A pilot randomized controlled trial of a decision aid with tailored fracture risk tool delivered via a patient portal.

We tested the feasibility of a fracture prevention decision aid in an online patient portal. The decision aid was acceptable for patients and successfully decreased decisional conflict. This study suggests the possible utility of leveraging the patient portal to enhance patient education and decision making in osteoporosis care. INTRODUCTION: Although interventions have improved osteoporosis screening and/or treatment for certain populations of high-risk patients, recent national studies suggest that large-scale uptake of these interventions has been limited. We aimed to determine the feasibility and potential efficacy of a patient portal-based osteoporosis decision aid (DA). METHODS: We conducted a pilot randomized controlled trial of primary care patients aged ≥55 who were enrolled in a patient portal and had a T-score of <-1. Intervention subjects were provided a link to a patient DA. The DA contained a 10-year fracture risk calculator, summary of medication risks and benefits (prescription and nonprescription), and an elicitation of values. Subjects completed questionnaires assessing the primary outcomes of decisional conflict and preparation for decision making and secondary outcomes related to feasibility and planning for a larger trial. Charts were reviewed for physician-subject interactions and medication uptake. RESULTS: The DA was acceptable to subjects, but 17 % of the patients in the decision aid arm incorrectly entered their T-scores into FRAX-based risk calculator. Decisional conflict was lower post-intervention for those who were randomized to the decision aid arm compared to controls (17.8 vs. 47.1, p < .001), and there was a significant difference in the percentage of patients who made a treatment decision at 3 months. No significant differences were observed in medication uptake. CONCLUSIONS: A portal-based osteoporosis DA was acceptable and improved several measures of decision quality. Given its effect on improving the quality of patients' decisions, future studies should examine whether it improves physician guideline adherence or medication adherence uptake among treated patients.

Effect of treatment on quality of life among men with clinically localized prostate cancer.

BACKGROUND: Quality-of-life outcomes are an important consideration for patients evaluating therapeutic options for localized prostate cancer. OBJECTIVES: The objective of this study was to describe the effect of treatment choice on change in health-related quality of life (HRQOL) among men with clinically localized prostate cancer. RESEARCH DESIGN: This was a prospective observational study. SUBJECTS: The study subjects were 122 men with clinically localized adenocarcinoma of the prostate. Forty-two subjects (34%) underwent radical prostatectomy, 51 (42%) underwent radiation therapy, and 29 (24%) were followed with expectant management. MEASURES: The University of California at Los Angeles Prostate Cancer Quality of Life Inde- and the Medical Outcomes Study Short Form-36 were administered before and 3 and 12 months after initial treatment. The study used an analysis of covariance model adjusted for baseline differences in clinical and demographic factors. RESULTS: Men who underwent radical prostatectomy experienced significant declines in urinary and sexual function and bother that persisted at 12 months after treatment. Men treated with radiation therapy experienced smaller but significant declines in sexual function and a decline in social function. Expectant management patients did not have a significant change in disease-targeted or generic HRQOL domains. Differential rates of change in urinary and sexual function between treatment groups persisted after adjustment for differences in pretreatment clinical and demographic factors. CONCLUSIONS: Men undergoing radical prostatectomy have substantial declines in urinary and sexual function, and men undergoing radiotherapy have declines in sexual function. Men undergoing expectant management have no change in disease-specific or general HRQOL in the first year after treatment.

Frequency or probability? A qualitative study of risk communication formats used in health care.

BACKGROUND: The communication of probabilistic outcomes is an essential aspect of shared medical decision making. METHODS: The authors conducted a qualitative study using focus groups to evaluate the response of women to various formats used in the communication of breast cancer risk. FINDINGS: Graphic discrete frequency formats using highlighted human figures had greater salience than continuous probability formats using bar graphs. Potential biases in the estimation of risk magnitude were associated with the use of highlighted human figures versus bar graphs and the denominator size in graphics using highlighted human figures. The presentation of uncertainty associated with risk estimates caused some to loose trust in the information, whereas others were accepting of uncertainty in scientific data. CONCLUSION: The qualitative studyidentified new constructs with regard to how patients process probabilistic information. Further research in the clinical setting is needed to provide a theoretical justification for the format used when presenting risk information to patients.

Relation between appropriateness of primary therapy for early-stage breast carcinoma and increased use of breast-conserving surgery.

BACKGROUND: Breast-conserving surgery is a more complex treatment than mastectomy, because a separate incision is needed for axillary lymph-node dissection, and postoperative radiotherapy is necessary. We postulated that adoption of this therapy into clinical practice might have led to discrepancies between the care recommended and that received. METHODS: We used records of the US national Surveillance, Epidemiology, and End Results tumour registry to study 144,759 women aged 30 years and older who underwent surgery for early-stage breast cancer between 1983 and 1995. We calculated the proportion undergoing at least the minimum appropriate primary treatment (defined, in accordance with the recommendations of a National Institutes of Health Consensus Conference in 1990, as total mastectomy with axillary node dissection or breast-conserving surgery with axillary node dissection and radiotherapy) during each 3-month period. FINDINGS: The proportion of women receiving appropriate primary therapy fell from 88% in 1983-89 to 78% by the end of 1995. This decline was observed in all subgroups of age, race, stage, and population density. Of all women in the cohort, the proportion undergoing an inappropriate form of mastectomy remained stable at about 2.7% throughout the study period. The proportion undergoing an inappropriate form of breast-conserving surgery (omission of radiotherapy, axillary node dissection, or both) increased from 10% in 1989 to 19% at the end of 1995. INTERPRETATION: Although most women undergo appropriate care, the appropriateness of care for early-stage breast cancer in the USA declined from 1990 to 1995. Because the proportion of all women who were treated by breast-conserving surgery increased, and because this approach was more likely than was mastectomy to be applied inappropriately, the proportion of all women having inappropriate care increased.

Osteoporosis: evaluation and treatment.

Osteoporosis is a common and costly disease. This article discusses the pathophysiology, diagnosis, and treatment of osteoporosis, including hormone replacement, bisphosphonates, calcitonin, raloxifene, and alternative therapies. As our population ages, osteoporosis will become an even more common disease.

The effect of an illustrated pamphlet decision-aid on the use of prostate cancer screening tests.

BACKGROUND: Prostate cancer screening with serum prostate-specific antigen (PSA) and digital rectal examination (DRE) continues to increase. Our goal was to test the effect of a prostate cancer screening decision-aid on patients' knowledge, beliefs, and use of prostate cancer screening tests. METHODS: Our study was a randomized controlled trial of a prostate cancer screening decision-aid consisting of an illustrated pamphlet as opposed to a comparison intervention. We included 257 men aged 50 to 80 years who were receiving primary care at a Department of Veterans Affairs Hospital in Milwaukee, Wisconsin. The decision-aid provided quantitative outcomes of prostate cancer screening with DRE and PSA. We subsequently evaluated prostate cancer screening knowledge, beliefs, and test use. RESULTS: The illustrated pamphlet decision-aid was effective in improving knowledge of prostate cancer screening tests: 95% of the experimental group were aware of the possibility of false-negative test results compared with 85% of the comparison group (P <.01). Ninety-one percent of the experimental group were aware of the possibility of a false-positive screening test result compared with 65% of the comparison group (P <.01). However, there was no difference in the use of prostate cancer screening between the experimental (82%) and comparison (84%) groups, (P >.05). CONCLUSIONS: When used in a primary care setting, an illustrated pamphlet decision-aid was effective in increasing knowledge of prostate cancer screening tests but did not change the use of these tests.

Underutilization of mammography in older breast cancer survivors.

BACKGROUND: Annual mammography is recommended for all breast cancer survivors. OBJECTIVES: To elucidate mammography use among older survivors of breast cancer and to explore determinants of such use. RESEARCH DESIGN: Retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) registry linked to Medicare claims. SUBJECTS: A cohort of 3885 breast cancer survivors aged > or =65 years diagnosed with early-stage breast cancer in the United States in 1991. MEASURES: Medicare mammogram claims during the 2-year period following initial breast cancer treatment. RESULTS: Overall, 62% of the cohort underwent annual mammography, 23% underwent mammography in 1 of 2 years, and 15% had no mammography claim in the 2 years evaluated. Twenty-two percent of the women who underwent breast-conserving surgery (BCS) without radiotherapy had no mammogram in the 2-year period evaluated, compared with 17% of those who underwent mastectomy and 4% of those who underwent BCS with radiotherapy. In multivariate analyses controlling for age, cancer stage, and other patient factors, the use of annual mammography was significantly lower among women treated with mastectomy or BCS without radiotherapy than among women treated with BCS with radiotherapy. CONCLUSIONS: Mammography is underused in the follow-up care of older breast cancer survivors. Underuse is of particular concern in women treated with BCS without radiotherapy because of the high risk of local disease recurrence. It is unknown whether poorer follow-up care contributes to the previously described lower rate of long-term survival among women who received this therapy.

Kirschner wire embolization to the heart: an unusual cause of pericardial tamponade.

A 50-year-old man presented with an abrupt onset of sharp, pleuritic, right-sided chest pain. A chest radiograph revealed a metallic foreign body over the cardiac silhouette; a chest CT scan localized the object to within the wall of the right ventricle. The patient subsequently developed pericardial tamponade necessitating pericardiocentesis. A 25-mm-long Kirschner wire protruding through the wall of the right ventricle was removed via thoracotomy. Forty-two months previously, the patient had undergone open reduction and fixation of a left radius fracture with two Kirschner wires. Clinicians caring for patients with orthopedic wires in place should be aware of wire migration with cardiac embolization as a potential complication.

Generalizability of the surveillance, epidemiology, and end results registry population: factors relevant to epidemiologic and health care research.

To assess the generalizability of the population included in the Surveillance, Epidemiology, and End Results (SEER) tumor registries to the overall United States population, we compared the population of the 198 SEER counties to the population of the 2882 non-SEER counties regarding sociodemographic factors, physician availability, and availability of pertinent hospital resources. The population residing within the SEER areas is more affluent, has lower unemployment, and is substantially more urban than the remainder of the U.S. population (p < 0.001 for each). The SEER areas have fewer general and family practice physicians, but more total nonfederal physicians, general internists, and specialists relevant to cancer care. SEER areas have fewer Joint Commission on Accreditation of Hospitals accredited hospitals, hospital beds, and hospitals with CT scanners, but more hospitals with bone marrow transplantation. The differences between the SEER population and the remainder of the United States, especially SEER's higher socioeconomic status and more urban population, should be considered when generalizing from SEER to the entire country.

Enhanced decision-making: the use of a videotape decision-aid for patients with prostate cancer.

We describe the development and evaluation of a videotape decision-aid to assist patients in considering treatment options for clinically localized prostate cancer. The content and form of the videotape were developed utilizing literature review, an expert opinion panel and patient focus groups. Thirty-two men, aged 50-85 years, who did not have prostate cancer underwent pre- and post-videotape testing. A quantitative analysis found the videotape to be moderately effective in improving short-term recall of treatment options and outcomes. Qualitative analysis demonstrate that after viewing the videotape, subjects were more likely to consider an active role in the treatment decision-making process. We conclude that a videotape decision-aid will benefit clinical practice by conveying knowledge to patients regarding treatment options and outcomes and encouraging them to participate with their physicians in medical decision-making.

Treatment of localized prostate cancer in African-American compared with Caucasian men. Less use of aggressive therapy for comparable disease.

The objective of this study is to evaluate differences in treatment for localized prostate cancer in African-American compared with Caucasian men. A cohort of patients was identified from the 1988-1989 Surveillance, Epidemiology, and End Results data base. Data were linked by county of residence to the Area Resource File. The main outcome measures were (1) the receipt of aggressive therapy (radical prostatectomy or external beam radiation) and (2) the treatment modality (radical prostatectomy or external beam radiation). Of 5,786 subjects, 15% were treated with a radical prostatectomy, 29% received external beam radiation, and 56% did not receive aggressive therapy. African Americans were less likely (relative risk 0.46; 95% confidence interval 0.39, 0.54) than Caucasians to receive aggressive therapy. Among those receiving aggressive therapy, African Americans were less likely (relative risk 0.64; 95% confidence interval 0.48, 0.86) than Caucasians to have a radical prostatectomy. Adjustment for patient, disease, and community health care availability characteristics did not change these results. We conclude that African-American and Caucasian men receive different treatments for localized prostate cancer. The reasons for the differences, and their ultimate effect on mortality and quality of life require further study.

The value of the forced expiratory time in the physical diagnosis of obstructive airways disease.

OBJECTIVE: To evaluate the test characteristics of the forced expiratory time (FET) in the diagnosis of obstructive airways disease. DESIGN: A cross-sectional diagnostic test study. The FET of 400 subjects was measured by a physician examiner and was compared with the criterion standard of spirometry. In a second sample of 100 subjects, the FET was measured by pairs of physician examiners to evaluate interexaminer agreement. SETTING: A pulmonary function test laboratory at a tertiary care hospital that receives referrals for preoperative evaluations, acute and chronic pulmonary disease, and occupational lung disease. SUBJECTS: A consecutive sample of patients who were referred to the pulmonary function laboratory from primary care internists, pulmonary physicians, and surgeons. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The sensitivity and specificity of the FET in the diagnosis of obstructive airways disease at cutoff values ranging from 2 to 14 seconds. A receiver operating characteristic curve was used to evaluate the diagnostic performance of the FET. Likelihood ratio lines were determined using a logistic regression model adjusting for the subjects age. Interexaminer agreement was evaluated with a kappa statistic. RESULTS: Using the FET maneuver with a cutoff value of 6 seconds will correctly diagnose the greatest number of subjects with obstructive airways disease. The FET maneuver is more discriminating for subjects 60 years or older compared with younger subjects. The positive likelihood ratio for a subject aged 60 years or older with an FET of 4 to 6 seconds is 0.42 (95% confidence interval [CI], 0.24 to 0.73); of 6 to 8 seconds, 2.19 (95% CI, 1.02 to 4.80); and of greater than 8 seconds, 4.08 (95% CI, 2.54 to 6.79). The kappa statistic for interexaminer agreement is 0.70. CONCLUSIONS: The FET demonstrates moderately good performance as a diagnostic test for obstructive airways disease. The value of the test will depend on the pretest probability of disease and the clinical circumstances in which it is used.

The effectiveness of ovarian cancer screening. A decision analysis model.

OBJECTIVE: To estimate the effectiveness of ovarian cancer screening with CA 125 and transvaginal sonography. DESIGN: Decision analysis was used to examine the no-screen compared with the screen strategy. SETTING: Estimates of cancer incidence, survival, and life expectancy were derived from population-based data and clinical series. SUBJECTS: A cohort of 40-year-old women of all races and residing in the United States. INTERVENTIONS: A one-time screening intervention. The criterion standard for diagnosis of ovarian cancer was evaluation with exploratory laparotomy. MAIN OUTCOME MEASURE: Average years of life expectancy gained by women in the screened group. RESULTS: Screening for ovarian cancer with a combination of CA 125 and transvaginal sonography increases the average life expectancy in the population by less than 1 day. CONCLUSIONS: Given the limited effect on overall life expectancy, it is unlikely that mass screening for ovarian cancer with CA 125 and transvaginal sonography would be an effective health policy.