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PubMed2004

Frequency Finder: a multi-source web application for collection of public allele frequencies of SNP markers.

Publicly available single nucleotide polymorphism (SNP) allele frequencies are an important resource for the selection of genetic markers that may be most useful for gene mapping and association studies. Data mining these allele frequencies through disparate public databases and Websites is time consuming and can result in inconsistent findings. We have developed a web-based software tool, Frequency Finder, to acquire SNP allele frequencies from multiple public data sources and return a summarized result to the user. Our software optimizes and automates the search of candidate markers, decreasing the amount of time it would take to extract pertinent data manually. We have included several methods to output the data, including on-screen and as a compressed text file. We show that Frequency Finder accurately retrieves available frequency data from the available sources. Using this tool, we detect significant differences between Asian, African and Caucasian populations in the allele frequency spectra of 246 097 SNPs. While limited to public databases that provide web-based access to allele frequencies, Frequency Finder provides a single, user-friendly interface for retrieving allele frequencies for large batches of SNPs from multiple data sources.

Algorithms↗
PubMed2004

Rituximab (MabThera) for aggressive non-Hodgkin's lymphoma: systematic review and economic evaluation.

OBJECTIVES: To determine the clinical and cost-effectiveness of adding rituximab to the CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) chemotherapy regime for adult patients with diffuse large B-cell lymphoma (DLBCL). DATA SOURCES: Electronic bibliographic database. REVIEW METHODS: Comparative studies were selected for review if they addressed the clinical or cost-effectiveness of adding rituximab to CHOP in people aged at least 18 years with DLBCL. The internal validity of the study was assessed through the use of the validated Jadad scoring system. Data were abstracted into standardised data extraction forms. Costs were estimated through resource use data taken from the published trial and the unpublished sponsor submission. Unit costs were taken from published sources, where available. An economic evaluation was undertaken to evaluate the cost-effectiveness of R-CHOP compared with CHOP alone for patients with DLBCL using data sources and methodology similar to the manufacturer's submission. RESULTS: In the systematic review of effectiveness, one randomised controlled trial was identified. The study was, in most respects, methodologically rigorous and well conducted and the statistical evidence favoured the addition of rituximab to CHOP. The total cost of rituximab with CHOP (R-CHOP) and CHOP alone estimated from the model developed by ScHARR was 14,456 pounds and 5773 pounds, respectively, for patients aged 60 years and over, and 15,181 pounds and 7311 pounds for patients aged less than 60 years over a 15-year time horizon. The ScHARR model estimated that the addition of rituximab to CHOP generated an additional 0.82 QALY at an extra cost of 8683 pounds compared with CHOP alone therapy over a 15-year time horizon, a cost/quality-adjusted life-year (QALY) ratio of 10,596 pounds for patients aged 60 years or more. For patients aged under 60 years, 1.05 QALY were generated at an additional cost of 7870 pounds, a cost/QALY ratio of 7533 pounds. Assuming that the societal value of a QALY was 30,000 pounds then R-CHOP is cost-effective compared with CHOP in the treatment of DLBCL. CONCLUSIONS: In the short term, the addition of rituximab to the CHOP regimen increased the likelihood of a complete-response by 20% without a significant rise in the risk of a serious adverse event in people aged 60 years or older. Over a 2-year follow-up period, the intervention reduced the risk of death, progression or relapse by 45% and reduced the risk of death by 47% in this population. There is no direct evidence for the clinical effectiveness of adding rituximab to CHOP in the treatment of DLBCL in those aged 18-59 years, although data from phase I and II trials confirm its safety and efficacy in a preclinical setting. The cost-effectiveness modelling presented here has shown that rituximab in combination with CHOP chemotherapy regimen is likely to be considered a cost-effective treatment for DLBCL when compared with the current standard treatment, CHOP chemotherapy only. Analysis of quality of life (QoL) in the area of NHL is limited and only one cost-utility analysis for the treatment of CHOP in NHL was identified. Both the SCHARR and the manufacturer's models utilised QoL utility scores from an unpublished data source. Further research within this area would help to improve the robustness of QoL utility analysis within DLBCL and also NHL as a whole. Further clinical trials might also establish whether R-CHOP may replace peripheral blood stem cell transplant in high-risk patients and whether the doses of chemotherapy in the elderly may be reduced if rituximab is added to less intensive regimens.

Adult↗
PubMed2000

Uninsured and unstably insured: the importance of continuous insurance coverage.

OBJECTIVE: To examine the importance of continuous health insurance for access to care by comparing the access and cost experiences of insured adults with a recent time uninsured to the experiences of currently uninsured adults and experiences of adults with no time uninsured within a reference time period (continuously insured). DATA SOURCES: Adults ages 18-64. Data draw from three different survey databases: the Robert Wood Johnson Foundation 1996-1997 Community Tracking Survey, the Kaiser/Commonwealth 1997 National Survey of Health Insurance, and the 1995-1997 Kaiser/Commonwealth State Low Income Surveys. STUDY DESIGN: The study groups individuals into three insurance categories based on respondents' reports of insurance coverage within a reference time period: continuously insured; insured when surveyed but with recent time uninsured; and currently uninsured. In the two Kaiser/Commonwealth surveys the recently uninsured group included any insured respondent with a time uninsured in the past two years. In the Community Tracking Survey, the recently uninsured group included any insured respondent with a time uninsured in the past year. Measures of access include foregoing health care when needed, usual source of care, use of health care services, difficulties paying for medical care, and satisfaction with care. DATA COLLECTION: All three surveys were conducted primarily by telephone. The Community Tracking Survey drew from 60 community sites, with an additional random national sample. The Kaiser/Commonwealth National Survey was a random national sample; the Kaiser/Commonwealth State Low Income Surveys included adults ages 18-64 with incomes at or below 250 percent of poverty in seven states: Minnesota, Oregon, Tennessee, Florida, Texas, New York, and California. PRINCIPAL FINDINGS: Compared to the continuously insured, those insured but with a recent time uninsured were at high risk of going without needed care and of having problems paying medical bills. This group was two to three times as likely as those with continuous coverage to report access problems. Rates of access and cost problems reported by insured adults with a recent time uninsured neared levels reported by those who were uninsured at the time of the survey. These two groups also rated care received more negatively than did adults with continuous insurance coverage. In general, the access gap between persons insured and uninsured widened as a result of distinguishing insured adults with a recent time uninsured from insured adults with no time uninsured. CONCLUSION: Studies that focus on current insurance status alone will underestimate the extent to which having a time uninsured during the year contributes to access difficulties and undermines quality of care, and will underestimate the proportion of the population at risk because they are uninsured. Policy reforms are needed to maintain continuous insurance coverage and avoid spells uninsured. Currently uninsured and unstably insured adults are both at high risk.

Adolescent↗
PubMed2005

Nurse Practitioner competency standards: findings from collaborative Australian and New Zealand research.

BACKGROUND: The title, Nurse Practitioner, is protected in most jurisdictions in Australia and New Zealand and the number of nurse practitioners is increasing in health services in both countries. Despite this expansion of the role, there is scant national or international research to inform development of nurse practitioner competency standards. OBJECTIVES: The aim of this study was to research nurse practitioner practice to inform development of generic standards that could be applied for the education, authorisation and practice of nurse practitioners in both countries. DESIGN: The research used a multi-methods approach to capture a range of data sources including research of policies and curricula, and interviews with clinicians. Data were collected from relevant sources in Australia and New Zealand. SETTINGS: The research was conducted in New Zealand and the five states and territories in Australia where, at the time of the research, the title of nurse practitioner was legally protected. PARTICIPANTS: The research was conducted with a purposeful sample of nurse practitioners from diverse clinical settings in both countries. Interviews and material data were collected from a range of sources and data were analysed within and across these data modalities. RESULTS: Findings included identification of three generic standards for nurse practitioner practice: namely, Dynamic Practice, Professional Efficacy and Clinical Leadership. Each of these standards has a number of practice competencies, each of these competencies with its own performance indicators. CONCLUSIONS: Generic standards for nurse practitioner practice will support a standardised approach and mutual recognition of nurse practitioner authorisation across the two countries. Additionally, these research outcomes can more generally inform education providers, authorising bodies and clinicians on the standards of practice for the nurse practitioner whilst also contributing to the current international debate on nurse practitioner standards and scope of practice.

Attitude of Health Personnel↗
PubMed2006

Joint inspection of services for people with learning disabilities in Scotland: compliance or commitment?

PURPOSE: The article describes the development of a practical model of joint, integrated inspection of managed care services for people with learning disabilities in Scotland. The model will give a reliable measure of the impact services are making to people's lives and the quality of service that individuals are actually receiving. CONTEXT OF CASE: At present health, social services and education services for people with learning disabilities in Scotland are inspected separately, by up to nine different agencies. The first joint, integrated inspections of all services for people with learning disabilities in Scotland will take place in 2006. This is the first inspection of its kind in the UK, and the first to involve carers and people with learning disabilities on the inspection team. DATA SOURCES: Quality Outcome Indicators were developed in 21 different areas, or domains. Evidence based best practice, and evaluative data from previous inspections were the primary sources of data. CASE DESCRIPTION: This paper reviews the background and rationale for the integrated, joint inspection process. Strengths and constraints of this approach to inspection are discussed, including the crucial importance of commitment from services and from inspectors, rather than mere compliance with demands. Some guidance on how to fully involve staff, carers and services users in the inspection process is given. CONCLUSIONS AND DISCUSSION: The model will produce data to inform decision-making for managers in integrated services and give services users clear information about how well local needs are being met, what areas need development, and what capacity the organisations have to improve. The model of inspection may be of interest to practitioners in a national and international context. The model will be evaluated, following the first joint inspection.

Journal Article↗
PubMed1994

Bed rest in pregnancy.

OBJECTIVE: To summarize existing data about the effectiveness of bed rest when used to improve various pregnancy outcomes and to determine how often bed rest is used and the cost associated with its use. DATA SOURCES: We used the MEDLINE data base to search for all English language papers evaluating the effectiveness of bed rest in pregnancy. We also reviewed a number of textbooks and the 1988 National Infant Mortality Survey. METHODS OF STUDY SELECTION: We reviewed these sources for recommendations about using bed rest in various obstetric conditions. We used the 1988 National Infant Mortality Survey to determine how often bed rest was used either to prevent or to treat various obstetric conditions and estimated the costs associated with its use. DATA EXTRACTION AND SYNTHESIS: Bed rest is used in nearly 20% of all pregnancies to prevent or treat a wide variety of conditions, including spontaneous abortion, preterm labor, fetal growth retardation, edema, chronic hypertension, and preeclampsia. There is little evidence of effectiveness. The estimated costs associated with bed rest, including hospitalization, lost wages, and lost domestic productivity, range from more than $250 million to billions of dollars per year. CONCLUSIONS: Bed rest is used extensively to treat a wide variety of pregnancy conditions, at substantial cost but with little proof of effectiveness. We recommend that because this intervention has failed the test of effectiveness, its use during pregnancy should be curtailed unless randomized trials demonstrate improvement in a specific outcome.

Bed Rest↗
PubMed2000

MappetShow: non-linear visualization for genome data.

The genome mapping projects now produce very dense maps with up to several thousands of markers per chromosome. Besides synteny plays a increasing role in mapping: enrichment of poor maps from the maps of close genomes (in terms of evolution) is a high-reward task. We propose a map viewer adapted to this situation: MappetShow gives a clear view of very dense maps and compares efficiently several maps. MappetShow is based on non-linear viewing and is written in Java. A map description language isolates the software from the data sources. This software was easily used on data coming from as different sources as an Object Request Broker, an Object-Oriented Database, or a flat data stream. MappetShow can be browsed at the URL http:¿www.infobiogen.fr/services/Mappet. More generally we discuss how to use the non-linear viewing concept in molecular biology data visualization.

Chromosome Mapping↗
PubMed1987

Use of court records for supplementing occupational disease surveillance.

To conduct surveillance of occupationally related health events, the New Hampshire Division of Public Health Services analyzes death certificates and workers' compensation claims. In an effort to bolster these limited data sources, a previously unrecognized data-set comprised of court records was explored. Court records obtained from the Federal District Court proved to be a readily accessible and detailed source of information for identifying suspected cases of asbestos-related disease and potential sources of asbestos exposure.

Asbestosis↗
PubMed2003

Pharmacy data in the VA health care system.

Recent advances in Department of Veterans Affairs (VA) health care data systems have greatly increased access to operational pharmacy information. This article presents a brief guide to VA pharmacy data sources: the Veterans Health Information Systems and Technology Architecture files, the Pharmacy Benefits Management database, Decision Support System (DSS) National Data Extracts for inpatient and outpatient care, the planned DSS National Pharmacy Extract, DSS databases at local VA facilities, and the Non-VA Fee Basis files. Depending on the source, available data elements include patient demographics, clinical care information, characteristics of the medication and of the prescribing physician, and cost. Access policies are detailed for VA and non-VA researchers. Linking these sources to VA databases containing data on inpatient and outpatient services offers a comprehensive view of health care within several VA populations of general interest, including people over age 65 and those with physical and psychiatric disabilities.

Bias↗
PubMed1993

A three-sample multiple-recapture approach to census population estimation with heterogeneous catchability.

"A central assumption in the standard capture-recapture approach to the estimation of the size of a closed population is the homogeneity of the 'capture' probabilities. In this article we develop an approach that allows for varying susceptibility to capture through individual parameters using a variant of the Rasch model from psychological measurement situations. Our approach requires an additional recapture. In the context of census undercount estimation, this requirement amounts to the use of a second independent sample or alternative data source to be matched with census and Post-Enumeration Survey (PES) data.... We illustrate [our] models and their estimation using data from a 1988 dress-rehearsal study for the 1990 census conducted by the U.S. Bureau of the Census, which explored the use of administrative data as a supplement to the PES. The article includes a discussion of extensions and related models."

Americas↗
PubMedDate not supplied

Effects of age, sex, and ethnicity on the association between apolipoprotein E genotype and Alzheimer disease. A meta-analysis. APOE and Alzheimer Disease Meta Analysis Consortium.

OBJECTIVE: To examine more closely the association between apolipoprotein E (APOE) genotype and Alzheimer disease (AD) by age and sex in populations of various ethnic and racial denominations. DATA SOURCES: Forty research teams contributed data on APOE genotype, sex, age at disease onset, and ethnic background for 5930 patients who met criteria for probable or definite AD and 8607 controls without dementia who were recruited from clinical, community, and brain bank sources. MAIN OUTCOME MEASURES: Odds ratios (ORs) and 95% confidence intervals (CIs) for AD, adjusted for age and study and stratified by major ethnic group (Caucasian, African American, Hispanic, and Japanese) and source, were computed for APOE genotypes epsilon2/epsilon2, epsilon2/epsilon3, epsilon2/epsilon4, epsilon3/epsilon4, and epsilon4/epsilon4 relative to the epsilon3/epsilon3 group. The influence of age and sex on the OR for each genotype was assessed using logistic regression procedures. RESULTS: Among Caucasian subjects from clinic- or autopsy-based studies, the risk of AD was significantly increased for people with genotypes epsilon2/epsilon4 (OR=2.6, 95% CI=1.6-4.0), epsilon3/epsilon4 (OR=3.2, 95% CI=2.8-3.8), and epsilon4/epsilon4 (OR=14.9, 95% CI= 10.8-20.6); whereas, the ORs were decreased for people with genotypes epsilon2/epsilon2 (OR=0.6, 95% CI=0.2-2.0) and epsilon2/epsilon3 (OR=0.6, 95% CI=0.5-0.8). The APOE epsilon4-AD association was weaker among African Americans and Hispanics, but there was significant heterogeneity in ORs among studies of African Americans (P<.03). The APOE epsilon4-AD association in Japanese subjects was stronger than in Caucasian subjects (epsilon3/epsilon4: OR=5.6, 95% CI=3.9-8.0; epsilon4/epsilon4: OR=33.1, 95% CI=13.6-80.5). The epsilon2/epsilon3 genotype appears equally protective across ethnic groups. We also found that among Caucasians, APOE genotype distributions are similar in groups of patients with AD whose diagnoses were determined clinically or by autopsy. In addition, we found that the APOE epsilon4 effect is evident at all ages between 40 and 90 years but diminishes after age 70 years and that the risk of AD associated with a given genotype varies with sex. CONCLUSIONS: The APOE epsilon4 allele represents a major risk factor for AD in all ethnic groups studied, across all ages between 40 and 90 years, and in both men and women. The association between APOE epsilon4 and AD in African Americans requires clarification, and the attenuated effect of APOE epsilon4 in Hispanics should be investigated further.

Adult↗
PubMed1998

Oklahoma Firearm-Related Injury Surveillance.

CONTEXT: The magnitude of firearm-related deaths is known, but few studies have evaluated the magnitude and epidemiology of nonfatal firearm-related injuries. The circumstances resulting in fatal versus nonfatal injury are likely very different. No single data source provides complete details on nonfatal shootings. OBJECTIVE: To establish a surveillance system to define the epidemiology of fatal and nonfatal firearm-related injuries. DESIGN: Data were collected on fatal and nonfatal firearm-related injuries that occurred in 1995. SETTING: State of Oklahoma. PARTICIPANTS: Medical Examiner, Vital Statistics, hospital emergency and medical records departments, police departments, newspaper clipping service. MAIN OUTCOME MEASURES: Incidence rate of firearm-related injuries; case-fatality rate; demographic, medical, and epidemiologic data; sensitivity of each reporting source; completeness of reporting. RESULTS: The incidence rate of firearm-related injuries was 45.5 per 100,000 population. The case fatality rate was 35%. Injury rates were highest among adolescents, young adults, males, and African Americans. The Medical Examiner and Vital Statistics reported 87% and 98% of fatal cases, respectively. Passive surveillance of hospital emergency departments identified 72% of patients seeking hospital treatment. Among inpatients, 81% were identified by medical records departments. Newspaper clippings were obtained for 31% of cases. Information on the victim-perpetrator relationship and the type of firearm was available for 79% and 80% of cases, respectively. CONCLUSIONS: Statewide surveillance of firearm-related injuries using multiple data sources is possible and provides a picture of the overall firearm-related injury problem. Strategies to enhance computer linkages of medical and police data should be pursued to maximize the sensitivity of reporting and minimize the costs of surveillance.

Adolescent↗
PubMed2006

Information mining over heterogeneous and high-dimensional time-series data in clinical trials databases.

An effective analysis of clinical trials data involves analyzing different types of data such as heterogeneous and high dimensional time series data. The current time series analysis methods generally assume that the series at hand have sufficient length to apply statistical techniques to them. Other ideal case assumptions are that data are collected in equal length intervals, and while comparing time series, the lengths are usually expected to be equal to each other. However, these assumptions are not valid for many real data sets, especially for the clinical trials data sets. An addition, the data sources are different from each other, the data are heterogeneous, and the sensitivity of the experiments varies by the source. Approaches for mining time series data need to be revisited, keeping the wide range of requirements in mind. In this paper, we propose a novel approach for information mining that involves two major steps: applying a data mining algorithm over homogeneous subsets of data, and identifying common or distinct patterns over the information gathered in the first step. Our approach is implemented specifically for heterogeneous and high dimensional time series clinical trials data. Using this framework, we propose a new way of utilizing frequent itemset mining, as well as clustering and declustering techniques with novel distance metrics for measuring similarity between time series data. By clustering the data, we find groups of analytes (substances in blood) that are most strongly correlated. Most of these relationships already known are verified by the clinical panels, and, in addition, we identify novel groups that need further biomedical analysis. A slight modification to our algorithm results an effective declustering of high dimensional time series data, which is then used for "feature selection." Using industry-sponsored clinical trials data sets, we are able to identify a small set of analytes that effectively models the state of normal health.

Algorithms↗
PubMed2000

Pathway analysis in metabolic databases via differential metabolic display (DMD).

MOTIVATION: A number of metabolic databases are available electronically, some with features for querying and visualizing metabolic pathways and regulatory networks. We present a unifying, systematic approach based on PETRI nets for storing, displaying, comparing, searching and simulating such nets from a number of different sources. RESULTS: Information from each data source is extracted and compiled into a PETRI net. Such PETRI nets then allow to investigate the (differential) content in metabolic databases, to map and integrate genomic information and functional annotations, to compare sequence and metabolic databases with respect to their functional annotations, and to define, generate and search paths and pathways in nets. We present an algorithm to systematically generate all pathways satisfying additional constraints in such PETRI nets. Finally, based on the set of valid pathways, so-called differential metabolic displays (DMDs) are introduced to exhibit specific differences between biological systems, i.e. different developmental states, disease states, or different organisms, on the level of paths and pathways. DMDs will be useful for target finding and function prediction, especially in the context of the interpretation of expression data.

Algorithms↗
PubMed1995

Rising primary malignant brain tumor mortality in the elderly. A manifestation of differential survival.

BACKGROUND: Increasing primary malignant brain tumor mortality among the elderly in developed countries over the past three decades has been attributed to improved diagnostic techniques and increased environmental carcinogens. OBJECTIVE: To demonstrate that rising primary malignant brain tumor mortality among the elderly can be accounted for by differential survival. DATA SOURCE: Published United States mortality data from the National Center for Health Statistics, 1962 to 1989. MEASURES: Age-specific primary malignant brain tumor mortality rates were determined for the age groups of more than 60 years old and compared with the population size of these age groups. RESULTS: Increasing primary malignant brain tumor mortality rates among the oldest age groups in the United States from 1962 to 1989 were directly proportional to the increasing population size of these age groups. CONCLUSIONS: Comparisons between age-specific mortality rates are generally considered valid since they are inherently age- and sex-matched. Moreover, age-specific mortality rates should not be related to population size. Rather than implying improved diagnosis or enhanced carcinogenesis, these results suggest that differential survival and its effect on the surviving gene pool in an aging population is an alternative explanation for the observed increase in primary malignant brain tumor mortality among the elderly.

Aged↗
PubMed1998

Management of rhinosinusitis in children: consensus meeting, Brussels, Belgium, September 13, 1996.

OBJECTIVES: To (1) provide definitions for the different forms of pediatric rhinosinusitis, with an enumeration of the main symptoms and signs; (2) provide indications for microbiological, allergic, and immunologic assessment as well as for imaging studies; (3) suggest standard medical management with judicious use of antimicrobial agents; and (4) discuss indications for surgery. DATA SOURCES: Clinical studies and literature data relevant to the different topics of pediatric rhinosinusitis. CONCLUSIONS: Rhinosinusitis in children is a multifactorial disease in which the importance of several predisposing factors changes with increasing age. Continued study to obtain a better understanding of the disease and carefully controlled comparative evaluations of medical and surgical therapies are suggested.

Child, Preschool↗
PubMed2004

Artificial liver support: potential to retard regeneration?

HYPOTHESIS: The concept of an "artificial liver" has been in development for over 40 years. Such devices aim to temporarily assume metabolic and excretory functions of the liver, with removal of potentially hepatotoxic substances, thereby clinically stabilizing patients and preventing deterioration while awaiting transplantation. If sufficient numbers of viable hepatocytes remain, regeneration and subsequent recovery of innate liver function may occur. However, these devices have not yet become part of routine clinical use. Much less is known regarding the effect such devices have, if any, on circulating cytokines and growth factors and the subsequent effects on the regenerating liver. If these devices remove or reduce factors known to promote regeneration, is the rate of regeneration retarded? Conversely, does the incorporation of hepatocytes into bioartificial support systems confer an advantage through the production of growth-promoting factors from these cultured hepatocytes?Data Sources, Extraction, and STUDY SELECTION: Data were obtained using PubMed search for reports involving liver support, extracorporeal circuits, dialysis, growth factors, and cytokines. Those reports specifically looking at the effect of artificial liver support on cytokines and growth factors are discussed. CONCLUSIONS: There is a paucity of information on the key events and substances involved in hepatic regeneration. In addition, there is a potential impact of liver support devices on the regeneration of substances associated with hepatic regeneration. Further study is needed.

Growth Substances↗
PubMed2005

Role of community risk factors and resources on breast carcinoma stage at diagnosis.

BACKGROUND: The current study investigated the individual and community determinants of breast carcinoma stage at diagnosis (BCSAD) using multiple data sources merged with cancer registry data. The literature review yielded 5 studies that analyzed cancer registry data merged with community-level variables (1995-2004). METHODS: Community variables constructed for the current study reflected social and economic risk factors, physician supply, and health maintenance organization penetration. Multivariate logistic regression was used to identify the significant predictors of increasingly progressive BCSAD. RESULTS: Disparities remained for black and Hispanic females in California, who were least likely to be diagnosed early compared with their white counterparts. Younger (< 40 years) and middle-aged (40-64 years) females were less likely to be diagnosed with early BCSAD, compared with older females (> or = 65 years). Utilizing services at hospitals serving a lower volume of patients with breast carcinoma was associated with later BCSAD. After controlling for individual-level factors, community-level variables constructed at the census block group and county level were tested. If a woman resided in a neighborhood with greater percentages of female-headed households, persons living below the poverty level, less educated people, and more recent immigrants, then her chances of being diagnosed at an earlier stage were diminished. If, conversely, she resided in a neighborhood with greater percentages of females > or = 65 years (a proxy for Medicare coverage), her access to medical care and the probability of earlier BCSAD increased. County-level insurance rates and residing in counties where greater percentages of women ever had a mammogram were associated with in situ and early-stage diagnosis. Similarly, the supply of primary care physicians and radiologists was associated positively with earlier BCSAD. CONCLUSIONS: Results confirmed community-level predictors of socioeconomic and delivery system context matter, although the individual-level predictors showed a stronger effect. Nevertheless, analysis of community variables is promising for guiding and evaluating the effects of health policy and developing community and delivery system interventions for earlier detection and treatment of breast carcinoma.

Adult↗