Four years analysis of cancer genetic clinics activity in France from 1994 to 1997: a survey on 801 patients. French Cooperative Network/Groupe Genetique et Cancer de la Federation Nationale des Centres de Lutte Contre le Cancer.
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AIM: In order to evaluate the characteristics and the evolution of cancer genetics activity in France, a survey was conducted at the national level during a period of 4 years from 1994 to 1997 through the French Cooperative Network, a multidisciplinary group formed to investigate inherited tumors. METHOD: A questionnaire was sent to all the 29 French non-specialized cancer genetic clinics to evaluate activity during a period of 4 consecutive weeks each year from 1994 to 1997. Items concerning the cancer genetic clinics, the consultees and the types of consultation were explored. RESULTS: A total number of 801 consultees were seen during the period of analysis. Some prominent characteristics of patients attending cancer genetic clinics were found. The majority of these are women (88%), and the mean age of consultees is 48 years. Fifty five percent of consultees are affected with cancer, and breast (personal and/or family history) is the most frequent site involved (63%). A genetic predisposition is certain or likely in about 53% of cases and unlikely in only 13% of consultations. The majority of consultations are devoted to new families (71%). The mean duration of consultations is 50 minutes, but 40% have a duration of at least 1 hour. Variations of several parameters during the 4 years period were observed and analyzed. Finally, since duration of consultations (more or equal to 1 hour) and personal or family history of breast/ovarian cancer appeared as pivotal elements in our study and consequently may affect the organization of clinics and the structuring as well as the evolution of cancer genetic activity in France, we analyzed more precisely the factors significantly associated with these 2 elements. CONCLUSION: Study compliance was fair (60% of centers) and these results give a good measure of cancer genetic activity in France. The variation of parameters from one year to another may reflect modifications in medical practice (medical orientation rather than research focus and content of cancer genetic clinics) and/or scientific breakthroughs in cancer genetics such as identification of genes predisposing to cancer. (+info)
Ethical, social and economic issues in familial breast cancer: a compilation of views from the E.C. Biomed II Demonstration Project.
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Demand for clinical services for familial breast cancer is continuing to rise across Europe. Service provision is far from uniform and, in most centres, its evolution has been determined by local conditions, specifically by local research interests, rather than by central planning. However, in a number of countries there is evidence of progress towards co-ordinated development and audit of clinics providing risk assessment, counselling, screening and, in some cases, prophylactic intervention. Much important information should emerge from continued observation and comparative assessment of these developments. In most countries for which relevant data are available, there is a distinct bias towards higher social class among those who avail themselves of clinic facilities (in line with findings from many other health-promotion initiatives). This should be addressed when considering future organisation of clinical services. Molecular genetic studies designed to identify the underlying mutations responsible for familial breast cancer are not generally regarded as part of the clinical service and are funded through research grants (if at all). Economic considerations suggest that there is a case for keeping this policy under review. Familial cancers throw into sharp relief certain ethical and legal issues that have received much recent attention from government advisory bodies, patients' representatives, professional commentators and the popular media. Two are of particular importance; first, the right to gain access to medical records of relatives, in order to provide accurate risk assessment for a given family member, versus the right to privacy in respect of personal medical information and, second, the obligation (or otherwise) to inform family members of their risk status if they have not actively sought that knowledge. The legal position seems to vary from country to country and, in many cases, is unclear. In view of pressures to establish uniform approaches to medical confidentiality across the EC, it is important to evaluate the experience of participants in this Demonstration Programme and to apply the principle of "non-malfeasance" in formulating regulations that should govern future practice in this field. Data on economic aspects of familial breast cancer are remarkably sparse and outdated. As evidence accrues on the influence of screening and intervention programmes on morbidity and mortality, there is a strong case for evaluating the cost-effectiveness of different models of service provision. (+info)
Linked production of antibodies to mammalian DNA and to human polyomavirus large T antigen: footprints of a common molecular and cellular process?
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OBJECTIVE: To test whether the presence of antibodies to human polyomavirus large T antigen, a viral DNA-binding protein essential for productive polyomavirus replication, correlates with the presence of antibodies to single-stranded DNA (ssDNA), double-stranded DNA (dsDNA), or the autologous TATA-binding protein (TBP). METHODS: Sera from patients with various diagnosed or suspected autoimmune syndromes were analyzed for the presence of antibodies to T antigen, DNA, or TATA-binding protein, and correlations were determined. Rheumatoid factor (RF) was studied as a control antibody. RESULTS: A highly significant correlation between antibodies to T antigen and antibodies to ssDNA or TATA-binding protein, but not between anti-T antigen antibodies and RF, was found in all patient groups. Of all sera that were positive for antibodies to dsDNA, 62% were positive for antibodies to T antigen (P<0.03). CONCLUSION: A non-self DNA-binding protein such as human polyomavirus large T antigen may render DNA immunogenic upon binding to nucleosomes when expressed in vivo. This is indicated by the strong correlation between antibodies to T antigen and antibodies to DNA or TBP and is consistent with a hapten-carrier model. This model implies cognate antigen-selective interaction of T antigen-specific T helper cells and DNA-specific B cells or B cells specific for other components of nucleosomes, consistent with the results of previous experiments. (+info)
The effect of the doctor-patient relationship on emergency department use among the elderly.
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OBJECTIVES: This study sought to determine the rate of emergency department use among the elderly and examined whether that use is reduced if the patient has a principal-care physician. METHODS: The Health Care Financing Administration's National Claims History File was used to study emergency department use by Medicare patients older than 65 years in Washington State during 1994. RESULTS: A total of 18.1% of patients had 1 or more emergency department visits during the study year; the rate increased with age and illness severity. Patients with principal-care physicians were much less likely to use the emergency department for every category of disease severity. After case mix, Medicaid eligibility, and rural/urban residence were controlled for, the odds ratio for having any emergency department visit was 0.47 for patients with a generalist principal-care physician and 0.58 for patients with a specialist principal-care physician. CONCLUSIONS: The rate of emergency department use among the elderly is substantial, and most visits are for serious medical problems. The presence of a continuous relationship with a physician--regardless of specialty--may reduce emergency department use. (+info)
Does the introduction of HDU reduce surgical mortality?
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The aim of this study was to assess the change in workload in a general surgery department over 2 consecutive 1-year periods and document the impact of a high dependency unit (HDU) on hospital mortality. Data were collected on all admissions, the number and type of operations performed for a 1-year period before and after a purpose-built HDU was opened. During the study period, the total number of admissions increased by 15%, with a disproportionately large increase (27%) in the number of emergency admissions. This was reflected by increases in the emergency out-of-hours operating by 12%. During the study period, the overall in-patient mortality rose from 2.16% to 3.2%. Introduction of HDU facilities alone does not lead to a reduction in hospital mortality. Alterations in emergency workload and changes in case-mix are important in determining outcome. League tables of hospital mortality are likely to be difficult to interpret without adequate information about facilities and case-mix. (+info)
Measuring hospital efficiency: a comparison of two approaches.
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OBJECTIVE: To compare the results of scoring hospital efficiency by means of two new types of frontier models, Data Envelopment Analysis (DEA) and stochastic frontier regression (SFR). STUDY SETTING: Financial records of Florida acute care hospitals in continuous operation over the period 1982-1993. STUDY DESIGN: Comparable DEA and SFR models are specified, and these models are then estimated to obtain the efficiency indexes yielded by each. The empirical results are subsequently examined to ascertain the extent to which they serve the needs of hospital policymakers. DATA COLLECTION: A longitudinal or panel data set is assembled, and a common set of output, input, and cost indicators is constructed to support the estimation of comparable DEA and SFR models. PRINCIPAL FINDINGS: DEA and SFR models yield convergent evidence about hospital efficiency at the industry level, but divergent portraits of the individual characteristics of the most and least efficient facilities. CONCLUSIONS: Hospital policymakers should not be indifferent to the choice of the frontier model used to score efficiency relationships. They may be well advised to wait until additional research clarifies reasons why DEA and SFR models yield divergent results before they introduce these methods into the policy process. (+info)
The association between chronic widespread pain and mental disorder: a population-based study.
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OBJECTIVE: Patients with chronic widespread pain (CWP) have been reported to have a greater prevalence of mental disorders and somatization than that found in the general population, but the true association between CWP and mental disorders is unknown. In this study, we investigated whether there is an increased prevalence of mental disorder in people with CWP from the general population. We also describe the psychiatric diagnoses associated with CWP. METHODS: In a population-based case-control study, 1,953 subjects (75% of a random sample of individuals age 18-65 years) completed a questionnaire that included a pain assessment and the 12-item General Health Questionnaire (GHQ-12). Of 710 subjects scoring >1 on the GHQ-12, 301 were assessed further using a structured psychiatric interview and detailed assessment of medical records to identify cases of mental disorder, in accordance with criteria of the 10th edition of the International Classification of Diseases. The association between CWP and mental disorder was modeled using logistic regression, adjusting for possible confounders including age, sex, and nonresponders. RESULTS: We estimated the overall population prevalence of mental illness to be 11.9%. The odds of having a mental disorder for subjects with versus those without CWP were 3.18 (95% confidence interval 1.97-5.11). Most subjects with mental disorders were diagnosed as having mood and anxiety disorders. Only 3 cases of somatoform disorders were identified, and all were associated with pain. CONCLUSION: This study, although unable to demonstrate a cause-and-effect relationship, showed that 16.9% of those with CWP were estimated to have a psychiatric diagnosis, suggesting that these disorders should be identified and treated. (+info)
Risk-adjusting acute myocardial infarction mortality: are APR-DRGs the right tool?
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OBJECTIVE: To determine if a widely used proprietary risk-adjustment system, APR-DRGs, misadjusts for severity of illness and misclassifies provider performance. DATA SOURCES: (1) Discharge abstracts for 116,174 noninstitutionalized adults with acute myocardial infarction (AMI) admitted to nonfederal California hospitals in 1991-1993; (2) inpatient medical records for a stratified probability sample of 974 patients with AMIs admitted to 30 California hospitals between July 31, 1990 and May 31, 1991. STUDY DESIGN: Using the 1991-1993 data set, we evaluated the predictive performance of APR-DRGs Version 12. Using the 1990/1991 validation sample, we assessed the effect of assigning APR-DRGs based on different sources of ICD-9-CM data. DATA COLLECTION/EXTRACTION METHODS: Trained, blinded coders reabstracted all ICD-9-CM diagnoses and procedures, and established the timing of each diagnosis. APR-DRG Risk of Mortality and Severity of Illness classes were assigned based on (1) all hospital-reported diagnoses, (2) all reabstracted diagnoses, and (3) reabstracted diagnoses present at admission. The outcome variables were 30-day mortality in the 1991-1993 data set and 30-day inpatient mortality in the 1990/1991 validation sample. PRINCIPAL FINDINGS: The APR-DRG Risk of Mortality class was a strong predictor of death (c = .831-.847), but was further enhanced by adding age and sex. Reabstracting diagnoses improved the apparent performance of APR-DRGs (c = .93 versus c = .87), while using only the diagnoses present at admission decreased apparent performance (c = .74). Reabstracting diagnoses had less effect on hospitals' expected mortality rates (r = .83-.85) than using diagnoses present at admission instead of all reabstracted diagnoses (r = .72-.77). There was fair agreement in classifying hospital performance based on these three sets of diagnostic data (K = 0.35-0.38). CONCUSIONS: The APR-DRG Risk of Mortality system is a powerful risk-adjustment tool, largely because it includes all relevant diagnoses, regardless of timing. Although some late diagnoses may not be preventable, APR-DRGs appear suitable only if one assumes that none is preventable. (+info)