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Biomedical subjects

H C Sox

Publications and source records attributed to H C Sox.

At least 37 records · Page 2Linked to original sources
PubMed2000

Women's understanding of the mammography screening debate.

BACKGROUND: The fractious public debate over mammography screening recommendations for women aged 40 to 49 years has received extensive attention in medical journals and in the press. OBJECTIVE: To learn how women interpret the mammography screening debate. METHODS: We mailed a survey to a random sample of American women 18 years and older, oversampling women of screening age (40-70 years). Sixty-six percent of women completed the survey (n = 503). MAIN OUTCOME MEASURES: The main outcome measures were women's reactions to the debate, their suggestion for the starting age for mammography screening, and their understanding of the source of the debate. RESULTS: Almost all women (95%) said that they had paid some attention to the recent discussion about mammography screening. Only 24% said the discussion had improved their understanding of mammography, while 50% reported being upset by the public disagreement among screening experts. Women's beliefs about mammography differed from those articulated by experts in the debate. Eighty-three percent believed that mammography had proven benefit for women aged 40 to 49 years, and 38% believed that benefit was proven for women younger than 40 years. Most women suggested that mammography screening should begin before age 40 years, while only 5% suggested a first mammogram should be performed at 50 years or older. In response to an open-ended question about why mammography has been controversial, 15% cited concerns about the potential harms of radiation and another 12% cited questions about efficacy. Nearly half (49%), however, identified costs as the major source of debate (eg, "Health maintenance organizations [HMOs] don't want to pay for mammography"). CONCLUSIONS: Most women paid attention to the recent debate about routine mammography screening for women aged 40 to 49 years, but many believed the debate was about money rather than the question of benefit. Policy makers issuing recommendations about implementation of large-scale mammography screening services need to consider how to effectively disseminate their message.

Adolescent↗
PubMed2000

US women's attitudes to false-positive mammography results and detection of ductal carcinoma in situ: cross-sectional survey.

OBJECTIVE: To determine women's attitudes and knowledge of both false-positive mammography results and the detection of ductal carcinoma in situ after screening mammography. DESIGN: Cross-sectional survey. SETTING: United States. PARTICIPANTS: A total of 479 women aged 18 to 97 years who did not report a history of breast cancer. Main outcome measures Attitudes and knowledge about false-positive results and the detection of ductal carcinoma in situ after screening mammography. RESULTS: Women were aware that false-positive results do occur. Their median estimate of the false-positive rate for 10 years of annual screening was 20% (25th percentile estimate, 10%; 75th percentile estimate, 45%). The women were highly tolerant of false-positive results: 63% thought that 500 or more false-positives per life saved was reasonable, and 37% would tolerate a rate of 10,000 or more. Women who had had a false-positive result (n = 76) expressed the same high tolerance: 30 (39%) would tolerate 10,000 or more false-positives. In all, 62% of women did not want to take false-positive results into account when deciding about screening. Only 8% of women thought that mammography could harm a woman without breast cancer, and 94% doubted the possibility of nonprogressive breast cancers. Few had heard of ductal carcinoma in situ, a cancer that may not progress, but when informed, 60% of women wanted to take into account the possibility of it being detected when deciding about screening. CONCLUSIONS: Women are aware of false-positive results and seem to view them as an acceptable consequence of screening mammography. In contrast, most women are unaware that screening can detect cancers that may never progress but think that such information would be relevant. Education should perhaps focus less on false-positive results and more on the less-familiar outcome of the detection of ductal carcinoma in situ.

Adolescent↗
PubMed1999

Principles of medical decision making.

The consequences of medical decisions are inherently uncertain at the decisive moment. Using clinical examples related to the diagnosis and management of low back pain, the authors review some principles that can help physicians deal with this uncertainty. This article addresses the following: the use of probability as a useful representation of uncertainty, the use of Bayes' theorem to update probability estimates when new information is obtained, the measurement of a diagnostic test's accuracy, the use of the threshold model for choosing a diagnostic test, the principles of expected-value decision making, the use of utility assessment as a way of attaching value to outcomes, and the use of quality-adjusted life years as a measure of value. These principles can aid physicians in approaching complex and uncertain decisions with their patients. As the use of computers becomes more integrated into the process of care, the opportunity exists to move formal decision models from the policy level to the patient care level.

Cost-Benefit Analysis↗
PubMed1999

The hospitalist model: perspectives of the patient, the Internist, and internal medicine.

The use of hospitalists has implications for patients, for internists, and for the specialty of internal medicine. For patients, the greatest concern is interrupting the continuity of a supportive relationship with their regular physican. For many internists, the hospitalist model is attractive, but they are concerned that health plans will compel physicians to transfer their patients to a hospitalist at the time of admission to the hospital (mandatory hand-off). Thus, the hospitalist could become the means to exclude internists from hospital care and deprive them of an important source of professional satisfaction. The specialty of internal medicine is very concerned about the mandatory hand-off because it threatens the internist's identity as the physician who can care for the sickest patients in any venue, making it harder for patients and health plans to distinguish the internist from family physicians and nurse practitioners. The hospitalist movement has much to offer internal medicine. To enjoy the benefits and avoid the harms associated with the hospitalist model, internal medicine must resist the imposition of the mandatory hand-off and use the hospitalist's focus on excellent inpatient care to improve the practice of medicine by all internists.

Continuity of Patient Care↗
PubMed1999

The potential size of the hospitalist workforce in the United States.

PURPOSE: In the United States, there are currently 1,000 to 2,000 physicians who specialize in inpatient hospital care. The number of such hospitatists appears to be growing rapidly, but the ultimate size of the hospitalist workforce is not known. METHODS: We obtained workload data from 365 practicing hospitalists who completed a survey by the National Association of Inpatient Physicians. We then estimated the number of potential hospitalists, based on published national hospital census data. We assumed that hospitalists would care for all medical inpatients, but only at hospitals large enough to require > or = 3 hospitalists. We also made estimates based on the primary care physician referral base and international benchmarks. We estimated hospitalists' primary care referral base from telephone interviews with key informants. Official sources in England and Germany provided international workforce data. RESULTS: Hospitalists reported an average workload of 13 inpatients. To cover all adult medical inpatients in the United States, we estimate a potential workforce of 19,000 hospitalists. Sensitivity analysis yielded 10,000 to 30,000 hospitalists. Our alternative models yielded estimates within this same range. CONCLUSIONS: The future hospitalist workforce is potentially quite large. This finding highlights the need to evaluate the economic and clinical outcomes of hospitalist systems.

Bed Occupancy↗
PubMed1999

Breast cancer screening.

Randomized controlled trials involving nearly 500,000 women on two continents have confirmed the early promise that screening mammography can reduce breast cancer mortality. The observed benefits of mammographic screening, however, are not the same in all women. The mortality reduction in women over age 70 is unknown, and women aged 40 to 49 do not appear to benefit from mammographic screening to the same extent as those over age 50. The reasons for this disparity are incompletely understood, but it depends in part upon differing tumor biology and mammographic test characteristics in younger women. Even if relative survival benefits were equal for women under and over age 50, absolute reduction in risk would remain considerably lower for younger women, a disparity that would not be corrected by improved screening technology or adjustment of interscreening intervals. The authors' review of the evidence leads them to strongly support mammographic screening of women aged 50 to 69 at an interval not longer than 2 years. The authors also feel it is reasonable to screen women over age 70 who have a favorable life expectancy. They conclude, however, that the evidence does not support a blanket recommendation in favor of screening women aged 40 to 49. Instead, they advocate a well-informed conversation between physician and patient regarding the present knowledge and the risks and benefits of screening for each individual woman. Definitive answers await the results of ongoing RCTs designed to study the survival benefit conferred by screening women aged 40 to 49. Disagreement will undoubtedly persist regarding which recommendations should determine private practice and public policy.

Adult↗
PubMed1999

Current controversies in screening: cholesterol, breast cancer, and prostate cancer.

Physicians must make decisions in day-to-day practice even when the balance of benefit and harm is not yet known. Adopting a clinical policy about screening is a case in point. Three controversies in screening healthy adults illustrate different aspects of resolving a dispute when the evidence is incomplete. The major controversy in cholesterol screening is whether to screen young adults. There has never been a randomized trial of treatment, let alone a trial of screening, in young adults. However, a patchwork of evidence strongly suggests that, because the baseline risk of coronary heart disease (CHD) is very small in young adults, the absolute reduction in risk from treatment would be very small. In breast cancer screening, randomized trials do not show conclusively that periodic mammography for women aged 40-49 years reduces breast cancer mortality. A 7-10 year delay between the first mammogram and a reduction in deaths from breast cancer suggests the hypothesis that the only benefit of screening women aged 40-49 years occurs from mammograms performed after age 50. There is no high quality evidence that early detection and treatment reduce the death rate from prostate cancer. In lieu of randomized trial data, we must depend on a decision analysis that shows that screening middle-aged men is cost-effective relative to other preventive services. However, this result depends on using optimistic survival data in the decision model, and most organizations do not recommend routine screening. The best strategy is to discuss the harms and benefits, and let the patient decide.

Adult↗
PubMed1997

History of visible rectal bleeding in a primary care population. Initial assessment and 10-year follow-up.

OBJECTIVE: To determine whether a complaint of visible rectal bleeding that is elicited by a screening review of systems merits investigation and to assess the accuracy of a defined protocol to evaluate bleeding. DESIGN: Prospective cohort study. SETTING: Primary care clinics in a veterans medical center. PATIENTS: We used an 8-item review of systems to identify 297 individuals with visible rectal bleeding; 201 (68%) of these individuals completed a specified protocol consisting of double-contrast barium enema (DCBE) examination, rigid sigmoidoscopy, and follow-up visit after 6 to 12 months. Ten years later we verified the diagnosis in 131 (93%) of 141 patients whose initial evaluation suggested no cause, or a benign anorectal cause, of bleeding. MAIN OUTCOME MEASURES: Final diagnoses after 2 and 10 years; sensitivity and specificity of symptoms, DCBE, and rigid sigmoidoscopy. RESULTS: We diagnosed serious disease in 48 (24%) of the 201 patients; 26 had polyps, 9 had inflammatory bowel disease, and 13 (6.5%) had colon cancer. Symptoms did not predict the diagnosis. Neither DCBE nor rigid sigmoidoscopy alone was sufficiently sensitive to be used alone, but the combination of DCBE and rigid sigmoidoscopy had a sensitivity of 0.96 and a specificity of 0.76 for the diagnosis of polyps, cancer, or inflammatory bowel disease. CONCLUSIONS: Self-reported rectal bleeding detected by means of a review of systems was associated with a high likelihood of important pathology. Physicians should ask all adults about visible rectal bleeding and should visualize the entire colon in those who report bleeding.

Adult↗
PubMed1997

Repeated testing. An overview and analysis.

Physicians often obtain the same test over and over again. This article first considers screening tests, such as mammographic screening for breast cancer, and describes several proposals for finding the interval that best balances cost, harms, and benefits. The same principles apply to monitoring a patient for recurrence of a disease, such as bladder cancer. The article closes with a theoretical consideration of the circumstances for repeating a test once to check a surprising value.

Cardiovascular Diseases↗
PubMed1996

The evaluation of diagnostic tests: principles, problems, and new developments.

This article describes the use of probability in reasoning about diagnostic test results and the importance of accurate measures of test performance. Most studies of test performance are retrospective analyses of unplanned observations. Retrospective studies are likely to result in biased estimates of test performance. This article shows how to adjust for biases in the results of retrospective studies and how to design a prospective study that will accurately measure the sensitivity and specificity of a test.

Bias↗
PubMed1996

Decision-making: a comparison of referral practice and primary care.

BACKGROUND: Should care by subspecialist physicians be more costly than care by primary care physicians? This article addresses diagnostic testing, one element of the answer to this question. METHODS: A theoretical analysis was conducted of the sequences of testing, treatment, or watchful waiting in patients with low, intermediate, or high probabilities of disease. This was followed by a reanalysis of data from a previously published study of patients with chest pain from two referral populations and two primary care populations. The study used a chest pain score as a summary measure of the number of suggestive findings. RESULTS: The analysis of sequences of testing, treatment, and watchful waiting suggests that patients with intermediate probabilities of disease are most likely to be referred. The study of patients with chest pain shows that the probability of disease for a given chest pain history score is higher in referred patients than it is in primary care patients, as is the proportion of patients with intermediate and high chest pain scores. This result is direct evidence that referral physicians get more patients with suspect but often uncertain histories. In general, the probability of disease given a particular history will be lower in primary care patients, and hence testing will be less fruitful. CONCLUSIONS: Subspecialists are more likely to see patients who represent a diagnostic puzzle and have intermediate probabilities of disease. Since patients with intermediate probabilities of disease are most likely to benefit from testing, a per capita rate of testing that is higher than in a primary care practice might be appropriate in a subspecialist's practice.

Adult↗