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Background Pandemic-related restrictions have limited traditional models of lactation support. Research Aims The primary aim of this study was to determine changes to breastfeeding support services during the coronavirus-2019 pandemic according to trained lactation providers. The secondary aim was to assess strengths and limitations of telehealth services. Methods A prospective survey was conducted entirely online using the Qualtrics platform during June 2020. Gatekeepers at Connecticut agencies and breastfeeding networks were forwarded an anonymous survey link to distribute to eligible lactation staff. Results A variety of participants ( N = 39) completed the survey and the majority (69.2%; n = 27) were providing only telehealth services. More than half (58.1%; n = 18) of the participants who conducting telehealth in any form, found that virtual lactation support was moderately effective compared to in-person support. Weakness of virtual support included technical and logistical difficulties, challenges assisting with latching or reading body language over the phone or online, and accurately assessing infant growth. Strengths related to virtual support included the flexibility and convenience of home-based support, expanded communication strategies, and safety from virus exposure. Further, visits with a lactation professional decreased significantly during the pandemic. Limited in-hospital and pediatrician support were also noted, particularly among groups without access to telehealth resources. Conclusions As a result of the pandemic and associated shifts in lactation services, breastfeeding disparities may be further exacerbated among those without equitable access to lactation support. Challenges and innovations in virtual support may influence adaptive options in the field moving forward.

Objectives The challenges of understanding how interventions influence follow-up medical care are magnified during genomic testing because few patients have received it to date and because the scope of information it provides is complex and often unexpected. We tested a novel strategy for quantifying downstream healthcare utilization after genomic testing to more comprehensively and efficiently identify related services. We also evaluated the effectiveness of different methods for collecting these data. Methods We developed a risk-based approach for a trial of newborn genomic sequencing in which we defined primary conditions based on existing diagnoses and family histories of disease and defined secondary conditions based on unexpected findings. We then created patient-specific lists of services associated with managing primary and secondary conditions. Services were quantified based on medical record reviews, surveys, and telephone check-ins with parents. Results By focusing on services that genomic testing would most likely influence in the short-term, we reduced the number of services in our analyses by more than 90% compared with analyses of all observed services. We also identified the same services that were ordered in response to unexpected findings as were identified during expert review and by confirming whether recommendations were completed. Data also showed that quantifying healthcare utilization with surveys and telephone check-ins alone would have missed the majority of attributable services. Conclusions Our risk-based strategy provides an improved approach for assessing the short-term impact of genomic testing and other interventions on healthcare utilization while conforming as much as possible to existing best-practice recommendations.

Restraint and seclusion continues to be a challenging topic in psychiatric nursing care. While there is a movement toward reduction and elimination of restraint, emergency situations still arise that require intervention for the safety of patients and staff. In addition to traditional methods of restraint (physical holds, four-point restraint, seclusion), the restraint chair has been introduced at some hospitals as an alternative to four-point restraint. The restraint chair allows the patient to be upright in a seated position during the restraint process. Little research on the restraint chair currently exists. The purpose of this study was to examine the nurses' experience with the restraint chair compared to four-point restraint. Results indicate nurses feel the restraint chair is easier to use, more humane, less traumatic, comforting, and enhances the therapeutic relationship compared to four-point restraint. Based on the reports of nurses in this study and prior quantitative work on the restraint chair (Castillo, Coyne, Chan, Hall, & Vilke, 2011; Visaggio et al., 2018), the restraint chair appears to be a safe and effective alternative to traditional four-point restraint. More research verifying these results at other hospitals in the United States and abroad is warranted.

Poverty is increasing and it has adverse effects on health. Nurses need to understand how to help patients in poverty meet health goals within interprofessional teams. Nursing students and Veteran's Affairs employees, consisting of patient care and support staff, were recruited for an interprofessional poverty simulation. Prior to and directly following the simulation, participants were asked to complete the Attitudes about Poverty and Poor People (APPP) scale, the Toronto Empathy Questionnaire (TEQ), and the Self Reflection and Insight Scale (SRIS). Scores on the APPP and TEQ improved. The SRIS results had no significant changes. Interprofessional simulation positively impacts attitudes toward poverty and empathy in nursing students and health professionals.

Obesity has been linked to job absenteeism and decreased job performance. Additionally, shift work may be related to abnormal eating in nurses. This study examines the relationship between body mass index, job performance, absenteeism, and eating disorder risk among nurses. Registered Nurses (n = 63) participated in a survey that included the Work Limitations Questionnaire and the Eating Attitudes Test. Most participants were either overweight or obese. Significant correlations were noted between body mass index and job performance, and body mass index and risk of eating disorders. An understanding of how increased body mass index can affect a nurse's job performance and wellness warrants continued attention from the nursing profession.

OBJECTIVE To describe a technique for endoscopic evaluation of the coelomic viscera of koi (Cyprinus carpio) and to evaluate the ability to visually examine coelomic structures by use of an approach cranial or caudal to the pelvic girdle. ANIMALS 16 subadult koi. PROCEDURES Koi were anesthetized with buffered tricaine methanesulfonate. Coelioscopic examination was performed via a ventral midline incisional approach cranial or caudal to the pelvic girdle. A 2.7-mm × 18-cm 30° oblique endoscope within a 4.8-mm operating sheath and infusion of saline (0.9% NaCl) solution was used. Ease of entry into the coelomic cavity and visual examination of structures were scored for each fish. Fish were euthanized 2 or 8 weeks after the procedure, and necropsy was performed. RESULTS The coelioscopic procedure was tolerated well, and all koi recovered uneventfully. For all fish, ease of entry and visual examination scores of the liver, intestines, gonads, heart, and anterior kidney were satisfactory to excellent. Visual examination of the posterior kidney and swim bladder was satisfactory to difficult, whereas the spleen and gallbladder were not visually identified. No significant differences were noted in entry or visual examination scores between the cranial and caudal approaches or between sexes. Minor complications included mild hemorrhage, rupture of the gonadal capsule, formation of adhesions between the viscera and incision site, and delayed healing of the incision. CONCLUSIONS AND CLINICAL RELEVANCE Diagnostic coelioscopy of koi appeared to be safe and effective. This procedure could have potential for use in examination of coelomic structures and disease diagnosis.

Background: The study aims to describe the prevalence of sexual violence experienced by nursing students and to understand nursing students' practices and attitudes toward working with patients with this trauma history. Method: A convenience sample ( n = 75) of female nursing students from the United States completed the Life Events Checklist and responded to statements about their practices and attitudes. Results: Over a quarter (26.7%) experienced an unwanted or uncomfortable sexual experience. Of the 18.7% who were sexually assaulted, more than half also experienced physical assault and more than 70% reported other unwanted sexual experiences. Largely, students believed that screening patients for trauma is important (88.7%); yet, most (73.2%) felt unprepared and approximately 60% had not been taught how. Conclusion: This knowledge can aid nursing educators in understanding their students' life experiences so issues can be addressed in safe learning environments and practices and attitudes related to screening and caring for patients can be highlighted. [ J Nurs Educ . 2018;57(11):662–667.]

Coronary artery anomalies have been reported in Bulldogs and present an increased risk when performing balloon valvuloplasty. Identification of coronary anomalies has been reported using multidetector-row computed tomographic (MDCT) angiography with electrocardiographic gating. However, the utility of non-electrocardiographic-gated 16-row computed tomographic for MDCT for the identification of coronary artery anatomy or anomalies to the authors' knowledge has not been fully investigated. The purpose of this study was to evaluate the feasibility of non-electrocardiographic-gated computed tomographic (CT) angiography to identify coronary anomalies in Bulldogs with pulmonary valve stenosis. In this prospective, observational study, Bulldogs with echocardiographically diagnosed pulmonary valve stenosis, an echocardiographically derived transpulmonic pressure gradient >70 mm Hg, and a clinician recommendation for balloon valvuloplasty were included. Anesthetized dogs underwent a 16-row MDCT non-electrocardiographic-gated CT angiography. A board-certified veterinary radiologist and board-certified veterinary cardiologist reviewed the CT angiography studies and identified the coronary artery anatomy. When normal coronary artery anatomy was detected on CT angiography, a right ventricular outflow tract fluoroscopic angiogram was performed and evaluated during levophase to confirm normal coronary anatomy prior to balloon valvuloplasty. Dogs with coronary anomalies noted on CT angiography were recovered from anesthesia and balloon valvuloplasty was not performed. All dogs (10/10; 100%) had interpretable images from the non-electrocardiographic-gated CT angiography. Coronary anomalies were identified in six dogs based on non-electrocardiographic-gated CT angiography, five with type R2A anomaly and one had a single left coronary ostium. Four dogs had normal coronary anatomy based on non-electrocardiographic-gated CT angiography. Balloon valvuloplasty was performed without incident in these four dogs. We conclude that non-electrocardiographic-gated CT angiography represents a noninvasive method for diagnosing coronary anomalies in Bulldogs with pulmonary valve stenosis.

The emergence of next-generation genomic sequencing (NGS) tests for use in clinical care has generated widespread interest around the globe, but little is known about the availability and funding of these tests worldwide. We examined NGS availability across world regions and countries, with a particular focus on availability of three key NGS tests—Whole-Exome Sequencing or Whole-Genome Sequencing for diagnosis of suspected genetic diseases such as intellectual disability disorders or rare diseases, non-invasive prenatal testing for common genetic abnormalities in fetuses and tumor sequencing for therapy selection and monitoring of cancer treatment. We found that these NGS tests are available or becoming available in every major region of the world. This includes both high-income countries with robust genomic programmes such as the USA and the UK, and growing availability in countries with upper-middle-income economies. We used exploratory case studies across three diverse health care systems (publicly funded/national (UK), publicly funded/provincial (Canada) and mixed private/public system (USA)) to illustrate the funding challenges and approaches used to address those challenges that might be adopted by other countries. We conclude by assessing what type of data and initiatives will be needed to better track and understand the use of NGS around the world as such testing continues to expand.

PurposeExome sequencing (ES) has the potential to improve management of congenital anomalies and neurodevelopmental disorders in fetuses, infants, and children. US payers are key stakeholders in patient access to ES. We examined how payers view insurance coverage and clinical utility of pediatric and prenatal ES.MethodsWe employed the framework approach of qualitative research to conduct this study. The study cohort represented 14 payers collectively covering 170,000,000 enrollees.ResultsSeventy-one percent of payers covered pediatric ES despite perceived insufficient evidence because they saw merit in available interventions or in ending the diagnostic odyssey. None covered prenatal ES, because they saw no merit. For pediatric ES, 50% agreed with expanded aspects of clinical utility (e.g., information utility), and 21% considered them sufficient for coverage. For prenatal ES, payers saw little utility until in utero interventions become available.ConclusionThe perceived merit of ES is becoming a factor in payers' coverage for serious diseases with available interventions, even when evidence is perceived insufficient. Payers' views on ES's clinical utility are expanding to include informational utility, aligning with the views of patients and other stakeholders. Our findings inform clinical research, patient advocacy, and policy-making, allowing them to be more relevant to payers.

Precision medicine is poised to have an impact on patients, health care delivery systems and research participants in ways that were only imagined 15 years ago when the human genome was first sequenced. While discovery using genome-based technologies has accelerated, these have only begun to be adopted into clinical medicine. Here we define precision medicine and the stakeholder ecosystem required to enable its integration into research and health care. We explore the intersection of data science, analytics and precision medicine in creating a learning health system that carries out research in the context of clinical care and at the same time optimizes the tools and information used to delivery improved patient outcomes. We provide examples of real world impact, and conclude with a policy and economic agenda that will be necessary for the adoption of this new paradigm of health care both in the United States and globally.

The Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Cooper, 1993; Fairburn, Cooper, & O’Connor, 2008) is a well-established self-report instrument that measures eating disorder behaviors and attitudes, and is derived from the Eating Disorder Examination (EDE) interview (Fairburn & Cooper, 1993; Fairburn et al., 2008). The EDE-Q is relatively brief and cost-efficient, and is used for research and clinical purposes. Normative data are needed for appropriate analysis and interpretation of EDE-Q scores. Additionally, normative data provides a baseline distribution in a representative sample of individuals with eating disorders and establishes a baseline for comparison to healthy controls and individuals who have recovered from an eating disorder. Currently, normative data exists in a myriad of adult populations such as undergraduate students (Darcy, Hardy, Lock, Hill, & Peebles, 2013; Keane, Clarke, McGrath, Farrelly, & MacHale, 2017; Kelly, Cotter, & Mazzeo, 2012; Lavender, De Young, & Anderson, 2010; Luce & Crowther, 1999; Luce, Crowther, & Pole, 2008; Nakai et al., 2014; Quick & Byrd-Bredbenner, 2013; Reas, Overas, & Ro, 2012; Ro, Reas, & Lask, 2010; Villarroel, Penelo, Portell, & Raich, 2011), community samples (Hilbert, de Zwaan, & Braehler, 2012; Machado et al., 2014; Mond, Hay, Rodgers, & Owen, 2006; Mond, Hay, Rodgers, Owen, & Beumont, 2004), eating disorder (ED) samples (Brewin, Baggott, Dugard, & Arcelus, 2014; Dahlgren, Stedal, & Ro, 2017; Jennings & Phillips, 2017; Smith et al., 2017), and both ED and community samples (Aardoom, Dingemans, Slof Op’t Landt, & Van Furth, 2012; Welch, Birgegard, Parling, & Ghaderi, 2011). Few studies have examined normative data in adolescent populations. Normative EDE-Q data are available for healthy adolescent girls in the United Kingdom (Carter, Stewart, & Fairburn, 2001) and Portugal (Machado et al., 2014), and healthy adolescent boys and girls in Australia (Mond et al., 2014), Malaysia (Musa et al., 2016), and Mexico (Penelo, Negrete, Portell, & Raich, 2013). One Swedish study (Mantilla & Birgegard, 2016) reported norms on clinical and healthy adolescents using a 14-day time frame version of the EDE-Q, which had been specifically modified for adolescents (Carter et al., 2001). To the knowledge of these researchers, despite increased research and clinical use of the EDE-Q in adolescent populations, normative data in a clinical sample in the United States (U.S.) has not been published. Thus, the purpose of the present study was to provide EDE-Q norms for a sample of adolescent females diagnosed with anorexia nervosa (AN) admitted to inpatient treatment for an eating disorder.

Purpose:To explore the extent to which factors that determine performance transfer within and between time-trial and mass-start events in the track-cycling Omnium.Methods:Official finish rank in the 3 time-trial events, in the 3 mass-start events, and in the competition overall were collated in 20 international Omnium competitions between 2010 and 2014 for 196 male and 140 female cyclists. Linear mixed modeling of the log-transformed finish time for the time-trial events and of log-transformed finish rank for all events and final rank provided estimates of within-athlete race-to-race changes in performance and average betweenathletes differences across a season. These estimates were converted to various correlations representing relationships within and between the various events and final rank.Results:Intraclass correlation coefficients, representing race-to-race reproducibility of performance, were similar whether derived from finish rank or finish time for the time-trial events. Log-transformed finish ranks are therefore a suitable measure to assess and compare performance in time-trial and mass-start events. Omnium cyclists were more predictable in their performances from race to race in the timed events, whereas reduced predictability was observed in mass-start events. Interevent correlations indicated stronger links in performance between the timed disciplines, whereas performance in any of the mass-start events had only a slight positive relationship with performance in the other massstart events and little or no relationship with the timed events.Conclusions:Further investigation is warranted to determine whether factors related to performance in mass-start events can be identified to improve reproducibility or whether variability in performance results from random chance.

Exome sequencing (ES) has the potential to improve management of congenital anomalies and neurodevelopmental disorders in fetuses, infants, and children. US payers are key stakeholders in patient access to ES. We examined how payers view insurance coverage and clinical utility of pediatric and prenatal ES.We employed the framework approach of qualitative research to conduct this study. The study cohort represented 14 payers collectively covering 170,000,000 enrollees.Seventy-one percent of payers covered pediatric ES despite perceived insufficient evidence because they saw merit in available interventions or in ending the diagnostic odyssey. None covered prenatal ES, because they saw no merit. For pediatric ES, 50% agreed with expanded aspects of clinical utility (e.g., information utility), and 21% considered them sufficient for coverage. For prenatal ES, payers saw little utility until in utero interventions become available.The perceived merit of ES is becoming a factor in payers' coverage for serious diseases with available interventions, even when evidence is perceived insufficient. Payers' views on ES's clinical utility are expanding to include informational utility, aligning with the views of patients and other stakeholders. Our findings inform clinical research, patient advocacy, and policy-making, allowing them to be more relevant to payers.

An 8 yr old female spayed poodle/terrier mixed-breed dog was referred for evaluation of a recurrent and metastatic ovarian dysgerminoma. A total dose of 20Gy was administered to both the mediastinal metastatic lesion and retroperitoneal recurrent dysgerminoma in five daily fractions of 4Gy. Acute side effects were mild and self-limiting. This was followed by several courses of chemotherapy using a variety of agents. Despite extensive disease, this patient was still alive at the time of publication, 524 days after presentation and 501 days following completion of radiation. This case report demonstrates tolerability and efficacy of palliative radiation and chemotherapy for this rare tumor type.

Objective To evaluate the diagnostic and therapeutic utility of bronchoscopy in dogs undergoing computed tomography (CT) and surgery for intrathoracic disease (pyothorax and pneumothorax) secondary to migrating plant awns (MPA) and to report outcomes in dogs that did and did not undergo bronchoscopy in addition to CT and surgery. Study design Retrospective case series. Animals Thirty-seven client-owned dogs. Methods Medical records from 2008 to 2017 were reviewed for dogs with documented MPA in the thoracic cavity treated with CT and surgery with or without bronchoscopy. Information regarding diagnostics, treatments, complications, and outcomes relating to hospitalization was evaluated. Results At least one abnormal lung lobe was identified by CT in all dogs. Bronchial abnormalities were identified with bronchoscopy in 21 of 22 dogs (95.4%) with available reports. Agreement between CT and bronchoscopy findings ranged from 50% to 81.8%, depending on lung lobe. Thirty-six dogs had one or more lung lobes surgically removed. Thirty-seven MPA were retrieved via bronchoscopy in 10 of 27 (37%) dogs, and 39 MPA were retrieved at surgery in 26 of 37 (70.3%) dogs. Actinomyces spp. were cultured from surgical samples in 7 of 33 (21.2%) dogs. Thirty-five of 37 (94.6%) dogs survived to discharge. Conclusion Migrating plant awns were successfully retrieved via bronchoscopy. Agreement between CT findings and bronchoscopy was inconsistent, so there may be roles for both modalities. Short- and long-term survival was excellent in this cohort. Clinical significance Bronchoscopy may allow for diagnostic and therapeutic advantages compared with CT in dogs with endobronchial MPA. Actinomyces spp appear to be variably present in surgically acquired bacterial cultures in dogs with MPA.

Previously published myelographic studies do not report findings at the junction between the seventh cervical (C7) and first thoracic vertebrae (T1). Modern digital radiographic equipment allows improved visualization of C7-T1. Based on clinical experience, we hypothesized that 50% reduction of the dorsal myelographic column or 20% reduction of the dural diameter, criteria commonly used as a supportive finding for spinal cord compression in the cervical vertebral column, do not apply at C7-T1. A myelographic study was performed on 12 healthy, neurologically normal horses. Our hypothesis was confirmed; using established criteria eight of 12 horses would have been classified as having evidence of spinal cord compression at C7-T1. The dorsal myelographic column reduction at C7-T1 was 48 ± 12%, while the C6-C7 dorsal myelographic column reduction was 33 ± 17% (mean ± standard deviation) (P=0.010). The dural diameter reduction at C7-T1 (22.0 ± 6.7%) was significantly greater than the dural diameter reduction at C6-C7 (13.2 ± 9.5%) (P=0.0007). Further measurements and comparisons suggested that the apparent greater reduction of dorsal myelographic column and dural diameter at C7-T1 was due to larger intravertebral measurements at C7 rather than smaller intervertebral values at C7-T1. Based on these findings, alternative criteria should be used at C7-T1 when assessing clinical cases for cervical stenotic myelopathy. Reduction of the dorsal myelographic column by 60% or of the dural diameter by 30% would avoid high numbers of false positive myelographic cases at C7-T1.

Purpose: To further the understanding of elite athlete performance in complex race environments by examining the changes in cyclists’ performance between solo time trials and head-to-head racing in match-sprint tournaments. Methods: Analyses were derived from official results of cyclists in 61 elite international sprint tournaments (2000–2016), incorporating the results of 2060 male and 1969 female head-to-head match races. Linear mixed modeling of log-transformed qualification and finish ranks was used to determine estimates of performance predictability as intraclass correlation coefficients. Correlations between qualifying performance and final tournament rank were also calculated. Chances of winning head-to-head races were estimated adjusting for the difference in the cyclists’ qualifying times. All effects were evaluated using magnitude-based inference. Results: Minor differences in predictability between qualification time trial and final tournament rank were suggestive of more competitiveness among men in the overall tournament. Performance in the qualification time trial was strongly correlated with, but not fully indicative of, performance in the overall tournament. Correspondingly, being the faster qualifier had a large positive effect on the chances of winning a head-to-head race, but small substantial differences between riders remained after adjustment for time-trial differentials. Conclusions: The present study provides further insight into how real-world competition data can be used to investigate elite athlete performance in sports where athletes must directly interact with their opponents. For elite match-sprint cyclists, qualifying time-trial performance largely determines success in the overall tournament, but there is evidence of a consistent match-race ability that modifies the chances of winning head-to-head races.

OBJECTIVE To describe vertebral left atrial size (VLAS), a quantitative method to estimate left atrial (LA) size radiographically, and to determine its diagnostic value for prediction of echocardiographic LA enlargement in dogs with myxomatous mitral valve disease (MMVD) of varying severity. DESIGN Prospective observational study. ANIMALS 103 client-owned dogs with a left-sided systolic murmur. PROCEDURES For each dog, 3-view thoracic radiographs were obtained within 24 hours of an echocardiographic examination. The VLAS was measured on right and left lateral thoracic radiographs and compared with the left atrium-to-aortic root ratio acquired from short-axis (LA:AoSx) and long-axis (LA:AoLx) echocardiographic images. Left atrial enlargement was defined as an LA:AoLx ≥ 2.6 or LA:AoSx ≥ 1.6. Dogs were allocated to 4 groups on the basis of MMVD severity. RESULTS Of the 103 dogs, 15, 40, 26, and 22 were assigned to the control (no echocardiographic abnormalities), stage B1 (hemodynamically irrelevant MMVD), B2 (hemodynamically relevant MMVD), and C-D (MMVD with congestive heart failure) groups, respectively. Median VLAS, LA:AoSx, and LA:AoLx for the stage B2 and C-D groups were significantly greater than the corresponding medians for the control and stage B1 groups. There was a moderate positive correlation between VLAS and both LA:AoSx and LA:AoLx. Receiver operating characteristic analyses revealed that a VLAS ≥ 2.3 vertebrae was a useful predictor of LA enlargement. Intraobserver and interobserver agreements for VLAS measurements were high. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated VLAS was a repeatable and useful radiographic measurement for prediction of LA enlargement in dogs with MMVD.

Genetic testing and spending on that testing have grown rapidly since the mapping of the human genome in 2003. However, it is not widely known how many tests there are, how they are used, and how they are paid for. Little evidence from large data sets about their use has emerged. We shed light on the issue of genetic testing by providing an overview of the testing landscape. We examined test availability and spending for the full spectrum of genetic tests, using unique data sources on test availability and commercial payer spending for privately insured populations, focusing particularly on tests measuring multiple genes in the period 2014-17. We found that there were approximately 75,000 genetic tests on the market, with about ten new tests entering the market daily. Prenatal tests accounted for the highest percentage of spending on genetic tests, and spending on hereditary cancer tests accounted for the second-highest. Our results provide insights for those interested in assessing genetic testing markets, test usage, and health policy implications, including current debates over the most appropriate regulatory and payer coverage mechanisms.

A cat was evaluated for an acute-onset of right pelvic limb paresis. Thoracic radiographs revealed normal cardiac size and tortuous pulmonary arteries. Abdominal ultrasound identified a heartworm (HW) extending from the caudal abdominal aorta into the right external iliac artery and right femoral artery. The cat was HW-antigen positive. Echocardiography revealed a HW within the right branch of the main pulmonary artery and evidence of pulmonary hypertension. An agitated-saline contrast echocardiogram revealed a small right to left intracardiac shunt at the level of the atria. Surgical removal of the HW was performed with no substantial postoperative complications. There was return of blood flow and improved motor function to the limb. The cat remains mildly paretic on the affected limb with no other clinical signs.

Objective This study estimates how making oral contraceptive pills (OCPs) available without a prescription may affect contraceptive use, unintended pregnancies and associated contraceptive and pregnancy costs among low-income women. Study Design Based on published figures, we estimate two scenarios [low over-the-counter (OTC) use and high OTC use] of the proportion of low-income women likely to switch to an OTC pill and predict adoption of OCPs according to the out-of-pocket costs per pill pack. We then estimate cost-savings of each scenario by comparing the total public sector cost of providing OCPs OTC and medical care for unintended pregnancy. Results Twenty-one percent of low-income women at risk for unintended pregnancy are very likely to use OCPs if they were available without a prescription. Women's use of OTC OCPs varies widely by the out-of-pocket pill pack cost. In a scenario assuming no out-of-pocket costs for the over-the counter pill, an additional 11–21% of low-income women will use the pill, resulting in a 20–36% decrease in the number of women using no method or a method less effective than the pill, and a 7–25% decrease in the number of unintended pregnancies, depending on the level of use and any effect on contraceptive failure rates. Conclusions If out-of-pocket costs for such pills are low, OTC access could have a significant effect on use of effective contraceptives and unintended pregnancy. Public health plans may reduce expenditures on pregnancy and contraceptive healthcare services by covering oral contraceptives as an OTC product. Implications Interest in OTC access to oral contraceptives is high. Removing the prescription barrier, particularly if pill packs are available at low or zero out-of-pocket cost, could increase the use of effective methods of contraception and reduce unintended pregnancy and healthcare costs for contraceptive and pregnancy care.

An exploratory factor analysis on the Eating Disorder Examination-Questionnaire (EDE-Q) is presented for a clinical sample of women with anorexia nervosa. THE EDE-Q was completed by 169 participants after admission to an inpatient unit for eating disorders. Results of the current study did not support the four-factor model presented by the EDE-Q. A new four-factor solution was obtained with two factors showing similarity to the Restraint and Eating Concern subscales of the original model. The Shape and Weight Concern items primarily loaded together on one factor, along with preoccupation with food and fear of losing control over eating, two Eating Concern items. Finally, an appearance factor was obtained that supports the results of prior research. [ Journal of Psychosocial Nursing and Mental Health Services, 56 (5), 33–39.].

PurposeGreat uncertainty exists about the costs associated with whole-genome sequencing (WGS).MethodsOne hundred cardiology patients with cardiomyopathy diagnoses and 100 ostensibly healthy primary care patients were randomized to receive a family-history report alone or with a WGS report. Cardiology patients also reviewed prior genetic test results. WGS costs were estimated by tracking resource use and staff time. Downstream costs were estimated by identifying services in administrative data, medical records, and patient surveys for 6 months.ResultsThe incremental cost per patient of WGS testing was $5,098 in cardiology settings and $5,073 in primary care settings compared with family history alone. Mean 6-month downstream costs did not differ statistically between the control and WGS arms in either setting (cardiology: difference = -$1,560, 95% confidence interval -$7,558 to $3,866, p = 0.36; primary care: difference = $681, 95% confidence interval -$884 to $2,171, p = 0.70). Scenario analyses showed the cost reduction of omitting or limiting the types of secondary findings was less than $69 and $182 per patient in cardiology and primary care, respectively.ConclusionShort-term costs of WGS were driven by the costs of sequencing and interpretation rather than downstream health care. Disclosing additional types of secondary findings has a limited cost impact following disclosure.

Purpose To investigate binge eating (BE) and weight-related behaviors in overweight and obese college students. Data sources This was a secondary analysis of data from 487 overweight and obese college-age students from a private university in the northeastern United States. Conclusions BE was reported by 34.9% of students. Only 6.2% of participants reported the use of compensatory behaviors (i.e., self-induced vomiting, laxative, or diuretic use) to prevent weight gain. BE was associated with smoking and exercising to lose weight. Gender differences emerged from the data as women were more likely to report being obese, the use of compensatory behaviors, and to perceive themselves as moderately or extremely overweight. Implications for practice BE is a significant problem on college campuses and is associated with the development of obesity and eating disorders. Nurse practitioners (NPs) are in an excellent position to effect change in this population through their frequent contact with young adults in community and school-based venues. NPs are well-prepared to identify at-risk college students and provide them with individualized care, education, and support.

Cell-free DNA (cfDNA) prenatal screening tests have been rapidly adopted into clinical practice, due in part to positive insurance coverage. We evaluated the framework payers used in making coverage decisions to describe a process that should be informative for other sequencing tests. We analyzed coverage policies from the 19 largest US private payers with publicly available policies through February 2016, building from the University of California San Francisco TRANSPERS Payer Coverage Policy Registry. All payers studied cover cfDNA screening for detection of trisomies 21, 18, and 13 in high-risk, singleton pregnancies, based on robust clinical validity (CV) studies and modeled evidence of clinical utility (CU). Payers typically evaluated the evidence for each chromosomal abnormality separately, although results are offered as part of a panel. Starting in August 2015, 8 of the 19 payers also began covering cfDNA screening in average-risk pregnancies, citing recent CV studies and updated professional guidelines. Most payers attempted, but were unable, to independently assess analytic validity (AV). Payers utilized the standard evidentiary framework (AV/CV/CU) when evaluating cfDNA screening but varied in their interpretation of the sufficiency of the evidence. Professional guidelines, large CV studies, and decision analytic models regarding health outcomes appeared highly influential in coverage decisions. Genet Med advance online publication 22 September 2016

Clinical outcomes have been shown to be better, and total costs lower, when patients with chronic illness such as diabetes are managed using a population health strategy in a primary care setting that includes structured coordination of care with specialty services. This "population health management approach" offers a promising new vision for addressing oral disease as a chronic illness through a collaborative partnership between primary care teams and dental professionals.

Many organizations are developing health care price information tools for consumers. However, consumers may avoid low-price care if they perceive price to be associated with quality. We conducted a nationally representative survey to examine whether consumers perceive that price and quality are associated and whether the way in which questions are framed affects consumers' responses. Most Americans (58-71 percent, depending on question framing) did not think that price and quality are associated, but a substantial minority did perceive an association (21-24 percent) or were unsure whether there was one (8-16 percent). Responses to questions framed in terms of high price and high quality differed from responses to questions framed in terms of low price and low quality. People who had compared prices were more likely than those who had not compared prices to perceive that price and quality were associated. We explore implications of these findings, including how behavioral economics can inform approaches to helping consumers use price and quality information.

Little is known about the out-of-pocket expenditures and dispensing patterns for oral contraceptive pills (OCPs), factors associated with these outcomes and whether they change over time.Observational cohort using 1996-2006 Medical Expenditure Panel Surveys.Women spent $16 out-of-pocket per pack, on average (median=$10.41). Of the OCP users, 38% paid $15 or more per pack and 44% obtained one pack per purchase. Over time, fewer women paid $15 or more (52% in 1996-1998 vs. 34% in 1999-2006, p.001) and fewer obtained one pack per purchase (76% in 1996-1998 vs. 35% in 1999-2006, p.001). Age and insurance were associated with out-of-pocket expenditures and dispensing patterns.Women paid a substantial amount out-of-pocket for OCPs and dispensing limits remained, although these improved over time. Better insurance coverage of contraception and policies targeting younger women and the uninsured in particular would help overcome barriers to OCP access.

The EGAPP Working Group (EWG) found insufficient evidence to make a recommendation for or against the use of tumor gene expression profiles to improve outcomes in defined populations of women with breast cancer. For one test, the EWG found preliminary evidence of potential benefit of testing results to some women who face decisions about treatment options (reduced adverse events due to low risk women avoiding chemotherapy), but could not rule out the potential for harm for others (breast cancer recurrence that might have been prevented). The evidence is insufficient to assess the balance of benefits and harms of the proposed uses of the tests. The EWG encourages further development and evaluation of these technologies.The measurement of gene expression in breast tumor tissue is proposed as a way to estimate the risk of distant disease recurrence in order to provide additional information beyond current clinicopathological risk stratification and to influence decisions about treatment in order to improve health outcomes. Based on their review of the EGAPP-commissioned evidence report, Impact of Gene Expression Profiling Tests on Breast Cancer Outcomes and other data summaries, the EWG found no direct evidence linking tumor gene expression profiling of women with breast cancer to improved outcomes, and inadequate evidence to construct an evidence chain. However, further evaluation on the clinical utility of some tests and management algorithms, including well-designed randomized controlled trials, is warranted.Some data on technical performance of assays were identified for MammaPrint and Oncotype DX, though estimates of analytic sensitivity and specificity could not be made. Published performance data on the laboratory developed Quest H:I Test were limited. Overall, the EWG found the evidence to be inadequate.The EWG found adequate evidence regarding the association of the Oncotype DX Recurrence Score with disease recurrence and adequate evidence for response to chemotherapy. The EWG found adequate evidence to characterize the association of MammaPrint with future metastases, but inadequate evidence to assess the added value to standard risk stratification, and could not determine the population to which the test would best apply. The evidence was inadequate to characterize the clinical validity of the Quest H:I Test.The EWG found no evidence regarding the clinical utility of the MammaPrint and Quest H:I Ratio tests, and inadequate evidence regarding Oncotype DX. These technologies have potential for both benefit and harm.The EWG reviewed economic studies that used modeling to predict potential effects of using gene profiling, and judged the evidence inadequate.

Objectives Colorectal cancer (CRC) screening uptake remains poor. Until we understand patient motivation and preferences for undertaking screening, it is unlikely the uptake will be optimal. Our objective is to examine patient preferences for CRC screening modalities and uptake rates using utility-based methods. Methods The preference survey was mailed to a random sample of Canadian subjects aged 40 to 60 years from a primary care network. A fractional factorial experimental design maximized D-efficiency and included four blocks with 12 choice tasks in a conditional two-step design, two-alternative discrete choice format with five screening attributes (process, pain, preparation, sensitivity, and specificity). Bivariate probit regression analysis was used to estimate patient preferences for attributes, choice probabilities for alternative modalities and expected rates of uptake. Results Five hundred forty-seven of 1047 surveys were returned. Almost 30% of respondents preferred no screening. The most preferred test attribute levels were noninvasiveprocess (e.g., CT), no preparation, no pain, 100% specificity, and 90% sensitivity. Accuracy-related attributes were more important than test process-related attributes. Virtual colonoscopy was the most preferred, followed by colonoscopy, barium enema, sigmoidoscopy, and fecal DNA testing, based on simulated choice probability estimates. Fecal occult blood testing (FOBT) was least preferred. Adjusted screening uptake rate estimates showed the greatest impact (42% increase) would be achieved if all CRC screening modalities were available rather than FOBT alone. Conclusion Our findings emphasize the important role of patient preferences for no screening and in selecting alternative CRC screening modalities. CRC screening implementation in Canada should consider patient preferences to optimize uptake.

A major health priority is to increase colorectal cancer screening, and colonoscopy has become an increasingly important method of screening. The Medicare program began coverage for colonoscopy for average risk individuals in 2001.We sought to examine whether overall colorectal cancer screening increased over time and whether these increases were a result of increased utilization of all methods or a result of greater use of colonoscopy but reduced use of other methods, whether the enactment of Medicare coverage was associated with an increase in colonoscopy among Medicare enrollees, and whether these trends equally affected subpopulations.We used nationally representative data from the 2000 and 2003 National Health Interview Surveys and analyzed data using used chi, difference-in-differences tests, and logistic regression analyses to examine whether screening rates differed between 2000 and 2003.The percentage of individuals being screened for colorectal cancer using any method increased modestly from 2000 to 2003 (3%), with increases a result of increased use of colonoscopy and a reduction in the use of other methods. Increases in colonoscopy use were significant among all populations except the insured, non-Medicare population with low incomes. Among Medicare enrollees with high/middle incomes, colonoscopy use increased 14% from 2000 to 2003 compared with an increase of only 7% among low-income groups, which was a significant difference (P0.01). Similarly, among insured, non-Medicare enrollees with high/middle incomes, colonoscopy use increased 11% from 2000 to 2003 compared with an increase of only 4% among low-income groups, which also was a significant difference (P0.01).Colorectal cancer screening utilization increased modestly from 2000 to 2003, with the increases that primarily were the result of increased colonoscopy use. Increases in colonoscopy use, however, were primarily among high/middle income groups. Although Medicare coverage may have indirectly facilitated the increase in colonoscopy, we could not determine that coverage directly increased screening rates. Screening rates remain modest and lower income individuals continue to be screened less. Topics for future research include approaches to facilitating screening among low-income individuals and evaluating the impact of policy coverage decisions.

Aim The purpose of this study was to explore binge eating (BE) behavior in male and female college students. Background BE is a disordered eating behavior frequently reported in college students and is of particular concern because of its link to the development of eating disorders and obesity. Methods An anonymous online survey was conducted and open-ended responses (n = 425) were coded using qualitative methods. Chi-square analyses were used to determine if gender differences existed. Results Findings indicate that females were more likely to report emotional concerns such as stress and negative affect prior to BE and poor body image and negative affect following episodes of BE. Meanwhile, males indicated more substance use, exercise, and hunger before a BE episode, with feeling satisfied or full after BE. Males were also more likely to report BE socially on meal type foods, while women were more likely to be at home or alone while BE. Conclusions Significant gender differences were noted indicating the need for tailored interventions. Nurses should screen college students for disordered eating behaviors, as well as associated concerns that may precede binge eating episodes including substance use, stress, and negative affect.

Author(s): Phillips, Kathryn A; Ladabaum, Uri; Pletcher, Mark J; Marshall, Deborah A; Douglas, Michael P

ObjectiveTo assess whether the specialty of a patient’s primary care physician or being part of a gatekeeper plan influence breast and cervical cancer screening. Methods: Cross-sectional study of women in a national sample. For mammography, we studied women aged 40 and above, and for Papanicolaou (Pap) smear, women aged 18–65years. Screening mammography or Pap smear within the previous two years was measured by patient self-report. The key independent variables were primary care physician specialty and whether the patient had a gatekeeper. Results: Among women seen by a family practice physician, there was a higher probability of being screened if the patient was part of a gatekeeper plan than if the patient was not part of a gatekeeper plan: mammography (OR=1.35; 95 CI=1.20–1.52) and Pap smear (OR=1.60; 95 CI=1.34–1.91). Among women seen by an internal medicine physician, cancer screening did not vary significantly by gatekeeper status. Conclusions: The impact of gatekeeper plans upon cancer screening varies according to the primary care physician’s specialty. Policy interventions designed to increase cancer screening should take into account different responses to gatekeeper requirements among different types of providers.

To examine preferences for HIV test methods using conjoint analysis, a method used to measure economic preferences (utilities).Self-administered surveys at four publicly funded HIV testing locations in San Francisco, California, between November 1999 and February 2000 (n = 365, 96 percent response rate).We defined six important attributes of HIV tests and their levels (location, price, ease of collection, timeliness/accuracy, privacy/anonymity, and counseling). A fractional factorial design was used to develop scenarios that consisted of combinations of attribute levels. Respondents were asked 11 questions about whether they would choose "Test A or B" based on these scenarios.We used random effects probit models to estimate utilities for testing attributes. Since price was included as an attribute, we were able to estimate willingness to pay, which provides a standardized measure for use in economic evaluations. We used extensive analyses to examine the reliability and validity of the results, including analyses of: (1) preference consistency, (2) willingness to trade among attributes, and (3) consistency with theoretical predictions.Respondents most preferred tests that were accurate/timely and private/anonymous, whereas they had relatively lower preferences for in-person counseling. Respondents were willing to pay an additional $35 for immediate, highly accurate results; however, they had a strong disutility for receiving immediate but less accurate results. By using conjoint analysis to analyze new combinations of attributes, we found that respondents would most prefer instant, highly accurate home tests, even though they are not currently available in the U.S. Respondents were willing to pay $39 for a highly accurate, instant home test.The method of conjoint analysis enabled us to estimate utilities for specific attributes of HIV tests as well as the overall utility obtained from various HIV tests, including tests that are under consideration but not yet available. Conjoint analysis offers an approach that can be useful for measuring and understanding the value of other health care goods, services, and interventions.

Ethnic disparities in access to health care is a persistent problem in the US. Despite the broad implementation of managed care, there is little information that specifically addresses how this type of coverage may affect ethnic disparities.To examine the effect of managed care insurance on the use of preventive care for different ethnic groups.Observational cohort using the 1996 Medical Expenditure Panel Survey.Adults with health insurance who report their ethnicity as white, black, Hispanic, or Asian/Pacific Islander.(1) Mammography within the past 2 years for women between 50 and 75 years of age; (2) clinical breast exam within the past 2 years for women between 40 and 75 years; (3) Papanicolaou smear within the past 2 years for women between 18 and 65 years; and (4) cholesterol screening within the past 5 years for men and women older than the age of 20 years.Hispanic people enrolled in a managed care plan report higher rates of mammography, breast exam, and Papanicolaou smear compared with Hispanic people with fee-for-service insurance. For example, the adjusted predicted probability of a mammogram for Hispanic women with managed care was 85.6% compared with 72.4% for Hispanic women with fee-for-service coverage (risk difference: 13.2%; 95% CI for the risk difference 0.7%-25.7%). White persons with managed care are also more likely than white persons with fee-for-service coverage to receive mammography and cholesterol screening. Managed care is not associated with less preventive care for any ethnic group.In this nationally representative household survey, it was found that managed care is associated with greater use of some preventive care for Hispanic persons and white persons than fee-for-service insurance. Despite a focus on prevention, the benefits of managed care are not apparent for black persons or Asian/Pacific Islanders.

Background— The coronary artery calcium (CAC) score predicts future coronary heart disease (CHD) events and could be used to guide primary prevention interventions, but CAC measurement has costs and exposes patients to low-dose radiation. Methods and Results— We estimated the cost-effectiveness of measuring CAC and prescribing statin therapy based on the resulting score under a range of assumptions using an established model enhanced with CAC distribution and risk estimates from the Multi-Ethnic Study of Atherosclerosis. Ten years of statin treatment for 10 000 55-year-old women with high cholesterol (10-year CHD risk, 7.5%) was projected to prevent 32 myocardial infarctions, cause 70 cases of statin-induced myopathy, and add 1108 years to total life expectancy. Measuring CAC and targeting statin treatment to the 2500 women with CAC>0 would provide 45% of the benefit (+501 life-years), but CAC measurement would cost $2.25 million and cause 9 radiation-induced cancers. Treat all was preferable to CAC screening in this scenario and across a broad range of other scenarios (CHD risk, 2.5%–15%) when statin assumptions were favorable ($0.13 per pill and no quality of life penalty). When statin assumptions were less favorable ($1.00 per pill and disutility=0.00384), CAC screening with statin treatment for persons with CAC>0 was cost-effective (100 or >300) were generally not cost-effective. Conclusions— CAC testing in intermediate risk patients can be cost-effective but only if statins are costly or significantly affect quality of life.

Little is known about the proportion of oral contraceptive pill (OCP) users that use progestin-only pills (POPs), factors associated with POP use, and whether out-of-pocket expenditures and dispensing patterns are similar to combined oral contraceptives (COCs).Observational cohort using 1996-2008 Medical Expenditure Panel Surveys.Among all OCP users, 4% used POPs and changed little between 1996 and 2008. Women were more likely to use POPs if they received postpartum care (p.001), had a diagnosis of hypertension (p.001) or resided in the West (p.01). POP users, compared to COC users, were more likely to pay $15 and more (p.01) and less likely to obtain more than one pack per purchase (p.001), controlling for age, race/ethnicity and insurance coverage.POP use is very low in the United States. POP users obtained fewer packs per purchase compared with COC users, suggesting that POP may be used as transitional OCPs, particularly during the postpartum period.

Scientific advances have improved our ability to target cancer interventions to individuals who will benefit most and spare the risks and costs to those who will derive little benefit or even be harmed. Several approaches are currently used for targeting interventions for cancer risk reduction, screening, and treatment, including risk prediction algorithms for identifying high-risk subgroups and diagnostic tests for tumor markers and germline genetic mutations. Economic evaluation can inform decisions about the use of targeted interventions, which may be more costly than traditional strategies. However, assessing the impact of a targeted intervention on costs and health outcomes requires explicit consideration of the method of targeting. In this study, we describe the importance of this principle by reviewing published cost-effectiveness analyses of targeted interventions in breast cancer. Few studies we identified explicitly evaluated the relationships among the method of targeting, the accuracy of the targeting test, and outcomes of the targeted intervention. Those that did found that characteristics of targeting tests had a substantial impact on outcomes. We posit that the method of targeting and the outcomes of a targeted intervention are inextricably linked and recommend that cost-effectiveness analyses of targeted interventions explicitly consider costs and outcomes of the method of targeting.

Testing has been advocated for all persons with newly diagnosed colorectal cancer to identify families with the Lynch syndrome, an autosomal dominant cancer-predisposition syndrome that is a paradigm for personalized medicine.To estimate the effectiveness and cost-effectiveness of strategies to identify the Lynch syndrome, with attention to sex, age at screening, and differential effects for probands and relatives.Markov model that incorporated risk for colorectal, endometrial, and ovarian cancers.Published literature.All persons with newly diagnosed colorectal cancer and their relatives.Lifetime.Third-party payer.Strategies based on clinical criteria, prediction algorithms, tumor testing, or up-front germline mutation testing, followed by tailored screening and risk-reducing surgery.Life-years, cancer cases and deaths, costs, and incremental cost-effectiveness ratios.The benefit of all strategies accrued primarily to relatives with a mutation associated with the Lynch syndrome, particularly women, whose life expectancy could increase by approximately 4 years with hysterectomy and salpingo-oophorectomy and adherence to colorectal cancer screening recommendations. At current rates of germline testing, screening, and prophylactic surgery, the strategies reduced deaths from colorectal cancer by 7% to 42% and deaths from endometrial and ovarian cancer by 1% to 6%. Among tumor-testing strategies, immunohistochemistry followed by BRAF mutation testing was preferred, with an incremental cost-effectiveness ratio of $36,200 per life-year gained.The number of relatives tested per proband was a critical determinant of both effectiveness and cost-effectiveness, with testing of 3 to 4 relatives required for most strategies to meet a threshold of $50,000 per life-year gained. Immunohistochemistry followed by BRAF mutation testing was preferred in 59% of iterations in probabilistic sensitivity analysis at a threshold of $100,000 per life-year gained. Screening for the Lynch syndrome with immunohistochemistry followed by BRAF mutation testing only up to age 70 years cost $44,000 per incremental life-year gained compared with screening only up to age 60 years, and screening without an upper age limit cost $88,700 per incremental life-year gained compared with screening only up to age 70 years.Other types of cancer, uncertain family pedigrees, and genetic variants of unknown significance were not considered.Widespread colorectal tumor testing to identify families with the Lynch syndrome could yield substantial benefits at acceptable costs, particularly for women with a mutation associated with the Lynch syndrome who begin regular screening and have risk-reducing surgery. The cost-effectiveness of such testing depends on the participation rate among relatives at risk for the Lynch syndrome.National Institutes of Health.

Background Administrative claims and medical records are important data sources to examine healthcare utilization and outcomes. Little is known about identifying personalized medicine technologies in these sources. Objectives To describe agreement, sensitivity, and specificity of administrative claims compared with medical records for 2 pairs of targeted tests and treatments for breast cancer. Research Design Retrospective analysis of medical records linked to administrative claims from a large health plan. We examined whether agreement varied by factors that facilitate tracking in claims (coding and cost) and that enhance medical record completeness (records from multiple providers). Subjects Women (35 to 65 y of age) with incident breast cancer diagnosed in 2006 to 2007 (n=775). Measures Use of human epidermal growth factor receptor 2 (HER2) and gene expression profiling (GEP) testing, trastuzumab, and adjuvant chemotherapy in claims and medical records. Results Agreement between claims and records was substantial for GEP, trastuzumab, and chemotherapy, and lowest for HER2 tests. GEP, an expensive test with unique billing codes, had higher agreement (91.6% vs. 75.2%), sensitivity (94.9% vs. 76.7%), and specificity (90.1% vs. 29.2%) than HER2, a test without unique billing codes. Trastuzumab, a treatment with unique billing codes, had slightly higher agreement (95.1% vs. 90%) and sensitivity (98.1% vs. 87.9%) than adjuvant chemotherapy. Conclusions Higher agreement and specificity were associated with services that had unique billing codes and high cost. Administrative claims may be sufficient for examining services with unique billing codes. Medical records provide better data for identifying tests lacking specific codes and for research requiring detailed clinical information.

As gene expression profile (GEP) testing for breast cancer may provide additional prognostic information to guide the use of adjuvant chemotherapy, we examined the association between GEP testing and use of chemotherapy, serious chemotherapy-related adverse effects, and total charges during the 12 months following diagnosis. Medical record review was conducted for women age 30–64 years, with incident, non-metastatic, invasive breast cancer diagnosed 2006–2008 in a large, national health plan. Of 534 patients, 25.8% received GEP testing, 68.2% received chemotherapy, and 10.5% experienced a serious chemotherapy-related adverse effect. GEP testing was most commonly used in women at moderate clinical risk of recurrence (52.0 vs. 25.0% of low-risk women and 5.5% of high-risk). Controlling for the propensity to receive GEP testing, women who had GEP were less likely to receive chemotherapy (propensity adjusted odds ratio, 95% confidence interval 0.62, 0.39–0.99). Use of GEP was associated with more chemotherapy use among women at low risk based on clinical characteristics (OR = 42.19; CI 2.50–711.82), but less use among women with a high risk based on clinical characteristics (OR = 0.12; CI 0.03–0.47). Use of GEP was not associated with chemotherapy for the moderate risk group. There was no significant relationship between GEP use and either serious chemotherapy-associated adverse effects or total charges. While GEP testing was associated with an overall decrease in adjuvant chemotherapy, we did not find differences in serious chemotherapy-associated adverse events or charges during the 12 months following diagnosis.

Given the likely proliferation of targeted testing and treatment strategies for cancer, a better understanding of the utilization patterns of human epidermal growth factor receptor 2 (HER2) testing and trastuzumab and newer gene expression profiling (GEP) for risk stratification and chemotherapy decision making are important.Cross-sectional.We performed a medical record review of women aged 35 to 65 years diagnosed between 2006 and 2007 with invasive localized breast cancer, identified using claims from a large national health plan (N = 775).Almost all women received HER2 testing (96.9%), and 24.9% of women with an accepted indication received GEP. Unexplained socioeconomic differences in GEP use were apparent after adjusting for age and clinical characteristics; specifically, GEP use increased with income. For example, those in the lowest income category ($40,000) were less likely than those with an income of $125,000 or more to receive GEP (odds ratio, 0.34; 95% confidence interval, 0.16 to 0.73). A majority of women (57.7%) with HER2-positive disease received trastuzumab; among these women, differences in age and clinical characteristics were not apparent, although surprisingly, those in the lowest income category were more likely than those in the high-income category to receive trastuzumab (P = .02). Among women who did not have a positive HER2 test, 3.9% still received trastuzumab. Receipt of adjuvant chemotherapy increased as GEP score indicated greater risk of recurrence.Identifying and eliminating unnecessary variation in the use of these expensive tests and treatments should be part of quality improvement and efficiency programs.

BACKGROUND This report describes the in-hospital experience with percutaneous transluminal coronary angioplasty (PTCA) for the state of California in 1989. Data are derived from the statewide hospital discharge abstracts. METHODS AND RESULTS A total of 24,883 PTCAs were performed; most patients (70%) were men and most procedures were single vessel (87%). About one fifth (19%) of patients had a principal diagnosis of acute myocardial infarction (AMI). Overall mortality was 1.4% and was higher in the AMI group (4.2%) versus the non-AMI group (0.8%, P = .0001). Mortality was higher for AMI patients having PTCA on the day of or day after admission (5.5%) versus those treated later (2.6%, P = .0001). Five percent of patients had coronary artery bypass surgery (CABG) after PTCA; CABG was performed on the same day as PTCA in 61.7% of cases. Patients presenting with AMI were more likely to have CABG (7.1%) than non-AMI patients (4.5%, P = .0001). Mortality associated with CABG was 7.3% and was higher in the AMI group (12.0%) than in the non-AMI group (5.5%, P = .0001). Factors predictive of increased mortality by bivariate analysis included age > 63 years (2.1% mortality versus 0.8% < or = 63, P = .01), female sex (1.9% versus 1.2% for men, P < .01), and the presence of diabetes (1.9% versus 1.3% for nondiabetics, P < .05). Multiple logistic regression showed that timings of PTCA with respect to admission (P = .004) and age (P = .05) were predictors of mortality, but female sex was predictive only in the non-AMI group (P = .03). Mean hospital charges were $19,597 (+/- SD, $18,213). Forty-two percent of the 110 hospitals performed more than the recommended minimum of 200 cases per year. The requirement for CABG during the same admission or the combined adverse outcome of CABG and/or death was increased in the lower-volume centers for both AMI and non-AMI patients (P < .001), although mortality alone was not. CONCLUSIONS The mortality and need for CABG surgery in the statewide California PTCA experience is higher than that generally reported in the literature. In patients with an admitting diagnosis of AMI, the overall mortality was higher, as was the need for CABG and the associated CABG mortality. Most hospitals performed fewer than 200 PTCAs per year. Rates of CABG surgery and the combination of CABG and/or mortality, adjusted only for the presence or absence of AMI, were increased at the low-volume institutions.

Divisions over abortion are a major obstacle for health reform legislation in the United States [1]. We use nationally representative data from a government survey to examine how much uninsured individuals, who will be covered under health reform, currently pay out-of-pocket for health care and how this compares to costs of abortion care.

Patient preferences can affect colorectal cancer (CRC) screening test use. We compared utility-based preferences for alternative CRC screening tests from a stated-preference discrete-choice survey of the general population and physicians in Canada and the United States.General population respondents (Canada, n = 501; US, n = 1087) participated in a survey with 12 choice scenarios and 9 CRC screening test attributes. Physicians (n = 100, both Canada and US) reported expected patient preferences. We estimated relative importance of attributes using bivariate probit regression analysis and calculated willingness-to-pay for various CRC screening tests.In 28 and 31% of scenarios, Canadian and US respondents, respectively, chose no screening over a hypothetical test. Canadian (45%) and US (46%) physicians expected patients to choose no screening more often. For all groups the most important attribute was sensitivity, but physicians' perception of patients' preferences are significantly different from actual preferences. Other key attributes are those related to test performance or the testing process. Fecal DNA, colonoscopy, and virtual colonoscopy were the most preferred tests by all groups, but respondents were willing-to-pay more than physicians predicted.Physicians' perception of patients' preferences are quite different from those of the general population. However, among general population and physicians, Canadian and US preferences were similar.

Of the roughly 1.3 million abortion procedures performed in the United States in 2003, only 25% of patients used their health insurance to pay for the medical expenses, even though 82% of all women between the ages 18 and 64 had some form of insurance that year (Finer & Henshaw, 2003; Kaiser Family Foundation, 2004). This finding is interesting in light of another study, which found that 87% of a nationally representative sample of 205 private health insurers covered abortion services by 2002, an increase from 70% of insurers sampled in 1993 (Sonfield, Gold, Frost, & Darroch, 2004). This evidence suggests that women who have health insurance and pay out of pocket (OOP) for abortion may be encountering obstacles to using health insurance for abortion procedures, an issue that has not yet been fully examined in the prior research literature. Our objective was to examine the evidence regarding insured women’s OOP payment for abortion. We first consider possible reasons for women’s uncertainty about insurance coverage for abortion procedures and the impact that privacy concerns, abortion clinics, and a limited decision-making timeframe have on this uncertainty. We then compare the abortion case study to another medical procedure, BRCA genetic screening, where some insured patients choose to pay OOP whereas others do not for these procedures. We conclude that the limited evidence suggests that there are barriers to women’s use of their health insurance plans for abortion procedures that should be addressed.

Introduction Studies show that the recommendations of a primary care physician for colorectal cancer screening may be one important influence on an individual's use of screening. However, another possible influence, the effect of regional differences in physicians' beliefs and recommendations on screening use, has not been assessed. Methods We linked data from the National Health Interview Survey on the use of colorectal cancer screening by respondents aged 50 years or older, by hospital-referral region, with data from the Survey of Colorectal Cancer Screening Practices on the colorectal cancer screening recommendations of primary care physicians, by region. Our principal independent variables were the proportion of physicians in a region who recommended screening at age 50 and continuing screening at the recommended frequency. Results On average, 53.3% of physicians in a region correctly recommended initiating colorectal cancer screening, and 64.8% advised screening at the recommended frequency. Of adults who lived in regions where less than 30% of physicians correctly recommended initiating screening, 47.3% had been screened, in contrast to 54.8% in areas where 70% or more of physicians made correct recommendations. Seventy-one percent of respondents living in regions where less than 30% of physicians advised screening at the recommended frequency were current on screening, in contrast to 79.9% of respondents living in regions where 70% or more of physicians made this recommendation. These differences were statistically significant after adjustment for individual characteristics. Conclusion Strategies to improve colorectal cancer screening recommendations of primary care physicians may improve the use of screening for millions of Americans.