Ovarian function in premenopausal women treated with adjuvant chemotherapy for breast cancer.

PURPOSE: Adjuvant chemotherapy for breast cancer causes significant changes in ovarian function. More young women survive breast cancer than ever before and they are at risk of the sequelae of early menopause. We attempted to (1) define menopausal status in the setting of adjuvant chemotherapy; (2) define chemotherapy-related amenorrhea (CRA); (3) document rates of permanent amenorrhea, temporary amenorrhea, and oligomenorrhea among different regimens; and (4) analyze variables that influence ovarian function. DESIGN: We reviewed reports of the effects of adjuvant chemotherapy for breast cancer on ovarian function in premenopausal women. We searched Medline and Cancerlit from 1966 to 1995 on the following terms: breast neoplasms; chemotherapy, adjuvant; menstruation disorders; premature menopause, and amenorrhea. Further references were obtained from reports retrieved in the initial search. RESULTS: A uniform definition of menopause and CRA is lacking. The wide range of CRA rates reported in adjuvant chemotherapy trials is a result, at least in part, of this problem. The average CRA rate reported in regimens based on cyclophosphamide, methotrexate, and fluorouracil (CMF) is 68% (95% confidence interval [CI], 66% to 70%), with a range of 20% to 100%. CRA incidence varies with age, cytotoxic agent, and cumulative dose. CONCLUSION: Ovarian damage is the most significant long-term sequela of adjuvant chemotherapy in premenopausal breast cancer survivors. We suggest a common definition of the following important terms: menopausal status, CRA (early and late), temporary CRA, and oligomenorrhea in the setting of adjuvant treatment. With uniform definitions in place, regimens can be more precisely compared with respect to this important complication.

Epidemiology of injury in people with Alzheimer's disease.

BACKGROUND: Previous studies have suggested that the risk of injury is elevated among persons with dementia, but these studies have focused primarily on falls and fractures. This study characterizes all injuries incurred in a large sample of community-dwelling persons with a specific form of dementia, Alzheimer's disease (AD). SUBJECTS AND METHODS: The sample consisted of 281 community-dwelling persons diagnosed with AD according to NINCDS/ADRDA guidelines. Information regarding all injuries occurring within the previous 6 months was obtained through a structured interview of a caregiver. RESULTS: The rate of injuries was 58.4 per 100 persons per year. Although falling was the single most common mechanism by which injuries occurred, it accounted for only 43.8% of all injuries. Fractures accounted for 13.7% of injuries. Medical treatment was sought for 52.1% of the injuries. After adjustment for age and gender, the likelihood of injury was significantly associated with cognitive impairment and with ADL limitation, but the independent contribution of these two factors could not be assessed. CONCLUSIONS: The findings suggest that injuries are a significant problem in persons with AD.

Effect of Medicaid managed care on pregnancy complications.

OBJECTIVE: This study examined the impact of managed care on hospital obstetric outcomes in Medicaid-sponsored women. METHODS: The study sample consisted of a total of 525,517 maternal deliveries for singleton births from three payer groups, Medicaid managed care, Medicaid fee-for-service, and private managed care in 439 short-term-stay nonfederal hospitals in California and Florida. Quality of care comparisons were made using six indicators. Data were derived from linked computer files of birth certificates, hospital discharge abstracts, Medicaid eligibility records, Medicaid health care claims, and surveys of hospital characteristics. RESULTS: The overall multivariate likelihood of an adverse maternal outcome during hospitalization for a delivery was not significantly different between Medicaid managed care and Medicaid fee-for-service groups in California and Florida. However, mothers in the Medicaid managed care group compared with mothers in the private managed care group experienced a higher likelihood of eclampsia (California) (adjusted odds ratio = 1.26; 95% confidence interval 1.05, 1.57; P = .04). CONCLUSION: Overall, managed care has not adversely affected pregnancy outcomes in Medicaid-sponsored women. Yet, payer system changes may be insufficient to achieve complete parity of outcomes relative to private managed care patients.

The cesarean birth rate: influence of hospital teaching status.

Knowledge of how cesarean birth rates vary by hospital characteristics may aid in understanding and perhaps modifying some of the structural and process components of newborn delivery services to decrease the necessity of birth by cesarean procedure. To examine the influence of select hospital characteristics, data on hospital newborn deliveries in Illinois for 1986 among women 10-50 years of age inclusive (N = 130,249) were obtained from computerized hospital discharge abstract files. Characteristics of the hospitals were obtained from the annual American Hospital Association survey. Adjusting for mother's age at delivery; presence of pregnancy, labor, and delivery complications; expected primary payer; and size of hospital, women delivering in hospitals with teaching status were less likely (odds ratio = 0.76, p less than .001, 95 percent CL: 0.73, 0.79) to have a primary cesarean birth than women delivering in hospitals without this designation. A significantly lower cesarean birth rate in teaching hospitals was also observed in women of all age groups, in Medicaid and non-Medicaid women, and for most categories of delivery complications. These data suggest the need to identify the programmatic, technologic, and manpower functions associated with hospital teaching status that could decrease the likelihood of a primary cesarean delivery. The study also suggests that changes aimed at the manner of diagnosis, monitoring, and/or management of pregnancy/delivery complications may reduce the cesarean birth rate because of large differences in the primary cesarean birth rate found between teaching and other hospitals for most categories of newborn delivery complications.

A comparison of capitated and fee-for-service Medicaid reimbursement methods on pregnancy outcomes.

OBJECTIVE: To determine if the payment method influenced the likelihood of selected obstetrical process measures and pregnancy outcome indicators among Medicaid women. DATA SOURCE/STUDY SETTING: Data from the live birth certificates computer file for 1993 from the State of California. The computer files contain information about the demographic characteristics of the mother, her medical conditions prior to delivery, medical problems during labor and delivery, delivery method, newborn and maternal outcomes, and expected principal source of payment for prenatal care and for hospital delivery. STUDY DESIGN: The study sample consisted of singleton live births to women in the California Medi-Cal program residing in one of two counties in which a mixed-model managed care plan was the method of reimbursement or in one of three counties in which fee-for-service was the payment method. The study and control counties were matched in terms of geographic proximity and sociodemographics. PRINCIPAL FINDINGS: Among Medi-Cal women, the likelihood of low birth weight (LBW) was lower in the capitated payment group than in the fee-for-service payment group even when controlling for maternal and newborn characteristics and adequacy of prenatal care. There was no difference in either the adequacy of prenatal care, the cesarean birth rate, or the likelihood of adverse pregnancy outcomes other than LBW between the two payer groups. CONCLUSIONS: Results of this "natural experiment" suggest that enrollment of pregnant Medi-Cal beneficiaries in capitated healthcare services through a primary care case management system in a county-organized health system/health insuring organization can have a beneficial effect on low birth weight and provide care comparable to a fee-for-service system.

Association between recovery outcomes for work-related low back disorders and personal, family, and work factors.

STUDY DESIGN: Incident cases of work-related low back disorders were identified in an automotive metal stamping plant. Individuals were asked to recall health and work habits at the time of diagnosis of the work-related disorder and to report their current low back pain and physical functioning. OBJECTIVES: To evaluate five measures of health outcomes for work-related low back disorders in an industrial population and to determine potentially modifiable correlates of recovery. SUMMARY OF BACKGROUND DATA: The factors that influence recovery in actively working adults and how to best measure recovery outcome in this population are not well known. METHODS: Eighty-eight hourly employees of a metal stamping plant who experienced a work-related low back disorder were interviewed. Health status, health habits, and family and work relations were assessed with a structured interview to determine their association with various recovery outcomes (low back pain, low back pain disability, physical functioning, general physical health, and lost workdays). Interview information was supplemented with data from the plant's Occupational Safety and Health Administration Form 200 log. RESULTS: The clinical measures of recovery from the work-related low back disorders examined had similar overall predictive ability. However, in multivariate analyses, different potentially modifiable prognostic variables emerged as significant among them. Poorer self-rated health status and high personal stress were correlated with low back pain disability. Higher levels of cigarette smoking were correlated with higher levels of low back pain disability, lower physical functioning, and more severe low back pain at follow-up. CONCLUSION: The choice of measure of recovery from work-related low back disorders should be made in the context of the rehabilitation intervention goal. Interventions designed to modify and promote healthful personal behavior should be given more emphasis in rehabilitation efforts for work-related low back disorders.

Comparison of five methods used to determine low back disorder risk in a manufacturing environment.

STUDY DESIGN: Five methods for quantifying work-related low back disorder (LBD) risk were used to assess 178 autoworkers from 93 randomly selected production jobs. OBJECTIVE: To determine if five occupational LBD risk evaluation methods yielded similar assessments of manual material handling tasks. SUMMARY OF BACKGROUND DATA: Several techniques are available for quantifying LBD risk in the workplace and are used in industry for job evaluation and redesign. It is unknown whether the methods yield similar results. METHODS: The five job evaluation methods were the 1993 National Institute for Occupational Safety and Health model, the Static Strength Prediction Program, the Lumbar Motion Monitor model, and two variations of the United Auto Workers (UAW)-General Motors Ergonomic Risk Factor Checklist. These methods were selected because they represent common practice within the automotive industry, the result of governmental efforts to protect the workforce, or models thought to be the most scientifically advanced. RESULTS: Intercorrelations between methods ranged between 0.21 and 0.80. Pairwise analysis of risk group classifications identified biases on the part of the National Institute for Occupational Safety and Health equation, which considered jobs to be of higher risk relative to other methods, and on the part of the Static Strength Prediction Program, which considered nearly all the jobs sampled to be low risk. CONCLUSIONS: There is little agreement among the five quantitative ergonomic analysis methods used. In part, this may be because of their differential focus on acute versus cumulative trauma, thereby suggesting that greater consideration needs to be given to the underlying causes of LBD within a facility before selecting an ergonomic evaluation method.

The diary as a means of understanding the quality of life of persons with cancer receiving home nursing care.

In order to gain insight into the quality of life from a patient perspective, individuals with cancer receiving home nursing care were given diaries to record the occurrence of health problems. On the average, health problems were reported on 35% of the recording days. Concerns related to somatic discomfort accounted for 76% of all health problems reported. Overall, digestive problems were the most commonly reported category of health problems. Those with lung cancer reported the highest average number of health problems per person (means = 9.3) and the greatest diversity of problems during the recording period. The results also suggest a common core of health problems important to cancer patients, with the relative importance of these problems varying by cancer diagnosis.

A national survey of certified, recertified, and noncertified oncology nurses: comparisons and contrasts.

PURPOSE/OBJECTIVES: To explore opinions about the OCN credential, the ways in which it was obtained and retained, and the extent to which it is valued by employers. DESIGN: A descriptive comparison study using a cross-sectional survey design. SAMPLE: Questionnaires were mailed to a nationwide sample of 2,429 RN members of the Oncology Nursing Society; 1,217 (50%) surveys were returned. The majority of respondents were female, 30-49 years of age. Caucasian, and had practiced nursing for more than 11 years. MAIN RESEARCH VARIABLES: Certification status, work role characteristics, preparation strategies for the certification examination, and motivation for obtaining certification. FINDINGS: Oncology nurses recognize the importance and value of OCN certification. The primary reasons oncology nurses obtain and retain certification include the desire for personal achievement, professional growth, and development. OCNs were more likely to work in a setting where the employer supports professional development through continuing nursing education. IMPLICATIONS FOR NURSING PRACTICE: Because health care is increasingly delivered in ambulatory/home settings and the population is aging, oncology certification needs to be encouraged among nurses who work in these settings or with geriatric populations. Certified nurses tended to experience more job satisfaction than noncertified nurses.

Relationships between certification and job perceptions of oncology nurses.

PURPOSE/OBJECTIVES: To explore relationships between oncology nursing certification and oncology nurses' job perceptions. DESIGN: Descriptive, correlational. SETTING: Questionnaire mailed to homes of Oncology Nursing Society (ONS) members. SAMPLE: 703 certified and 514 noncertified ONS members (N = 1,217; 50% response rate). METHODS: Data were collected using survey methods and grouped by respondents' certification status for statistical analysis. MAIN RESEARCH VARIABLES: Certification, group cohesion, organizational commitment, and job satisfaction. FINDINGS: Certification was weakly correlated with cohesion, commitment, and satisfaction. Work setting, rather than certification, accounted for differences in job perceptions. Job perceptions were most positive in settings characterized by a high percentage of patients with cancer (> 75%), a high percentage of RNs (> or = 80%), and monetary support for continuing education. CONCLUSIONS: The hypothesis that oncology nurses' certification status is associated with job perceptions that are valued by employers was not supported. IMPLICATIONS FOR NURSING PRACTICE: Nurses' job perceptions have been linked to control over nursing practice and participation in organizational and clinical decision making. Managerial strategies that empower certified nurses to practice with more autonomy and participate in decisions that affect patient care should be emphasized.

Linking the delivery of health care to service population needs: the role of the epidemiologist on the health care management team.

Historically, in the United States, the practice of most epidemiologists has been oriented toward the public health needs of persons living in communities, and has focused on the determination of rates of disease, risk factors for disease, and evaluating prevention and screening efforts. Continuous profound changes in demographic patterns throughout the world, increases in the rates of many chronic and communicable diseases and disabling conditions, and payer constraints all test the ability of health systems managers to provide quality health care. Over time, managers of health systems will recognize that the most cost-effective strategies will be derived from a population-based perspective. With this viewpoint, the epidemiologist can be a pivotal link in assisting the management team to align the delivery of health care services more effectively with the needs of populations targeted for services, either those residing in communities or those currently receiving services by a system, organization, or an individual provider. This article will describe the increasing role of the epidemiologist in health care organizations and illustrate the functions of the epidemiologist on the health care management team based upon the author's own experience at Rush-Presbyterian-St. Luke's Medical Center, an academic health care center in Chicago, Illinois.

A population-based evaluation of the impact of interventions for improving care to cancer patients in the home setting.

A federally-funded demonstration project was conducted by the Illinois Cancer Council and the Illinois Department of Public Health to determine if the introduction of modest changes in the home health system would effect certain cancer patient patterns of care and outcomes. Certified home health agencies in two health planning regions of Illinois were randomized into one of three study groups, two of which received an intervention (oncology nurse specialist with continuing education on cancer, or continuing education on cancer alone), and the third was an "observation only" group. The pre/post differences of a number of evaluation parameters were investigated. Overall, the group which received the services of the oncology nurse specialist and continuing education on cancer demonstrated the largest percentage increase in cancer patient referrals to home care, and experienced a significant decrease in cancer patient mortality. No significant difference among cancer patients in the three study groups was noted for hospitalization rate or incidence of physiologic complications while on agency caseload.

Work-related injuries of the hand: data from an occupational injury/illness surveillance system.

Administrative and clinical data from a network of occupational medicine clinics were combined to evaluate the utility of these data in the surveillance of non-fatal occupational injuries. Incident cases of work-related hand injuries were characterized to evaluate that process. In 1988, hand and finger injuries were found to be among the most common (n = 4,120) of all occupational injuries recorded in the system. Hand/finger injuries accounted for 30.0 percent of all episodes of work-related injuries treated, with the incidence of these decreasing with increasing company size. Hand injuries were found to be potentially severe with nearly 20 percent resulting from a crushing motion and nearly 10 percent being fractures or amputations. Hands being caught in machines or struck by metal items or hand tools accounted for 36.2 percent of the injuries. A surveillance system based upon ambulatory care data can be a feasible method for identifying priority areas for the prevention of work-related injuries.

Work-related injuries to the foot. Data from an occupational injury/illness surveillance system.

In 1988, a total of 990 work-related injuries to the foot of employees from private-sector companies were characterized in an occupational injury/illness surveillance system maintained by a network of occupational health centers. The mean age of the worker with a foot injury was 34.2 years (+/- 12.0), with 83% occurring among men; 22.3% of the cases were fractures or sprains/strains. Jobs involving extensive manual material handling or vehicular operations were the most often listed occupations among those with work-related foot injuries. Across occupational groups, being struck by an object accounted for 58.4% of the foot injuries. Regardless of industry group, metal items and vehicles were related to 50.7% of all work-related foot injuries. Specifically, foot injuries were found to be associated with being struck by boxes, metals, or vehicles, or to being caught in, under, or between vehicles or machinery. A peak of work-related injuries involving the foot is observed during the summer months.

Total quality management in a health care organization: how are employees affected?

Since the late 1980s, health care managers have exhibited a rapidly growing interest in large-scale total quality management (TQM) programs. This quasi-experimental study examines the effects of one such TQM program on employee job satisfaction, perceptions of organizational climate, and general opinions concerning the work situation. Two years after the TQM program had been introduced, responses of participants and nonparticipants were compared. Participants in the program exhibited a higher level of job satisfaction and more favorable opinions regarding both the organization and their work.

A model for occupational injury surveillance by occupational health centers.

Injuries account for more than 90% of the reported work-related health problems in the United States. However, a complete and standardized reporting system for occupational injuries does not exist in this country. This paper describes the first year's experience of a clinic-based occupational injury surveillance system involving occupational medicine clinics. During 1988, health and hazard information was collected on 14,156 work-related admissions. An analysis of these cases showed that most patients received care for minor trauma, with 78.4% of the cases classified as cuts or lacerations, sprains or strains, or contusions. Overall, 53.8% of the cases were caused by metal items, boxes, machines, or working surfaces. These preliminary results support the feasibility of conducting clinic-based occupational injury surveillance as a means of assisting employers with the control of work-related conditions.

Information dissemination and the cesarean birth rate. The Illinois experience.

A study was initiated to investigate the impact of information dissemination in Illinois upon the projected rise in the cesarean birth rate over the period from 1986 through 1988. The total cesarean birth rate in Illinois had not changed significantly during this period, whereas the rate of vaginal births after cesarean sections (VBAC) increased by 58.4% (p < .001). Information dissemination may have contributed to stemming an increase in the cesarean birth rate in Illinois while promoting VBAC deliveries.

Reducing the risk of high-order multiple pregnancy after ovarian stimulation with gonadotropins.

BACKGROUND: The incidence of multiple gestation after therapy for infertility is especially high among women in whom ovulation is induced with gonadotropins. Whether the number of high-order multiple pregnancies (those with three or more fetuses) can be reduced is not known. METHODS: We analyzed data on 3347 consecutive treatment cycles in 1494 infertile women, 441 of which resulted in pregnancy. The data collected included the peak serum estradiol concentration, the number of follicles 16 mm or larger in diameter, and the total number of follicles on the day of induction of ovulation with human chorionic gonadotropin. Receiver-operating-characteristic curves and ordinal logistic-regression analyses were used to identify values that predicted multiple conceptions. RESULTS: Among the 441 pregnancies, 314 resulted from the conception of singletons, 88 of twins, 22 of triplets, 10 of quadruplets, 5 of quintuplets, and 2 of sextuplets. Neither the number of follicles 16 mm or larger nor peak serum estradiol concentrations greater than 2000 or 2500 pg per milliliter (7342 or 9178 pmol per liter) (the cutoff values currently in wide use) were significantly associated with the incidence of high-order multiple pregnancy. However, increasing total numbers of follicles and increasing peak serum estradiol concentrations correlated significantly with an increasing risk of high-order multiple pregnancy (P<0.001), as did younger age (P=0.008). The risk of high-order multiple pregnancy was significantly increased in women with a peak serum estradiol concentration of 1385 pg per milliliter (5084 pmol per liter) or higher (multivariate odds ratio, 1.9; 95 percent confidence interval, 1.3 to 2.8) or with seven or more follicles (multivariate odds ratio, 2.1; 95 percent confidence interval, 1.2 to 3.9) on the day of induction of ovulation. CONCLUSIONS: Gonadotropin stimulation that is less intensive than is currently customary may reduce the incidence of high-order multiple pregnancy in infertile women, though only to a limited extent and at the expense of overall pregnancy rates.