Validity of diabetes self-reports in the Women's Health Initiative.

OBJECTIVE: This study aims to determine the positive and negative predictive values of self-reported diabetes during the Women's Health Initiative (WHI) clinical trials. METHODS: All WHI trial participants from four field centers who self-reported diabetes at baseline or during follow-up, as well as a random sample of women who did not self-report diabetes, were identified. Women were surveyed regarding diagnosis and treatment. Medical records were obtained and reviewed for documented treatment with antidiabetes medications or for physician diagnosis of diabetes supported by laboratory measurements of glucose. RESULTS: We identified 1,275 eligible participants; 732 consented and provided survey data. Medical records were obtained for 715 women (prevalent diabetes, 207; incident diabetes, 325; no diabetes, 183). Records confirmed 91.8% (95% CI, 87.0-95.0) of self-reported prevalent diabetes cases and 82.2% (95% CI, 77.5-86.1) of incident diabetes cases. Among those who never self-reported diabetes, there was no medical record or laboratory evidence for diabetes in 94.5% (95% CI, 89.9-97.2). Women with higher body mass index were more likely to accurately self-report incident diabetes. In a subgroup of participants enrolled in fee-for-service Medicare, a claims algorithm correctly classified nearly all diabetes cases and noncases. CONCLUSIONS: Among WHI clinical trial participants, there are high positive predictive values of self-reported prevalent diabetes (91.8%) and incident diabetes (82.2%) and a high negative predictive value (94.5%) when diabetes is not reported. For participants enrolled in fee-for-service Medicare, a claims algorithm has high positive and negative predictive values.

Development of the cancer survivorship care plan: what's next? Life after cancer treatment.

Long-term information needs are increasingly important as more people are diagnosed with cancer and living well beyond initial diagnosis and treatment. Consequently, cancer is joining the ranks of chronic conditions (e.g., asthma, diabetes) for which ongoing, long-term surveillance and management should be the model of care. However, the post-treatment period is fraught with uncertainty for patients and care providers. The "who, what, and when" of follow-up care, in particular, can be complex and confusing. Therefore, survivorship care plans (SCPs) are recommended. The Minnesota Cancer Alliance, a coalition working to improve quality of life for cancer survivors, developed a patient-focused SCP. This user-friendly SCP could be considered for use in patient care--particularly by nurses, who are well suited and positioned to implement SCPs.

Healthcare providers' perspectives on communicating incontinence and skin damage information with patients with dementia and their family caregivers: a descriptive study.

Communication between healthcare providers and patients/family caregivers about incontinence and associated skin damage is wanting, and information about healthcare providers perspectives on improving this communication is limited. A descriptive study was conducted using semi-structured, tape-recorded interviews with 11 healthcare providers with clinical expertise in geriatrics and dementia working in a large integrated healthcare system. The survey was developed by the authors based on a review of the relevant literature with guidance from a three-member Advisory Committee and consisted of nine open-ended questions related to communication with patients and families about incontinence and skin damage. Specifically, information was obtained about providers' perspectives on the timing of inquiring about these problems, how best to tailor language and approach the topic, barriers and facilitators to discussion of incontinence, and recommendations for educational and supportive resources. Responses were analyzed using a content analysis approach. Using a purposeful sampling technique, 11 experienced healthcare professionals agreed to participate in the study. Main themes observed included: 1) incontinence issues are not routinely or voluntarily addressed by all providers, 2) caregivers are receptive to discussion if the topic is broached by patient/caregiver, and 3) main barriers to providing information include limited clinician time and patient/family caregiver embarrassment. Participant clinicians expressed interest in readily available, single-topic, printed patient/caregiver-focused educational materials to enhance patient-provider communication and serve as a resource. These materials were subsequently developed. Further research is warranted to test the effectiveness of the recommendations and the materials developed as a result of the study.

An intervention to decrease adolescent indoor tanning: a multi-method pilot study.

PURPOSE: Indoor tanning usually begins during adolescence, but few strategies exist to discourage adolescent use. We developed and tested a parent-teenager intervention to decrease indoor tanning use. METHODS: Through focus groups, we identified key messages to enhance parent-teenager communication about indoor tanning, and then developed a pamphlet for parents and postcards for adolescents to use in a direct mail experiment with randomly selected households. Two weeks after the mailing, we asked intervention parents (n = 87) and adolescents (n = 69) and nonintervention parents (n = 31) and adolescents (n = 28) about intervention receipt and content recall, parental concern, monitoring, parent-teenager conversations, and indoor tanning intention. RESULTS: In intervention households, 54% of mothers and 56% of girls recalled receipt and reported reading materials, but few boys and no fathers did. Among mothers, 57% in intervention households indicated concern about daughters' indoor tanning, and 25% would allow daughters to tan indoors, whereas 43% of nonintervention mothers had concerns and 46% would allow indoor tanning. Fewer girls in intervention households than in nonintervention households thought parents would allow indoor tanning (44% vs. 65%), and fewer intended to tan indoors (36% vs. 60%). Most mothers and daughters who read the intervention materials also reported discussions about indoor tanning. Moreover, the less likely girls were to think that their mothers would allow indoor tanning, the less likely it was that they intended to tan indoors, a relationship mediated by perceptions of maternal monitoring. CONCLUSIONS: A systematic qualitative and quantitative research approach yielded well-received indoor tanning prevention messages for mothers and female adolescents. Enhancing maternal monitoring has potential to decrease adolescent indoor tanning.

Barriers in identification and referral to genetic counseling for familial cancer risk: the perspective of genetic service providers.

The purpose of this study was to obtain genetic counselors' perspectives about the identification of appropriate patients and barriers to referral of high-risk patients for cancer genetic counseling services. Genetic service providers from eight integrated health systems were surveyed. Data analysis included descriptive statistics. Twenty-eight of 40 potential participants responded (70%). Referrals for familial cancer risk assessment overwhelmingly came from providers (89%); only 10% were self-referrals. Use of guidelines to assist providers with referral was reported by 46% of the respondents. Genetic service providers perceived patient barriers to seeking genetic counseling after referral included: risk evaluation viewed as a non-priority (72%), concerns about impact on insurability (52%), distance to appointments (48%), lack of insurance (44%), lack of patient/provider knowledge about the value of genetic counseling (36%), discouragement by family members (28%), and fear (20%). The best approaches suggested by respondents to increase appropriate referrals were attending meetings and giving presentations to oncologists, surgeons, primary care and gynecologists. The genetic service providers reported several barriers to the referral and use of genetic counseling. This finding is consistent with current literature from the providers' perspective. Our survey adds the genetic service providers' perspective and identifies areas of opportunity for further research and intervention as few of the perceived barriers are being addressed through current educational efforts.

An opportunity for improving osteoporosis treatment in home health care.

PURPOSE: To examine osteoporosis prevention and treatment among home health care (HHC) patients at risk of fragility fracture in a large, Midwestern integrated HHC system. METHODS: All patients who received HHC services in 2006 were identified. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes and pharmaceutical data were examined between January 1, 2004 and December 31, 2005 to determine risk status (high vs average) for fragility fracture. Patients with a documented diagnosis of osteoporosis, osteopenia, previous fragility fracture, stroke, or those taking a glucocorticoid were categorized as high risk. Pharmaceutical data (eg, estrogen, bisphosphonates) were obtained during the same 2-year period to determine treatment status. Descriptive statistics documented the proportion at high risk and treatment status. Inferential statistics tested differences in characteristics (age, gender, race, number of comorbidities) among high-risk patients with and without treatment. RESULTS: 2798 patients were seen in HHC during 2006 and had utilization data available in 2004 and 2005. Of these, 754 were categorized as high risk and 2044 as average risk. Approximately one third (34%) of high-risk patients received osteoporosis medication compared to 4% of average risk (P < .0001). We found no treatment differences based on age. Those with higher comorbidity profiles were less likely to receive treatment (P < .0001). CONCLUSION: Only 34% of HHC patients at high risk for fracture received adequate treatment. Patients with more comorbidities were least likely to receive treatment. Since these individuals are receiving medical and nursing care, an opportunity exists to increase treatment rates for those at greatest risk.

Development, implementation and evaluation of an electronic medical record prompt for bone density testing.

The purpose of this study was to assess whether an electronic prompt promoting BMD testing affected the proportion of patients who received BMD and/or bone health medication. Rheumatology providers of patients 40+, on prednisone, with no record of BMD testing in the past 2 years, were targeted with the message: 'This patient is at risk for osteoporosis due to prednisone use. We have no record of a recent Dexa scan.' We also surveyed providers on the prompt's value. The use of prednisone remained stable; BMD testing was quite low in all periods but increased slightly (non-statistically) over time, as did bone health medication use. Providers found the prompt not tailored enough to be clinically meaningful. Electronic prompts seem beneficial in theory; however, putting them into practice has challenges. While the EMR has great potential to improve care, more needs to be done to ensure optimal use.

Knowledge, attitudes, and preferences regarding advance directives among patients of a managed care organization.

OBJECTIVES: To examine attitudes, experiences, and preferences regarding advance directives (ADs) among adults of all ages. STUDY DESIGN: Subjects were surveyed regarding end-of-life (EOL) care wishes. The survey included items measuring knowledge, experiences, and attitudes regarding ADs, as well as preferences toward initiation of discussions. METHODS: Subjects included a random sample of patients (age range, 20 to >80 years) from a large midwestern managed care organization stratified by age decade. Descriptive statistics were used to summarize variables, and chi2 tests were performed to examine differences by age category. RESULTS: One hundred eighty-seven surveys were completed. The likelihood of having completed an AD increased with age (P <.001). Of those without an AD, 44% reported having talked with someone about their wishes. Many (62%) subjects thought that it was up to them to raise the topic of EOL care. However, 70% of subjects reported that they would be comfortable if their provider initiated discussion. Participants 60 years or older were more likely to report being very comfortable with their provider bringing up the subject compared with those younger than 60 years (60% vs 39%, P = .02). Few differences were found by age. CONCLUSIONS: Room for improvement exists for increasing the number of patients who complete an AD or engage in discussion of their wishes. Ways to involve healthcare providers in the process should be explored, as it seems that patients are receptive to physician-initiated discussions of ADs.

Complications at the end of life in ovarian cancer.

Women dying of ovarian cancer vary considerably in their complications and in the types of health care they receive. The objective of this study was to describe the complications of ovarian cancer, other than pain, and their treatment at the end of life. This study used a cohort of 421 enrollees in three nonprofit managed-care organizations who died with ovarian cancer during 1995-2000. Data were collected from abstraction of paper and electronic medical records. Proportions of women experiencing complications and undergoing treatments were calculated. Logistic regression was used to evaluate the association of patient characteristics with the probability of receiving an intervention for complications. The most common complications recorded in the medical record were fatigue or weakness (75%), nausea or vomiting (71%), constipation (49%), edema of the extremities (44%), and anemia (34%). The prevalence of major complications was as follows: ascites, 28%; bowel obstruction, 12%; pleural effusion, 10%; bladder obstruction, 3%; and disordered nutrition that required support with parenteral nutrition, 9%. Patients may not always have received interventions for major complications; for example, pleural effusion apparently was left untreated in almost half of the women with this problem. After adjustment, women who died at younger ages were more likely to receive an intervention, compared to older women (odds ratio for each decade of age, 0.71, 95% confidence interval=0.53, 0.94, P for trend=0.02). The study, which preceded the establishment of palliative care programs, suggests that care given to ovarian cancer patients at the end of life may be inadequate.

Social support among women who died of ovarian cancer.

GOALS OF WORK: We investigated the effects of social support in the last 6 months of life for women who died of ovarian cancer. MATERIALS AND METHODS: The study population included women enrolled in one of three Managed Care Organizations who died of ovarian cancer (1995-2000). Information was collected on demographics, living environment, presence of escorts to oncology encounters, comorbidities, medications, outpatient and inpatient encounters, and referrals to home health and hospice. Two characteristics of social support were examined: living with others and being escorted to one or more oncology visits. RESULTS: Of 421 subjects, both aspects of social support were known for 345 (82%). Of these, 227 (66%) lived with others and were escorted, 33 (10%) lived with others but were never escorted, 59 (17%) lived alone but were escorted, and 26 (8%) lived alone and never were accompanied. Women living alone were less likely to be taking a psychotropic medication (57% vs 70%, p = 0.021) and were somewhat less likely to receive hospice referral (42% vs 53%, p = 0.054). Women who were never escorted had fewer outpatient encounters (12.60 vs 15.77, p = 0.033) and were less likely to be referred to home health (18% vs 30%, p = 0.046). CONCLUSIONS: This study indicates that social support has some beneficial effects on receipt of personal health services. Friends and family may act as proponents for the patient in obtaining services. Health care professionals should be encouraged to assess the cancer patient's social situation and identify areas where help may be needed.

Geriatric depression, antidepressant treatment, and healthcare utilization in a health maintenance organization.

OBJECTIVES: To assess the separate effects of depressive symptoms and antidepressant treatment on healthcare utilization and cost. SETTING: Social Health Maintenance Organization (HMO) at HealthPartners in Minnesota. PARTICIPANTS: Geriatric Social HMO enrollees were screened for depressive symptoms using the 30-item Geriatric Depression Scale. A stratified sample was created, composed of geriatric enrollees with depressive symptoms, with antidepressant prescriptions, or with neither (n = 516). DESIGN: Regression analyses were conducted with separate equations for utilization and charge outcome variables, both outpatient and inpatient (log-transformed). The Charlson Comorbidity Index, age, and gender served as covariates. MEASUREMENT: Depressive symptoms were identified through the Diagnostic Interview Schedule. Antidepressant treatment was determined from the HMO pharmacy database. RESULTS: Having depressive symptoms was associated with a 19 increase in the number of outpatient encounters and a 30 increase in total outpatient charges. Antidepressant treatment was associated with a 32 increase in total outpatient charges but was not significantly associated with number of outpatient encounters. Depressive symptoms and antidepressant therapy were not significantly associated with inpatient utilization or charges. CONCLUSION: This study found that patients with depressive symptoms generated more outpatient health care and higher charges but not necessarily more inpatient care. Our findings suggest that programs targeted to geriatric patients whose depression is comorbid with other chronic medical conditions might be cost-effective and particularly appropriate for geriatric care.