopausia , Premenopausia , Sensibilidad y Especificidad , Elastómeros de Silicona/uso terapéuticoRESUMEN
Physician counseling about sun protection and routine screening for skin cancer in high-risk individuals have been widely recommended. The purpose of this study was to assess the skin cancer control practices and knowledge among physicians in a university-based general medicine practice. Fifty-two physicians completed a survey on attitudes toward, behaviors in, and knowledge of skin cancer control. In addition, the ability of general medicine residents and attending physicians to correctly identify and make biopsy recommendations for ten photographed skin lesions was compared with that of third-year medical students and dermatology residents and attendings. The results of the survey illustrate a need for improving primary care physicians' knowledge and identification of skin cancer risk factors, and increasing the frequency and consistency with which they perform skin cancer prevention counseling and complete skin examination in high-risk patient groups.
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Medicina Familiar y Comunitaria , Conocimientos, Actitudes y Práctica en Salud , Neoplasias Cutáneas/prevención & control , Consejo , Recolección de Datos , Hospitales Universitarios , Humanos , Internado y Residencia , Melanoma/diagnóstico , Pautas de la Práctica en Medicina , Factores de Riesgo , Neoplasias Cutáneas/diagnóstico , Estudiantes de MedicinaRESUMEN
OBJECTIVE: To determine factors predicting adherence to a health care provider's screening mammography recommendation in a general internal medicine practice. DESIGN: Prospective observational study. SETTING: An urban academic general internal medicine practice. PATIENTS: Three hundred forty-nine asymptomatic women, aged 50 years and older, without prior history of breast cancer, who received a health care provider's recommendation for screening mammography. MEASUREMENT: Independent variables were: patient age, race, insurance type, educational level, and duration of affiliation with the practice; visit type; and health care provider gender and level of training. Dependent variables were acceptance of the recommendation and adherence, defined as undergoing mammography within three months of the recommendation. RESULTS: Overall, 193 (55%) of the women underwent the recommended mammography. Two hundred ninety-eight (85%) initially agreed to the recommendation, and of these, 190 (64%) completed mammography within three months. By univariate analysis, acceptance of the recommendation decreased significantly with increasing age (p < 0.01), and by race (African-Americans 89% vs whites 82%, p = 0.05). Only age remained independently predictive of acceptance in a multiple variable analysis. Among women who accepted the recommendation, adherence varied significantly according to race (white 70% vs nonwhite 59%, p = 0.05), insurance type [Medicare as only insurance 45%, Medicaid 66%, non-health maintenance organization (non-HMO) private 62%, HMO 73%, p = 0.03], and health care provider training (attending physicians 73%, residents 58%, nurse practitioners 47%, p = 0.02). In a logistic regression analysis, insurance type and health care provider training remained independently predictive of adherence. CONCLUSION: Acceptance of screening mammography recommendations decreases with age. Among the women who agreed to the recommendation for screening mammography, insurance type and health care provider level of training best predicted adherence.