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Cannabis includes 140 active cannabinoid compounds, the most important of which are tetrahydrocannabinol and cannabidiol (CBD). Tetrahydrocannabinol is primarily responsible for the intoxicating effects of cannabis; CBD has potential therapeutic effects, including reduction in chronic pain. Recent legislative changes have resulted in the legal availability of cannabinoids in all 50 states, as well as a marked increase in patients' interest in their use. Despite an abundance of data, albeit of varied quality, clinicians may feel poorly prepared to counsel patients seeking advice on the suitability of CBD products for various indications, particularly chronic neuropathic pain. In 2018, on the basis of a systematic review of the literature, a Canadian Evidence Review Group published a guideline with recommendations for clinicians on prescribing cannabinoids in primary care practice. The overall quality of evidence was low to very low. In a meta-analysis of 15 randomized trials of medical cannabis for treating chronic pain, 39% of patients achieved at least a 30% reduction in pain. The corresponding value for placebo-treated patients was 30%; the number needed to treat was 11. More evidence exists for neuropathic pain than for other types of noncancer pain. Here, a general internist with a focus on addiction medicine and an addiction psychiatrist discuss how they would apply the literature to make recommendations for a patient with painful diabetic neuropathy, including counseling on both potential benefits and harms.

About 15% of adults in the United States-37 million persons-have chronic kidney disease (CKD). Chronic kidney disease is divided into 5 groups, ranging from stage 1 to stage 5 CKD, whereas end-stage kidney disease (ESKD) is defined as permanent kidney failure. The treatment options for ESKD are kidney replacement therapy (KRT) and conservative management. The options for KRT include hemodialysis (either in-center or at home), peritoneal dialysis, and kidney transplant. Conservative management, a multidisciplinary model of care for patients with stage 5 CKD who want to avoid dialysis, is guided by patient values, preferences, and goals, with a focus on quality of life and symptom management. In 2015, the Kidney Disease Outcomes Quality Initiative recommended that patients with an estimated glomerular filtration rate below 30 mL/min/1.73 m2 be educated about options for both KRT and conservative management. In 2018, the National Institute for Health and Care Excellence recommended that assessment for KRT or conservative management start at least 1 year before the need for therapy. It also recommended that in choosing a management approach, predicted quality of life, predicted life expectancy, patient preferences, and other patient factors be considered, because little difference in outcomes has been found among options. Here, 2 experts-a nephrologist and a general internist-palliative care physician-reflect on the care of a patient with advanced CKD and mild to moderate dementia. They discuss the management options for patients with advanced CKD, the pros and cons of each method, and how to help a patient choose among the options.

Approximately 12 million adults in the United States receive a diagnosis of chronic obstructive pulmonary disease (COPD) each year, and it is the fourth leading cause of death. Chronic obstructive pulmonary disease refers to a group of diseases that cause airflow obstruction and a constellation of symptoms, including cough, sputum production, and shortness of breath. The main risk factor for COPD is tobacco smoke, but other environmental exposures also may contribute. The GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2020 Report aims to provide a nonbiased review of the current evidence for the assessment, diagnosis, and treatment of patients with COPD. To date, no conclusive evidence exists that any existing medications for COPD modify mortality. The mainstay of treatment for COPD is inhaled bronchodilators, whereas the role of inhaled corticosteroids is less clear. Inhaled corticosteroids have substantial risks, including an increased risk for pneumonia. Here, 2 experts, both pulmonologists, reflect on the care of a woman with severe COPD, a 50-pack-year smoking history, frequent COPD exacerbations, and recurrent pneumonia. They consider the indications for inhaled corticosteroids in COPD, when inhaled corticosteroids should be withdrawn, and what other treatments are available.

Nonvariceal upper gastrointestinal bleeding is common, morbid, and potentially fatal. Cornerstones of inpatient management include fluid resuscitation; blood transfusion; endoscopy; and initiation of proton-pump inhibitor therapy, which continues in an individualized manner based on risk factors for recurrent bleeding in the outpatient setting. The International Consensus Group released guidelines on the management of nonvariceal upper gastrointestinal bleeding in 2019. These guidelines provide a helpful, evidence-based roadmap for management of gastrointestinal bleeding but leave certain management details to the discretion of the treating physician. Here, 2 gastroenterologists consider the care of a patient with nonvariceal upper gastrointestinal bleeding from a peptic ulcer, specifically debating approaches to blood transfusion and endoscopy timing in the hospital, as well as the recommended duration of proton-pump inhibitor therapy after discharge.

Breast cancer will develop in 12% of women during their lifetime and is the second leading cause of cancer death among U.S. women. Mammography is the most commonly used tool to screen for breast cancer. Considerable uncertainty exists regarding the age at which to begin screening and the optimal screening interval. Breast density is a risk factor for breast cancer. In addition, for women with dense breasts, small tumors may be missed on mammography and the sensitivity of screening is diminished. At the time of publication, 35 states had passed laws mandating that breast density be reported in the letters that radiologists send to women with their mammogram results. The mandated language may be challenging for patients to understand, and such reporting may increase worry for women who are told that their risk for breast cancer is higher than average on the basis of breast density alone. The U.S. Preventive Services Task Force and the American College of Radiology (ACR) have each issued guidelines that address breast cancer screening for women with dense breasts. Both organizations found insufficient evidence to recommend for or against magnetic resonance screening, whereas the ACR advises consideration of ultrasonography for supplemental screening. In this Beyond the Guidelines, 2 experts-a radiologist and a general internist-discuss these controversies. In particular, the discussants review the role of supplemental breast cancer screening, including breast ultrasonography or magnetic resonance imaging for women with dense breasts. Finally, the experts offer specific advice for a patient who finds her mammography reports confusing.

Venous thromboembolism (VTE), which includes both deep venous thrombosis and pulmonary embolism, is a common and potentially fatal condition. Medical inpatients are at high risk for VTE because of immobility as well as acute and chronic illness. Several randomized trials demonstrated that chemoprophylaxis, or low-dose anticoagulation, prevents VTE in selected medical inpatients. The 2018 American Society of Hematology clinical practice guideline on prophylaxis for hospitalized and nonhospitalized medical patients conditionally recommends chemoprophylaxis for non-critically ill medical inpatients, leaving much to the discretion of the treating physician. Here, 2 experts, a hematologist and a hospitalist, reflect on the care of a woman hospitalized with a rheumatologic disorder. They consider the risks and benefits of chemoprophylaxis, discuss VTE risk stratification, and recommend which patients should receive chemoprophylaxis and with which agents.

Pelvic examinations have historically been a part of regular preventive care. However, because women can now be screened for cervical cancer at intervals up to every 5 years, the question of whether women need to be seen annually for routine pelvic examinations has arisen. In July 2014, the American College of Physicians (ACP) issued a guideline presenting the available evidence on screening for pathologic conditions using pelvic examination in adult, asymptomatic women at average risk. The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice had previously issued a committee opinion in August 2012 on the need for annual examinations and provided guidelines on important elements of this procedure, including when to examine asymptomatic women. ACOG reaffirmed its initial position after publication of the ACP guideline. The guidelines differ-the ACP guideline recommends against and the ACOG committee opinion recommends in favor of routine annual pelvic examination. This paper summarizes a discussion between an internist and a gynecologist on how they would balance these recommendations in general and what they would suggest for an individual patient.

In the United States, 9.4% of all adults-and 25% of those older than 65 years-have diabetes. Diabetes is the leading cause of blindness and end-stage renal disease and contributes to both microvascular and macrovascular complications. The management of patients with type 2 diabetes (T2D) is a common and important activity in primary care internal medicine practice. Measurement of hemoglobin A1c (HbA1c) provides an estimate of mean blood sugar levels and glycemic control. The optimal HbA1c target level among various persons with T2D is a subject of controversy. Guidelines regarding HbA1c targets have yielded differing recommendations. In 2018, the American College of Physicians (ACP) published a guideline on HbA1c targets for nonpregnant adults with T2D. In addition to a recommendation to individualize HbA1c target levels, the ACP proposed a level between 7% and 8% for most patients. The ACP also advised deintensification of therapy for patients who have an HbA1c level lower than 6.5% and avoidance of HbA1c-targeted treatment for patients with a life expectancy of less than 10 years. This guidance contrasts with a recommendation from the American Diabetes Association to aim for HbA1c levels less than 7% for many nonpregnant adults and to consider a target of 6.5% if it can be achieved safely. Here, 2 experts, a diabetologist and a general internist, discuss how to apply the divergent guideline recommendations to a patient with long-standing T2D and a current HbA1c level of 7.8%.

Prostate cancer screening is a contentious subject. In this session of Beyond the Guidelines, an internist and a urologist compare their approaches to prostate-specific antigen (PSA)-based screenin...

Osteoporosis is a skeletal disorder characterized by reduced bone strength that increases the risk for fracture. Approximately 10 million men and women in the United States have osteoporosis, and more than 2 million osteoporosis-related fractures occur annually. In 2016, the American Association of Clinical Endocrinologists issued the "Clinical Practice Guideline for the Diagnosis and Treatment of Postmenopausal Osteoporosis," and in 2017, the American College of Physicians issued the guideline "Treatment of Low Bone Density or Osteoporosis to Prevent Fracture in Men and Women." Both guidelines agree that patients diagnosed with osteoporosis should be treated with an antiresorptive agent, such as alendronate, that has been shown to reduce hip and vertebral fractures. However, there is no consensus on how long patients with osteoporosis should be treated and whether bone density should be monitored during and after the treatment period. In this Beyond the Guidelines, 2 experts discuss management of osteoporosis in general and for a specific patient, the role of bone density monitoring during and after a 5-year course of alendronate, and treatment recommendations for a patient whose bone density decreases during or after a 5-year course of alendronate.

Hormone therapy (HT) was widely prescribed in the 1980s and 1990s and has been controversial since the initial results of the Women's Health Initiative (WHI) trial in the early 2000s suggested that it increased risk for breast cancer and coronary heart disease and did not prolong life. However, more recent data and reexamination of the WHI results suggest that HT is safe and effective for many women when used around the time of menopause. Two experts debate the 2017 Hormone Therapy Position Statement of The North American Menopause Society, which recommends HT as first-line treatment of vasomotor symptoms, and apply it to the care of Ms. R, a 52-year-old woman with severe hot flashes, sleep disturbance, and irritability.

BACKGROUND The Gail model is validated to estimate breast carcinoma risk. The authors assessed the association of Gail risk scores with screening and cancer risk perception. METHODS Using the 2000 National Health Interview Survey, the authors studied women ages 41–70 without a cancer history. Gail scores ≥ 1.66% defined increased risk. The authors used logistic regression to assess associations between breast carcinoma risk and previous and recent (≤ 1 year) mammography and clinical breast examination (CBE). RESULTS Of 6410 women, 15.7% had increased risk. High-risk women more frequently reported previous mammograms (94% vs. 85%; P < 0.0001), previous CBE (93% vs. 88%; P < 0.0001), recent mammograms (70% vs. 54%; P < 0.0001), recent CBE (71% vs. 61%; P < 0.0001), and high cancer risk perception (20% vs. 9%; P < 0.0001). However, 30% of high-risk women had not received a recent mammogram. After adjustment for sociodemographic factors, access to care factors, and cancer risk perception, high-risk women remained more likely to have received recent mammography (adjusted odds ratio [OR], 1.45, 95% confidence interval [95% CI], 1.19–1.77), recent CBE (OR, 1.32; 95% CI, 1.08–1.61]), and previous mammography than average-risk women. The authors observed an interaction between risk and age, with women ages 41–49 years more frequently reporting previous mammography (OR, 4.79; 95% CI, 1.55–4.81) than average-risk, same-age women. For women age ≥ 50 years, the odds of previous mammography were similar regardless of risk. CONCLUSIONS In a nationally representative sample, 15.7% of women had increased breast carcinoma risk using the Gail model. High-risk women perceived higher cancer risk and more often received screening. However, nearly one in three high-risk women did not receive recent screening and most of these women did not perceive increased risk. Cancer 2004. © 2004 American Cancer Society.

Aspirin exerts antiplatelet effects through irreversible inhibition of cyclooxygenase-1, whereas its anticancer effects may be due to inhibition of cyclooxygenase-2 and other pathways. In 2009, the U.S. Preventive Services Task Force endorsed aspirin for primary prevention of cardiovascular disease. However, aspirin's role in cancer prevention is still emerging, and no groups currently recommend its use for this purpose. To help physicians balance the benefits and harms of aspirin in primary disease prevention, the Task Force issued a guideline titled, "Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer" in 2016. In the evidence review conducted for the guideline, cardiovascular disease mortality and colorectal cancer mortality were significantly reduced among persons taking aspirin. However, there was no difference in nonfatal stroke, cardiovascular disease mortality, or all-cause mortality, nor in total cancer mortality, among those taking aspirin. Aspirin users were found to be at increased risk for major gastrointestinal bleeding. In this Beyond the Guidelines, the guideline is reviewed and 2 experts discuss how they would apply it to a 57-year-old man considering starting aspirin for primary prevention. Our experts review the data on which the guideline is based, discuss how they would balance the benefits and harms of aspirin therapy, and explain how they would incorporate shared decision making into clinical practice.

Depression is a major public health problem and a common cause of disability. To help physicians choose among available treatment options, the American College of Physicians recently issued a guideline titled "Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients with Major Depressive Disorder." The evidence review done for the guideline found no statistically significant difference in the efficacy of second-generation antidepressants (SGAs) versus most other treatments for this disorder. However, rates of adverse events and discontinuation were generally higher in patients treated with SGAs. This Beyond the Guidelines reviews the guideline and includes a discussion between 2 experts on how they would apply it to a 64-year-old man with depression who is reluctant to begin medication. They review the data on which the guideline is based, discuss the limitations of applying the data to real-world settings, review how they would incorporate patient preferences when making treatment decisions, and outline options for patients in whom first-line therapy has failed.

BACKGROUND: Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority. OBJECTIVES: To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation). DESIGN: Prospective cohort study. PARTICIPANTS: We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive. MEASUREMENTS: We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year). RESULTS: Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02). CONCLUSIONS: Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes. Language: en

BACKGROUND: To determine if physician specialty, length of time in practice, and fear of malpractice influence the diagnosis and management of breast cancer in older women. METHODS: We used a fractional factorial design that controlled for patient age (65 or 80 years), race, socioeconomic status, mobility, comorbidity, and assertive behavior through 2 videotaped scenarios (a potential breast cancer [no. 1] and a known stage IIA breast cancer [no. 2]). One hundred twenty-eight white male physicians equally divided by specialty (surgeon versus nonsurgeon) and time in practice (≤15 or >15 years) viewed the videotapes and made recommendations. RESULTS: The physician subjects saw 46 patients per week, 59% female, and 47% age ≥65. Their concern over malpractice was 4.7 (on a 10-point Likert scale with a higher score indicating more concern) and did not differ by specialty or time in practice ( P values > 0.7). After viewing scenario no. 1, surgeons were less likely than nonsurgeons to consider breast cancer as the principal diagnosis (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2 to 0.9) and to obtain a tissue diagnosis (OR = 0.3, 95% CI=0.1 to 0.9). However, in scenario no. 2, surgeons were more likely to offer reconstruction (OR = 3.8, 95% CI=1.4 to 10.4). Physicians in practice ≤15 years were more likely than those in practice CONCLUSIONS: With the uncertainty of how to diagnose and treat older women with breast cancer, physician specialty, length of time in practice, and concern over malpractice do influence clinical decisions.

In November 2013, the U.S. Preventive Services Task Force issued a guideline on medications for risk reduction of primary breast cancer in women. Although mammography can detect early cases, it cannot prevent development of breast cancer. Tamoxifen and raloxifene are selective estrogen receptor modulators that have been shown to reduce the risk for estrogen receptor-positive breast cancer and are approved by the U.S. Food and Drug Administration (FDA) for this indication. However, neither medication reduces the risk for estrogen receptor-negative breast cancer or all-cause mortality. The Task Force concluded that postmenopausal women with an estimated 5-year risk for breast cancer of 3% or greater will probably have more net benefit than harm and recommends that clinicians engage in shared, informed decision making about these medications. The American Society of Clinical Oncology issued a practice guideline on use of pharmacologic interventions for breast cancer in 2013. It recommends that women aged 35 years or older at increased risk, defined as a 5-year absolute risk for breast cancer of 1.66% or greater, discuss breast cancer prevention medications with their primary care practitioner. The Society includes the aromatase inhibitor exemestane in addition to tamoxifen and raloxifene as a breast cancer prevention medication, although exemestane is not FDA approved for this indication. Here, an oncologist and an internist discuss how they would balance these recommendations and what they would suggest for an individual patient.

In May 2015, the U.S. Preventive Services Task Force issued a guideline on screening for thyroid disease that included a systematic evidence review and an update of its 2004 recommendations. The review assessed the effect of treating screen-detected subclinical thyroid dysfunction on health outcomes. It found adequate evidence that treating subclinical hypothyroidism does not provide clinically meaningful improvements in blood pressure, body mass index, bone mineral density, lipid levels, or quality-of-life measures. The review also concluded that evidence was inadequate to determine whether screening for thyroid dysfunction reduced cardiovascular disease or related morbidity and mortality. In separate guidelines, the American Association of Clinical Endocrinologists and American Thyroid Association advocated aggressive case-finding and recommended screening persons with certain clinical conditions or characteristics rather than the general population. These societies argue that subclinical hypothyroidism adversely affects cardiovascular outcomes and thus merits case-finding. Here, 2 experts discuss their perspectives on whether treating subclinical hypothyroidism reduces morbidity and mortality, whether there are harms of treatment, and how they would balance the benefits and harms of treatment both in general and for a specific patient.

To determine the feasibility of providing cholesterol screening in the emergency department (ED) and to determine compliance with follow-up recommendations.A prospective observational study.The Ambulatory Care and Treatment Section of the George Washington University Medical Center ED.All patients seen in the Ambulatory Care and Treatment Section of the ED who were 18 years of age or older and who were residents of the metropolitan Washington, D.C., area were eligible to participate. During the six-month study period, 660 patients were asked to participate and 539 (82%) agreed.Fingerstick cholesterol measurements were performed on all participants. Participants who had elevated cholesterol levels, as determined by the National Cholesterol Education Program guidelines, were scheduled for a six-week follow-up visit in the Lipid Research Clinic, where repeat fingerstick cholesterol measurements were performed. Those participants with elevated cholesterol levels were instructed to follow up with their primary care physicians. Compliance with follow-up was assessed by a telephone contact four months after the initial ED visit.Of the 539 participants, 100 (19%) were found to have elevated cholesterol levels. Fifty-three (53%) returned for the six-week follow-up visit. Of the 53 who returned, 7 (13%) had normal and 46 (87%) had elevated cholesterol levels. Of the 46 participants with elevated cholesterol levels, 15 (33%) reported four months after their ED visit that they had received further follow-up care.Cholesterol screening in the ED is feasible, but compliance with follow-up is less than desirable.

Background : We surveyed primary care providers to evaluate breast cancer risk assessment and management practices. Methods : Primary care providers included staff (attendings, fellows, nurse practitioners) and residents practicing ≥1 session/week in an outpatient general medicine practice or community practices. Of 201 eligible providers, 107 (53%) completed a self-administered questionnaire ascertaining attitudes, perceived barriers, and clinical practices related to assessing and managing breast cancer risk. Results : Of providers, 96% mostly or definitely agreed that assessing breast cancer risk was a primary care provider's responsibility. In assessing risk, most providers reported usually or always asking about family history (71%), but fewer usually or always ask about parity (48%), biopsies (40%), or menarche (35%), and most never calculate Gail scores (76%). In managing women at high risk for breast cancer, many providers reported usually or always communicating increased risk to patients (58%) and tailoring screening based on risk (53%); however fewer providers usually or always discuss chemoprevention (13%) or genetic testing (16%) or refer to specialists (35%). Addressing more immediate issues (25%) and lacking confidence in knowledge of risk and risk assessment (20%) were the most commonly reported barriers to assessing risk ( n =83). Conclusion : Primary care providers generally assess breast cancer risk primarily using family history, potentially missing women at increased risk based on other criteria. In addition, although providers tailor screening and refer women at high risk to specialists, they infrequently discuss chemoprevention or genetic testing. Addressing perceived barriers to assessing risk may improve care.

BACKGROUND AND OBJECTIVE: Many women with increased breast cancer risk have not been screened recently. Provider recommendation for mammography is an important reason many women undergo screening. We examined the association between breast cancer risk and reported provider recommendation for mammography in recently unscreened women. DESIGN: Cross-sectional study using 2000 National Health Interview Survey. PARTICIPANTS: In all, 1673 women ages 40 to 75 years without cancer who saw a health care provider in the prior year and had no mammogram within 2 years. MEASUREMENTS AND ANALYSIS: We assessed breast cancer risk by Gail score and risk factors. We used multivariable logistic regression models in SUDAAN adjusted for age, race and illness burden, to examine the association between risk and reported recommendation for mammography within 1 year for all women and women ages 50 to 75 years. RESULTS: Of 1673 recently unscreened women, 29% reported a recommendation. Twelve percent of women had increased Gail risk and of these recently unscreened, high-risk women, 25% reported a recommendation. After adjustment, high-risk women were not more likely to report a recommendation than average-risk women. Results were similar for women 50 to 75 years old. No individual breast cancer factors other than age were associated with reporting a recommendation. CONCLUSIONS: Approximately 70% of recently unscreened women seen by a health care provider in the prior year reported no recommendation for mammography, regardless of breast cancer risk. This did not include women who received a recommendation and were screened. Increasing reported recommendation rates may represent an opportunity to increase screening participation among recently unscreened women, particularly for women with increased breast cancer risk.

To identify factors associated with hospitalization of elderly hospice patients with cancer and to describe their hospital experiences.Retrospective analysis of the last year of life.Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database.Medicare beneficiaries dying of lung or colorectal cancer between 1988 and 1998 who enrolled in hospice.Hospitalization after hospice entry. For hospitalized patients, we describe admission diagnoses, aggressiveness of care, and in-hospital death.Of the 23608 patients, 1423 (6.0%) were hospitalized after hospice enrollment. Hospitalization declined over time by 7.0% per year of hospice enrollment. Factors associated with higher hospitalization rates were younger age, male gender, black race/ethnicity, local cancer stage at diagnosis, and hospice enrollment within 4 months of cancer diagnosis. The most common reasons for hospital admission were lung cancer, metastatic disease, bone fracture, pneumonia, and volume depletion. Of the 1423 patients hospitalized, 34.6% received aggressive care and 35.8% died in the hospital.The rates of hospitalization for elderly hospice patients with lung or colorectal cancer appear to be declining. However, patients who are hospitalized undergo aggressive care and often die in the hospital rather than at home. This aggressive care may be consistent with changes in patients' care preferences, but could also reflect the current culture of acute care hospitals, which focuses on curative treatment and is ill-equipped to provide palliative care.

Purpose: To identify factors associated with hospice enrollment and length of stay in hospice among patients dying with lung or colorectal cancer. Methods: We used the Linked Medicare-Tumor Registry Database to conduct a retrospective analysis of the last year of life among Medicare beneficiaries diagnosed with lung or colorectal cancer at age ≥ 66 years between January 1, 1973, and December 31, 1996, in the Surveillance, Epidemiology, and End Results Program who died between January 1, 1988, and December 31, 1998. Our outcomes of interest were time from cancer diagnosis to hospice enrollment and length of stay in hospice care. We used Cox proportional hazards regression to adjust for demographic and clinical information. Results: We studied elderly patients dying with lung cancer (n = 62,117) or colorectal cancer (n = 57,260). Overall, 27% of patients (n = 16,750) with lung cancer and 20% of patients (n = 11,332) with colorectal cancer received hospice care before death. Median length of stay for hospice patients with lung and colorectal cancer was 25 and 28 days, respectively. Overall, 20% of patients entered hospice within 1 week of death, whereas 6% entered more than 6 months before death. Factors associated with later hospice enrollment include being male; being of nonwhite, nonblack race; having fee-for-service insurance; and residing in a rural community. Many of these factors also were associated with shorter stays in hospice. Conclusion: Although use of hospice care has increased dramatically over time, specific patient groups, including men, patients residing in rural communities, and patients with fee-for-service insurance continue to experience delays in hospice enrollment.

BACKGROUND: Women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Yet, older women are least likely to undergo mammography, perhaps because mammography's value is less well demonstrated in older women. OBJECTIVE: To investigate the relationship between prior mammography use, cancer stage at diagnosis, and breast cancer mortality among older women with breast cancer. DESIGN: Retrospective cohort study using the Linked Medicare-Tumor Registry Database. SETTING: Population-based data from three geographic areas included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. PARTICIPANTS: Women aged 67 and older diagnosed with a first primary breast cancer, from 1987 to 1993, residing in Connecticut, metropolitan Atlanta, Georgia, or Seattle-Puget Sound, Washington. MEASUREMENTS: Medicare claims were reviewed and women were classified according to their mammography use during the 2 years before diagnosis: nonusers (no prior mammograms), regular users (at least two mammograms at least 10 months apart), or peri-diagnosis users (only mammogram(s) within 3 months before diagnosis). Mammography utilization was linked with SEER data to determine stage at diagnosis and cause of death. Our main outcome variables were (1) stage at diagnosis, classified as early (in situ/Stage I) or late (Stage II or greater), and (2) breast cancer mortality, measured from diagnosis until death from breast cancer or end of the follow-up period (December 31, 1994). RESULTS: Older women who were nonusers of mammography were diagnosed with breast cancer at Stage II or greater more often than regular users (adjusted odds ratio (OR), 3.12; 95% confidence interval (CI), 2.74–3.58). This association was present within each age group studied. Nonusers of mammography were at significantly greater risk of dying from their breast cancer than regular users for all women (adjusted hazard ratio (HR), 3.38; 95% CI, 2.65–4.32) and for women within each age group. Even assuming a lead time of 1.25 years, nonusers of mammography continued to be at increased risk of dying from breast cancer. Our findings remained significant for all women and for the two youngest age groups (67–74 years, 75–85 years), although the benefit was no longer statistically significant for the oldest women (85 years and older). CONCLUSIONS: Older women who undergo regular mammography are diagnosed with an earlier stage of disease and are less likely to die from their disease. These data support the use of regular mammography in older women and suggest that mammography can reduce breast cancer mortality in older women, even for women age 85 and older.

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge. METHODS: Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988–1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA). RESULTS: In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P < .01). Stroke patients discharged to home health had the lowest rehospitalization rates (P < .05) Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P < .05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement. CONCLUSIONS: The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.

Older black women are less likely to undergo mammography and are more often given a diagnosis of advanced-stage breast cancer than older white women.To investigate the extent to which previous mammography explains observed differences in cancer stage at diagnosis between older black and white women with breast cancer.Retrospective cohort study using the Linked Medicare-Tumor Registry Database.Population-based data from three geographic areas of the United States included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program (Connecticut; metropolitan Atlanta, Georgia; and Seattle-Puget Sound, Washington).Black and white women 67 years of age and older in whom breast cancer was diagnosed between 1987 and 1989.Medicare claims were used to classify women according to mammography use in the 2 years before diagnosis as nonusers (no previous mammography), regular users (or =2 mammographies done at least 10 months apart), or peri-diagnosis users (mammography done only within 3 months before diagnosis). Information on mammography use was linked with SEER data to determine cancer stage at diagnosis. Stage was classified as early (in situ or local) or late (regional or distant).Black women were more likely to not undergo mammography (odds ratio [OR], 3.00 [95% CI, 2.41 to 3.75]) and to be given a diagnosis of late-stage disease (OR, 2.49 [CI, 1.59 to 3.92]) than white women. When women were stratified by previous mammography use, the black-white difference in cancer stage occurred only among nonusers (adjusted OR, 2.54 [CI, 1.37 to 4.71]). Among regular users, cancer was diagnosed in black and white women at similar stages (adjusted OR, 1.34 [CI, 0.40 to 4.51]). In logistic modeling, previous mammography alone explained about 30% of the excess late-stage disease in black women. In a separate model, previous mammography explained 12% of the excess late-stage disease among black women after adjustment for sociodemographic and comorbidity information.Differences in breast cancer stage at diagnosis between older black and white women are related to previous mammography use. Increased regular use of mammography may result in a shift toward earlier-stage disease at diagnosis and narrow the observed differences in stage at diagnosis between older black and white women.

Objectives. The puropse of this research was to determine the influence of patient and physician characteristics on physicians' level of variability and certainty in breast cancer care. Methods. One hundred twenty-eight physicians viewed a videotape of a simulated physician-patient interaction in which the patient has an "atypical" breast lump. Six patient characteristics (age, race, socioeconomic status, physical mobility, comorbidity, presentation style) were manipulated experimentally, resulting in a balanced set of 32 different "patients." Physician subjects were recruited to fill four equal strata defined by specialty (surgeons versus nonsurgeons) and experience (≤15 or >15 years since graduation from medical school). Results. More than half of the physicians offered a diagnosis of benign breast disease, a third offered a diagnosis of breast cancer, and the rest believed that the patient had a normal breast or something "other." Results also indicated that physicians' level of certainty and test ordering behavior varied with the diagnosis that was offered. Of the six patient characteristics, only socioeconomic status influenced physician certainty; physicians were more certain of their diagnosis when the patient was of a higher socioeconomic status. Surgeons were found to be more certain of their diagnosis compared with nonsurgeons. However, surgeons were less likely to order radiologic tests or a tissue sample for metastatic evaluation than were nonsurgeons. Conclusions. Overall, physicians displayed considerable variability and uncertainty when diagnosing and managing possible breast cancer.

OBJECTIVES: To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF). DESIGN: Prospective cohort study PARTICIPANTS: A total of 519 patients, aged ≥ 65, who were discharged alive after a hospitalization for CHF (DRG = 127). MEASUREMENTS: Outcomes (Activities of Daily Living (ADLs), shortness of breath when walking, perceived health, living situation, rehospitalization, and mortality) were measured at 3 times (6 weeks, 6 months, and 1 year) post-discharge. RESULTS: The 205 men were, on average, younger (77 ± 7 vs 80 ± 8, P < .001), wealthier (46% vs 21% earned ≥ $10,000, P < .001), and more often married (50% vs 19%, P < .001). Men were more likely than women to have a previous history of CHF (71% vs 63%, P = .052). Men also had higher 1-year mortality than women (48% vs 35%, P = .009), even after adjusting for age, comorbidity, physiological severity (APACHE II APS and RAND discharge instability), radiological evidence of CHF, prior ADLs, walking ability, living situation, and perceived health. Men and women survivors at 1-year had similar and substantial impairment for all non-fatal outcomes considered (all P values ≥ .489). Their adjusted mean ADL scores were consistent with complete dependence on one essential activity (range 0–6 dependencies); 35% were short of breath walking less than 1 block; 62% had fair or poor perceived health; 32% received some formal care; and 46% were rehospitalized within 1 year of discharge. CONCLUSIONS: Men with CHF have a higher mortality than women with CHF. Men and women who survive have similar and substantial impairment for all non-fatal outcomes (ADLs, shortness of breath upon walking, perceived health, living situation, and rehospitalization).

Hip replacement is the preferred treatment for displaced femoral neck fractures, whereas other less expensive procedures are preferred for nondisplaced fractures. The authors determined whether there was geographic variation in the use of hip replacement to treat displaced and nondisplaced fractures.The authors studied 332 patients, age 65 years or older, hospitalized with a femoral neck fracture in three cities.The population was 55% over age 80, 80% female, and lived in Houston (17%), Pittsburgh (29%), and Minneapolis (54%). Rates of hip replacement varied by city (Houston-84%, Pittsburgh-77%, Minneapolis-63%; P = 0.002), with great variability among patients with nondisplaced fractures (Houston-88%, Pittsburgh-77%, and Minneapolis-56%; P = 0.0001), and no variation among those with displaced fractures (P = 0.72). Other factors associated with hip replacement are history of hip fracture (P = 0.003) and cerebrovascular disease (Por = 0.10), APACHE II-APS score (P = 0.09), and impacted fracture (P = 0.001). Sociodemographic and functional status (perceived health; activities of daily living and instrumental activities of daily living dependencies) were not associated with hip replacement (P0.10). In a logistic model controlling for prior history, APACHE II-APS, and fracture characteristics, city remained a significant predictor of hip replacement (P0.001).Despite an absence of evidence supporting its appropriateness and a much higher cost, hip replacement is used to treat nondisplaced fractures much more frequently in Houston and Pittsburgh than in Minneapolis.

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbiditics, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation and treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.

To determine rates of, and explore physician factors associated with, repeat mammography, administrative data for 791 women aged 50 years and older were examined. Three-fourths of the women (73%) received repeat mammography (i.e., a second mammogram was obtained within six to 18 months of the first). Provider factors associated with higher repeat mammography rates were: being a woman, practicing in the women’s health group rather than the general internal medicine service, and being a fellow or an attending physician (p-values

ContextFor most patients aged 65 years or older with cancer, hospice services are uniformly covered by Medicare. Hospice care is believed to improve care for patients at the end of life. However, few patients use hospice and others enroll too late to maximize the benefits of hospice services.ObjectivesBecause type of insurance may affect use, we examined whether patients with Medicare managed care insurance enrolled in hospice earlier and had longer hospice stays than patients with Medicare fee-for-service (FFS) insurance.Design and SettingRetrospective analysis of the last year of life using the Linked Medicare-Tumor Registry Database in 1 of 9 Surveillance, Epidemiology, and End Results program coverage areas.PatientsA total of 260 090 Medicare beneficiaries aged 66 years or older diagnosed with first primary lung (n = 62 117), colorectal (n = 57 260), prostate (n = 59 826), female breast (n = 37 609), bladder (n = 19 598), pancreatic (n = 11 378), gastric (n = 9599), or liver (n = 2703) cancer between January 1, 1973, and December 31, 1996, and who died between January 1, 1988, and December 31, 1998.Main Outcome MeasuresTime from diagnosis to hospice entry and hospice length of stay for patients enrolled in FFS vs managed care plans after adjusting for patient demographics, tumor registry, year of hospice entry, and type and cancer stage.ResultsOf the 260 090 patients, most were men (59%), white (85%), and enrolled in FFS (89.7%). Only 54 937 patients (21.1%) received hospice care before death. Hospice use varied by type of primary cancer ranging from 31.8% of patients with pancreatic cancer to 15.6% with bladder cancer. Managed care patients were more likely to use hospice than FFS patients (32.4% vs 19.8%, P