Repeat mammography use among women ages 50-75.

It has been demonstrated clearly that the use of regular screening mammography reduces mortality among women ages 50 years and over. The primary objective of this study was to investigate factors associated with repeat mammography participation. A random sample of women ages 50-75 years residing in four Washington State counties was surveyed by telephone during mid-1989. The Health Belief Model was used as a conceptual framework for the analysis. Three groups of women with different mammography experiences in the previous 5 years were compared: (a) nonusers; (b) onetime users; and (c) repeat users. The survey response rate was 72%, and the study sample included 1357 women. One time users were more likely to have health insurance coverage, to visit a gynecologist or other primary care physician regularly, and to believe mammography is more effective than breast self-examination; they were less likely to think that at least 1 in 10 women are diagnosed with breast cancer or that mammography is inconvenient to obtain than were nonusers. Factors associated with repeat versus onetime use included routinely visiting a gynecologist, thinking the lifetime risk of breast cancer is at least 10%, and perceiving a high personal susceptibility to disease. Women who perceive themselves as being vulnerable to breast cancer are more likely to report repeat mammograms. Visiting a gynecologist regularly is associated with repeat as well as initial mammography use. These factors could be considered as the focus of promotional efforts moves from encouraging women to obtain their first mammogram to encouraging repeat use.

Cervical cancer screening among Cambodian-American women.

Southeast Asian women have higher invasive cervical cancer incidence rates and lower Pap testing frequencies than most other racial/ethnic groups in the United States. However, there is little information about the cervical cancer screening behavior of Cambodian-American women. Cambodian residents of Seattle were surveyed in person during late 1997 and early 1998. The PRECEDE model was used to guide the development of items that assessed predisposing, reinforcing, and enabling factors associated with cervical cancer screening participation. The estimated overall survey response was 72%. Four hundred thirteen women completed our questionnaire. Approximately one-quarter (24%) of the respondents had never had a Pap test, and over one-half (53%) had not been screened recently. The following variables were positively associated with a history of at least one Pap smear: younger age, greater number of years since immigration, belief about Pap testing for postmenopausal women, prenatal care in the United States, and physician recommendation. Women who believed in karma were less likely to have ever been screened for cervical cancer than those who did not. Six variables independently predicted recent screening: age; beliefs about regular checkups, cervical cancer screening for sexually inactive women, and the prolongation of life; having a female doctor; and a previous physician recommendation for Pap testing. The study findings indicate that culturally specific approaches might be effective in modifying the cervical cancer screening behavior of immigrant women. Programs targeting Cambodian-Americans are likely to be more effective if they are multifaceted and simultaneously address predisposing, reinforcing, and enabling factors.

Placental previa in relation to induced and spontaneous abortion: a population-based study.

OBJECTIVE: To evaluate the impact of induced abortion and spontaneous abortion on the occurrence of placenta previa in later pregnancies. METHODS: A population-based, case-control study was conducted using 1984-1987 Washington state birth certificate data. The study population included 486 white women with a pregnancy complicated by placenta previa and 1598 randomly selected controls without placenta previa. Unconditional logistic regression was used to estimate odds ratios and 95% confidence intervals (CIs). RESULTS: After adjustment for confounding variables, the odds ratio in association with one or more induced abortions was 1.28 (95% CI 1.00-1.63). For one or more spontaneous abortions, the odds ratio was 1.30 (95% CI 1.01-1.66). CONCLUSIONS: Women who report one or more induced or spontaneous abortions are 30% more likely to have a subsequent pregnancy complicated by placenta previa than women without such a history. The results should not be generalized to areas where suction curettage is not the preferred method of induced abortion.

Placenta previa and prior cesarean delivery: how strong is the association?

OBJECTIVE: To investigate the occurrence of placenta previa following a cesarean delivery. METHODS: We conducted a case-control study using 1984-1987 Washington state birth certificate data. Analysis was restricted to women who reported one or more previous live births. The study population included 490 women with a pregnancy complicated by placenta previa and 1477 randomly selected controls. Unconditional logistic regression was used for statistical analysis. RESULTS: After adjustment for confounding factors, the odds ratio for placenta previa in association with one or more previous cesarean deliveries was 1.48 (95% confidence interval 1.13-1.95). CONCLUSIONS: Women with a history of cesarean delivery are 50% more likely to have a subsequent birth complicated by placenta previa than those without such a history. This magnitude of excess risk is lower than the relative risks reported in previous studies.

Increased risk of placenta previa among women of Asian origin.

OBJECTIVE: To investigate the frequency of placenta previa among Asian women. METHODS: We conducted a population-based case-control study using Washington state birth certificate data from 1984-1987. Our study population included 810 women with pregnancies complicated by placenta previa and 2917 randomly selected controls. Unconditional logistic regression was used to estimate odds ratios (OR) and their 95% confidence intervals (CI), and interaction terms were used to examine effect modification. Potential confounding by maternal age, gravidity and parity, maternal smoking during pregnancy, and a history of abortion or cesarean delivery was adjusted for in the analysis. RESULTS: The frequency of placenta previa during the study period was 3.3 per 1000 live births. Women of Asian origin were 86% more likely (OR 1.86, 95% CI 1.38-2.51) to have a delivery complicated by placenta previa than were white women. This association was stronger among women without a previous live birth (OR 2.51, 95% CI 1.57-4.01) than those who previously had experienced a live birth (OR 1.50, 95% CI 1.01-2.25). CONCLUSION: Asian women residing in the United States are at increased risk of placenta previa. If confirmed by others, our results suggest that obstetricians should consider meticulous ultrasound evaluations during pregnancy to rule out the presence of placenta previa in Asian-American women.

Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State.

OBJECTIVE: To examine back and neck hospitalizations in the Province of Ontario and Washington State. Because of their different organization and financing, there has been considerable interest in comparing healthcare systems in Canada and the United States. Features of healthcare systems might be expected to result in greater variations in care for elective than urgent conditions. DATA SOURCE: Automated hospital discharge databases. STUDY DESIGN: Previously developed algorithms were used to identify surgical and nonsurgical hospitalizations for back and neck problems in the administrative databases. We compared overall rates of hospitalization and lengths of hospital stay in Ontario and Washington as well as small area variations within the province and state. PRINCIPAL FINDINGS: Surgical back and neck hospitalizations were three times as common in Washington, but medical hospitalizations were twice as common in Ontario. Provincial lengths of stay were longer for both surgical and nonsurgical hospitalizations. Admission rates varied substantially and significantly among small areas in both Washington and Ontario. Variations in hospital length of stay were greater in Ontario, particularly for nonsurgical back and neck hospitalizations. CONCLUSION: The two jurisdictions had very different patterns of hospital utilization for one of the most common health problems seen by physicians. Our results suggest that the global controls on hospital budgets and access to technology in Ontario were associated with lower rates of surgery, higher rates of hospital-based medical care, and longer lengths of stay. They also indicate that the utilization review process in Washington was associated with lower small area variation rates for medical back care.

Use of qualitative methods to study diet, acculturation, and health in Chinese-American women.

Improving the health status of minority populations in the United States is a major public health challenge. This report describes an anthropological approach to obtaining information needed for designing and evaluating a culturally appropriate dietary intervention for Chinese-Americans. Ninety-minute qualitative interviews were conducted with 30 less-acculturated Chinese-American women in their native language (Cantonese or Mandarin), soliciting information from participants regarding usual food consumption; knowledge, attitude, and beliefs about diet and disease; and factors that influence food choices. Interviews were recorded, translated, transcribed, and coded for themes. Two focus groups with 6 participants each were conducted to cross-validate the interview findings. Among our participants, breakfast was usually the first meal to be "Westernized," largely for reasons of convenience. Food quality, cost, and availability were some of the most important predictors of dietary change after immigration to the United States. Respondents said that there was a strong connection between diet and disease. However, they were not familiar with US dietary guidelines, food labels, or other sources of dietary information, but reported that friends and Chinese newspapers were their primary source of nutrition information. We used these findings to develop quantitative dietary survey instruments adapted for Chinese-Americans. This type of qualitative groundwork is an important precursor to the design, implementation, and evaluation of dietary interventions for minorities.

Development of scales to measure dietary acculturation among Chinese-Americans and Chinese-Canadians.

OBJECTIVE: To develop simple scales to measure a Chinese immigrant's adoption of Western eating patterns (dietary acculturation). STUDY DESIGN AND PARTICIPANTS: Data are from 244 less-acculturated women of Chinese ethnicity living in Seattle, Wash, and Vancouver, British Columbia, Canada. Interviewers collected information on sociodemographic characteristics, acculturation indices, items that reflect Western and Chinese dietary behavior, and consumption of fruits, vegetables, and fat. STATISTICAL ANALYSES: Analysis of variance and linear regression analyses examined associations among dietary measures and acculturation variables, controlling for age, education, and city of residence. RESULTS: We developed 2 scales to assess dietary acculturation: the Western Dietary Acculturation Scale and the Chinese Dietary Acculturation Scale, measuring Western and Chinese eating behavior, respectively. Although the population in this study was a less-acculturated sample, most participants reported some Western dietary practices, such as drinking milk (78%), eating cheese (78%), eating at Western fast-food restaurants (56%), and eating between meals (72%). Younger, highly educated women employed outside the home had the highest Western dietary acculturation scores (P < .001). Women with high scores on the Western scale reported higher-fat dietary behaviors and had increased fruit and vegetable intake since immigration compared to those with lower scores (P < .001). There was good agreement between the dietary acculturation scales and traditional acculturation indicators (P < .001). APPLICATIONS: Nutrition programs for immigrant/minority groups may be more effective if they are tailored to level of dietary acculturation. Therefore, the ability to accurately assess dietary acculturation is an important component of nutrition education, interventions, and counseling in these populations.

Low back pain hospitalization. Recent United States trends and regional variations.

STUDY DESIGN: This study describes recent United States trends and regional variations in the management of low back pain. OBJECTIVES: The authors investigated recent temporal trends and compared practices in different geographic regions. SUMMARY OF BACKGROUND DATA: Controversy exists concerning the appropriate medical and surgical management of patients with low back pain. METHODS: National Hospital Discharge Survey data from 1979 through 1990 were analyzed. Case selection was based on previously developed algorithms intended to exclude nonmechanical causes of back pain. RESULTS: Over the period of study, nonsurgical hospitalizations for low back pain decreased dramatically. In contrast, low back operation rates, particularly for fusion surgery, increased substantially. In recent years, surgery and hospitalization rates were highest in the South and lowest in the West. CONCLUSIONS: Rapidly increasing surgical rates and wide geographic variations suggest the need for a more consistent approach to back problems.

Surgical treatment of patients with back problems covered by workers compensation versus those with other sources of payment.

STUDY DESIGN: The present study examines relationships between workers compensation coverage and the surgical treatment of patients with low back problems. OBJECTIVES: To examine the mix of surgical procedures, reoperation rates, and resource use among patients receiving workers compensation and these with other sources of payment. SUMMARY OF BACKGROUND DATA: There is evidence that patients with low back pain who receive workers' compensation have poorer clinical outcomes than other patients with back problems. METHODS: The authors used data from Washington State's automated hospital discharge system for 1988 through 1991. The study group included 1502 patients receiving workers compensation and 2674 patients not receiving workers compensation. RESULTS: If the patients were covered by workers' compensation, they were 1.37 times more likely to undergo surgery involving fusion (95% confidence interval, 1.04-1.80) and almost twice as likely to have a subsequent reoperation within 3 years of the index surgery (odds ratio, 1.80; 95% confidence interval, 1.50-2.15. CONCLUSIONS: In Washington state, patients receiving workers' compensation have higher rates of low back fusion surgery and reoperations than other patients.

Patient-oriented outcomes from low back surgery: a community-based study.

STUDY DESIGN: This study used a prospective cohort design. OBJECTIVE: To examine factors associated with favorable self-reported patient outcomes 1 year after elective surgery for degenerative back problems. SUMMARY OF BACKGROUND DATA: Many previous studies addressing the results of low back surgery have been conducted in academic institutions or by single surgeons. As part of a quality improvement effort, surgeons in private practice led a community-based outcomes management project in Washington State. METHODS: Patients ages 18 and older with the following diagnoses were eligible for the study: degenerative changes, herniated disc, instability, and spinal stenosis. Nine orthopedists and neurosurgeons enrolled a total of 281 patients. Participants were asked to complete baseline and 1-year follow-up surveys. Data concerning diagnoses, clinical signs, and operative procedures were provided by the surgeons. The researchers examined sociodemographic characteristics, self-reported symptoms before surgery, preoperative clinical signs, diagnoses, and operative procedures associated with three primary outcomes: better functioning, improved quality of life, and overall treatment satisfaction. RESULTS: Follow-up surveys were completed by 236 (84%) of the enrolled patients. Approximately two thirds of the study participants reported much better functioning (65%), a great quality of life improvement (64%), and a very positive perspective about their treatment outcome (68%). The following variables were associated with worse patient outcomes: older age, previous low back surgery, workers' compensation coverage, and consultation with an attorney before surgery. Patients undergoing a fusion procedure were more likely to report good outcomes. CONCLUSIONS: The authors' experience indicates that community-based outcomes data collection efforts are feasible and can be incorporated into usual clinical practice. The study results indicate that compensation payments and litigation are two important predictors of poor outcomes after low back surgery in community practice. Because of small numbers, varied diagnoses, and possible selection bias, the findings with respect to fusion should be interpreted cautiously.

Analysis of automated administrative and survey databases to study patterns and outcomes of care.

Large computerized databases often arise from national surveys, insurance claims, and statewide health care registries. These databases are increasingly used to examine patterns of medical care and certain outcomes of care and may be helpful in planning clinical trials. They are highly representative of defined populations, but have limited clinical information. Methods have been developed to identify episodes of low back pain and to quantify the severity of unrelated, comorbid medical conditions. Pitfalls in analysis are discussed, including limitations of diagnosis and procedure coding, cross-sectional nature of most data, limited clinical detail, and the necessarily observational (not experimental) nature of any group comparisons. There is growing interest in expanding the clinical information in such databases, for both quality improvement and research purposes.

Medical community involvement in a breast cancer screening promotional project.

The analysis, mobilization, and involvement of medical communities in two counties targeted for intervention by the Washington State Community Breast Cancer Screening Project is described. Principles of community organization were applied to the health care sectors in the counties, and the PRECEDE-PROCEED model was used as a conceptual framework for considering individual physician behavior. Quantitative and qualitative medical community assessment methods included a demographic study, a survey of primary care physicians, personal interviews with physicians, and medical office staff focus groups. In both intervention areas, physician planning groups selected, developed, and helped implement intervention activities targeting the health care sectors. These activities included informational mailings to physicians, training of medical office staff members and clinical mammographers, and support for a reminder system. The experience demonstrated that physicians practicing in medium-sized cities are willing to be active in community disease prevention programs.

The role of the community nurse on health committees.

With the changes in health care occurring in South Africa, new functions concerning the community nurse are being presented. The goal of the study was to explore and describe the role of the community nurse in health committees. An explorative, descriptive design was used and the empirical part was undertaken within the context of a metropolitan local authority. After conducting a literature study, six major roles of the community nurse on health committees were identified. After that a questionnaire was presented to community nurses to explore and describe their perceptions about the role of the community nurse on health committees. An interview schedule based on the literature study was drafted for presentation to selected members of health committees. Lastly guidelines describing the role of the community nurse on health committees were developed based on the findings of the study.

Perinatal mortality in infants of two different ethnic groups.

In a retrospective survey of 1433 Chinese and 1130 Gurkha (Nepali) births in an Armed Services environment in Hong Kong, neonatal mortality rates were analysed according to birthweight. The data thus obtained were compared with similar data from published surveys with the aim of ascertaining any differences in mortality rates.

Occupational respiratory disease in the United Kingdom 1989: a report to the British Thoracic Society and the Society of Occupational Medicine by the SWORD project group.

A voluntary scheme for the surveillance of work related and occupational respiratory disease (SWORD) was established in January 1989 with help from the British Thoracic Society and the Society of Occupational Medicine and support from the Health and Safety Executive. Three hundred and fifty four chest physicians representing 90% of the chest clinics in the United Kingdom and 361 occupational physicians submit reports regularly of newly diagnosed cases of work related respiratory illness with information on age, sex, residence, occupation, and suspected causal agent. In 1989 2101 cases were notified, of which frequent diagnoses were asthma (26%), mesothelioma (16%), pneumoconiosis (15%), benign pleural disease (11%), and allergic alveolitis (6%). Incidence rates calculated against denominators from the Labour Force Survey showed very large differences between occupational groups, especially for asthma and asbestos related diseases. Substantial regional variation in the incidence of asthma was not explained by the geographical distribution of high risk industries and was probably due to differing levels of ascertainment. The results imply that the true frequency of acute occupational respiratory disease in the United Kingdom may have been three times greater than that reported.

Use of screening mammography by general internists.

While physician endorsement has been shown to be highly important in motivating women to obtain screening mammograms, there is evidence that doctors do not refer women for the procedure as often as they should. The objective of this study was to help understand why physicians do not routinely utilize screening mammography. Randomly selected Washington State general internists were surveyed by mail, concerning mammography, during 1989. An expanded theory of reasoned action was used as a broad conceptual framework for considering factors potentially associated with use. The survey response rate was 66%, yielding a study sample of 85. Only 38% of the respondents reported they always ordered mammograms for women aged 50 years and over during preventive office visits. Nearly half (43%) had no reminder system for the test. Correlates of use included beliefs concerning the screening behavior of other doctors, the location of mammography facilities in relation to physician offices, and age. Physician-related barriers, such as doubts about effectiveness, were found to affect use more than patient-related barriers, such as cost. The recommendations of professional organizations were shown to have been important in influencing physician use of screening mammography. This study indicates a proportion of general internists are not routinely ordering mammograms for their age-eligible female patients. The findings identify barriers to use of mammography that need to be overcome if national efforts to promote use of the procedure by primary care physicians are to succeed. Implications for intervention are reviewed.

Low back pain hospitalization in Washington State: recent trends and geographic variations.

For several years, interest in clinical practice patterns has increased due to concerns about the costs and quality of health care. Our objectives were to examine recent trends and geographic variations in low back pain hospitalization. We analyzed data from a Washington State automated database for 1987-1992. Low back surgery rates in Washington changed little during the study years. In contrast, nonsurgical hospitalization rates fell from 15.5 to 5.1 per 10,000. The proportion of operations involving fusion decreased from 15.8% in 1987 to 11.7% in 1990, and then remained stable. During 1990, important county-to-county variations were observed in surgery rates, nonsurgical hospitalization rates, the proportion of operations involving fusion, and the percentage of surgical patients undergoing reoperation within 3 years. Wide county variations suggest that there may be overutilization or underutilization of low back pain treatments in some geographic areas. A more consistent approach to the management of back problems may benefit patients.

Peri-operative hypoxaemia in children undergoing application of a plaster jacket for scoliosis.

Twenty children (six female), median age 24 months (range 12-156) who presented for application of a plaster jacket for scoliosis were studied pre-operatively with pulse oximetry overnight and on the first postoperative night. Pre-operatively the median (range) arterial oxygen saturation was 97 (95-98)%, although eight children had short episodes of desaturation to < 90%. Postoperatively the median saturation was unchanged, and nine children had short episodes of desaturation. Neither the presence of episodes of desaturation pre-operatively, nor the median or lowest saturation recorded were predictors of postoperative median saturation or the presence of episodes of desaturation. Despite the presumed reduction in chest wall compliance, the application of a plaster jacket for scoliosis in these young children was not associated with a significant change in their oxygenation.

Hepatitis B knowledge among Vietnamese immigrants: implications for prevention of hepatocellular carcinoma.

BACKGROUND: Vietnamese have higher liver cancer rates than any other racial/ethnic group in the United States. Approximately 80% of liver cancers are etiologically associated with hepatitis B virus (HBV) infection, which is endemic in Southeast Asia. METHODS: A telephone survey of randomly selected Vietnamese households (n = 75) was conducted during 1998 to examine HBV knowledge among Seattle's Vietnamese community. The questionnaire included items related to the transmission of HBV, the possible sequelae of infection, and disease prevention. RESULTS: The response rate was 70% among reachable and eligible households. Prior to being provided with a description of the disease, two thirds of our respondents had heard of HBV infection. Less than 60% knew that asymptomatic individuals can transmit the disease to others. Most thought that HBV infection can cause liver cancer (63%) and death (80%). However, only a minority knew that infection can be lifelong (38%) and incurable (22%). Finally, 28% had never heard of the HBV vaccine. There were significant associations between knowledge and educational level as well as home ownership. CONCLUSIONS: The findings suggest that Vietnamese immigrants have low levels of knowledge about HBV infection, and indicate a need for targeted educational interventions aimed at reducing HBV-related liver cancer mortality.