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Biomedical subjects

N Urban

Publications and source records attributed to N Urban.

At least 55 records · Page 3Linked to original sources
PubMed1995

Community organization to promote breast cancer screening among women ages 50-75.

BACKGROUND: To reduce breast cancer mortality, ways to promote the use of mammography screening among women age 50 and above are needed. Community organization may be a useful approach. METHODS: The Washington State Community Breast Cancer Screening Project involved implementation of promotional activities initiated by physician and lay community boards in two communities. Two comparable communities served as controls for evaluation purposes. Random-digit-dial telephone interviews were used to assess recent use of mammography at baseline and follow-up in independent samples of women ages 50 to 75 from the four communities. The extent of exposure to intervention activities and the relationship between exposure to intervention activities and mammography use were estimated from data collected at follow-up. RESULTS: Exposure to patient reminders from physicians, wallet reminder cards, and newspaper advertisements were consistently related to mammography use. Physician office staff encouragement and a display board were significantly related to mammography use only in Intervention Communities A and B, respectively. Neither exposure to promotional activities nor the change in prevalence of mammography use was significantly higher in the intervention communities than in the comparison communities at follow-up. CONCLUSIONS: Although several activities were useful in promoting mammography use, organization of the community did not enhance efforts undertaken spontaneously by comparable communities.

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PubMed1995

Repeat mammography use among women ages 50-75.

It has been demonstrated clearly that the use of regular screening mammography reduces mortality among women ages 50 years and over. The primary objective of this study was to investigate factors associated with repeat mammography participation. A random sample of women ages 50-75 years residing in four Washington State counties was surveyed by telephone during mid-1989. The Health Belief Model was used as a conceptual framework for the analysis. Three groups of women with different mammography experiences in the previous 5 years were compared: (a) nonusers; (b) onetime users; and (c) repeat users. The survey response rate was 72%, and the study sample included 1357 women. One time users were more likely to have health insurance coverage, to visit a gynecologist or other primary care physician regularly, and to believe mammography is more effective than breast self-examination; they were less likely to think that at least 1 in 10 women are diagnosed with breast cancer or that mammography is inconvenient to obtain than were nonusers. Factors associated with repeat versus onetime use included routinely visiting a gynecologist, thinking the lifetime risk of breast cancer is at least 10%, and perceiving a high personal susceptibility to disease. Women who perceive themselves as being vulnerable to breast cancer are more likely to report repeat mammograms. Visiting a gynecologist regularly is associated with repeat as well as initial mammography use. These factors could be considered as the focus of promotional efforts moves from encouraging women to obtain their first mammogram to encouraging repeat use.

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PubMed1995

Clinical guidelines: fad, fact, or vision.

Interest in clinical guidelines is expanding significantly. Clinical guidelines have been developed by the Agency for Health Care Policy and Research, specialty organizations representing almost every health-care discipline, and individual agencies and facilities. Clinical guidelines may be used in the development of practice and patient care standards and within care delivery models such as case management. Clinical guidelines offer professional nurses an opportunity to define their practice and their contributions to outcomes-based patient care. Clinical guidelines also may enable interdisciplinary continuous quality improvement to ensure ongoing optimization of care delivery and patient outcome. Therefore, clinical guidelines can be used to design patient care that is truly driven by patient need and that empowers optimal contributions by nurses and all other members of the caregiving team.

Clinical Protocols↗
PubMed1994

Mammography screening: how important is cost as a barrier to use?

OBJECTIVES: Recent legislation will improve insurance coverage for screening mammography and effectively lower its cost to many women. Although cost has been cited as a barrier to use, evidence of the magnitude of its effect on use is limited. METHODS: Mammography use in the past 2 years among women aged 50 to 75 residing in four suburban or rural counties in Washington State was estimated from 1989 survey data. Logistic regression analysis was used to estimate the odds ratio of mammography use as a function of economic and other variables. Within a residential area, averages were used to measure the market price of mammography and the time cost to obtain a mammogram. RESULTS: Use was lower among women who faced a higher net price or who preferred to obtain a mammogram during weekend or evening hours and higher among women with higher incomes. Visiting no doctor regularly and smoking were predictors of failure to use mammography. CONCLUSION: The effects of economic variables on mammography use are important and stable across subsets of the population, but they are modest in size.

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PubMed1993

Research cost analyses to aid in decision making in the conduct of a large prevention trial, CARET. Carotene and Retinol Efficacy Trial.

Because of their larger study populations and longer durations, prevention trials typically are more costly than treatment trials. Thus it is important to analyze costs systematically to aid in making cost-effective decisions during the conduct of prevention trials as well as in the original design. Cost analysis must be tied to sample size estimation because costs depend on such factors as the total number of person-years of follow-up and the number of trial outcomes, which are not basic design parameters but are derived quantities resulting from sample size estimation. We illustrate the use of cost analysis to decide among options for future conduct of an ongoing prevention trial with three issues that have arisen during the Carotene and Retinol Efficacy Trial (CARET): the trade-off between extending the duration of the trial or increasing the number of participants, the effect on costs of delay in accrual, and the cost effectiveness of particular retention activities.

Anticarcinogenic Agents↗
PubMed1993

Effects on response rates and costs of stamps vs business reply in a mail survey of physicians.

In the general population, the use of stamps rather than business reply postage significantly improves response rates in mail surveys. Among physicians, however, a smaller effect might be anticipated due to their greater sophistication. An experiment was conducted to test the hypothesis that stamps would improve response rates and lower costs in a physician survey that included intensive follow up. In 1989, 380 physicians who reported providing primary care were surveyed. The protocol included two mailings, a postcard reminder, and two telephone reminders. Physicians were randomly assigned to receive a return envelope with a first-class stamp or an envelope that had been preprinted "business reply mail" in the first and second mailings. Response rates, calculated as completed surveys divided by eligible physicians, were 83.8 and 72.1% for stamps and business reply respectively, a difference of 11.7 percentage points (p < 0.01). Moreover, the total cost per completed survey was $11.18 for the physicians receiving stamps and $14.25 for the physicians receiving business reply. As in mail surveys of the general public, the use of first-class stamps on return envelopes both improves response rates and reduces cost in surveys of physicians.

Data Collection↗
PubMed1993

A breast cancer screening educational intervention targeting medical office staff.

There is persistent evidence that breast cancer screening techniques remain under-utilized. While physicians cite lack of time as a barrier to the provision of preventive services, nurses and other medical office staff are in an ideal position to educate women and motivate adherence to screening recommendations. This paper describes the design, implementation and process evaluation of a breast cancer screening educational program targeting primary care medical office staff. This intervention was conducted in two Washington State counties as part of a larger community organization study. The PRECEDE model, educational outreach principles and focus groups were used to guide the program development. Consistent with 'academic detailing' concepts, the sessions were delivered at health care facilities. The program included a review of breast cancer-related data and screening methods, an overview of the nurse's role as a 'change agent' and breast self-examination instructor, and a discussion of women's barriers to mammography. Community-level penetration was relatively high, with sessions being completed by approximately 50% of the eligible staff. Overall, participants were positive about the value of the program. Medical office-based educational sessions have the potential of reaching a large proportion of primary health care workers and increasing disease prevention in communities.

Breast Neoplasms↗
PubMed1993

Comparisons of strategies to prevent breast cancer mortality.

A health system should meet the health needs of the population. Given limited resources, choices are made about problems--typically, diseases--to attack. Then, choices must be made as to how to identify, treat, and ultimately, prevent their occurrences. This process is the subject of this article; it uses the case of breast cancer to examine allocation of resources to disease prevention and treatment. The paper reviews current allocation patterns among three strategies for prevention: primary, secondary, and tertiary. Each varies with respect to where the disease process is halted and in the amount of technological support required. Currently, the U.S. health care system allocates most resources to tertiary prevention, with scant support of primary and limited support of secondary prevention. Possible explanations for the current allocation patterns are discussed. Areas where social sciences have made contributions are highlighted. Finally, cost-effectiveness analyses are presented to illustrate a relatively balanced method for making decisions about future allocations.

Breast Neoplasms↗
PubMed1993

Integrating the hemodynamic profile with clinical assessment.

Hemodynamic profiling has become common practice in critical care units. While the ability to monitor, measure, and calculate the many parameters related to cardiac output is a valuable adjunct in the care of the critically ill, it cannot be used as a substitute for sound clinical assessment. The ability to integrate the hemodynamic profile with clinical assessment is necessary if patients are to receive comprehensive critical care. In addition, assessment frameworks such as Forrester's subsets of hemodynamic compromise provide clinically useful guidance in the diagnosis and treatment of a variety of clinical challenges.

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PubMed1992

Correlates of maintenance of a low-fat diet among women in the Women's Health Trial.

BACKGROUND: The Women's Health Trial (WHT) was a feasibility study for a randomized controlled trial designed to test the hypothesis that a reduction in dietary fat reduces breast cancer incidence among women age 45 to 69. Between 1984 and 1988, 2,064 women participated in its two phases. METHODS: A follow-up study of 525 women who were randomized to receive the WHT dietary intervention program was conducted to assess maintenance of the diet 1 year on average after the trial ended. Among 448 participants, the mean percentage of energy from fat as measured by a food frequency questionnaire was 40.0% at baseline, 26.3% at the end of the trial, and 27.7% at follow-up. Based on 408 women with complete data, a recursive model was estimated, describing the influence of baseline characteristics of the women on attendance at intervention program sessions, adherence to the diet during the trial, and long-term maintenance of the diet after the trial ended. The effects of women's experiences during the trial on adherence and long-term maintenance were investigated as well. RESULTS: Attendance at the educational sessions was strongly related to adherence to the diet during the trial (P less than 0.001), and adherence was the most important predictor of long-term maintenance (P less than 0.001). The percentage of energy from dietary fat at baseline was an important correlate of both adherence (P less than 0.001) and long-term maintenance (P less than 0.001). College-educated women were more likely to adhere to the diet during the trial (P less than 0.001). Feelings of deprivation adversely affected long-term maintenance (P less than 0.01), primarily through their effect on adherence during the trial (P = 0.01). Costliness of the diet in time and money negatively influenced long-term maintenance (P less than 0.05). Development of a distaste for fat encouraged adherence (P = 0.06). CONCLUSIONS: The low-fat dietary pattern established during the WHT was maintained for as long as 20 months after the trial ended. A recursive model was useful in analyzing the process and correlates of long-term maintenance of dietary behavior change. Both predisposing variables and women's experiences while on a low-fat diet were associated with long-term maintenance. The results suggest that feelings of deprivation should be avoided, perhaps by use of low-fat substitutes, by those attempting to lower their dietary fat and that more research is needed on the development of a distaste for fat among individuals who adopt low-fat diets.

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PubMed1992

Long-term maintenance of a low-fat diet: durability of fat-related dietary habits in the Women's Health Trial.

The Women's Health Trial (WHT) was a feasibility study for a randomized trial of a low-fat diet for the prevention of breast cancer. One year after the WHT was terminated, a random sample of 894 participants who had been active in the WHT for an average of 16 months (range = 5 to 37) completed questionnaires about their dietary habits (a 21-item instrument that measures five dimensions of low-fat dietary habits) and food intake (a food frequency questionnaire). Women who participated in the intervention program maintained most of the low-fat dietary habits adopted during the study: mean total fat intake increased from 37.8 g to 41.0 g and scales describing substitution of specially manufactured low-fat foods and modification of meats to be lower in fat increased only slightly (by 0.11 and 0.14, respectively, on a scale of 1 = always to 4 = never). Scales describing avoiding meat and avoiding fats as a flavoring increased by 0.23 and 0.22, respectively, which suggests some recidivism. Women in the control group lowered their dietary fat intake from 65.0 to 57.5 g, but all differences in fat intake and fat-related dietary habits scales between women in the control and intervention groups remained highly statistically significant. In multiple regression models, all five low-fat dietary habits scales were independently associated with percentage of energy from fat, but the strongest association was for avoiding fats as flavorings. These results suggest that substitutions of specially manufactured low-fat foods are easily adopted and maintained dietary changes, but that maintenance of new habits related to avoiding fats as flavorings and avoiding meat will require long-term reinforcement strategies.(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMed1991

Estimating the treatment costs of breast and lung cancer.

The Continuous Medicare History Sample File (CMHSF) was used to derive an estimate of the lifetime direct medical expenses attributable to two chronic diseases, lung cancer and female breast cancer. These two cancers are the leading cancer causes of death in men and women in the United States. They inflict large costs on the population, both direct and indirect, but the costs have been difficult to measure. The primary obstacle to quantification is the intermittent and long-term nature of treatment for these diseases. A complete record of expenses cannot usually be obtained from one source, however, a review of all the national health surveys, as well as the Medicare statistical files identified the CMHSF, which is maintained by the Health Care Financing Administration in a format suitable for calculation of cumulative medical expenses. Some of the pertinent features of the CMHSF include the following: 1) it is a nationally representative sample of the Medicare population, 2) it is longitudinal covering an 8-year period from 1974 to 1981, 3) it captures the majority of medical expenses for each enrollee, and 4) it can be linked to other national data bases such as the National Death Index. Charges for three phases of cancer treatment were derived from the file: initial therapy, maintenance care, and terminal care. A method is described for computing the present value of life-time treatment costs from the phase-specific charges. The lifetime cost of treating breast cancer in 1984 dollars is $36,926 and lung cancer is $12,510.

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PubMed1990

Analysis of the costs of a large prevention trial.

Total direct costs of the Women's Health Trial (WHT), a large multicenter prevention trial, were reduced by more than 50% by means of research cost analysis conducted during the trial design phase. The unit costs of specific trial activities were estimated so that total direct costs of the trial could be predicted from design parameters. The relative costs of screening, treatment, and follow-up, and the fixed costs associated with each clinical center in a multicenter prevention trial were taken into account. Direct costs of the WHT were reduced from +195 million to +95 million by refinement of the trial protocol, selection of an efficient design, and consideration of trial logistics. The analyses suggest several ways to reduce costs in a prevention trial. Use of the case-cohort approach can reduce costs substantially when the protocol includes collection of specimens or data that are costly to process. When establishing and maintaining a clinical center represents a significant proportion of a clinical center's costs, use of a smaller number of larger clinical centers offers important cost savings. Because restrictive eligibility requirements reduce the recruitment potential of each clinical center, use of high-risk participants may not improve the efficiency of a prevention trial; its favorable impact on sample size may fail to compensate for its cost in terms of additional clinical centers and higher recruitment costs.

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PubMed1990

Hemodynamic clinical profiles.

Hemodynamic profiling provides valuable information about cardiac output and its determinants: preload, afterload, and contractility. The direct and derived parameters of these determinants are used by expert critical care nurses in collaboration with medical directives for intervention to enhance clinical assessment, decisionmaking, and evaluation. This article reviews the basic and advanced aspects of hemodynamic profiling. The parameters that must be included in a complete hemodynamic profile are discussed with emphasis on the importance of index values. An algorithm is included as a guideline for use of the hemodynamic profile. A variety of clinical examples are discussed to illustrate the importance of hemodynamic profiling as an adjunct to expert critical care nursing practice.

Cardiovascular Diseases↗