Engaging patients in medical decision making.
Explore the source record for details and available documents.
Attitude to Health↗
Biomedical subjects
J Melnikow
Publications and source records attributed to J Melnikow.
New tests for cervical cancer screening.
The Papanicolaou (Pap) smear has been used to screen women for cervical cancer since 1940. Recently, a number of new technologies have been developed to improve the detection of cervical cancer and its precursors. However, there is substantial controversy about whether the new tests offer meaningful advantages over the conventional Pap smear. Ideally, these new tests will increase the early detection of meaningful Pap smear abnormalities, reduce the number of unsatisfactory smears and provide fewer ambiguous results. It is also hoped that these new screening methods will not increase the number of false-positive results, but will improve the productivity of cytology laboratories without substantially increasing costs. The new tests include liquid-based/thin-layer preparations to improve the quality and adequacy of the Pap smear; computer-assisted screening methods to improve Pap smear interpretation; and new-generation human papillomavirus testing methods that may be useful in triaging patients with atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions. Evidence on these new tests is reviewed and the advantages and disadvantages of their use are discussed.
Cytopathogenic Effect, Viral↗
Vaginal birth after cesarean in California.
OBJECTIVE: To estimate rates at which women were offered and consented to trial of labor in California hospitals with high and low risk-adjusted cesarean delivery rates. METHODS: From 267 nonfederal acute-care hospitals in California that performed more than 678 deliveries in 1992-1993, 51 hospitals were selected in a stratified sample. Hospitals in the sample were categorized as having high, medium, and low risk-adjusted cesarean rates using a logistic regression model based on data from the California Patient Discharge Data System. We reviewed medical records of women with previous cesareans for evidence of counseling regarding trial of labor, other clinical variables, and method of delivery. Differences in proportions between the three groups of hospitals were compared. RESULTS: According to records of 369 women with previous cesareans, after excluding contraindications, 312 were potentially eligible for trial of labor. Hospitals with low risk-adjusted cesarean rates documented counseling women for trial of labor in over 99% of records reviewed, compared with 85% and 79%, respectively, of hospitals with intermediate and high rates (P <.001). Rates of completed vaginal births after cesarean were 71% in hospitals with low risk-adjusted cesarean rates, compared with 39% and 31% in hospitals with intermediate and high rates (P <.05). CONCLUSIONS: California hospitals with high cesarean rates in 1992-1993 had markedly higher rates of repeat elective cesarean delivery without evidence of counseling regarding trial of labor. Informed patient choice is a critical element of the decision for trial of labor or elective repeat cesarean, and lack of documented counseling is cause for concern.
Adult↗
Treatment outcomes for squamous intraepithelial lesions.
OBJECTIVE: To assess the effectiveness of cone biopsy, cryotherapy, laser ablation and the loop electrosurgical procedure in the treatment of squamous intraepithelial lesions. METHOD: Systematic review of randomized controlled trials in subjects who underwent treatment of low- and high-grade squamous intraepithelial lesions with these modalities. Main outcome measures included the following: percent resolution and persistence of a lesion and notable complications for each procedure. RESULT: Pooled rates of resolution for low-grade, high-grade, or combined squamous intraepithelial lesions were similar across the different treatment modalities (range 85.2-94.7%), with substantial overlap among the 95% confidence intervals. Significant hemorrhage occurred most frequently in subjects who received cone biopsy (4.6%) (95% CI: 2.15, 6.99), followed by laser ablation (1.75%) (95% CI: 0.70, 2.81), and LEEP (1.35%) (95% CI: 0.24, 2.47). No hemorrhages were reported among subjects who received cryotherapy. Study sample sizes were relatively small. There were no reported cases of progression to invasive cancer, but duration of follow-up (median follow-up time for all eligible studies = 12 months) was not sufficient to evaluate long-term outcomes. CONCLUSIONS: There were no substantive differences in outcomes regarding persistence and resolution in the treatment of squamous intraepithelial lesions for subjects receiving cone biopsy, cryotherapy, laser ablation, or LEEP.
Biopsy↗
Comparing the use of physician time and health care resources among patients speaking English, Spanish, and Russian.
BACKGROUND AND OBJECTIVES: The number of US residents with limited English proficiency (LEP) is 14 million and rising. The goal of this study was to estimate the effects of LEP on physician time and resource use. DESIGN: This was a prospective, observational study. SETTING AND SUBJECTS: The study included 285 Medicaid patients speaking English (n = 112), Spanish (n = 62), or Russian (n = 111) visiting the General Medicine and Family Practice Clinics at the UC Davis Medical Center in 1996-1997 (participation rate, 85%). Bilingual research assistants administered patient questionnaires, abstracted the medical record, and conducted detailed time and motion studies. MAIN OUTCOME MEASURES: We used seemingly unrelated regression models to evaluate the effect of language on visit time, controlling for patient demographics and health status, physician specialty, visit type, and resident involvement in care. We also estimated the effect of LEP on cross-sectional utilization of health care resources and adherence to follow-up with referral and testing appointments. RESULTS: The 3 language groups differed significantly by age, education, and reason for visit but not gender, number of active medical conditions, physical functioning, or mental health. Physician visit time averaged 38+/-20 minutes (mean+/-SD). Compared with English-speaking patients and after multivariate adjustment, Spanish and Russian speakers averaged 9.1 and 5.6 additional minutes of physician time, respectively (P <0.05). The language effect was confined largely to follow-up visits with resident physicians (house staff). Compared with English speakers, Russian speakers had more referrals (P = 0.003) and Spanish speakers were less likely to follow-up with recommended laboratory studies (P = 0.031). CONCLUSIONS: In these academic primary care clinics, some groups of patients using interpreters required more physician time than those proficient in English Additional reimbursement may be needed to ensure continued access and high-quality care for this special population.
California↗
Put prevention into practice: a controlled evaluation.
OBJECTIVES: The purpose of this study was to evaluate whether Put Prevention Into Practice (PPIP) materials affected the delivery of 8 clinical preventive services. METHODS: Program materials were provided to a family medicine practice serving a diverse, low-income population. Appropriate use of clinical preventive services was assessed via medical record reviews at baseline, 6 months, 18 months, and 30 months at both intervention and control sites. RESULTS: The delivery rates of 7 clinical preventive services were higher in the intervention site at 6 months. These rates had flattened or decreased by 30 months. CONCLUSIONS: Use of PPIP materials modestly improved delivery of certain clinical preventive services. Sustained improvement will require substantial system changes and ongoing support.
Adult↗
Determining costs of health care services for cost-effectiveness analyses: the case of cervical cancer prevention and treatment.
OBJECTIVES: To estimate costs for the prevention and treatment of cervical cancer based on resource utilization and to compare those costs to published estimates and to local charges and reimbursements. DESIGN: Cost estimates for cervical cancer prevention services were based on clinic staff time, use of specialized equipment and supplies, laboratory costs, and clinic overhead. Cost estimates for cervical cancer treatment were based on HMO expenditures for cervical cancer patients and control patients. These costs were adjusted for stage distribution and survival rates. Published cost estimates were obtained from a systematic review of the medical literature between 1990 and 1996. SETTING: Three family planning clinics (for prevention costs) and a staff-model HMO (for treatment costs). PATIENTS: For treatment costs: 98 cervical cancer patients and 133,058 female control patients, matched by age and chronic disease score. MAIN OUTCOME MEASURES: Estimated costs for prevention and treatment of cervical cancer. Cost-to-charge and cost-to-reimbursement ratios. RESULTS: Costs of cervical cancer prevention and treatment services have been determined using a variety of methods. We found substantial variation in these estimates, even for studies with similar methodologies. Detailed resource-based estimation suggests that prevention costs are generally lower than those previously published in the literature, whereas the costs of cervical cancer treatment are generally higher. CONCLUSIONS: It is practical and desirable to employ resource use-based estimates of medical costs in cost-effectiveness analyses. Failure to do so for cervical cancer may affect policy recommendations by understating the relative benefits of prevention programs.
California↗
Natural history of cervical squamous intraepithelial lesions: a meta-analysis.
OBJECTIVE: To define the strengths and weaknesses of existing research on the natural history of cervical squamous intraepithelial lesions (SIL) and to estimate rates of progression and regression without treatment. DATA SOURCES: Studies of women whose cervical smears showed squamous atypia or worse and who were observed for a minimum of 6 months were identified by a search of MEDLINE from 1966 to 1996, Current Contents, the Federal Research in Progress database, and references of review articles and identified studies, and by experts in the field. METHODS OF STUDY SELECTION: Fifteen of 81 studies were eligible for data extraction. To be eligible, studies had to report a minimum of 6 months' follow-up without treatment; relate entry cytologic findings to outcomes; and report entry cytologic findings so that the study population could be stratified into categories of atypical cells of undetermined significance (ASCUS), low-grade SIL, or high-grade SIL. Studies published before 1970 were excluded. TABULATION, INTEGRATION, AND RESULTS: Eligible studies, representing 27,929 patients, were stratified according to entry cytologic findings. The following rates of progression to high-grade SIL at 24 months were found: ASCUS, 7.13% (95% confidence interval [CI] 0.8%, 13.5%); low-grade SIL, 20.81% (6.08%, 35.55%); and high-grade SIL, 23.37% (12.82%, 32.92%). The following rates of invasive cancer at 24 months were found: ASCUS, 0.25% (0%, 2.25%); low-grade SIL, 0.15% (0%, 0.71%); and high-grade SIL, 1.44% (0%, 3.95%). The following rates of regression to normal were found: ASCUS, 68.19% (57.51%, 78.86%); low-grade SIL, 47.39% (35.92%, 58.86%); and high-grade SIL, 35.03% (16.57%, 53.49%). Study heterogeneity was not explained by regression analysis of study level variables. CONCLUSION: Our findings for borderline and low-grade abnormal cervical cytologic results suggest a relatively low risk of invasive cervical cancer with observation up to 24 months and support the clinical policy of early colposcopy for high-grade lesions.
Carcinoma in Situ↗
Detection of high-grade cervical dysplasia: impact of age and Bethesda system terminology.
Pap smear, colposcopy, and biopsy results were collected from 1988-1993 at a group of family planning clinics. Positive predictive values and likelihood ratios were calculated for diagnosis of high-grade lesions based on age and Pap smear results. One thousand and forty-seven colposcopies were logged; 771 had a biopsy or endocervical curettage. Seventy-nine (10%) were high-grade lesions. If only human papillomavirus (HPV) was reported on the Pap smear, the likelihood of a high-grade biopsy was lowest (positive predictive value, 4.5%; likelihood ratio, 0.4). Women under age 25 were less likely to have high-grade biopsies (positive predictive value, 7.3%; likelihood ratio 0.7). Repeat Pap smears for atypical cells of undetermined significance (ASCUS) and low grade squamous intra-epithelial lesion (LGSIL) showing only HPV in women under age 30 would have reduced the immediate colposcopy rate by 60% and delayed diagnosis by 23% of high-grade lesions. Consideration of patient age and whether HPV is the only Pap smear finding may reduce referral for immediate colposcopy.
Adult↗
Effect of a transportation incentive on compliance with the first prenatal appointment: a randomized trial.
OBJECTIVE: To evaluate the effectiveness of incentives for improving compliance with the first prenatal appointment. METHODS: One hundred four low-income women, intending to enroll for prenatal care in a system of Northern California family planning clinics, were recruited for a randomized trial. Study subjects were assigned randomly to one of three groups, receiving a taxicab voucher or a baby-blanket coupon or an appointment slip (controls). Intention-to-treat analysis was used to compare compliance with the first prenatal appointment between the three groups. RESULTS: Subjects receiving the taxi voucher had a compliance rate of 82% for the first prenatal appointment, 22% higher than mean appointment compliance in the other groups. The odds ratio for missing the first appointment was 0.32 (95% confidence interval 0.12, 0.88) in the taxi voucher group. This was not affected by controlling for possible confounders. Despite better appointment compliance, only one of 34 taxi vouchers distributed was actually used. CONCLUSION: A taxi voucher incentive was effective in improving compliance with the first prenatal appointment, despite the fact that only one subject actually used the voucher.
Adult↗
Cancer prevention and screening in women.
Although there is no recommended screening for ovarian or endometrial cancers, the use of oral contraceptives is a primary prevention maneuver. The prevention of cervical cancer is accomplished best by Pap smear screening every 1 to 3 years. Clinical breast examination and mammography every 1 to 2 years after age 50 years are effective in reducing breast cancer mortality. Screening for BRCA1 and BRCA2 mutations is now available, but the role of these tests is still not clear; extensive patient counseling is required.
Adult↗
Management choices for patients with "squamous atypia" on Papanicolaou smear. A toss up?
Appropriate management of borderline abnormalities on Papanicolaou (Pap smears is controversial. This decision analysis compared two strategies for management of women with the Pap smear result of "squamous atypia." A policy of immediate colposcopy and biopsy was compared with repeating the cervical smear at 6-month intervals. Relevant probabilities and ranges were extracted from published studies in the English language medical literature from 1966 to 1993. When no relevant studies could be located, probabilities with a plausible range were determined through consensus of a panel of experts. Outcome values were assigned for the analysis to contrast the time period (approximately 2 years) covered by the analysis. Using baseline estimates, either policy resulted in an essentially equivalent probability of invasive cervical cancer. The estimated likelihood of remaining free of invasive cervical cancer was .9974 for follow-up by repeat smear versus .9976 for immediate colposcopy and biopsy. In sensitivity analysis, very high probabilities of progression to invasive cervical cancer favored the policy of immediate colposcopy and biopsy. Follow-up of squamous atypia on cervical smear by repeating the smear at 6-month intervals is unlikely to result in a detectable increase in invasive cervical cancers.
California↗
Management of patients with atypical and low-grade Pap smear abnormalities.
Family physicians frequently encounter patients with atypical and low-grade Papanicolaou (Pap) smear findings. While near consensus exists regarding the evaluation and management of patients with high-grade dysplasia and carcinoma detected on Pap smear, the appropriate management of patients with atypical and low-grade abnormalities continues to be controversial. Recent guidelines from the National Cancer Institute propose consideration of a more conservative management approach, with repeat Pap smear as an alternative to immediate colposcopy. Conservative management, as an alternative to an ablative or excisional procedure, has also been proposed for women with histologic evidence of lowgrade dysplasia. It is unlikely that an approach including a conservative diagnostic strategy and careful follow-up will result in an increase in the number of missed cases of cervical cancer. This assumption needs to be assessed by prospective clinical trials.
Algorithms↗
Hormone replacement therapy and breast cancer risk.
Explore the source record for details and available documents.
Breast Neoplasms↗
Electrosurgical loop excision of the cervical transformation zone.
Explore the source record for details and available documents.
Adolescent↗
Patient compliance and medical research: issues in methodology.
Compliance with medication and medical appointments is presumed to have a critical influence on outcomes of medical interventions. However, compliance may not always be easily defined or accurately measured. No single method of measuring compliance with appointments or medication is applicable in all settings. The apparent effects of compliance on outcome may be both direct and indirect; research is needed to define more clearly how these effects may be mediated. Identifying effective methods of enhancing compliance requires accurate methods of measuring compliance. In addition, the effectiveness of interventions may decay over time, and differences in effectiveness in acute versus long-term settings have not been well studied. Researchers conducting clinical trials of medical interventions must evaluate compliance in the population studied and consider the potential impact of noncompliance on trial results and their generalizability. In some trial designs, data may best be analyzed by considering compliance a dependent or an outcome variable. Under appropriate circumstances, compliance may be considered an independent variable. Readers of the medical literature should consider how compliance was measured and analyzed when interpreting the results of clinical trials. Table 4 suggests criteria for critical appraisal of compliance-related issues in reports of clinical trials.
Appointments and Schedules↗
Management of common breast-feeding problems.
The benefits of breast-feeding have been well documented in the literature: it reduces morbidity from many illnesses and is considered the ideal nutrition for the newborn infant. This paper reviews common breast-feeding problems that family physicians may be called upon to manage: maternal problems, infant problems, and problems related to the need for maternal medication. Ensuring proper position of the infant at the breast and attention to the let-down reflex is the recommended method for prevention and treatment of nipple soreness. Prompt identification and treatment of blocked ducts, mastitis, and monilial infection of the nipple can prevent complications and allow uninterrupted nursing. Poor weight gain in the infant is managed by more frequent nursing. Neonatal jaundice or infant gastroenteritis rarely requires discontinuation of breast-feeding. Although physicians frequently recommend that women discontinue breast-feeding because of the administration of some maternal medications, maternal illness can often be managed with medications that do not interfere with nursing. Given proper advice and support, many mothers continue to breast-feed even after returning to work.
Breast Diseases↗
Does the system of Papanicolaou test nomenclature affect the rate of referral for colposcopy? A survey of family physicians.
OBJECTIVE: To determine whether a new system of Papanicolaou test nomenclature (the Bethesda system) or other physician variables influence recommendations for colposcopy and biopsy for women with borderline to moderately abnormal Papanicolaou test results. We hypothesized that physician demographic and practice variables, in addition to Papanicolaou test nomenclature, would influence recommendations for colposcopy. DESIGN: A survey was mailed to a random sample of 510 active members of the American Academy of Family Physicians. PARTICIPANTS: Three hundred thirty-five (66%) of the eligible physicians responded, representing all 50 states. Of those in active practice, 78% were in private practice, with a mean age of 44 years and a mean time in practice of 10 years. Ninety-three percent of respondents in active practice performed Papanicolaou tests. MAIN OUTCOME MEASURE: Rates of recommendation for colposcopy and biopsy in response to abnormal Papanicolaou test reports framed by a single clinical scenario. RESULTS: Physicians recommended colposcopy more often when the Bethesda nomenclature system was used to describe the results of the Papanicolaou test. These differences were significant for four specific Papanicolaou smear pairs. Inclusion of recommendations for further evaluation strongly influenced physicians to recommend colposcopy. In multivariable analyses, demographic and practice variables were not associated with recommendations for colposcopy. CONCLUSIONS: The Bethesda system of nomenclature, when compared with a traditional descriptive nomenclature system, influenced family physicians to recommend colposcopy and biopsy more often for abnormal Papanicolaou test results presented in a clinical scenario. Greater utilization of technology and higher medical care costs may result from use of the Bethesda system. Guidelines for evaluation of abnormal Papanicolaou test results are needed for use in conjunction with the Bethesda system guidelines for Papanicolaou test reports.
Adult↗