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1.  The Effect of Immediate Reading of Screening Mammograms on Medical Care Utilization and Costs after False-Positive Mammograms 
Health Services Research  2007;42(4):1464-1482.
Objective
To investigate whether decreased anxiety associated with immediate reading of screening mammograms resulted in lower downstream utilization and costs among women with false-positive mammograms.
Data Sources/Study Setting
We identified 1,140 women,≥age 40, with false-positive mammograms and 12-month follow-up after participating in a trial of immediate versus batch mammographic reading between February 1999 and January 2001 in a multispecialty group managed care practice in Massachusetts.
Study Design
We determined downstream utilization and costs for study participants by immediate and batch reading status.
Data Collection/Extraction Methods
Demographic, comorbidity, and medical care utilization data were obtained from survey data and computerized medical record databases. Costs included direct medical costs, patient time, travel and copayments, and additional professional time costs associated with immediate reading.
Principal Findings
Immediate reading cost an additional $4.40 per screening mammogram. Women with immediate readings had more follow-up mammograms (781 versus 750, p = 0.018) and fewer diagnostic ultrasounds (176 versus 219, p = 0.016) than women with batch readings. Costs to the health plan for breast care were approximately 10 percent higher for immediate readings in multivariable analyses (p = 0.046), but no significant difference was seen in total societal costs (p = 0.072).
Conclusions
Immediate mammogram reading was associated with increased costs to the health plan and changes in follow-up radiology procedures. These costs must be examined alongside beneficial effects of immediate reading.
doi:10.1111/j.1475-6773.2006.00660.x
PMCID: PMC1955276  PMID: 17610433
Mammography; immediate reading; controlled trial; utilization; costs
2.  Screening Mammograms by Community Radiologists: Variability in False-Positive Rates 
Background
Previous studies have shown that the agreement among radiologists interpreting a test set of mammograms is relatively low. However, data available from real-world settings are sparse. We studied mammographic examination interpretations by radiologists practicing in a community setting and evaluated whether the variability in false-positive rates could be explained by patient, radiologist, and/or testing characteristics.
Methods
We used medical records on randomly selected women aged 40–69 years who had had at least one screening mammographic examination in a community setting between January 1, 1985, and June 30, 1993. Twenty-four radiologists interpreted 8734 screening mammograms from 2169 women. Hierarchical logistic regression models were used to examine the impact of patient, radiologist, and testing characteristics. All statistical tests were two-sided.
Results
Radiologists varied widely in mammographic examination interpretations, with a mass noted in 0%–7.9%, calcification in 0%–21.3%, and fibrocystic changes in 1.6%–27.8% of mammograms read. False-positive rates ranged from 2.6% to 15.9%. Younger and more recently trained radiologists had higher false-positive rates. Adjustment for patient, radiologist, and testing characteristics narrowed the range of false-positive rates to 3.5%–7.9%. If a woman went to two randomly selected radiologists, her odds, after adjustment, of having a false-positive reading would be 1.5 times greater for the radiologist at higher risk of a false-positive reading, compared with the radiologist at lowest risk (95% highest posterior density interval [similar to a confidence interval] = 1.17 to 2.08).
Conclusion
Community radiologists varied widely in their false-positive rates in screening mammograms; this variability range was reduced by half, but not eliminated, after statistical adjustment for patient, radiologist, and testing characteristics. These characteristics need to be considered when evaluating false-positive rates in community mammographic examination screening.
PMCID: PMC3142994  PMID: 12237283
4.  Specificity of Clinical Breast Examination in Community Practice 
Background
Millions of women receive clinical breast examination (CBE) each year, as either a breast cancer screening test or a diagnostic test for breast symptoms. While screening CBE had moderately high specificity (∼94%) in clinical trials, community clinicians may be comparatively inexperienced and may conduct relatively brief examinations, resulting in even higher specificity but lower sensitivity.
Objective
To estimate the specificity of screening and diagnostic CBE in clinical practice and identify patient factors associated with specificity.
Design
Retrospective cohort study.
Subjects
Breast-cancer-free female health plan enrollees in 5 states (WA, OR, CA, MA, and MN) who received CBE (N = 1,484).
Measurements
Medical charts were abstracted to ascertain breast cancer risk factors, examination purpose (screening vs diagnostic), and results (true-negative vs false-positive). Women were considered “average-risk” if they had neither a family history of breast cancer nor a prior breast biopsy and “increased-risk” otherwise.
Results
Among average- and increased-risk women, respectively, the specificity (true-negative proportion) of screening CBE was 99.4% [95% confidence interval (CI): 98.8–99.7%] and 97.1% (95% CI: 95.7–98.0%), and the specificity of diagnostic CBE was 68.7% (95% CI: 59.7–76.5%) and 57.1% (95% CI: 51.1–63.0%). The odds of a true-negative screening CBE (specificity) were significantly lower among women at increased risk of breast cancer (adjusted odds ratio 0.21; 95% CI: 0.10–0.46).
Conclusions
Screening CBE likely has higher specificity among community clinicians compared to examiners in clinical trials of breast cancer screening, even among women at increased breast cancer risk. Highly specific examinations, however, may have relatively low sensitivity for breast cancer. Diagnostic CBE, meanwhile, is relatively nonspecific.
doi:10.1007/s11606-006-0062-7
PMCID: PMC1824753  PMID: 17356964
breast cancer; sensitivity and specificity; screening; physical examination
5.  Specificity of Clinical Breast Examination in Community Practice 
Background
Millions of women receive clinical breast examination (CBE) each year, as either a breast cancer screening test or a diagnostic test for breast symptoms. While screening CBE had moderately high specificity (∼94%) in clinical trials, community clinicians may be comparatively inexperienced and may conduct relatively brief examinations, resulting in even higher specificity but lower sensitivity.
Objective
To estimate the specificity of screening and diagnostic CBE in clinical practice and identify patient factors associated with specificity.
Design
Retrospective cohort study.
Subjects
Breast-cancer-free female health plan enrollees in 5 states (WA, OR, CA, MA, and MN) who received CBE (N = 1,484).
Measurements
Medical charts were abstracted to ascertain breast cancer risk factors, examination purpose (screening vs diagnostic), and results (true-negative vs false-positive). Women were considered “average-risk” if they had neither a family history of breast cancer nor a prior breast biopsy and “increased-risk” otherwise.
Results
Among average- and increased-risk women, respectively, the specificity (true-negative proportion) of screening CBE was 99.4% [95% confidence interval (CI): 98.8–99.7%] and 97.1% (95% CI: 95.7–98.0%), and the specificity of diagnostic CBE was 68.7% (95% CI: 59.7–76.5%) and 57.1% (95% CI: 51.1–63.0%). The odds of a true-negative screening CBE (specificity) were significantly lower among women at increased risk of breast cancer (adjusted odds ratio 0.21; 95% CI: 0.10–0.46).
Conclusions
Screening CBE likely has higher specificity among community clinicians compared to examiners in clinical trials of breast cancer screening, even among women at increased breast cancer risk. Highly specific examinations, however, may have relatively low sensitivity for breast cancer. Diagnostic CBE, meanwhile, is relatively nonspecific.
doi:10.1007/s11606-006-0062-7
PMCID: PMC1824753  PMID: 17356964
breast cancer; sensitivity and specificity; screening; physical examination
6.  Barriers to self-monitoring of blood glucose among adults with diabetes in an HMO: A cross sectional study 
Background
Recent studies suggest that patients at greatest risk for diabetes complications are least likely to self-monitor blood glucose. However, these studies rely on self-reports of monitoring, an unreliable measure of actual behavior. The purpose of the current study was to examine the relationship between patient characteristics and self-monitoring in a large health maintenance organization (HMO) using test strips as objective measures of self-monitoring practice.
Methods
This cross-sectional study included 4,565 continuously enrolled adult managed care patients in eastern Massachusetts with diabetes. Any self-monitoring was defined as filling at least one prescription for self-monitoring test strips during the study period (10/1/92–9/30/93). Regular SMBG among test strip users was defined as testing an average of once per day for those using insulin and every other day for those using oral sulfonylureas only. Measures of health status, demographic data, and neighborhood socioeconomic status were obtained from automated medical records and 1990 census tract data.
Results
In multivariate analyses, lower neighborhood socioeconomic status, older age, fewer HbA1c tests, and fewer physician visits were associated with lower rates of self-monitoring. Obesity and fewer comorbidities were also associated with lower rates of self-monitoring among insulin-managed patients, while black race and high glycemic level (HbA1c>10) were associated with less frequent monitoring. For patients taking oral sulfonylureas, higher dose of diabetes medications was associated with initiation of self-monitoring and HbA1c lab testing was associated with more frequent testing.
Conclusions
Managed care organizations may face the greatest challenges in changing the self-monitoring behavior of patients at greatest risk for poor health outcomes (i.e., the elderly, minorities, and people living in low socioeconomic status neighborhoods).
doi:10.1186/1472-6963-3-6
PMCID: PMC153532  PMID: 12659642
7.  Increased Patient Concern After False-positive Mammograms 
OBJECTIVE
To measure how often a breast-related concern was documented in medical records after screening mammography according to the mammogram result (normal, or true-negative vs false-positive) and to measure changes in health care utilization in the year after the mammogram.
DESIGN
Cohort study.
SETTING
Large health maintenance organization in New England.
PATIENTS
Group of 496 women with false-positive screening mammograms and a comparison group of 496 women with normal screening mammograms, matched for location and year of mammogram.
MEASUREMENTS AND MAIN RESULTS
1) Documentation in clinicians' notes of patient concern about the breast and 2) ambulatory health care utilization, both breast-related and non–breast-related, in the year after the mammogram. Fifty (10%) of 496 women with false-positive mammograms had documentation of breast-related concern during the 12 months after the mammogram, compared to 1 (0.2%) woman with a normal mammogram (P = .001). Documented concern increased with the intensity of recommended follow-up (P = .009). Subsequent ambulatory visits, not related to the screening mammogram, increased in the year after the mammogram among women with false-positive mammograms, both in terms of breast-related visits (incidence ratio, 3.07; 95% confidence interval [CI], 1.69 to 5.93) and non-breast-related visits (incidence ratio, 1.14; 95% CI, 1.03 to 1.25).
CONCLUSIONS
Clinicians document concern about breast cancer in 10% of women who have false-positive mammograms, and subsequent use of health care services are increased among women with false-positive mammogram results.
doi:10.1111/j.1525-1497.2001.00329.x
PMCID: PMC1495181  PMID: 11318909
mammography; screening; false positive; anxiety; health care utilization
8.  The Relation of Household Income to Mammography Utilization in a Prepaid Health Care System 
Managed care organizations should be expected to provide equivalent access to preventive and screening services to all members. We studied mammography in 1,667 women members of one HMO who had an overall utilization rate of 84.9%. Significant correlates of mammography utilization included age, estimated household income, and division of the managed care organization in which the member was enrolled. Each $10,000 increment of income increased mammography rates by 2.5 percentage points (95% confidence interval [CI], 1.4% to 3.6%), independent of age and division. Our findings suggest that coverage for mammography services is not sufficient to ensure equivalent use of screening across income groups.
doi:10.1111/j.1525-1497.2001.00228.x
PMCID: PMC1495187  PMID: 11318916
mammography; socioeconomical status; manged care
9.  Measuring access to effective care among elderly medicare enrollees in managed and fee-for-service care: a retrospective cohort study 
Background
Our aim was to compare access to effective care among elderly Medicare patients in a Staff Model and Group Model HMO and in Fee-for-Service (FFS) care.
Methods
We used a retrospective cohort study design, using claims and automated medical record data to compare achievement on quality indicators for elderly Medicare recipients. Secondary data were collected from 1) HMO data sets and 2) Medicare claims files for the time period 1994–95. All subjects were Medicare enrollees in a defined area of New England: those enrolled in two divisions of a managed care plan with different physician payment arrangements: a staff model, and a group model; and the Medicare FFS population. We abstracted information on indicators covering several domains: preventive, diagnosis-specific, and chronic disease care.
Results
On the indicators we created and tested, access in the single managed care plan under study was comparable to or better than FFS care in the same geographic region. Percent of Medicare recipients with breast cancer screening was 36 percentage points higher in the staff model versus FFS (95% confidence interval 34–38 percentage points). Follow up after hospitalization for myocardial infarction was 20 percentage points higher in the group model than in FFS (95% confidence interval 14–26 percentage points).
Conclusion
According to indicators developed for use in both claims and automated medical record data, access to care for elderly Medicare beneficiaries in one large managed care organization was as good as or better than that in FFS care in the same geographic area.
doi:10.1186/1472-6963-1-11
PMCID: PMC59902  PMID: 11716798
10.  Breast Cancer Screening Use by African Americans and Whites in an HMO 
OBJECTIVE
To examine racial differences in breast cancer screening in an HMO that provides screening at no cost.
DESIGN
Retrospective cohort study of breast cancer screening among African-American and white women. Breast cancer screening information was extracted from computerized medical records.
SETTING
A large HMO in New England.
PATIENTS/PARTICIPANTS
White and African-American women (N =2,072) enrolled for at least 10 years in the HMO.
MAIN RESULTS
Primary care clinicians documented recommending a screening mammogram significantly more often for African Americans than whites (70% vs 64%; P <.001). During the 10-year period, on average, white women obtained more mammograms (4.49 vs 3.93; P <.0001) and clinical breast examinations (5.35 vs 4.92; P <.01) than African-American women. However, a woman's race was no longer a statistically significant predictor of breast cancer screening after adjustment for differences in age, estimated household income, estrogen use, and body mass index (adjusted number of mammograms, 4.47 vs 4.25, P =.17; and adjusted number of clinical breast examinations, 5.35 vs 5.31, P =.87).
CONCLUSIONS
In this HMO, African-American and white women obtained breast cancer screening at similar rates. Comparisons with national data showed much higher screening rates in this HMO for both white and African-American women.
doi:10.1111/j.1525-1497.2000.01339.x
PMCID: PMC1495437  PMID: 10759997
breast cancer screening; race; ethnicity; socioeconomic status

Results 1-11 (11)