Development and evaluation of the CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey for in-center hemodialysis patients.

BACKGROUND: The US Centers for Medicare & Medicaid Services assess patient experiences of care as part of the end-stage renal disease prospective payment system and Quality Incentive Program. This article describes the development and evaluation of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) In-Center Hemodialysis Survey. STUDY DESIGN: We conducted formative research to generate survey questions and performed statistical analyses to evaluate the survey's measurement properties. SETTING & PARTICIPANTS: Formative research included focus groups, cognitive interviews, and field testing the survey with dialysis patients. MEASUREMENTS & OUTCOMES: We assessed internal consistency reliability (Cronbach alpha) and center-level reliability for 3 multi-item scales. We evaluated construct validity using correlations of the scales with global ratings of the kidney doctor, staff, and dialysis center. RESULTS: Response rate was 46% (1,454 completed surveys). Analyses support 3 multi-item scales: Nephrologists' Communication and Caring (7 items, alpha=0.89), Quality of Dialysis Center Care and Operations (22 items, alpha=0.93), and Providing Information to Patients (11 items, alpha=0.75). The communication scale was correlated the most strongly with the global rating of the "kidney doctor" (r=0.78). The Dialysis Center Care and Operations scale was correlated most strongly with global ratings of staff (r=0.75) and the center (r=0.69). Providing Information to Patients was correlated most strongly with the global rating of the staff (r=0.41). LIMITATIONS: A relatively small number of patients completed the survey in Spanish. CONCLUSIONS: This study provides support for the reliability and validity of the CAHPS In-Center Hemodialysis Survey for assessing patient experiences of care at dialysis facilities. The survey can be used to compare care provided at different facilities.

Decision dissonance: evaluating an approach to measuring the quality of surgical decision making.

BACKGROUND: Good decision making has been increasingly cited as a core component of good medical care, and shared decision making is one means of achieving high decision quality. If it is to be a standard, good measures and protocols are needed for assessing the quality of decisions. Consistency with patient goals and concerns is one defining characteristic of a good decision. A new method for evaluating decision quality for major surgical decisions was examined, and a methodology for collecting the needed data was developed. METHODS: For a national probability sample of fee-for-service Medicare beneficiaries who had a coronary artery bypass graft (CABG), a lumpectomy or a mastectomy for breast cancer, or surgery for prostate cancer during the last half of 2008, a mail-survey of selected patients was carried out about one year after the procedures. Patients' goals and concerns, knowledge, key aspects of interactions with clinicians, and feelings about the decisions were assessed. A decision dissonance score was created that measured the extent to which patient ratings of goals ran counter to the treatment received. The construct and predictive validity of the decision dissonance score was then assessed. RESULTS: When data were averaged across all four procedures, patients with more knowledge and those who reported more involvement reported significantly lower Decision Dissonance Scores. Patients with lower Decision Dissonance Scores also reported more confidence in their decisions and feeling more positively about how the treatment turned out, and they were more likely to say that they would make the same decision again. CONCLUSIONS: Surveying discharged surgery patients is a feasible way to evaluate decision making, and Decision Dissonance appears to be a promising approach to validly measuring decision quality.

Decision-making process reported by Medicare patients who had coronary artery stenting or surgery for prostate cancer.

BACKGROUND: Patients facing decisions should be told about their options, have the opportunity to discuss the pros and cons, and have their preferences reflected in the final decision. OBJECTIVES: To learn how decisions were made for two major preference-sensitive interventions. DESIGN: Mail survey of probability samples of patients who underwent the procedures. PARTICIPANTS: Fee-for-service Medicare beneficiaries who had surgery for prostate cancer or elective coronary artery stenting in the last half of 2008. MAIN MEASUREMENTS: Patients' reports of which options were presented for serious consideration, the amount of discussion of the pros and cons of the chosen option, and if they were asked about their preferences. RESULTS: The majority (64%) of prostate cancer surgery patients reported that at least one alternative to surgery was presented as a serious option. Almost all (94%) said they and their doctors discussed the pros, and 63% said they discussed the cons of surgery "a lot" or "some". Most (76%) said they were asked about their treatment preferences. Few who received stents said they were presented with options to seriously consider (10%). While most (77%) reported talking with doctors about the reasons for stents "a lot" or "some", few (19%) reported talking about the cons. Only 16% said they were asked about their treatment preferences. CONCLUSIONS: While prostate cancer surgery patients reported more involvement in decision making than elective stent patients, the reports of both groups document the need for increased efforts to inform and involve patients facing preference-sensitive intervention decisions.

Racial and ethnic differences in preferences for end-of-life treatment.

BACKGROUND: Studies using local samples suggest that racial minorities anticipate a greater preference for life-sustaining treatment when faced with a terminal illness. These studies are limited by size, representation, and insufficient exploration of sociocultural covariables. OBJECTIVE: To explore racial and ethnic differences in concerns and preferences for medical treatment at the end of life in a national sample, adjusting for sociocultural covariables. DESIGN: Dual-language (English/Spanish), mixed-mode (telephone/mail) survey. PARTICIPANTS: A total of 2,847 of 4,610 eligible community-dwelling Medicare beneficiaries age 65 or older on July 1, 2003 (62% response). MEASUREMENTS: Demographics, education, financial strain, health status, social networks, perceptions of health-care access, quality, and the effectiveness of mechanical ventilation (MV), and concerns and preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. RESULTS: Respondents included 85% non-Hispanic whites, 4.6% Hispanics, 6.3% blacks, and 4.2% "other" race/ethnicity. More blacks (18%) and Hispanics (15%) than whites (8%) want to die in the hospital; more blacks (28%) and Hispanics (21.2%) than whites (15%) want life-prolonging drugs that make them feel worse all the time; fewer blacks (49%) and Hispanics (57%) than whites (74%) want potentially life-shortening palliative drugs, and more blacks (24%, 36%) and Hispanics (22%, 29%) than whites (13%, 21%) want MV for life extension of 1 week or 1 month, respectively. In multivariable analyses, sociodemographic variables, preference for specialists, and an overly optimistic belief in the effectiveness of MV explained some of the greater preferences for life-sustaining drugs and mechanical ventilation among non-whites. Black race remained an independent predictor of concern about receiving too much treatment [adjusted OR = 2.0 (1.5-2.7)], preference for dying in a hospital [AOR = 2.3 (1.6-3.2)], receiving life-prolonging drugs [1.9 (1.4-2.6)], MV for 1 week [2.3 (1.6-3.3)] or 1 month's [2.1 (1.6-2.9)] life extension, and a preference not to take potentially life-shortening palliative drugs [0.4 (0.3-0.5)]. Hispanic ethnicity remained an independent predictor of preference for dying in the hospital [2.2 (1.3-4.0)] and against potentially life-shortening palliative drugs [0.5 (0.3-0.7)]. CONCLUSIONS: Greater preference for intensive treatment near the end of life among minority elders is not explained fully by confounding sociocultural variables. Still, most Medicare beneficiaries in all race/ethnic groups prefer not to die in the hospital, to receive life-prolonging drugs that make them feel worse all the time, or to receive MV.

Relationship between regional per capita Medicare expenditures and patient perceptions of quality of care.

CONTEXT: Wide variations in Medicare expenditures exist across regions, but little is known about whether beneficiaries residing in low-expenditure regions perceive receiving lower-quality care than those in high-expenditure regions. OBJECTIVE: To evaluate how Medicare beneficiaries' perceptions of their health care are related to per capita expenditure in the areas where they live. DESIGN, SETTING, AND RESPONDENTS: A probability sample of Medicare beneficiaries living in households in the United States was surveyed by a combination of mail and telephone in 2005. Each respondent was allocated to 1 of 5 quintiles, depending on mean age-, sex-, and race-adjusted per capita Medicare expenditures based on Centers for Medicare & Medicaid Services claims data. MAIN OUTCOME MEASURES: The survey included 3 questions about perceived unmet need for care, 4 questions about the perceived quality of ambulatory care, and 3 questions rating the perceived quality of overall care. RESULTS: Of 4000 Medicare beneficiaries sampled, 160 (4%) were ascertained to have died or to be living in a long-term care facility. Of the remaining 3840 potentially eligible beneficiaries, 2515 (65%) responded. Per capita expenditures were highly related to receiving more medical care, such as mean number of ambulatory visits to physicians in the past year (range from lowest to highest expenditure quintile, 3.4-3.9; P < .001 for linear trend) and more cardiac tests (respondents reporting receiving tests in past year, 158/387 [40.1%] to 468/739 [63.5%]; P < .001 for linear trend). However, 7 of the 10 measures of perceived quality, including perceived unmet needs for tests and treatment (respondents reporting unmet needs, 15/387 [3.9%] to 37/739 [5.0%]; P = .25 for linear trend) and spending enough time with physicians (respondents reporting adequate time, 311/387 [88.7%] to 603/739 [87.0%]; P = .94 for linear trend), were unrelated to expenditures, while the overall rating of perceived quality of care was higher in the lower-expenditure areas (respondents reporting overall care rating of 9 or 10, 242/387 [63.3%] to 404/739 [55.4%]; P = .008 for linear trend). CONCLUSION: In this representative sample of Medicare beneficiaries, no consistent association was observed between the mean per capita expenditure in a geographic area and the perceptions of the quality of medical care of the people who live in those areas.

The Development of a Pediatric Inpatient Experience of Care Measure: Child HCAHPS.

The Centers for Medicare and Medicaid Services (CMS) uses Adult Hospital Consumer Assessment of Healthcare Providers and Systems (Adult HCAHPS) scores for public reporting and pay-for-performance for most US hospitals, but no publicly available standardized survey of inpatient experience of care exists for pediatrics. To fill the gap, CMS and the Agency for Healthcare Research and Quality commissioned the development of a pediatric version (Child HCAHPS), a survey of parents/guardians of pediatric patients (<18 years old) who were recently hospitalized. This article describes the development of Child HCAHPS, which included an extensive review of the literature and quality measures, expert interviews, focus groups, cognitive testing, pilot testing of the draft survey, a national field test with 69 hospitals in 34 states, psychometric analysis, and end-user testing of the final survey. We conducted extensive validity and reliability testing to determine which items would be included in the final survey instrument and develop composite measures. We analyzed national field test data of 17,727 surveys collected in November 2012 to January 2014 from parents of recently hospitalized children. The final Child HCAHPS instrument has 62 items, including 39 patient experience items, 10 screeners, 12 demographic/descriptive items, and 1 open-ended item. The 39 experience items are categorized based on testing into 18 composite and single-item measures. Our composite and single-item measures demonstrated good to excellent hospital-level reliability at 300 responses per hospital. Child HCAHPS was developed to be a publicly available standardized survey of pediatric inpatient experience of care. It can be used to benchmark pediatric inpatient experience across hospitals and assist in efforts to improve the quality of inpatient care.

The effect of response scale, administration mode, and format on responses to the CAHPS Clinician and Group survey.

OBJECTIVE: To examine how different response scales, methods of survey administration, and survey format affect responses to the CAHPS (Consumer Assessment of Healthcare Providers and Systems) Clinician and Group (CG-CAHPS) survey. STUDY DESIGN: A total of 6,500 patients from a university health center were randomly assigned to receive the following: standard 12-page mail surveys using 4-category or 6-category response scales (on CG-CAHPS composite items), telephone surveys using 4-category or 6-category response scales, or four-page mail surveys. PRINCIPAL FINDINGS: A total of 3,538 patients completed surveys. Composite score means and provider-level reliabilities did not differ between respondents receiving 4-category or 6-category response scale surveys or between 12-page and four-page mail surveys. Telephone respondents gave more positive responses than mail respondents. CONCLUSIONS: We recommend using 4-category response scales and the four-page mail CG-CAHPS survey.

Hybrid life cycle assessment comparison of colloidal silica and cement grouted soil barrier remediation technologies.

Site remediation involves balancing numerous costs and benefits but often neglects the environmental impacts over the entire project life cycle. Life cycle assessment (LCA) offers a framework for inclusion of global environmental "systems-level" decision metrics in combination with technological and cost analysis. We compare colloidal silica (CS) and cement grouted soil barrier remediation technologies for soils affected by low level radionuclides at a U.S. Superfund site using hybrid LCA methods. CS is a new, high performance grouting material installed using permeation grouting techniques. Cement, a more traditional grouting material, is typically installed using jet grouting techniques. Life cycle impacts were evaluated using the US EPA TRACI 2 model. Results show the highest life cycle environmental impacts for the CS barrier occur during materials production and transportation to the site. In general, the life cycle impacts for the cement barrier were dominated by materials production; however, in the extreme scenario the life cycle impacts were dominated by truck transportation of spoils to a distant, off-site radioactive waste facility. It is only in the extreme scenario tested in which soils are transported by truck (Option 2) that spoils waste transport dominates LCIA results. Life cycle environmental impacts for both grout barriers were most sensitive to resource input requirements for manufacturing volumes and transportation. Uncertainty associated with the efficacy of new technology such as CS over its required design life indicates that barrier replacement could increase its life cycle environmental impact above that of the cement barrier.

Adverse effects of robotic-assisted laparoscopic versus open retropubic radical prostatectomy among a nationwide random sample of medicare-age men.

PURPOSE: Robotic-assisted laparoscopic radical prostatectomy is eclipsing open radical prostatectomy among men with clinically localized prostate cancer. The objective of this study was to compare the risks of problems with continence and sexual function following these procedures among Medicare-age men. PATIENTS AND METHODS: A population-based random sample was drawn from the 20% Medicare claims files for August 1, 2008, through December 31, 2008. Participants had hospital and physician claims for radical prostatectomy and diagnostic codes for prostate cancer and reported undergoing either a robotic or open surgery. They received a mail survey that included self-ratings of problems with continence and sexual function a median of 14 months postoperatively. RESULTS: Completed surveys were obtained from 685 (86%) of 797 eligible participants, and 406 and 220 patients reported having had robotic or open surgery, respectively. Overall, 189 (31.1%; 95% CI, 27.5% to 34.8%) of 607 men reported having a moderate or big problem with continence, and 522 (88.0%; 95% CI, 85.4% to 90.6%) of 593 men reported having a moderate or big problem with sexual function. In logistic regression models predicting the log odds of a moderate or big problem with postoperative continence and adjusting for age and educational level, robotic prostatectomy was associated with a nonsignificant trend toward greater problems with continence (odds ratio [OR] 1.41; 95% CI, 0.97 to 2.05). Robotic prostatectomy was not associated with greater problems with sexual function (OR, 0.87; 95% CI, 0.51 to 1.49). CONCLUSION: Risks of problems with continence and sexual function are high after both procedures. Medicare-age men should not expect fewer adverse effects following robotic prostatectomy.

Variation in cardiologists' propensity to test and treat: is it associated with regional variation in utilization?

BACKGROUND: Regional variation in healthcare utilization, including cardiac testing and procedures, is well documented. Some factors underlying such variation are understood, including resource supply. However, less is known about how physician behaviors and attitudes may influence variation in utilization across regions. METHODS AND RESULTS: We performed a survey of a national sample of cardiologists using patients vignettes to ascertain physicians' self-reported propensity to test and treat patients with cardiovascular problems, computing a Cardiac Intensity Score for each physician based on his/her responses intended to measure the physician's propensity to recommend high-tech and/or invasive tests and treatments. In addition, we asked under what circumstances they would order a cardiac catheterization "for other than purely clinical reasons." For some survey items, there was substantial variation in physician responses. We found that the Cardiac Intensity Score was associated with 2 measures of population based healthcare utilization measured within geographic regions, with a stronger association with general healthcare spending than with delivery of cardiac services. Although nearly all physicians denied ordering a potentially unnecessary cardiac catheterization for financial reasons, some physicians acknowledged ordering the test for other reasons, including meeting patient and referring physician expectations, meeting peer expectations, and malpractice concerns. More than 27% of respondents reported ordering a cardiac catheterization if a colleague would in the same situation frequently or sometimes, and nearly 24% reported doing so out of fear of malpractice. These 2 factors were significantly associated with the propensity to test and treat, but only fear of malpractice was associated with regional utilization. CONCLUSIONS: Variability in cardiologists' propensity to test and treat partly underlies regional variation in utilization of general health and cardiology services. The factor most closely associated with this propensity was fear of malpractice suits. This factor may be an appropriate target of intervention.

Regional variations in palliative care: do cardiologists follow guidelines?

OBJECTIVES: Regional variation in health care use in the last 6 months of life is well documented. Our objective was to examine whether an association exists between cardiologists' tendencies to discuss palliative care for patients with advanced heart failure and the regional use of health care in the last 6 months of life. METHODS: We performed a national mail survey of a random sample of 994 eligible Cardiologists from the American Medical Association Masterfile. Hypothetical patient scenarios were used to explore physician management of patient scenarios. RESULTS: We received 614 responses (response rate: 62%). In a 75-year-old with symptomatic chronic heart failure and asymptomatic nonsustained ventricular tachycardia, cardiologists in regions with high use in the last 6 months of life were less likely to have discussions about palliative care (23% versus 32% for comparisons between the highest and lowest quintiles, p = 0.04). Similarly, in an 85 year-old with symptomatic chronic heart failure and an acute exacerbation, cardiologists in high use regions were less likely to have discussions about palliative care (35% versus 47%, p = 0.0008). CONCLUSIONS: Despite professional guidelines suggesting that cardiologists discuss palliative care with patients with late stage heart failure, less than half of cardiologists would discuss palliative care in two elderly patients with late-stage heart failure and this guideline discordance was worse in the regions with more health care use in the last 6 months of life.

A randomized trial comparing mail versus in-office distribution of the CAHPS Clinician and Group Survey.

OBJECTIVE: To assess the effect of survey distribution protocol (mail versus handout) on data quality and measurement of patient care experiences. DATA SOURCES/STUDY SETTING: Multisite randomized trial of survey distribution protocols. Analytic sample included 2,477 patients of 15 clinicians at three practice sites in New York State. DATA COLLECTION/EXTRACTION METHODS: Mail and handout distribution modes were alternated weekly at each site for 6 weeks. PRINCIPAL FINDINGS: Handout protocols yielded an incomplete distribution rate (74 percent) and lower overall response rates (40 percent versus 58 percent) compared with mail. Handout distribution rates decreased over time and resulted in more favorable survey scores compared with mailed surveys. There were significant mode-physician interaction effects, indicating that data cannot simply be pooled and adjusted for mode. CONCLUSIONS: In-office survey distribution has the potential to bias measurement and comparison of physicians and sites on patient care experiences. Incomplete distribution rates observed in-office, together with between-office differences in distribution rates and declining rates over time suggest staff may be burdened by the process and selective in their choice of patients. Further testing with a larger physician and site sample is important to definitively establish the potential role for in-office distribution in obtaining reliable, valid assessment of patient care experiences.

How much do patients' preferences contribute to resource use?

Regional variation in health care use may stem, in part, from the fact that patients in high-utilization regions demand and receive more-intensive care. We examine the association between patients' care-seeking preferences and use of services, using a national survey of Medicare patients. Patients' preferences, in addition to health and sociodemographic characteristics, are associated with differences in individuals' use of office visits. However, we find that patients' preferences for seeking primary and specialty medical care do not play a significant role in explaining regional variation in health care use.

Discretionary decision making by primary care physicians and the cost of U.S. Health care.

Efforts to improve the quality and costs of U.S. health care have focused largely on fostering physician adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. We surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care. Physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low-spending regions; however, both appear equally likely to recommend guideline-supported interventions. Greater attention should be paid to the local factors that influence physicians' clinical judgment in discretionary settings.

Are regional variations in end-of-life care intensity explained by patient preferences?: A Study of the US Medicare Population.

OBJECTIVE: We sought to test whether variations across regions in end-of-life (EOL) treatment intensity are associated with regional differences in patient preferences for EOL care. RESEARCH DESIGN: Dual-language (English/Spanish) survey conducted March to October 2005, either by mail or computer-assisted telephone questionnaire, among a probability sample of 3480 Medicare part A and/or B eligible beneficiaries in the 20% denominator file, age 65 or older on July 1, 2003. Data collected included demographics, health status, and general preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. EOL concerns and preferences were regressed on hospital referral region EOL spending, a validated measure of treatment intensity. RESULTS: A total of 2515 Medicare beneficiaries completed the survey (65% response rate). In analyses adjusted for age, sex, race/ethnicity, education, financial strain, and health status, there were no differences by spending in concern about getting too little treatment (39.6% in lowest spending quintile, Q1; 41.2% in highest, Q5; P value for trend, 0.637) or too much treatment (44.2% Q1, 45.1% Q5; P = 0.797) at the end of life, preference for spending their last days in a hospital (8.4% Q1, 8.5% Q5; P = 0.965), for potentially life-prolonging drugs that made them feel worse all the time (14.4% Q1, 16.5% Q5; P = 0.326), for palliative drugs, even if they might be life-shortening (77.7% Q1, 73.4% Q5; P = 0.138), for mechanical ventilation if it would extend their life by 1 month (21% Q1, 21.4% Q5; P = 0.870) or by 1 week (12.1% Q1, 11.7%; P = 0.875). CONCLUSIONS: Medicare beneficiaries generally prefer treatment focused on palliation rather than life-extension. Differences in preferences are unlikely to explain regional variations in EOL spending.

Development and validation of a new health-related quality of life instrument for patients with sinusitis.

BACKGROUND AND OBJECTIVE: There are few validated measures of sinusitis-specific health-related quality of life (HRQL). This study used patient focus and pretesting groups followed by a prospective cohort study to develop and validate a HRQL instrument for patients with sinusitis. METHODS: Instrument development involved a systematic literature review, use of expert input, and patient focus and pretesting groups. Patients were recruited from the practices of primary care providers and otolaryngologists. The derived survey instrument then underwent prospective testing in patients with acute sinusitis, chronic sinusitis, allergic rhinitis, and asymptomatic controls. Reduced item scales of the original instrument were developed for symptom frequency and bothersomeness. The psychometric properties of the survey instrument were evaluated for reliability, construct validity, responsiveness, and interpretability. RESULTS: In the prospective study, 47 patients with acute sinusitis and 50 patients with chronic sinusitis were compared to 18 patients with allergic rhinitis and 60 patients without nasal symptoms. Forty-three (91.5%) patients with acute sinusitis completed the questionnaire at baseline and at 1-month follow-up. Internal consistency was high for the symptom impact scale for acute and chronic sinusitis patients. The symptom frequency and especially bothersomeness scales had lower internal consistency particularly for acute sinusitis patients. Reproducibility among surgical patients retested prior to their procedure was good for each scale. A high degree of disciminant validity was demonstrated when comparing sinusitis patients to other groups, and a high degree of convergent validity was seen when the new measures were compared to other HRQL measures at baseline. Among patients with acute sinusitis, the responsiveness and interpretability of the symptom frequency, bothersomeness and impact scales were excellent. CONCLUSIONS: This study developed and validated a new sinusitis-specific HRQL instrument. The instrument included symptom frequency, bothersomeness and impact scales. It was shown to be valid in patients with acute and chronic sinusitis, and highly responsive and interpretable in acute sinusitis patients managed in the primary care setting.

Using telephone interviews to reduce nonresponse bias to mail surveys of health plan members.

OBJECTIVE: To assess the nonresponse bias associated with mail-survey returns and the potential for telephone interviews with nonrespondents to reduce that bias. METHODS: A mail survey about health care experiences was conducted with samples of 800 members in each of four health plans. Subsequent attempts were made to interview nonrespondents by telephone. RESULTS: Response rates for the mail surveys averaged 46%; the telephone effort raised the average to 66%. On 17 of 19 measures of health status or need and use of health services, mail respondents were in poorer health and needed more services than interviewed nonrespondents. Thirteen of 36 reports and ratings of health care also differed significantly between the two groups. Based on administrative data, telephone interviews of mail nonrespondents improved the demographic representativeness of the responding samples. Adjusting mail returns to sample population characteristics could not replicate the dual-mode results. CONCLUSIONS: Returns to mail surveys are likely to be related to survey content and hence are potentially biased. Nonresponse to phone surveys is less directly related to survey content. Telephone interviews with mail nonrespondents not only increase response rates but also can produce less biased samples than mail-only protocols.

Photocarcinogenesis in human adult skin grafts.

It has been demonstrated previously that the exposure to 7,12-dimethyl[a]benzanthracene (DMBA) and UVB radiation leads to the development of epidermal cysts, squamous cell carcinomas (SCC), melanocytic hyperplasia and melanoma in human foreskins from newborns grafted to immunodeficient mice. Improved techniques in grafting full-thickness skin from adults have enabled us to study photocarcinogenesis in human skin from different body sites and from older donors. One hundred and fifty-five normal white skin specimens from the trunk and face of 53 adult individuals were grafted onto severe combined immunodeficient (SCID) and recombinase activating gene-1 (Rag-1) knockout mice and irradiated two to three times weekly with 40 mJ/cm(2) UVB or solar-simulated UV (SSUV) over a period of up to 10 months with or without one prior topical application of DMBA. Over an observation period of 2-22 months, histopathological and immunohistochemical analyses of 134 specimens revealed actinic keratoses in 30% of the DMBA- + UV-treated grafts, in 18% of the grafts exposed to SSUV only, and in 10% of the grafts exposed to UVB only. Actinic keratoses were absent in grafts treated with DMBA only. One SCC was found in an abdominal skin graft 3 months after exposure to DMBA followed by UVB. Point mutations in codon 61 of the human Ha-ras gene were detected in the SCC, five of six analyzed actinic keratoses and in non-lesional epidermis of DMBA- and UVB-treated grafts, indicating that DMBA as well as UVB alone can induce these mutations in human skin. In contrast to the previous experience with neonatal foreskin grafts, melanocytic lesions were not found except for mild hyperplasia in few cases. The data suggest that melanocytes from young individuals are more susceptible to the transforming effects of genotoxic agents than melanocytes from adults.