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Biomedical subjects

James S Goodwin

Publications and source records attributed to James S Goodwin.

At least 19 recordsLinked to original sources
PubMed2003

Discrepancy between consensus recommendations and actual community use of adjuvant chemotherapy in women with breast cancer.

BACKGROUND: Although the efficacy of adjuvant chemotherapy in prolonging survival for women with breast cancer has been well documented, limited population-based information is available on the actual use of chemotherapy. OBJECTIVE: To examine the relationship between age and chemotherapy use. DESIGN: Cohort study. SETTING: New Mexico. PATIENTS: 5101 women 20 years of age or older receiving a diagnosis of stage I, stage II, or stage IIIA breast cancer from 1991 through 1997. MEASUREMENTS: Pattern of chemotherapy use by age; logistic regression analysis to generate the odds and probabilities of receiving chemotherapy; and sensitivity analysis to estimate potential effects of unmeasured confounders. RESULTS: Overall, 29% of women received chemotherapy. The rate of chemotherapy use for women with stage I, stage II, or stage IIIA breast cancer was 11%, 47%, and 68%, respectively. Across all tumor stages, the use of chemotherapy decreased substantially with increasing age (P < 0.001). Overall, 66% of women younger than 45 years of age received chemotherapy compared with 44% of women between 50 and 54 years of age, 31% of women between 55 and 59 years of age, and 18% of women between 60 and 64 years of age. The decreasing pattern of chemotherapy use with age continued after adjustment for prognostic factors and was relatively insensitive to changes in unmeasured factors. CONCLUSIONS: There is considerable discrepancy between the 1990 National Institutes of Health Consensus Conference recommendations for chemotherapy administration in women with breast cancer and the actual use of chemotherapy in the community. The decrease in use with age may relate to the decreasing efficacy of chemotherapy with age, as reported in clinical trials. Outcomes studies should address whether the recommendations are overly aggressive or whether practicing oncologists are too conservative in their use of chemotherapy.

Adult↗
PubMed2003

Effect of nurse case management on the treatment of older women with breast cancer.

OBJECTIVES: To evaluate the effect of nurse case management on the treatment of older women with breast cancer. DESIGN: Randomized prospective trial. SETTING: Sixty surgeons practicing at 13 community and two public hospitals in southeast Texas. PARTICIPANTS: Three hundred thirty-five women (166 control and 169 intervention) aged 65 and older newly diagnosed with breast cancer. INTERVENTION: Women seeing surgeons randomized to the intervention group received the services of a nurse case manager for 12 months after the diagnosis of breast cancer. MEASUREMENTS: The primary outcome was the type and use of cancer-specific therapies received in the first 6 months after diagnosis. Secondary outcomes were patient satisfaction and arm function on the affected side 2 months after diagnosis. RESULTS: More women in the intervention group received breast-conserving surgery (28.6% vs 18.7%; P=.031) and radiation therapy (36.0% vs 19.0%; P=.003). Of women undergoing breast-conserving surgery, greater percentages in the case management group received adjuvant radiation (78.3% vs 44.8%; P=.001) and axillary dissection (71.4% vs 44.8%; P=.057). Women in the case management group were also more likely to receive more breast reconstruction surgery (9.3% vs 2.6%, P=.054), and women in the case management group with advanced cancer were more likely to receive chemotherapy (72.7% vs 30.0%, P=.057). Two months after surgery, higher percentages of women in the case manager group had normal arm function (93% vs 84%; P=.037) and were more likely to state that they had a real choice in their treatment (82.2% vs 69.9%, P=.020). Women with indicators of poor social support were more likely to benefit from nurse case management. CONCLUSION: Nurse case management results in more appropriate management of older women with breast cancer.

Age Factors↗
PubMed2003

Cognitive function and incidence of stroke in older Mexican Americans.

BACKGROUND: Given the high prevalence of cognitive impairment in older Mexican Americans and limited longitudinal research examining cognitive function in this ethnic group, we conducted a study examining whether cognitive impairment is a risk factor for new onset of stroke among older Mexican Americans. METHODS: We performed a prospective cohort study of 2682 Mexican Americans aged 65 years and older living in the southwestern United States. For subjects with no prior history of stroke and who completed the Mini-Mental State Examination (MMSE) at baseline, stroke incidence was assessed after 2, 5, and 7 years of follow-up. RESULTS: In Cox proportional regression models, MMSE score at baseline predicted risk of incident stroke over a 7-year follow-up period. For the unadjusted model, subjects with an MMSE score of 21 or higher were half as likely to report stroke at follow-up (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.35-0.69; p <.001) compared with those with a score of less than 21. We found similar results after controlling for relevant risk factors for stroke including age, gender, smoking status, education, body mass index, diabetes, heart attack, systolic blood pressure, and depressive symptoms (HR, 0.54; 95% CI, 0.38-0.77; p =.001). Additionally, each 1-point increase in MMSE score was associated with a 5% reduction in risk (HR, 0.95; 95% CI, 0.92-0.99; p =.01). CONCLUSIONS: Increasing MMSE score is associated with a decreasing incidence of stroke in older Mexican Americans. This study highlights the need for a more aggressive focus on identifying and addressing cognitive decline in the Mexican American population.

Aged↗
PubMed2003

Embracing complexity: A consideration of hypertension in the very old.

The consequences of hypertension and its treatment differ in very old men and women compared to younger populations. In populations aged 85 years and older, higher levels of systolic and diastolic blood pressures are associated with increased survival, and this relationship is not eliminated by controlling for comorbidity, blood pressure treatment, and other relevant factors. In addition, in 3 of the 4 published randomized controlled trials of treatment of hypertension that included subjects aged 80 years or older, the investigators reported loss of efficacy of treatment in preventing the primary end points in subjects aged 80 and older. In a meta-analysis of those trials, total mortality was actually 14% higher (p =.05) in the treatment group for subjects aged 80 years and older. These data suggest 2 conclusions. First, we should reexamine that dictum that nontreatment of hypertension in those aged 80 years and older is de facto evidence of "ageism." Second, we are unlikely to come to any set of coherent "rules" regarding treatment of hypertension (and several other conditions) in the very old until we routinely stratify all older subjects enrolled in interventional or observational trials by indicators of physiologic vigor.

Aged↗
PubMed2003

Measuring the performance of screening mammography in community practice with Medicare claims data.

BACKGROUND: Few studies have examined the outcomes of screening mammography in community practice, particularly the extent of false positive exams among older asymptomatic women. RESEARCH DESIGN: Subjects were female Medicare beneficiaries, age 67 or older, residing in one of eleven SEER areas, with no evidence of breast cancer. Medicare claims data were used to identify their screening mammograms over two time periods, 1993-1995 and 1996-1998, and to measure their use of follow-up diagnostic testing (diagnostic mammography, breast ultrasound and breast biopsy) within three months of the screening mammogram. RESULTS: There were significant differences among the rates of diagnostic testing for each age group (67-74; 75+ ) by year, but no clear trend toward higher or lower rates over time. Although rates of diagnostic testing differed significantly by geographic region in both time periods 1993-1995 and 1996-1998, estimates of specificity for all regions were within AHRQ clinical practice guidelines (specificity greater than 90%). Specificity significantly improved with the volume of the radiologist's practice for the latter time period (1996-1998) but not for the former (1993-1995). CONCLUSION: Medicare claims offer an accessible population-based source of data for mammography performance indicators. As such, they offer a low cost method for evaluating individual mammography practices as well as monitoring the impact of reimbursement policies, practice guidelines and laws mandating requirements for accrediting facilities.

Aged↗
PubMed2003

Potentially inappropriate medication use by elderly Mexican Americans.

BACKGROUND: Use of inappropriate medications by the elderly is a public health concern with potentially serious health consequences. Research indicates relatively high rates of inappropriate prescription drug usage for older whites and African Americans. However, rates for older Mexican Americans are unknown. OBJECTIVE: To examine the prevalence and predictors of inappropriate prescription medication use by older Mexican Americans. METHODS: A cross-sectional study of 3050 Mexican Americans aged > or =65 years living in the southwestern US was conducted. In-home interviews in 1993 and 1994 assessed prescription medication use. Descriptive statistics and logistic regression models were used to estimate prevalence and risk of inappropriate prescription drug use. RESULTS: Approximately 12% (n = 365) of the sample had used at least 1 of 32 potentially inappropriate prescription medications within 2 weeks of the baseline assessment. Four drugs, chlorpropamide, propoxyphene, amitriptyline, and dipyridamole, accounted for 54% of all inappropriate prescribing. Unmarried subjects, those with >/=1 chronic diseases, high depressive symptoms, frequent physician visits, and combined Medicaid and Medicare insurance were more likely to have used at least 1 of the 32 potentially inappropriate drugs. CONCLUSIONS: The prevalence of inappropriate medication use is lower in older Mexican Americans than in similar white and African American populations. More studies are needed on the pattern of inappropriate prescribing over time and on intervention programs to reduce potentially adverse health outcomes in older Mexican Americans most at risk.

Aged↗
PubMed2003

Hospice use by older women dying with breast cancer between 1991 and 1996.

The purpose of this study was to assess the use of hospice by women dying with breast cancer as a function of time period, geographic area, and patient characteristics. We used data from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database to study hospice care use in the United States in women aged 65 and older, diagnosed with breast cancer from 1986 to 1996, who died from 1991 to 1996. Of the 25,161 women who met those criteria, 5,198 (20.7%) were enrolled in hospice before they died. The rate of hospice use in this population increased from 11.5% in 1991 to 27.1% in 1996. Use of hospice care was inversely related to age and was higher among those who were married. There were no differences in use by ethnicity. Rates of use varied significantly by geographic area. Future research should further examine why rates of hospice use differ by geographic area and certain patient characteristics.

Aged↗
PubMed2002

Population-based assessment of hospitalizations for toxicity from chemotherapy in older women with breast cancer.

PURPOSE: There are no population-based data on hospitalization rate for toxicity from breast cancer chemotherapy, and even large clinical trials often do not report this information. Medicare data, linked to the Surveillance, Epidemiology, and End-Results (SEER) tumor registries, are now used to assess rates of hospitalization for chemotherapy-related toxicity in a population-based setting. PATIENTS AND METHODS: A total of 35,060 women diagnosed with stages I through IV breast cancer aged >or= 65 from 1991 through 1996 were identified from the SEER-Medicare linked program and studied. Patients were defined as being hospitalized for adverse effects of chemotherapy if there was a Medicare inpatient claim for neutropenia, fever, thrombocytopenia, or adverse effect of systemic therapy less than 7 months after diagnosis of breast cancer. RESULTS: More than 9% of women with breast cancer who received chemotherapy were admitted with the diagnosis of neutropenia, fever, thrombocytopenia, or adverse effect of systemic therapy, compared with 0.5% of women with breast cancer who did not receive chemotherapy. The rates for stage I to IV were 6.3%, 8.1%, 12.3%, and 13.2% in those treated with chemotherapy, and 0.4%, 0.6%, 0.7%, and 1.5% in women not treated with chemotherapy. The hospitalization rates for adverse effects increased significantly with comorbidity score and varied more than two-fold across the nine SEER areas but did not vary by age. Use of anthracycline-containing chemotherapy agents was associated with greater odds of these toxicities (eg, odds ratio, 2.53 for neutropenia; 95% confidence interval, 1.97 to 3.26). CONCLUSION: This study demonstrated the feasibility of using Medicare data to assess rates of hospitalization for serious toxicity associated with cancer chemotherapy. Rates in actual practice were higher than those reported in clinical trials and did not vary by age.

Aged↗
PubMed2002

Regular mammography use is associated with elimination of age-related disparities in size and stage of breast cancer at diagnosis.

BACKGROUND: There is little consensus about recommending mammography for women 75 years of age and older. These women have mammography less frequently and are more likely to receive a diagnosis of advanced breast cancer. OBJECTIVE: To examine the relationship between use of screening mammography and size and stage of cancer at diagnosis in older women. DESIGN: Retrospective cohort study. SETTING: Tumor registries in the Surveillance, Epidemiology, and End Results (SEER) program. PATIENTS: 12 038 women who were Medicare beneficiaries, were at least 69 years of age, resided in a SEER area, and received a new diagnosis of breast cancer in 1995 through 1996. MEASUREMENTS: Screening mammograms obtained in the 2 years before breast cancer diagnosis (none, one, or at least two) and stage and size of tumor at diagnosis. RESULTS: Older women (> or =75 years of age) had larger tumors at diagnosis and were less likely to have undergone screening mammography than younger women (69 to 74 years of age). The association between increased mammography use and smaller tumor size and stage was significantly greater in older women than in younger women (P = 0.010 for stage; P = 0.001 for size). The percentage of regular mammography users who received a diagnosis of high-stage disease (28% vs. 26%; P > 0.2) and the mean size of the tumors (15.0 mm vs. 15.1 mm; P > 0.2) did not significantly differ between younger and older women, respectively. These findings remained constant after controlling for factors that might contribute to biases. CONCLUSION: Mammography in older women is associated with elimination of age-related disparities in size and stage of breast cancer at diagnosis.

Age Distribution↗
PubMed2002

Bringing the patient back in. Guidelines, practice variations, and the social context of medical practice.

We challenge assumptions that have guided much research and policy aimed at understanding and reducing medical practice variation. Paramount is the focus on doctors as the cause of variation to the neglect of other possible influences. Some research literature suggests that patients, families, and the community context of practice may also influence treatment decisions. Failure to question present assumptions, despite weak evidence in support of them, may account for inability to explain persistent practice variation, develop appropriate implementable guidelines, or anticipate the effect on treatment decisions of greater patient involvement. In this paper, we discuss the weak response to the NIH Consensus Conference on early stage breast cancer because it may have reflected these problems. We urge a more complex and more empirical approach in explaining treatment choice and guidelines sensitive to the potential for value differences.

Attitude to Health↗
PubMed2002

Survival of women after breast conserving surgery for early stage breast cancer.

BACKGROUND: Increasing numbers of older women with breast cancer are receiving breast-conserving surgery (BCS). However, substantial numbers of them are not receiving either axillary dissection or adjuvant irradiation. OBJECTIVE: To determine whether failure to perform axillary dissection or irradiation is associated with decreased survival in women with early-stage breast cancer. METHOD: We studied 26,290 women aged > or = 25 in 1988-1993 from the surveillance, epidemiology, and end results (SEER) data and 5,328 women aged > or = 65 in 1991-1993 from SEER-Medicare linked data, who had early-stage breast cancer and received BCS. RESULTS: Twenty seven percent of women aged > or = 25 receiving BCS did not receive axillary dissection, most of whom (74%) were age > or = 65. Women receiving BCS with axillary dissection had lower 7-year breast cancer-specific mortality than did those without dissection (hazard ratio = 0.53, 95% confidence interval: 0.44-0.63). We found an interaction between receipt of axillary dissection and radiotherapy on survival of older women after BCS. Women who received either axillary dissection or radiotherapy experienced similar survivals to those who received both axillary dissection and radiation, while women who received neither treatment experienced poorer survival (hazard ratio = 1.76, 1.23-2.52), after controlling for demographics, tumor size and comorbidity. CONCLUSIONS: Women who receive neither axillary dissection nor radiation therapy after BCS experience an increased risk of death from breast cancer. The lack of improvement in the past two decades in survival of older women with breast cancer may be explained in part by the increasing use of treatments that do not address potential tumor in axillary nodes.

Adult↗
PubMed2002

Differential effects of premorbid physical and emotional health on recovery from acute events.

OBJECTIVES: Emotional health may have an important effect on disease onset, but there has been little work evaluating premorbid emotional health on recovery from disability that results from acute medical events. The aim of this study is to determine whether premorbid emotional health is predictive of recovery in functional ability 1 year after reporting a stroke, heart attack, or hip fracture (event). DESIGN: A prospective cohort study of an older population-based sample from 1986 to 1992. SETTING: Data are from baseline and six annual follow-ups of the North Carolina Established Population for Epidemiological Study of the Elderly. PARTICIPANTS: Two hundred forty whites and blacks aged 65 and older who reported a stroke, heart attack, or hip fracture during one of the first five follow-up interviews and had an increased level of disability at that follow-up. MEASUREMENT: Improvement in disability in activities of daily living (ADLs) 1 year postevent. RESULTS: High depressive symptoms at baseline showed a significant association with poorer recovery in functional ability 1-year postevent after adjustments were made for sociodemographic characteristics, smoking status, ADLs at time of event, cognitive status, and prior history of disease. Compared with nondepressed subjects, depressed subjects had an odds ratio (OR) of 0.38 (95% confidence interval (CI) = 0.16-0.94) for recovery 1 year after reporting a stroke, heart attack, or hip fracture. Additionally, among subjects who reported low depressive symptoms, high positive affect was significantly associated with increased odds of recovery (OR = 2.70, 95% CI = 1.10-6.68), adjusting for the same variables. CONCLUSIONS: Emotional health, independent of other baseline measures, is associated with recovery in functional ability 1 year after a major health event. Our findings suggest that reducing premorbid levels of depressive symptoms or increasing positive affect may help the recovery process.

Activities of Daily Living↗
PubMed2002

Developing a geriatric business plan for an academic medical center.

Leaders of geriatric programs at academic health centers (AHCs) face several challenges in seeking support for clinical program development. These challenges relate to how revenues from Medicare activities flow within AHCs. Typically, clinical departments such as the Department of Medicine see a very small proportion of total AHC Medicare revenue and frequently experience losses on their Medicare activities. In contrast, hospitals in AHCs see the bulk of the revenues and typically experience substantial profits. This article examines this situation in some detail, with specific examples from AHCs with which the author has consulted.The unique effect of Medicare revenue on AHCs requires the geriatric leader to identify who gains and who loses from Medicare activity within his or her AHC and to seek support for geriatric programs based on that analysis.

Academic Medical Centers↗
PubMed2002

Handgrip strength and mortality in older Mexican Americans.

OBJECTIVES: To examine the association between handgrip strength and mortality in older Mexican American men and women. DESIGN: A 5-year prospective cohort study. SETTING: Five southwestern states: Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: A population-based sample of 2,488 noninstitutionalized Mexican-American men and women aged 65 and older. MEASUREMENTS: Maximal handgrip strength, timed walk, and body mass index were assessed at baseline during 1993/94. Self-reports of functional disability, various medical conditions, and status at follow-up were obtained. RESULTS: Of the baseline sample with complete data, 507 persons were confirmed deceased 5 years later. Average handgrip strength +/- standard deviation was significantly higher in men (28.4 kg +/- 9.5) than in women (18.2g +/- 6.5). Of men who had a handgrip strength less than 22.01 kg and women who had a handgrip strength less than 14 kg, 38.2% and 41.5%, respectively, were dead 5 years later. In men in the lowest handgrip strength quartile, the hazard ratio of death was 2.10 (95% confidence interval (CI) = 1.31-3.38) compared with those in the highest handgrip strength quartile, after controlling for sociodemographic variables, functional disability, timed walk, medical conditions, body mass index, and smoking status at baseline. In women in the lowest handgrip strength quartile, the hazard ratio of death was 1.76 (95%I = 1.05-2.93) compared with those in the highest handgrip strength quartile. Poorer performance in the timed walk and the presence of diabetes mellitus, hypertension, and cancer were also significant predictors of mortality 5 years later. CONCLUSION: Handgrip strength is a strong predictor of mortality in older Mexican Americans, after controlling for relevant risk factors.

Aged↗
PubMed2002

Diabetes mellitus as a risk factor for hip fracture in mexican american older adults.

BACKGROUND: Hip fracture in older adults is a significant medical, social, and economic concern to society. Little is known regarding diabetes as a risk factor for hip fracture in the Mexican American population. The objective of this study was to examine diabetes and other potential risk factors for hip fracture in a sample of community-dwelling, older, Mexican American adults. METHODS: The study was a prospective cohort design involving the Hispanic Established Population for the Epidemiologic Study of the Elderly, a longitudinal study involving a weighted probability sample of Mexican American adults (>65 years) living in the southwestern United States. Included in the study were 3050 older Mexican American subjects who were originally interviewed and tested at baseline and then followed with reassessment at 2, 5, and 7 years. Incidence of hip fracture was examined for subjects over 7-year follow-up. RESULTS: At baseline, 690 subjects were identified with diabetes. One hundred and thirty-four subjects experienced a first-time hip fracture during follow-up. Cox proportional hazard regression revealed an increased hazard ratio for hip fracture in subjects with diabetes compared to those without diabetes (hazard ratio = 1.57, 95% confidence interval [CI(95)] = 1.03, 2.39, p <.04) when adjusted for age, body mass index, smoking, and previous stroke. The hazard ratio for Mexican Americans taking insulin was 2.84 (CI(95) = 1.49, 5.43, p <.002) when adjusted for covariates. CONCLUSIONS: We found diabetes was associated with increased risk for a hip fracture in older Mexican Americans, particularly subjects taking insulin. Diabetes has not previously been considered a risk factor for hip fracture in older adults. The high incidence of type 2 diabetes in the Mexican American population highlights the need for increased research on risk factors in this ethnic group.

Age Factors↗
PubMed2002

The interaction of cognitive and emotional status on subsequent physical functioning in older mexican americans: findings from the Hispanic established population for the epidemiologic study of the elderly.

BACKGROUND: Optimal mental health (cognitive and emotional functioning) is an important factor for maintaining physical function. This study investigated the effects of cognitive and emotional status on subsequent lower body function in a population-based sample of older Mexican Americans. METHODS: A 2-year prospective cohort study included Mexican Americans aged 65 and older who scored 18 or higher on the Mini-Mental State Examination (MMSE) at baseline interview and for whom complete data on a summary performance measure of lower body function were available at the 2-year follow-up interview (n = 2068). In-home interviews in 1993-1994 and 1995-1996 assessed sociodemographic variables, physical health conditions, cognitive function, emotional health, and lower body function. RESULTS: In a multivariate analysis, continuous MMSE (b = 0.06; SE 0.02, p =.004) and Center for Epidemiological Studies-Depression (CES-D) (b = -0.53; SE 0.17, p =.002) scores at baseline were significantly associated with a summary performance measure of lower body function 2 years later, controlling for age, gender, marital status, education, selected medical conditions, and baseline summary performance score. A significant MMSE-by-CES-D interaction (p =.002) on summary performance score was also found after adjustments were made for age, gender, marital status, education, chronic health conditions, and baseline summary performance score. After adjusting for age, gender, marital status, education, selected medical conditions, and baseline summary performance score, subjects with low cognition (MMSE score 18-21) and high depressive symptoms (CES-D score > or = 16) were the most likely to have poor summary performance scores 2 years later (b = -0.95, SE 0.36, p =.008), followed by subjects with high cognition (MMSE score > 21) and high depressive symptoms (CES-D score > or = 16) (b = -0.57, SE 0.19, p =.003), and those with low cognition (MMSE score 18-21) and low depressive symptoms (CES-D score < 16) (b = -0.47, SE 0.22, p =.03), with high cognition (MMSE score > 21) and low depressive symptoms (CES-D score < 16) used as the reference. CONCLUSIONS: Our results confirm prior investigations showing both cognitive function and emotional health predict subsequent lower body function, and extend these findings to older Mexican Americans. In addition, our results indicate that good emotional health moderates the impact of low cognition on subsequent physical function.

Age Factors↗
PubMed2002

Geographic variations in breast cancer survival among older women: implications for quality of breast cancer care.

BACKGROUND: Breast cancer care, such as utilization of screening procedures and types of treatment received, varies substantially by geographic region of the United States. However, little is known about variations in survival with breast cancer. METHODS: We examined breast cancer incidence, survival, and mortality in the 66 health service areas covered by the Surveillance, Epidemiology, and End Results (SEER) program for women aged 65 and older at diagnosis. Incidence and survival data were derived from SEER, while breast cancer mortality data were from Vital Statistics data. RESULTS: There was considerable variation in breast cancer survival among the 66 health service areas (chi2 = 202.7, p <.0001). There was also significant variation in incidence and mortality from breast cancer. In a partial correlation weighted for the size of the health service area, both incidence (r =.812) and percent 5-year survival (r = -.587) correlate with mortality. In a Poisson regression analysis, the combination of variation in incidence and variation in survival explains 90.9% of the variation in mortality. CONCLUSIONS: There is considerable geographic variation in survival from breast cancer among older women, and this contributes to variation in breast cancer mortality. Geographic variations in breast cancer mortality should diminish as the quality of breast cancer care becomes more standardized.

Aged↗