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S H Taplin

Publications and source records attributed to S H Taplin.

At least 37 records · Page 2Linked to original sources
PubMed1995

Primary and secondary prevention services in clinical practice. Twenty years' experience in development, implementation, and evaluation.

This article reviews lessons from 20 years of experience in development and provision of clinical preventive services at Group Health Cooperative of Puget Sound, a large health maintenance organization. Critical factors for enhancing service include the use of a population-based epidemiologic viewpoint coupled with specific evidence-based criteria to examine issues; involvement of practitioners in the process; a systems approach to implementation focused on predisposing factors of the practitioners and enabling factors in the practice, organizational, and community environments; feedback of program outcomes; and the use of automated clinical information systems. Outcome results from our clinical prevention efforts include a 32% decrease in late-stage breast cancer (1989 to 1990); 89% of 2-year-old children with complete immunizations (1994); decrease in adult smokers from 25% to 17% (1985 to 1994); and an increase in bicycle safety helmet use among children from 4% to 48% along with a 67% decrease in bicycle-related head injuries (1987 to 1992). Systematic population-based approaches to the development and provision of clinical preventive services targeting the one-to-one level of primary care and multiple infrastructure levels of care are forging a synthesis of clinical medicine and public health approaches. This approach will become pervasive as clinical information systems improve, risk information is captured routinely, and practitioners gain skills in the art of patient risk behavior change and population-based care.

Breast Neoplasms↗
PubMed1995

Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care.

PURPOSE: This study was conducted to evaluate the effect of stage at diagnosis, age, and level of comorbidity (presence of other illness) on the costs of treating three types of cancer among members of a health maintenance organization. METHODS: Among 388,000 members enrolled anytime during 1990 and 1991 in Group Health Cooperative (GHC) of Puget Sound (Washington State), we estimated the total and net direct costs of medical care for colon, prostate, and breast cancers, including both incident (290, 554, and 645 patients, respectively) and prevalent (1046, 1295, and 2299 patients, respectively) cases. We summarized costs for initial, continuing, and terminal phases of care. Net costs were the difference between the costs of the care of each case subject and the average costs of the care for all enrollees without the cancer of interest who were of the same sex and in the same 5-year age group. Differences in estimated total and net costs by stage at diagnosis, age, and comorbidity were separately evaluated using multivariate regression modeling. All P values were two-sided. Comorbidity was based on a score calculated from 1988 pharmacy data. RESULTS: Total costs of initial care increased with stage at diagnosis for colon (P = .0013) and breast (P < .0001) cancer cases, but not for prostate cancer cases. Total initial costs decreased with age for prostate (P = .0225) and breast (P = .0002) cancers but did not change with degree of comorbidity for any of the three cancers. Total continuing medical care costs increased with stage at diagnosis for colon (P < .0001) and breast (P < .0001) cancer cases but not for prostate cancer cases. Total terminal care costs were similar by stage for all three cancers. Net initial costs differed with stage for all three cancers (P < .05). Net continuing care costs increased with stage (P < .0001) and decreased with age (P < .001) for colon and breast cancers but not for prostate cancer. Net continuing care costs decreased with comorbidity for all three cancers (P = .004, P = .011, and P < .0001 for colon, prostate, and breast cancers, respectively). Among regional stage cancers, continuing care costs decreased with age for colon (P < .0017) and breast (P = .033) cancers but not for prostate cancers. CONCLUSIONS: The results show that total costs vary by stage at diagnosis and age, but the patterns of variation differ for each cancer. Costs of cancer are not simply additive to costs of other conditions. IMPLICATIONS: More needs to be done to explore the reasons and implications of age-related cost differences. Cost-effectiveness analyses of cancer control interventions that shift cancer stage distributions may need to consider both the age and comorbidity of the target populations.

Adult↗
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.

Aged↗
PubMed1995

Practicing population-based care in an HMO: evaluation after 18 months.

OBJECTIVE: To determine whether population-based care in a primary care practice results in improvement in compliance with patient care guidelines. DESIGN: Time series analysis. SETTING: One primary care practice in Group Health Cooperative of Puget Sound (GHC). PARTICIPANTS: Approximately 1500 enrollees cared for by the practice. INTERVENTIONS: An ongoing approach to aid clinical planning at the level of the primary care team--population-based care--that depends on clinical guidelines, a computing system to provide epidemiologic data on guideline performance in the practice and reminders, and a process whereby the practice team analyzed and designs interventions for specific clinical problems. MAIN OUTCOME MEASURES: We compared compliance with practice guidelines for preventive care and chronic illness management at baseline and after 18 months in the intervention population with other patients in the same clinic and with patients in GHC as a whole. RESULTS: Compliance with breast cancer screening and colorectal cancer screening guidelines in the intervention population increased from baseline 32% and 18% respectively. These increases were significantly greater than in the remainder of the clinic or in GHC as a whole. CONCLUSIONS: The availability of practice-based data, clinical guidelines and a local intervention design process resulted in significant improvements in compliance with patient care guidelines.

Algorithms↗
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.

Aged↗
PubMed1994

A population-based case-cohort evaluation of the efficacy of mammographic screening for breast cancer.

Screening efficacy may be evaluated in population-based, observational studies, provided one addresses biases that arise in nonrandomized screening evaluations. The authors evaluated the association of mammographic screening with breast cancer mortality among women without prevalent breast cancer. The cohort consisted of 94,656 women, aged > or = 40 years, enrolled in a large health maintenance organization in Washington State during the period 1982-1988. A case-cohort design limited chart abstraction of risk factor and screening information to 4% of the cohort. There were 1,144 incident breast cancer cases, including 126 who died of breast cancer during the study interval. An age-stratified proportional hazards analysis compared the screening experience of the breast cancer deaths with that of 2,237 controls. The family history of breast cancer, previous biopsy, and parity were included in the model to control for potential confounding effects of selection bias. With a mean follow-up of only 3.5 years postscreening, there was a small but statistically nonsignificant reduction in the risk of breast cancer mortality among women screened 1 year prior to diagnosis compared with unscreened women. The relative risk was 0.80 (95% confidence interval 0.34-1.85) for women aged > or = 40 years and 0.61 (95% confidence interval 0.23-1.62) for women aged > or = 50 years. This paper illustrates how case-cohort methodology can be used to perform efficient assessment of screening efficacy in large cohorts, while eliminating or controlling for sources of bias.

Adult↗
PubMed1994

Using physician correspondence and postcard reminders to promote mammography use.

OBJECTIVES: In a health maintenance organization that mails letters to women recommending that they schedule mammograms, we conducted a randomized trial to evaluate simple methods of increasing the use of screening mammography. METHODS: Using a 2 x 2 factorial design, we tested the effects of (1) mailing the recommendation letter from each woman's primary care physician rather than from the program director and (2) sending a subsequent reminder postcard. RESULTS: Sending a reminder postcard nearly doubled the odds that women would get mammograms within 1 year (participate). The letter from the woman's personal physician had no effect. Attending a clinic more than 45 minutes from the screening center, being a current smoker, or being in fair or poor health were negatively associated with subsequently obtaining a mammogram. The odds of participation doubled if women had had previous mammograms. CONCLUSIONS: When preceded by written recommendations to schedule mammograms, reminder postcards effectively increased participation. Future randomized trials to promote use of screening mammography should compare interventions with a reminder condition.

Aged↗
PubMed1993

A randomized trial of the impact of risk assessment and feedback on participation in mammography screening.

BACKGROUND: Although rates of mammography screening among women in the general population have been increasing they still fall short of national goals. This study evaluated the effects on rates of participation in mammography screening of obtaining risk factor information and providing general or personalized risk information through direct mailed correspondence. METHODS: Women enrollees in a health maintenance organization (N = 2,076), age 50 and above, were randomized to one of the following four groups: (a) no risk factor questionnaire + generic invitation, (b) no risk factor questionnaire + general risk invitation, (c) risk factor questionnaire + general risk invitation, and (d) risk factor questionnaire + personal risk invitation. Computerized visit records were monitored for 12 months following a mailed invitation to assess whether a mammogram had been obtained. RESULTS: Overall participation was 37.5% and the rate of participation did not differ significantly across groups (P = 0.26). Participation was related to age (P < 0.02), with rates highest for women ages 60-69 years (42.7%) compared with those for women ages 50-59 (35.5%) and those age 70+ (33.7%). Among women with a family history of breast cancer, the personalized risk invitation was associated with significantly higher participation compared with general risk invitation (66.7 versus 42.9%, respectively; P < 0.003). CONCLUSIONS: Women with a family history of breast cancer are more likely to obtain a mammogram if that fact is reinforced as a risk factor. Research on environmental barriers to mammography screening may suggest alternative strategies for increasing participation.

Adult↗
PubMed1992

Principles of cancer screening for clinicians.

This chapter has outlined some principles of tumor growth, test characteristics, and the evaluation of screening technologies. We have emphasized that test specificity is the critical parameter in the evaluation of technologies because it is the healthy people who will suffer the most from the adverse effects of screening. We have also emphasized that the efficacy of a test is best evaluated by examining mortality reductions in comparable populations. The purpose has been to assist clinicians with their interpretation of the literature. Busy clinicians may not always have the time or inclination to do this themselves. In those cases they need to examine how organizations who make recommendations are coming to their conclusions because it is physicians, not organizations that will do the screening. In particular, it is important to ask the following: (1) Were criteria followed to justify the recommendations being made? (2) If so, what were they, and can the organization demonstrate that they are being met? (3) What perspectives and biases do the organizations bring to the judgments they inevitably have to make? (4) Do you share those perspectives? and (5) When the recommendation is adopted, can you guarantee that it will "first do no harm."

Adult↗
PubMed1991

A test of an expanded theory of reasoned action to predict mammography participation.

This paper presents the results of a prospective study testing an expanded theory of reasoned action (TRA) to predict mammography participation. A questionnaire was developed to measure each of the expanded TRA model components. A sample was identified of 946 women age 40 and above who were invited to obtain a mammogram at the Group Health Cooperative of Puget Sound Breast Cancer Screening Program (BCSP). The sample was stratified by risk category as determined by the screening program. The study questionnaire was administered to all women in the sample within 2 weeks after they were sent the invitation to obtain a mammogram. Mammography participation was obtained from the BCSP data base 6 months after the invitation. Regression analyses found attitude, affect, subjective norm, and facilitating conditions to all be significantly associated with participation. The expanded TRA model explained 39% of the variance in women's intentions and 20% of the variance in participation behavior. A stepwise hierarchical regression found that no other psychosocial measures were able to improve the model predictions of behavior. An interaction between habit and intention was found such that women with larger numbers of previous mammograms were less likely to carry out their intentions than women with fewer previous mammograms. Contrary to expectations, some demographic characteristics did significantly improve prediction. The need for further work investigating the roles of fear and experience is discussed.

Adult↗
PubMed1990

Revisions in the risk-based Breast Cancer Screening Program at Group Health Cooperative.

To pursue the goal of achieving regular use of mammography in women 40 years of age and older, a risk-based selective approach to screening was implemented at a 400,000-member managed health care system in the Northwest in 1985. This article describes the context for this approach to selective screening and reviews revisions in the algorithm used to determine when and how a woman should be screened. Changes made in 1988 with respect to age criteria, intervals for mammography, and which risk factors to include are discussed. The result of these changes is that 83% of women 40 years of age and older are now eligible for regular mammography compared with 57% under the former system. The total use of mammography in any given year remains unchanged. The results of this analysis have implications for other organizations attempting to promote the use of mammography.

Adult↗
PubMed1988

Cost-justification analysis of prenatal maternal serum alpha-feto protein screening.

The costs to an insurer of a 10-year maternal serum alpha-feto protein (MSAFP) screening program were subtracted from future medical care costs avoided by the insurer (benefits) to examine whether such a program would be cost-justified from the perspective of a managed health care system (i.e., result in net costs greater than or equal to 0). The analysis considered MSAFP screening for neural tube defects (NTDs) alone and then was repeated to consider screening for both NTDs and Down's syndrome. Using a 5% discount rate for future dollars, the costs to the insurer of a screening program for NTDs alone over 10 years exceeded costs avoided by $10.00 per person screened. Adding screening for Down's syndrome using the same MSAFP test increased the net cost by $22.00 to a total of--$32.00 per screenee. The estimate of the cost to the insurer was sensitive to assumptions regarding the costs of medical care avoided, the expense of MSAFP, the proportion of screened women requiring a genetic amniocentesis, and the cost of that procedure. The conclusion that screening would not result in a cost savings to the insurer was not changed by reasonable assumptions regarding 1) the appropriate discount rate; 2) the costs of MSAFP; 3) the costs of genetic amniocentesis; 4) the sensitivity of MSAFP; 5) the proportion of the population requiring genetic amniocentesis; and 6) the costs of 10 years of medical care for someone affected by Down's syndrome or an NTD. Other analyses suggested that screening for NTDs or Down's syndrome would be cost-justified when viewed from the perspective of society. The present work suggests this conclusion does not hold when the perspective of the insurer is taken because avoided costs of care realized by society exceed those realized by the insurer.

Adult↗
PubMedDate not supplied

Health promotion in an HMO. Ad astra per aspera.

The shift in emphasis towards disease prevention and health promotion is forcing changes in the traditional health provider model. At Group Health Cooperative of Puget Sound (GHC), a 349,000 member staff model HMO, consensus development on health promotion issues is the responsibility of a permanent Committee on Prevention (COP). By spreading the workload over multiple subcommittees that involve cross-sections of the medical, nursing, and other professional staff, the COP has prepared the groundwork for a number of major health care decisions at GHC. The COP has also been the starting point for programs such as the GHC Breast Cancer Screening Program, colon cancer screening, a senior influenza immunization program, and an institutional ban on smoking.

Decision Making, Organizational↗
PubMedDate not supplied

Specialty differences and the ordering of screening mammography by primary care physicians.

BACKGROUND: Careful attention to factors that affect women and their physicians is necessary to achieve the national goal that, by the year 2000, 60 percent of women should have had a screening mammogram in the previous 2 years. This report evaluates factors that differentiate primary care physicians who regularly order mammograms from those who do not. The study was conducted as part of a large demonstration project in Washington State and includes a survey of women served by the physicians. METHODS: We conducted a survey of primary care physicians and women in four counties to assess factors that influenced self-reported ordering of screening mammography. RESULTS: Among the 73 percent of family physicians, general practitioners, internists, and obstetrician-gynecologists who returned the questionnaire, there were more obstetrician-gynecologists (76 percent) who reported ordering screening mammograms in 90 percent or more of women aged 50 to 75 years, but they cared for only 15 percent of women in the sample. Women's survey results confirmed the physicians' reported differences and also revealed demographic characteristics that distinguished populations associated with particular primary care specialists. These specialists differed in their perceptions of their colleague's mammography practices, the adequacy of insurance coverage, and how often they had spent an unreasonable time explaining mammography results. In a multivariate model of factors expected to influence behavior, performance of clinical breast examination rather than specialty was the salient factor associated with ordering screening mammography. CONCLUSIONS: These results suggest that the context of practice, rather than specialty type or beliefs about mammography, has the major influence upon behavior. To achieve national screening mammography goals in the Northwest, we must influence the context of family physicians' preventive care practices because they care for 47 percent of women aged 50 years or older.

Aged↗