61 results on '"Risa B. Burns"'
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2. Would You Recommend a Statin to This Patient for Primary Prevention of Cardiovascular Disease?
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Gerald W. Smetana, Mark D. Benson, Stephen P. Juraschek, and Risa B. Burns
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Primary Prevention ,Cardiovascular Diseases ,Risk Factors ,Teaching Rounds ,Internal Medicine ,Humans ,Cholesterol, LDL ,General Medicine ,Hydroxymethylglutaryl-CoA Reductase Inhibitors ,Risk Assessment ,United States ,Article - Abstract
Cardiovascular disease (CVD) is the leading cause of death in the United States. Hypercholesterolemia is a principal modifiable risk factor for the primary prevention of CVD. In addition to lifestyle modification, statins are an important tool to reduce risk for CVD in selected patients. A useful strategy to identify candidates for statins is to estimate the 10-year risk for CVD through the use of a validated risk calculator. Commonly used calculators include the Framingham risk score and the pooled cohort equation. Multiple randomized controlled trials have shown that statins reduce the risk for CVD in patients without known CVD. Two recent guidelines have proposed an approach to the use of statins in primary prevention of CVD. The American College of Cardiology/American Heart Association and the U.S. Department of Veterans Affairs guidelines form the basis for this discussion. The guidelines differ on the use of advanced testing to modify the 10-year CVD risk estimate and on the need for low-density lipoprotein cholesterol targets to establish the efficacy of statins. Advanced testing with coronary artery calcium measurement may be helpful for patients who are potentially eligible for statin therapy but who are uncertain if they wish to take a statin. In this paper, 2 experts, a preventive cardiologist and a general internist, discuss their approach to the use of statins for primary prevention of CVD and how they would apply the guidelines to an individual patient. more...
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- 2022
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3. How Would You Treat This Patient With Acute and Chronic Pain From Sickle Cell Disease?
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Zahir Kanjee, Maureen Okam Achebe, Wally R. Smith, and Risa B. Burns
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Analgesics, Opioid ,Practice Guidelines as Topic ,Teaching Rounds ,Internal Medicine ,Humans ,Anemia, Sickle Cell ,General Medicine ,Chronic Pain ,United States - Abstract
Sickle cell disease is prevalent in large numbers of patients in the United States and has a significant global impact. Its complications span numerous organs and lead to reduced life expectancy. Acute and chronic sickle cell pain is a common cause of patient suffering. The American Society of Hematology published updated guidelines on management of acute and chronic pain from sickle cell disease in 2019. Several of the recommendations are conditional and leave specific decisions to the treating physician. These include conditional recommendations about the use of ketamine for acute pain and the initiation and discontinuation of long-term opioid therapy for chronic pain. Here, 2 hematologists discuss these guidelines and make contrasting recommendations for the management of acute and chronic pain for a patient with sickle cell disease. more...
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- 2022
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4. Would You Recommend Aspirin to This Patient for Primary Prevention of Atherosclerotic Cardiovascular Disease?
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Erin D. Michos, Michael Pignone, Zahir Kanjee, and Risa B. Burns
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medicine.medical_specialty ,Risk Assessment ,Risk Factors ,Primary prevention ,Internal Medicine ,Humans ,Medicine ,Intensive care medicine ,Aged ,Cause of death ,Risk level ,Aspirin ,business.industry ,Task force ,Atherosclerotic cardiovascular disease ,General Medicine ,Guideline ,Atherosclerosis ,Primary Prevention ,Aspirin therapy ,Cardiovascular Diseases ,Female ,business ,Platelet Aggregation Inhibitors ,medicine.drug - Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death in the United States. Reducing ASCVD risk through primary prevention strategies has been shown to be effective; however, the role of aspirin in primary prevention remains unclear. The decision to recommend aspirin has been limited by the difficulty clinicians and patients face when trying to balance benefits and harms. In 2016, the U.S. Preventive Services Task Force addressed this issue by determining the risk level at which prophylactic aspirin generally becomes more favorable, recommending aspirin above a risk cut point (>10% estimated ASCVD risk). In 2019, the American College of Cardiology and the American Heart Association issued a guideline on the primary prevention of CVD that recommends low-dose aspirin might be considered for the primary prevention of ASCVD among select adults aged 40 to 70 years who are at higher ASCVD risk but not at increased risk for bleeding. Here, 2 experts discuss how to apply this guideline in general and to a patient in particular while answering the following questions: How do you assess ASCVD risk, and what is the role, if any, of the coronary artery calcium score?; At what risk threshold of benefits and harms would you recommend aspirin or not?; and How do you help a patient come to a decision about starting or stopping aspirin therapy? more...
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- 2021
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5. Should You Recommend Cannabinoids for This Patient With Painful Neuropathy?
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Jeanette M. Tetrault, Risa B. Burns, Gerald W. Smetana, and Kevin P. Hill
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medicine.medical_specialty ,biology ,business.industry ,Addiction ,media_common.quotation_subject ,Chronic pain ,General Medicine ,medicine.disease ,biology.organism_classification ,law.invention ,Addiction medicine ,Randomized controlled trial ,law ,Neuropathic pain ,Internal Medicine ,medicine ,Number needed to treat ,Cannabis ,Intensive care medicine ,business ,Effects of cannabis ,media_common - Abstract
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. more...
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- 2021
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6. Management Options for an Older Adult With Advanced Chronic Kidney Disease and Dementia
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Risa B. Burns, Zahir Kanjee, Sushrut S. Waikar, and Melissa W. Wachterman
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Nephrology ,medicine.medical_specialty ,Palliative care ,business.industry ,medicine.medical_treatment ,General Medicine ,medicine.disease ,Peritoneal dialysis ,Quality of life (healthcare) ,Internal medicine ,Internal Medicine ,medicine ,Dementia ,Hemodialysis ,business ,Intensive care medicine ,Dialysis ,Kidney disease - Abstract
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. more...
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- 2020
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7. Should You Recommend Inhaled Corticosteroids for This Patient With Chronic Obstructive Pulmonary Disease?
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Mary B. Rice, Risa B. Burns, Gerald W. Smetana, and Asha Anandaiah
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medicine.medical_specialty ,COPD ,business.industry ,010102 general mathematics ,General Medicine ,medicine.disease ,01 natural sciences ,Obstructive lung disease ,Tobacco smoke ,respiratory tract diseases ,03 medical and health sciences ,Pneumonia ,0302 clinical medicine ,Internal Medicine ,medicine ,Eosinophilia ,030212 general & internal medicine ,0101 mathematics ,medicine.symptom ,Risk factor ,Intensive care medicine ,business ,Pulmonologists ,Cause of death - Abstract
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. more...
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- 2020
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8. How Would You Manage This Patient With Nonvariceal Upper Gastrointestinal Bleeding? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center
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Risa B. Burns, Akwi W. Asombang, Tyler M. Berzin, and Zahir Kanjee
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medicine.medical_specialty ,Resuscitation ,Gastrointestinal bleeding ,Blood transfusion ,medicine.medical_treatment ,MEDLINE ,Endoscopy, Gastrointestinal ,Recurrence ,Risk Factors ,Internal Medicine ,medicine ,Humans ,Blood Transfusion ,Teaching Rounds ,Intensive care medicine ,Pantoprazole ,Aged ,medicine.diagnostic_test ,business.industry ,Proton Pump Inhibitors ,General Medicine ,After discharge ,medicine.disease ,Endoscopy ,Peptic Ulcer Hemorrhage ,Practice Guidelines as Topic ,Female ,Upper gastrointestinal bleeding ,business - Abstract
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. more...
- Published
- 2021
9. Should This Woman With Dense Breasts Receive Supplemental Breast Cancer Screening?
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Risa B. Burns, Christoph I. Lee, Gerald W. Smetana, and Joann G. Elmore
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medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,General surgery ,Breast ultrasonography ,General Medicine ,medicine.disease ,03 medical and health sciences ,Breast cancer screening ,0302 clinical medicine ,Breast cancer ,030220 oncology & carcinogenesis ,Internal Medicine ,Medicine ,Mammography ,030212 general & internal medicine ,Breast density ,Risk factor ,Ultrasonography ,skin and connective tissue diseases ,business ,Small tumors - Abstract
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. more...
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- 2018
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10. How Would You Manage This Patient With Osteoporosis?
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Risa B. Burns, Harold Rosen, Sarah Berry, and Gerald W. Smetana
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03 medical and health sciences ,0302 clinical medicine ,Internal Medicine ,030209 endocrinology & metabolism ,030212 general & internal medicine ,General Medicine - Published
- 2018
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11. Should You Treat This Acutely Ill Medical Inpatient With Venous Thromboembolism Chemoprophylaxis?
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Risa B. Burns, Anthony C. Breu, Zahir Kanjee, and Kenneth A. Bauer
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medicine.medical_specialty ,business.industry ,010102 general mathematics ,MEDLINE ,General Medicine ,Guideline ,medicine.disease ,01 natural sciences ,Pulmonary embolism ,law.invention ,03 medical and health sciences ,Venous thrombosis ,0302 clinical medicine ,Randomized controlled trial ,law ,Rheumatologic Disorder ,Chemoprophylaxis ,Internal Medicine ,medicine ,cardiovascular diseases ,030212 general & internal medicine ,0101 mathematics ,Hematologist ,business ,Intensive care medicine - Abstract
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. more...
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- 2020
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12. Hormone Therapy for Menopausal Symptoms
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Martha Richardson, Eileen E. Reynolds, Carol K. Bates, and Risa B. Burns
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Oncology ,medicine.medical_specialty ,medicine.medical_treatment ,MEDLINE ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Breast cancer ,Internal medicine ,Biopsy ,Internal Medicine ,medicine ,Humans ,030212 general & internal medicine ,Teaching Rounds ,Israel ,medicine.diagnostic_test ,business.industry ,Estrogen Replacement Therapy ,General Medicine ,medicine.disease ,Menopause ,Hormonal therapy ,Female ,Hormone therapy ,business ,Hormone - Published
- 2018
13. Screening Pelvic Examinations in Adult Women
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Hope A. Ricciotti, Jennifer Potter, Risa B. Burns, and Eileen E. Reynolds
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Gynecology ,Cervical cancer ,medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,General Medicine ,Guideline ,Evidence-based medicine ,medicine.disease ,Gynecological Examination ,Preventive care ,Adult women ,Family medicine ,Internal Medicine ,medicine ,business ,Pelvic examination ,Mass screening - Abstract
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. more...
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- 2015
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14. Treatment of Blood Cholesterol to Reduce Risk for Atherosclerotic Cardiovascular Disease
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Murray A. Mittleman, Gerald W. Smetana, Risa B. Burns, and William C. Taylor
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medicine.medical_specialty ,Statin ,Atherosclerotic cardiovascular disease ,medicine.drug_class ,business.industry ,General Medicine ,Guideline ,Primary prevention ,Cohort ,Internal Medicine ,medicine ,Blood cholesterol ,Physical therapy ,Intensive care medicine ,Adverse effect ,Risk assessment ,business - Abstract
In November 2013, the American College of Cardiology and the American Heart Association released a clinical practice guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults. The recommendation identifies 4 patient groups with strong evidence that the benefits of reduction in ASCVD events from statin therapy exceed adverse events. For these patients, initiating statin therapy of an appropriate intensity to reduce ASCVD risk and minimize adverse effects is recommended. A new risk estimator based on a pooled cohort equation is presented for estimating 10-year ASCVD risk. There is also a recommendation to engage in a clinician-patient discussion before initiating a statin, especially for primary prevention of ASCVD. This paper summarizes a discussion between a cardiologist and an internist about how each clinician would balance these factors and what treatment they would suggest for an individual patient. more...
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- 2015
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15. To What Target Hemoglobin A1c Level Would You Treat This Patient With Type 2 Diabetes?
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Gerald W. Smetana, Risa B. Burns, David M. Nathan, and David C. Dugdale
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medicine.medical_specialty ,endocrine system diseases ,business.industry ,010102 general mathematics ,nutritional and metabolic diseases ,Blood sugar ,General Medicine ,Disease ,Type 2 diabetes ,Guideline ,medicine.disease ,01 natural sciences ,03 medical and health sciences ,0302 clinical medicine ,Hemoglobin A ,Diabetes mellitus ,Emergency medicine ,Internal Medicine ,medicine ,Life expectancy ,030212 general & internal medicine ,0101 mathematics ,business ,Glycemic - Abstract
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%. more...
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- 2019
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16. Would You Recommend Prostate-Specific Antigen Screening for This Patient?
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Aria F. Olumi, Risa B. Burns, Gerald W. Smetana, and Douglas K Owens
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medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,Prostate Diseases ,010102 general mathematics ,Cancer ,General Medicine ,urologic and male genital diseases ,medicine.disease ,01 natural sciences ,female genital diseases and pregnancy complications ,Cancer treatment ,03 medical and health sciences ,Breast cancer screening ,Prostate cancer ,Prostate-specific antigen ,0302 clinical medicine ,Prostate cancer screening ,Family medicine ,Cancer screening ,Internal Medicine ,medicine ,030212 general & internal medicine ,0101 mathematics ,business - Abstract
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... more...
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- 2019
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17. How Would You Manage This Patient With Gout?
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Anjala Tess, Robert H. Shmerling, C. Christopher Smith, and Risa B. Burns
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030203 arthritis & rheumatology ,Pediatrics ,medicine.medical_specialty ,Bone density ,business.industry ,Osteoporosis ,General Medicine ,Guideline ,Postmenopausal osteoporosis ,medicine.disease ,Gout ,Clinical Practice ,03 medical and health sciences ,0302 clinical medicine ,Skeletal disorder ,Internal Medicine ,medicine ,Low bone density ,030212 general & internal medicine ,business - Abstract
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. more...
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- 2018
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18. Should This Patient Receive Hormone Therapy for Her Menopausal Symptoms?
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Martha Richardson, Carol K. Bates, Risa B. Burns, and Eileen E. Reynolds
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Pediatrics ,medicine.medical_specialty ,Sleep disorder ,030219 obstetrics & reproductive medicine ,Vasomotor ,medicine.drug_class ,business.industry ,medicine.medical_treatment ,Hormone replacement therapy (menopause) ,General Medicine ,medicine.disease ,Irritability ,Menopause ,03 medical and health sciences ,0302 clinical medicine ,Breast cancer ,Estrogen ,Internal Medicine ,medicine ,030212 general & internal medicine ,Hormone therapy ,medicine.symptom ,business - Abstract
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. more...
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- 2018
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19. Breast carcinoma screening and risk perception among women at increased risk for breast carcinoma
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Russell S. Phillips, Ellen P. McCarthy, Risa B. Burns, Susan A. Sabatino, Roger B. Davis, and Ya-Hua Chen
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Adult ,Cancer Research ,medicine.medical_specialty ,Breast Neoplasms ,Risk Factors ,Humans ,Mass Screening ,Medicine ,Mammography ,National Health Interview Survey ,Risk factor ,Physical Examination ,Mass screening ,Aged ,Gynecology ,medicine.diagnostic_test ,business.industry ,Obstetrics ,Cancer ,Odds ratio ,Middle Aged ,medicine.disease ,Health Surveys ,Risk perception ,Oncology ,Female ,Breast carcinoma ,business - Abstract
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. more...
- Published
- 2004
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20. Older asian americans and pacific islanders dying of cancer use hospice less frequently than older white patients
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Roger B. Davis, Risa B. Burns, Ellen P. McCarthy, Frederick P. Li, Russell S. Phillips, and Quyen Ngo-Metzger
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Male ,Gerontology ,medicine.medical_specialty ,Pacific Islands ,White People ,Foreign born ,Neoplasms ,Epidemiology ,Humans ,Medicine ,Risk factor ,Aged ,Retrospective Studies ,Cause of death ,Asian ,business.industry ,Public health ,Age Factors ,General Medicine ,Odds ratio ,United States ,Hospice Care ,Logistic Models ,Pacific islanders ,Managed care ,Female ,business ,Demography - Abstract
Purpose Cancer is the leading cause of death among Asian Americans, yet little is known about their use of hospice care. We examined hospice use by Asian patients compared with white patients, and assessed whether utilization differs among those born in the United States or abroad. Methods We studied Asian and white Medicare beneficiaries registered in the Surveillance, Epidemiology, and End Results (SEER) Program who died of primary lung, colorectal, prostate, breast, gastric, or liver cancer between 1988 and 1998. We used logistic regression to determine the effects of race/ethnicity and birthplace on hospice use, adjusting for demographic characteristics, managed care insurance, year of diagnosis, tumor stage at diagnosis, and tumor registry. Results Of the 184,081 patients, 5% (n = 8614) were Asian Americans, of whom 45% (n = 3847) were foreign born. Compared with whites, Asian Americans were more likely to be male, married, and enrolled in managed care. Compared with U.S.-born Asian Americans, foreign-born Asian Americans were more likely to reside in low-income areas. After adjustment, patients who were Asian American (odds ratio [OR] = 0.67; 95% confidence interval [CI]: 0.62 to 0.73) and born abroad (OR = 0.90; 95% CI: 0.86 to 0.94) were less likely to use hospice care than were white patients. These results were consistent across the six cancer diagnoses that were examined. Conclusion Older Asian Americans dying of cancer, especially those who are born abroad, are less likely than white patients to use hospice care at the end of life. Additional research is needed to understand the reasons for these differences and to eliminate potential barriers to hospice care. more...
- Published
- 2003
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21. Should This Patient Receive Aspirin?
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Eileen E. Reynolds, Mandeep S. Sawhney, Risa B. Burns, and Kelly L. Graham
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Aspirin ,medicine.medical_specialty ,Gastrointestinal bleeding ,Cancer prevention ,business.industry ,Colorectal cancer ,General Medicine ,Guideline ,Disease ,030204 cardiovascular system & hematology ,medicine.disease ,Primary disease ,03 medical and health sciences ,0302 clinical medicine ,Aspirin therapy ,Internal Medicine ,Medicine ,030212 general & internal medicine ,business ,Intensive care medicine ,medicine.drug - Abstract
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. more...
- Published
- 2017
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22. Should This Patient Receive an Antidepressant?
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Risa B. Burns, Gerald W. Smetana, and Roscoe O. Brady
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medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Public health ,Comparative effectiveness research ,Alternative medicine ,General Medicine ,Guideline ,medicine.disease ,030227 psychiatry ,Discontinuation ,Cognitive behavioral therapy ,03 medical and health sciences ,0302 clinical medicine ,Internal Medicine ,medicine ,Major depressive disorder ,030212 general & internal medicine ,Psychiatry ,business ,Depression (differential diagnoses) - Abstract
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. more...
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- 2017
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23. Do Hip Replacements Improve Outcomes for Hip Fracture Patients?
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Risa B. Burns, Ellen P. McCarthy, Robert L. Kane, Arlene S. Ash, Mark A. Moskowitz, and Michael D. Finch
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Male ,medicine.medical_specialty ,Activities of daily living ,Arthroplasty, Replacement, Hip ,Health Status ,Minnesota ,medicine.medical_treatment ,Poison control ,Patient Readmission ,Hip replacement (animal) ,Fracture Fixation ,Activities of Daily Living ,medicine ,Humans ,Internal fixation ,Prospective Studies ,Prospective cohort study ,Aged ,Femoral neck ,Aged, 80 and over ,Hip fracture ,business.industry ,Public Health, Environmental and Occupational Health ,Pennsylvania ,medicine.disease ,Texas ,Arthroplasty ,Femoral Neck Fractures ,Surgery ,Cross-Sectional Studies ,Treatment Outcome ,medicine.anatomical_structure ,Physical therapy ,Manipulation, Orthopedic ,Female ,business - Abstract
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 more...
- Published
- 1999
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24. Physician Characteristics
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John B. McKinlay, Linda Kasten, Karen M. Freund, Henry A. Feldman, Mark A. Moskowitz, and Risa B. Burns
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medicine.medical_specialty ,business.industry ,Public health ,Specialty ,General Medicine ,Odds ratio ,medicine.disease ,Comorbidity ,Confidence interval ,Surgery ,Breast cancer ,Malpractice ,Family medicine ,medicine ,business ,Socioeconomic status - Abstract
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. more...
- Published
- 1997
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25. Variability in Mammography Use Among Older Women
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Karen M. Freund, Mark A. Moskowitz, Risa B. Burns, Michael Shwartz, Sandra L. Marwill, Arlene S. Ash, and Ellen P. McCarthy
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Gerontology ,Databases, Factual ,Health Services for the Aged ,Population ,Primary care ,Zip code ,White People ,Humans ,Medicine ,Mammography ,Medical prescription ,education ,Aged ,Health care financing ,Aged, 80 and over ,education.field_of_study ,Median income ,medicine.diagnostic_test ,business.industry ,Age Factors ,United States ,Black or African American ,Income ,Female ,Residence ,Geriatrics and Gerontology ,business ,Demography - Abstract
OBJECTIVE: To determine rates of and explore factors associated with mammography use among older women. DESIGN: Retrospective review of part B (physician) bills submitted to Medicare during 1990. SETTING: Health Care Financing Administration (HCFA) data, including sociodemographic information and part B physician bills for all services delivered to Medicare-eligible women in 1990. PATIENTS/PARTICIPANTS: Women age 65 or older as of January 1, 1990, residing in one of 10 states with part B coverage through December 31, 1990. MEASUREMENTS AND MAIN RESULTS: The outcome was receipt of a mammogram (yes/no). We explored factors associated with mammography use within three age groups: 65 to 74, 75 to 84, and 85 +. The factors considered were race, state, median income of ZIP Code of residence (from the 1990 US Census, and used to divide the population into quintiles within each state), and number of primary care visits (0, 1, 2, and 3+). Overall, 15% of women had a mammogram: 20% of women age 65 to 74, 12% of women age 75 to 84, and 4% of women age 85 and older. Mammography use was lowest in Oklahoma and highest in Washington. However, in each state the older the age category, the less the mammography use (e.g., 9% vs 5% vs 2% in Oklahoma and 25% vs 16% vs 5% in Washington for women 65–74, 75–84, and 85+, respectively). Mammography use was lower for black than for white women age 65 to 74 (14% vs 21%, P < .001) and 75 to 84 (9% vs 12%, P < .001). Women in each of these two age groups had lower mammography use if they resided in the lowest income quintile and highest if they resided in the highest income quintile (17% vs 23% 65–74, and 10% vs 13% 75–84, P values < .001). Among the oldest women (those 85+), mammography use was low (4%) and varied minimally by race and income (P = .907 and .003, respectively). In all age groups, mammography use was lowest among women who did not have a primary care visit, was greater among women who had at least one visit, and continued to rise with increasing numbers of visits (all P values < .001). For example, among women age 75 to 84, mammography use increased from 5% to 10%, 14%, and 17% for those with 0, 1, 2, and 3+ visits. CONCLUSIONS: We found that mammography use was less for women who were older, of black race, who did not visit a primary care provider, and who lived in areas with lower median income and certain geographic locations (states). Similar factors influenced mammography use in women age 65 to 74, where there is greater consensus as to who should receive a mammogram, and women age 75 to 84, where there is neither consensus nor data. Surprisingly, neither race nor income had much influence on mammography use among women age 85 or older. J Am Geriatr Soc 44:922–926, 1996. more...
- Published
- 1996
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26. Should We Offer Medication to Reduce Breast Cancer Risk?
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Risa B. Burns, Howard Libman, Mara A. Schonberg, and Nadine Tung
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medicine.medical_specialty ,medicine.drug_class ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,Breast cancer ,Exemestane ,Internal Medicine ,medicine ,Mammography ,Raloxifene ,030212 general & internal medicine ,skin and connective tissue diseases ,Intensive care medicine ,Gynecology ,Aromatase inhibitor ,medicine.diagnostic_test ,business.industry ,Absolute risk reduction ,General Medicine ,medicine.disease ,chemistry ,030220 oncology & carcinogenesis ,Risk assessment ,business ,Tamoxifen ,medicine.drug - Abstract
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. more...
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- 2016
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27. Should We Treat for Subclinical Hypothyroidism?
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Pamela Hartzband, Risa B. Burns, Carol K. Bates, and Gerald W. Smetana
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education.field_of_study ,medicine.medical_specialty ,business.industry ,Thyroid disease ,Population ,Thyroid ,030209 endocrinology & metabolism ,General Medicine ,Disease ,Guideline ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Endocrinology ,medicine.anatomical_structure ,Internal medicine ,Internal Medicine ,medicine ,030212 general & internal medicine ,education ,business ,Intensive care medicine ,Risk assessment ,Body mass index ,Subclinical infection - Abstract
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. more...
- Published
- 2016
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28. Newspaper reporting of the medical literature
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Lewis E. Kazis, Michael A. Osband, Risa B. Burns, and Mark A. Moskowitz
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Information Services ,Public information ,business.industry ,Information Dissemination ,MEDLINE ,Newspapers as Topic ,Public relations ,United States ,Newspaper ,Public participation ,Internal Medicine ,Information system ,Medicine ,Periodicals as Topic ,business ,Mass media ,Medical literature - Abstract
To examine whether the media are providing information to the public about important medical advances in a timely manner and whether the degree of importance is associated with other aspects of newspaper reporting (presence, extent, and prominence).The authors explored the amount, extent, prominence, and timeliness of newspaper coverage received by New England Journal of Medicine and JAMA articles published in 1988, by searching ten leading U.S. newspapers. The journal articles were independently rated based on the public's need to know the medical information contained in the article. The intraclass reliability coefficient for this need-to-know importance score was 0.77.Overall, 35% of the journal articles received newspaper coverage (276/786). The articles were frequently covered by more than one newspaper [extensive coverage (161/276, 58%)] and often appeared on the front page [prominent coverage (42/276, 15%)]. Articles considered most important to the public (92/786, 12%) received more extensive and prominent coverage than did less important articles (p0.01). More than three fourths of the newspaper stories appeared within two days of the journal article's issue date. Stories about the most important articles appeared sooner than did those about the less important articles (p0.0001).Articles reported in two prominent medical journals are often viewed as being important to the public, and these articles are receiving newspaper coverage that is extensive, prominent, and timely. This is particularly true for those articles considered most important to the public. more...
- Published
- 1995
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29. Update: A 66-year-old man with an abdominal aortic aneurysm
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Risa B. Burns and Neha Trivedi
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Male ,medicine.medical_specialty ,business.industry ,Abdominal aorta ,General Medicine ,medicine.disease ,Abdominal aortic aneurysm ,Surgery ,Aortic aneurysm ,medicine.anatomical_structure ,Renal Artery ,medicine.artery ,Circulatory system ,Medicine ,Humans ,Radiology ,business ,Watchful Waiting ,Blood vessel ,Artery ,Aged ,Aortic Aneurysm, Abdominal - Published
- 2011
30. Self-Report Versus Medical Record Functional Status
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Michael D. Finch, Arlene S. Ash, Robert L. Kane, Sharon Bak, Risa B. Burns, and Mark A. Moskowitz
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Self-assessment ,Self-Assessment ,medicine.medical_specialty ,Activities of daily living ,Bathing ,Dependency, Psychological ,MEDLINE ,Documentation ,Logistic regression ,Sensitivity and Specificity ,Medical Records ,Interviews as Topic ,Activities of Daily Living ,Health Status Indicators ,Humans ,Medicine ,Geriatric Assessment ,Aged ,business.industry ,Medical record ,Public Health, Environmental and Occupational Health ,Reproducibility of Results ,Odds ratio ,Patient Discharge ,United States ,Logistic Models ,Evaluation Studies as Topic ,Emergency medicine ,Functional status ,business - Abstract
The importance of assessing functional status in the hospitalized patient is gaining recognition. However, the availability and accuracy of medical record functional status data are uncertain. We collected data on 2,504 patients greater than 65 years of age discharged alive. A personal interview conducted 2 days before discharge recorded the patient's self-reported ability to perform 5 activities of daily living scales. Medical record abstraction was used independently to determine ability to perform the same activities of daily living scales. Patients who required any human assistance to perform a function were considered dependent. Patients were also contacted after discharge to determine the site of posthospital care (28% discharged to a nursing home). The amount of missing medical record functional status data varied by function from 20% for bathing to 50% for dressing. Ten percent of patients had no medical record functional status documentation concerning any of the five functions. The prevalence of self-reported dependence at discharge varied by function from 24% for feeding to 93% for bathing. The total number of dependencies differed between the two methods (medical records, 2.3 +/- 1.9; self-report data, 3.2 +/- 1.5). There was exact agreement between the two methods on the total number of dependencies in 28% of cases and differences of greater than or equal to 3 in 20%. In a stepwise logistic model predicting discharge to a nursing home and adjusting for other relevant variables, the number of dependencies as determined by self-report and medical record data each remained significant (Odds Ratios = 1.6). Self-report and medical record functional status data differ substantially, and the medical record data remain independently associated with nursing home placement. Several possible explanations for this finding are explored. more...
- Published
- 1992
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31. Cholesterol screening in the emergency department
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Craig F. Feied, Mark S. Smith, Elizabeth Nash, Diane B. Stoy, and Risa B. Burns
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Adult ,Male ,medicine.medical_specialty ,Hypercholesterolemia ,Hospitals, University ,Internal Medicine ,medicine ,Humans ,Mass Screening ,Prospective Studies ,Intensive care medicine ,Mass screening ,Aged ,Aged, 80 and over ,business.industry ,Emergency department ,Middle Aged ,medicine.disease ,humanities ,Cholesterol blood ,Cholesterol ,District of Columbia ,Feasibility Studies ,Female ,Medical emergency ,Emergency Service, Hospital ,business ,Cholesterol screening - Abstract
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. more...
- Published
- 1991
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32. Advance Care Planning and Health Care Preferences of Community-Dwelling Elders: The Framingham Heart Study
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Ellen P. McCarthy, Risa B. Burns, Michael J. Pencina, Ralph B. D'Agostino, Joanne M. Murabito, Margaret Kelly-Hayes, Jane C. Evans, and Elizabeth J. Oberacker
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Advance care planning ,Aged, 80 and over ,Male ,Aging ,medicine.medical_specialty ,Terminal Care ,Activities of daily living ,business.industry ,Psychological intervention ,Article ,Advance Care Planning ,Patient satisfaction ,Framingham Heart Study ,Ambulatory care ,Patient Satisfaction ,Family medicine ,Health care ,Cohort ,Activities of Daily Living ,medicine ,Humans ,Female ,Geriatrics and Gerontology ,business ,Advance Directives - Abstract
Objective The study objective was to describe self-reported advance care planning, health care preferences, use of advance directives, and health perceptions in a very elderly community-dwelling sample. Methods We interviewed surviving participants of the original cohort of the Framingham Heart Study who were cognitively intact and attended a routine research examination between February 2004 and October 2005. Participants were queried about discussions about end-of-life care, preferences for care, documentation of advance directives, and health perceptions. Results Among 220 community-dwelling respondents, 67% were women with a mean age of 88 years (range 84-100 years). Overall, 69% discussed their wishes for medical care at the end of life with someone, but only 17% discussed their wishes with a physician or health care provider. Two thirds had a health care proxy, 55% had a living will, and 41% had both. Most (80%) respondents preferred comfort care over life-extending care, and 71% preferred to die at home; however, substantially fewer respondents said they would rather die than receive specific life-prolonging interventions (chronic ventilator [63%] or feeding tube [64%]). Many were willing to endure distressing health states, with fewer than half indicating that they would rather die than live out their life in a great deal of pain (46%) or be confused and/or forgetful (45%) all of the time. Conclusions Although the vast majority of very elderly community-dwellers in this sample appear to prefer comfort measures at the end of life, many said they were willing to endure specific life-prolonging interventions and distressing health states to avoid death. Our results highlight the need for physicians to better understand patients' preferences and goals of care to help them make informed decisions at the end of life. more...
- Published
- 2008
33. Breast cancer risk assessment and management in primary care: provider attitudes, practices, and barriers
- Author
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Russell S. Phillips, Susan A. Sabatino, Ellen P. McCarthy, and Risa B. Burns
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Risk ,Cancer Research ,medicine.medical_specialty ,Health Knowledge, Attitudes, Practice ,MEDLINE ,Breast Neoplasms ,Risk Assessment ,Breast cancer ,Nursing ,Surveys and Questionnaires ,medicine ,Humans ,Mass Screening ,Family history ,Practice Patterns, Physicians' ,Mass screening ,Genetic testing ,medicine.diagnostic_test ,Primary Health Care ,business.industry ,medicine.disease ,Oncology ,Family medicine ,Practice Guidelines as Topic ,Menarche ,Missing women ,Female ,Risk assessment ,business ,Mammography - Abstract
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. more...
- Published
- 2007
34. Breast cancer risk and provider recommendation for mammography among recently unscreened women in the United States
- Author
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Ellen P. McCarthy, Russell S. Phillips, Roger B. Davis, Susan A. Sabatino, and Risa B. Burns
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Adult ,Risk ,medicine.medical_specialty ,Breast Neoplasms ,Logistic regression ,Breast cancer ,Epidemiology ,Internal Medicine ,medicine ,National Health Interview Survey ,Mammography ,Humans ,Mass Screening ,Risk factor ,Practice Patterns, Physicians' ,Aged ,Gynecology ,medicine.diagnostic_test ,business.industry ,Editorials ,Cancer ,Original Articles ,Middle Aged ,medicine.disease ,United States ,Cross-Sectional Studies ,SUDAAN ,Family medicine ,Multivariate Analysis ,Regression Analysis ,Female ,business - Abstract
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. more...
- Published
- 2006
35. Trends in Breast Conserving Surgery Among Asian Americans and Pacific Islanders, 1992–2000
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Mita Sanghavi Goel, Risa B. Burns, Russell S. Phillips, Roger B. Davis, Quyen Ngo-Metzger, and Ellen P. McCarthy
- Subjects
Adult ,Asia ,Native Hawaiian or Other Pacific Islander ,Asian ,Breast Neoplasms ,Middle Aged ,Mastectomy, Segmental ,Combined Modality Therapy ,United States ,Age Distribution ,Internal Medicine ,Humans ,Original Article ,Female ,Aged ,Neoplasm Staging ,SEER Program - Abstract
Breast-conserving surgery (BCS) has been the recommended treatment for early-stage breast cancer since 1990 yet many women still do not receive this procedure.To examine the relationship between birthplace and use of BCS in Asian-American and Pacific-Islander (AAPI) women, and to determine whether disparities between white and AAPI women persist over time.Retrospective cohort study.Women with newly diagnosed stage I or II breast cancer from 1992 to 2000 in the Surveillance, Epidemiology, and End Results program.Receipt of breast -conserving surgery for initial treatment of stage I or II breast cancer.Overall, AAPI women had lower rates of BCS than white women (47% vs 59%; P.01). Foreign-born AAPI women had lower rates of BCS than U.S.-born AAPI and white women (43% vs 56% vs 59%; P.01). After adjustment for age, marital status, tumor registry, year of diagnosis, stage at diagnosis, tumor size, histology, grade, and hormone receptor status, foreign-born AAPI women (adjusted OR [aOR], 0.49; 95% CI, 0.32 to 0.76) and U.S.-born AAPI women (aOR, 0.77; 95% CI, 0.62 to 0.95) had lower odds of receiving BCS than white women. Use of BCS increased over time for each racial/ethnic group; however, foreign-born AAPI women had persistently lower rates of BCS than non-Hispanic white women.AAPI women, especially those who are foreign born, are less likely to receive BCS than non-Hispanic white women. Of particular concern, differences in BCS use among foreign-born and U.S.-born AAPI women and non-Hispanic white women have persisted over time. These differences may reflect inequities in the treatment of early-stage breast cancer for AAPI women, particularly those born abroad. more...
- Published
- 2005
36. Hospitalization of hospice patients with cancer
- Author
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Ellen P. McCarthy, Alexie Cintron, Russell S. Phillips, Roger B. Davis, Risa B. Burns, and Mary Beth Hamel
- Subjects
medicine.medical_specialty ,Lung Neoplasms ,Colorectal cancer ,MEDLINE ,Disease ,Medicare ,Risk Factors ,Epidemiology ,medicine ,Humans ,Intensive care medicine ,Lung cancer ,General Nursing ,Aged ,Proportional Hazards Models ,Retrospective Studies ,Aged, 80 and over ,business.industry ,Proportional hazards model ,Hospices ,Cancer ,Retrospective cohort study ,General Medicine ,medicine.disease ,United States ,Hospitalization ,Anesthesiology and Pain Medicine ,Emergency medicine ,Regression Analysis ,business ,Colorectal Neoplasms ,SEER Program - Abstract
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. more...
- Published
- 2003
37. Barriers to hospice care among older patients dying with lung and colorectal cancer
- Author
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Risa B. Burns, Ellen P. McCarthy, Roger B. Davis, and Russell S. Phillips
- Subjects
Male ,Cancer Research ,medicine.medical_specialty ,Attitude to Death ,Lung Neoplasms ,Time Factors ,Colorectal cancer ,Rectum ,Internal medicine ,Epidemiology ,medicine ,Humans ,Registries ,Lung cancer ,Aged ,Retrospective Studies ,Aged, 80 and over ,Insurance, Health ,business.industry ,Public health ,Respiratory disease ,Cancer ,Retrospective cohort study ,Length of Stay ,medicine.disease ,Surgery ,medicine.anatomical_structure ,Hospice Care ,Oncology ,Female ,business ,Colorectal Neoplasms ,SEER Program - Abstract
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. more...
- Published
- 2003
38. A 47-year-old woman with tension-type headaches, 1 year later
- Author
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Erin E. Hartman and Risa B. Burns
- Subjects
medicine.medical_specialty ,Analgesics ,Tension headache ,business.industry ,Analgesic ,Tension-Type Headache ,General Medicine ,Neurological disorder ,Middle Aged ,medicine.disease ,Surgery ,Neuroprotective Agents ,Serotonin Agents ,Tension-Type Headaches ,Chronic Disease ,medicine ,Humans ,Hypnotics and Sedatives ,Central Nervous System Stimulants ,Drug Therapy, Combination ,Female ,business - Published
- 2002
39. Mammography use, breast cancer stage at diagnosis, and survival among older women
- Author
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Risa B. Burns, Karen M. Freund, Ellen P. McCarthy, Arlene S. Ash, Michael Shwartz, Mark A. Moskowitz, and Sandra L. Marwill
- Subjects
Washington ,medicine.medical_specialty ,Georgia ,Population ,Breast Neoplasms ,Medicare ,Cohort Studies ,Breast cancer ,Cause of Death ,medicine ,Mammography ,Humans ,education ,Aged ,Neoplasm Staging ,Retrospective Studies ,Gynecology ,Aged, 80 and over ,Insurance Claim Reporting ,education.field_of_study ,medicine.diagnostic_test ,business.industry ,Obstetrics ,Hazard ratio ,Cancer ,Retrospective cohort study ,Odds ratio ,medicine.disease ,Survival Analysis ,United States ,Connecticut ,Female ,Medical Record Linkage ,Geriatrics and Gerontology ,business ,Cohort study ,SEER Program - Abstract
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. more...
- Published
- 2000
40. Functional outcomes of posthospital care for stroke and hip fracture patients under medicare
- Author
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Qing Chen, Mark A. Moskowitz, Robert L. Kane, Lynn A. Blewett, Risa B. Burns, and Michael D. Finch
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Cost-Benefit Analysis ,Aftercare ,Medicare ,Disability Evaluation ,Activities of Daily Living ,medicine ,Humans ,Stroke ,Geriatric Assessment ,Reimbursement, Incentive ,Reimbursement ,Aged ,Aged, 80 and over ,Hip fracture ,Rehabilitation ,business.industry ,Hip Fractures ,Prospective Payment System ,Mortality rate ,medicine.disease ,Patient Discharge ,United States ,Cerebrovascular Disorders ,Treatment Outcome ,Cohort ,Physical therapy ,Prospective payment system ,Geriatrics and Gerontology ,business ,Cohort study - Abstract
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. more...
- Published
- 1998
41. Mammography use helps to explain differences in breast cancer stage at diagnosis between older black and white women
- Author
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Sandra L. Marwill, Karen M. Freund, Risa B. Burns, Arlene S. Ash, Michael Shwartz, Ellen P. McCarthy, Mark A. Moskowitz, Janet C. Rice, and Steven S. Coughlin
- Subjects
Washington ,medicine.medical_specialty ,Georgia ,Breast Neoplasms ,White People ,Breast cancer ,Epidemiology of cancer ,Epidemiology ,Internal Medicine ,medicine ,Mammography ,Humans ,Registries ,Aged ,Neoplasm Staging ,Retrospective Studies ,Gynecology ,Aged, 80 and over ,Cancer prevention ,medicine.diagnostic_test ,Obstetrics ,business.industry ,Mortality rate ,General Medicine ,medicine.disease ,Black or African American ,Connecticut ,Socioeconomic Factors ,Female ,business ,Negroid ,Cohort study - Abstract
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. more...
- Published
- 1998
42. Prevalence of Domestic Violence in an Inpatient Female Population
- Author
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Karen M. Freund, Ellen P. McCarthy, Risa B. Burns, and Katherine C. McKenzie
- Subjects
Gerontology ,Adult ,medicine.medical_specialty ,Domestic Violence ,Adolescent ,Abusive relationship ,Short Communications ,Poison control ,Suicide prevention ,Occupational safety and health ,Injury prevention ,Health care ,Internal Medicine ,medicine ,Prevalence ,Humans ,music ,Inpatients ,music.instrument ,business.industry ,Public health ,Middle Aged ,Hospitalization ,Family medicine ,Domestic violence ,Female ,business - Abstract
Studies have evaluated the prevalence of domestic violence in populations of patients in emergency and primary care settings, but there are little data on patients admitted to hospitals. We undertook a study to evaluate the prevalence of domestic violence among female inpatients. Of 131 consecutive female patients between the ages of 18 and 60 admitted to a nontrauma urban teaching hospital asked to complete a self-administered survey about domestic violence, 101 completed the questionnaire. Twenty-six percent of the respondents reported being in an abusive relationship at one time. Two patients felt that domestic violence contributed to their current reason for admission. No respondents were asked about domestic violence by health care providers. Domestic violence is an uncommon but important precipitant to nontrauma hospital admissions. Physicians should query all female inpatients about domestic assault. more...
- Published
- 1998
43. Physician variability and uncertainty in the management of breast cancer. Results from a factorial experiment
- Author
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Linda Kasten, Kate Woodman, Julie T. Irish, Mark A. Moskowitz, Risa B. Burns, John B. McKinlay, Henry A. Feldman, Karen M. Freund, and Deborah A. Potter
- Subjects
Adult ,Male ,medicine.medical_specialty ,Decision Making ,Specialty ,Patient characteristics ,Tissue sample ,Breast Neoplasms ,Interviews as Topic ,Random Allocation ,Breast cancer ,Medicine ,Humans ,Practice Patterns, Physicians' ,Socioeconomic status ,Aged ,Aged, 80 and over ,business.industry ,Public Health, Environmental and Occupational Health ,Middle Aged ,medicine.disease ,Comorbidity ,Massachusetts ,Socioeconomic Factors ,Research Design ,Family medicine ,Female ,Breast disease ,business ,Factor Analysis, Statistical ,Normal breast - Abstract
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. more...
- Published
- 1998
44. Outcomes for older men and women with congestive heart failure
- Author
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Mark A. Moskowitz, Arlene S. Ash, Risa B. Burns, Ellen P. McCarthy, Robert L. Kane, and Michael D. Finch
- Subjects
Gerontology ,Male ,medicine.medical_specialty ,Activities of daily living ,Sex Factors ,Internal medicine ,Epidemiology ,Activities of Daily Living ,Outcome Assessment, Health Care ,medicine ,Humans ,Hospital Mortality ,Prospective Studies ,Sex Distribution ,Prospective cohort study ,Geriatric Assessment ,Survival analysis ,Aged ,Aged, 80 and over ,Heart Failure ,APACHE II ,business.industry ,medicine.disease ,Prognosis ,Comorbidity ,Survival Analysis ,Patient Discharge ,Socioeconomic Factors ,Heart failure ,Female ,Geriatrics and Gerontology ,business ,human activities ,Cohort study - Abstract
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). more...
- Published
- 1997
45. Variations in the performance of hip fracture procedures
- Author
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Ellen P. McCarthy, Arlene S. Ash, Risa B. Burns, Michael D. Finch, Mark A. Moskowitz, and Robert L. Kane
- Subjects
Male ,medicine.medical_specialty ,medicine.medical_treatment ,Health Status ,Minnesota ,Geographic variation ,Femoral Neck Fractures ,Hip replacement (animal) ,Hospitals, Urban ,Activities of Daily Living ,medicine ,Humans ,Practice Patterns, Physicians' ,Diagnosis-Related Groups ,APACHE ,Aged ,Aged, 80 and over ,Hip fracture ,business.industry ,Public Health, Environmental and Occupational Health ,Pennsylvania ,medicine.disease ,Arthroplasty ,Texas ,Surgery ,Female ,Health Services Research ,Hip Prosthesis ,business - Abstract
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. more...
- Published
- 1997
46. Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment
- Author
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Risa B. Burns, Henry A. Feldman, Karen M. Freund, John B. McKinlay, Mark A. Moskowitz, Brooke S. Harrow, Linda Kasten, Richard Durante, and Julie T. Irish
- Subjects
medicine.medical_specialty ,Decision Making ,Specialty ,Breast Neoplasms ,Breast cancer ,Sex Factors ,Clinical decision making ,Risk Factors ,medicine ,Humans ,Medical diagnosis ,Practice Patterns, Physicians' ,Socioeconomic status ,Aged ,Aged, 80 and over ,Physician-Patient Relations ,business.industry ,Health Policy ,Public Health, Environmental and Occupational Health ,Age Factors ,Cognition ,Factorial experiment ,Middle Aged ,Patient Acceptance of Health Care ,medicine.disease ,Presentational and representational acting ,Patient Simulation ,Massachusetts ,Socioeconomic Factors ,Family medicine ,Mental Recall ,Female ,Patient Participation ,business - Abstract
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. more...
- Published
- 1997
47. Use of post-hospital care by Medicare patients
- Author
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Qing Chen, Mark A. Moskowitz, Robert L. Kane, Michael D. Finch, Risa B. Burns, and Lynn A. Blewett
- Subjects
Gerontology ,Male ,medicine.medical_specialty ,medicine.medical_treatment ,Minnesota ,Aftercare ,Medicare ,Residence Characteristics ,Activities of Daily Living ,medicine ,Humans ,Diagnosis-Related Groups ,Multinomial logistic regression ,Aged ,Rehabilitation ,business.industry ,Public health ,Medical record ,Pennsylvania ,Texas ,Hospital care ,Patient Discharge ,United States ,Logistic Models ,Emergency medicine ,Predictive power ,Functional status ,Female ,Prospective payment system ,Health Services Research ,Geriatrics and Gerontology ,business ,Follow-Up Studies - Abstract
BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has shortened hospital stays and, as a consequence, has increased the use of post-hospital care. Medicare coverage provides for various types of post-hospital care. This paper examines the characteristics of patients, cities, and hospitals associated with discharge to these different types of post-hospital care. METHODS: A total of 2248 consecutive Medicare patients having one of five diagnosis related groups (DRGs), who were about to be discharged from 52 hospitals in three cities in 1988–1989, were enrolled in the study. These DRGs comprised approximately one-eighth of all Medicare hospital discharges and 40% of all Medicare-paid post-hospital care. Patients were interviewed in person before discharge and again 6 weeks after discharge. Clinical severity measures were developed from information abstracted from each patient's medical record. For each DRG, multinomial logit regression equations were developed to identify factors associated with the choice of one of four possible discharge locations: home with no formal care, home health care, nursing home care, or rehabilitation. RESULTS: Discharge location could be predicted correctly in 52 to 71% of cases, depending on the DRG. This level of predictive accuracy was significantly greater than relying on the modal discharge location, which accounted for 33 to 62% of cases. Most of the predictive power came from information gathered at the discharge interview. The variables associated significantly with the discharge location varied with the DRG and location examined. Living alone and functional dependency at discharge were the significant predictors found most often. CONCLUSIONS: Rather than assuming that everyone is discharged to the modal location, patient discharge location can be predicted. Much of the the explanation can be traced to a few variables such as functional status and living situation. The lack of greater accuracy suggests that factors other than those identified as important by clinical panels are involved in discharge planning for Medicare patients. J Am Geriatr Soc 44:242–250, 1996. more...
- Published
- 1996
48. The exclusion of non-English-speaking persons from research
- Author
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Eric Hardt, Amy K. Rosen, Risa B. Burns, Susan M. Frayne, and Mark A. Moskowitz
- Subjects
Gerontology ,Research design ,Medical education ,medicine.medical_specialty ,genetic structures ,business.industry ,viruses ,Public health ,Communication Barriers ,MEDLINE ,Ethnic group ,Emigration and Immigration ,Medical research ,environment and public health ,United States ,Research Design ,Internal Medicine ,medicine ,Humans ,lipids (amino acids, peptides, and proteins) ,business ,Language - Abstract
We sought to determine how often non-English-speaking (NES) persons are excluded from medical research. DESIGN. Self-administered survey.A Medline search identified all original investigations on provider-patient relations published in major U.S. journals from 1989 through 1991, whose methodologies involved direct interaction between researcher and subject (N = 216). Each study's corresponding author was surveyed; 81% responded.Of the 172 respondents, 22% included NES persons; among these includers, 16% had not considered the issue during the study design process, and 32% thought including the NES had affected their study results. Among the 40% who excluded the NES (excluders), the most common reason was not having thought of the issue (51%), followed by translation issues and recruitment of bilingual staff. The remaining 35% (others) indicated that there were no NES persons in their study areas.NES persons are commonly excluded from provider-patient communication studies appearing in influential journals, potentially limiting the generalizability of study findings. Because they are often excluded through overnight, heightened awareness among researchers and granting institutions, along with the development of valid instruments in varied languages, may increase representation of non-English-speaking subjects in research. more...
- Published
- 1996
49. Who gets repeat screening mammography: the role of the physician
- Author
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Arlene S. Ash, Risa B. Burns, Lisa Antab, Ruth E. Hall, Michael Shwartz, and Karen M. Freund
- Subjects
medicine.medical_specialty ,medicine.diagnostic_test ,Screening mammography ,Practice patterns ,business.industry ,Medical screening ,Public health ,Patient Selection ,Internship and Residency ,Middle Aged ,medicine.disease ,Hospitals, University ,Physicians, Women ,Breast cancer ,Family medicine ,Internal Medicine ,medicine ,Mammography ,Humans ,Women's Health ,Female ,Practice Patterns, Physicians' ,business ,Boston - Abstract
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 more...
- Published
- 1995
50. Update: A 60-Year-Old Woman With Sexual Difficulties
- Author
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Risa B. Burns, Nadine Farag, and Anna A. Mattson-DiCecca
- Subjects
Pediatrics ,medicine.medical_specialty ,business.industry ,MEDLINE ,General Medicine ,Middle Aged ,Postmenopause ,Sexual Dysfunction, Physiological ,Sexual dysfunction ,medicine ,Humans ,Female ,medicine.symptom ,business - Published
- 2009
- Full Text
- View/download PDF
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