Shared decision making is the process of interacting with patients in arriving at informed values-based choices when options have features that patients value differently. Patient decision aids (PtDAs) are evidence-based tools designed to facilitate that process. Numerous randomized trials indicate that PtDAs improve decision quality and prevent overuse of options that informed patients do not value. Therefore, they have a potential role in reducing unwarranted variations in the use of preference-sensitive health care options. However, barriers to their widespread use need to be addressed with coherent plans for ensuring good standards, improving access to PtDAs, training practitioners, testing practice models, and launching demonstration projects.

Preference regarding cancer screening and treatment is greatly affected by information about medical uncertainties. Because informed patient choices vary. PSA screening decisions should incorporate individual preferences.

Context Despite a widespread interest in increasing the numbers of primary care physicians to improve care and to moderate costs, the relationship of the primary care physician workforce to patient-level outcomes remains poorly understood. Objective To measure the association between the adult primary care physician workforce and individual patient outcomes. Design, Setting, and Participants A cross-sectional analysis of the outcomes of a 2007 20% sample of fee-for-service Medicare beneficiaries aged 65 years or older (N = 5 132 936), which used 2 measures of adult primary care physicians (general internists and family physicians) across Primary Care Service Areas (N = 6542): (1) American Medical Association (AMA) Masterfile nonfederal, office-based physicians per total population and (2) office-based primary care clinical full-time equivalents (FTEs) per Medicare beneficiary derived from Medicare claims. Main Outcome Measures Annual individual-level outcomes (mortality, ambulatory care sensitive condition [ACSC] hospitalizations, and Medicare program spending), adjusted for individual patient characteristics and geographic area variables. Results Marked variation was observed in the primary care physician workforce across areas, but low correlation was observed between the 2 primary care workforce measures (Spearman r = 0.056; P < .001). Compared with areas with the lowest quintile of primary care physician measure using AMA Masterfile counts, beneficiaries in the highest quintile had fewer ACSC hospitalizations (74.90 vs 79.61 per 1000 beneficiaries; relative rate [RR], 0.94; 95% confidence interval [CI], 0.93–0.95), lower mortality (5.38 vs 5.47 per 100 beneficiaries; RR, 0.98; 95% CI, 0.97–0.997), and no significant difference in total Medicare spending ($8722 vs $8765 per beneficiary; RR, 1.00; 95% CI, 0.99–1.00). Beneficiaries residing in areas with the highest quintile of primary care clinician FTEs compared with those in the lowest quintile had lower mortality (5.19 vs 5.49 per 100 beneficiaries; RR, 0.95; 95% CI, 0.93–0.96), fewer ACSC hospitalizations (72.53 vs 79.48 per 1000 beneficiaries; RR, 0.91; 95% CI, 0.90–0.92), and higher overall Medicare spending ($8857 vs $8769 per beneficiary; RR, 1.01; 95% CI, 1.004–1.02). Conclusion A higher level of primary care physician workforce, particularly with an FTE measure that may more accurately reflect ambulatory primary care, was generally associated with favorable patient outcomes.

Mailed interventions enhance patient knowledge and self-reported participation in decision making, and alter screening preferences. The pamphlet and video interventions evaluated are comparable in effectiveness. The lower-cost pamphlet approach is an attractive option for clinics with limited resources.

A total of 388 men undergoing transurethral resection of the prostate for benign prostatic hypertrophy during 1988 entered a prospective cohort study designed to examine the outcome of surgery during postoperative year 1. Self-administered questionnaires were completed preoperatively, and at 3, 6 and 12 months postoperatively. The surgeons completed 1 questionnaire shortly after surgery and another questionnaire 3, 6 or 12 months later. The mortality rate during the 12 months of followup was 2.8% (11 deaths). The surgeons reported perioperative complications in 14% of the patients and immediate postoperative complications, excluding urinary tract infections, in 17%. During the first 3 months postoperatively 38% of the patients reported incontinence and 25% had a urinary tract infection. Between 6 and 12 months postoperatively only 12% of the patients were troubled by either condition. The postoperative prevalence of impotence (24%) did not alter during followup and was similar to that reported preoperatively (22%). Of the patients 74% reported feeling better and 78% experienced a decrease in the overall level of symptoms postoperatively. The improvement in symptom levels was greatest in those with the most severe preoperative symptoms, and obstructive symptoms were alleviated slightly more than irritative symptoms.

No abstract

The management of radiation injuries following a catastrophic event where large numbers of people may have been exposed to life-threatening doses of ionizing radiation will rely critically on the availability and use of suitable biodosimetry methods. In vivo electron paramagnetic resonance (EPR) tooth dosimetry has a number of valuable and unique characteristics and capabilities that may help enable effective triage. We have produced a prototype of a deployable EPR tooth dosimeter and tested it in several in vitro and in vivo studies to characterize the performance and utility at the state of the art. This report focuses on recent advances in the technology, which strengthen the evidence that in vivo EPR tooth dosimetry can provide practical, accurate, and rapid measurements in the context of its intended use to help triage victims in the event of an improvised nuclear device. These advances provide evidence that the signal is stable, accurate to within 0.5 Gy, and can be successfully carried out in vivo. The stability over time of the radiation-induced EPR signal from whole teeth was measured to confirm its long-term stability and better characterize signal behavior in the hours following irradiation. Dosimetry measurements were taken for five pairs of natural human upper central incisors mounted within a simple anatomic mouth model that demonstrates the ability to achieve 0.5 Gy standard error of inverse dose prediction. An assessment of the use of intact upper incisors for dose estimation and screening was performed with volunteer subjects who have not been exposed to significant levels of ionizing radiation and patients who have undergone total body irradiation as part of bone marrow transplant procedures. Based on these and previous evaluations of the performance and use of the in vivo tooth dosimetry system, it is concluded that this system could be a very valuable resource to aid in the management of a massive radiological event.

PURPOSE An earlier randomized controlled trial of prevention care management (PCM) found signifi cant improvement in breast, cervical, and colorectal cancerscreening rates among women attending Community Health Centers but required substantial research support. This study evaluated the impact of a streamlined PCM delivered through a Medicaid managed care organization (MMCO), an infrastructure with the potential to sustain this program for the long term. METHODS This randomized trial was conducted within an MMCO serving NewYork City between May 2005 and December 2005. A total of 1,316 women aged 40 to 69 years and not up to date for at least 1 targeted cancer-screening test were randomized to either PCM or a comparison group. Women in the PCM group received up to 3 scripted telephone calls to identify barriers and provide support to obtain any needed breast, cervical, and colorectal cancer-screening tests. Women in the comparison group received a modifi ed version of the MMCO's established mammography telephone outreach program, also in up to 3 calls. Women in both groups received a fi nancial incentive on confi rmation that they had received a mammogram. Screening status was assessed through MMCO administrative data. Groups were compared using odds ratios. RESULTSIn an intent-to-treat comparison adjusted for baseline screening status, PCM women were 1.69 times more likely to be up-to-date for colorectal cancerscreening tests at follow-up than women in the comparison group (95% confidence interval, 1.03-2.77). Follow-up screening rates for cervical and breast cancer did not differ signifi cantly between study groups on an intent-to-treat basis. CONCLUSIONSThe abbreviated PCM telephone intervention was feasible to deliver through an MMCO and improved screening for 1 cancer. This approach has the potential to improve cancer-screening rates signifi cantly in settings that can provide telephone support to women known to be overdue. 2007;5:320-327. DOI: 10.1370/afm.701. Ann Fam Med INTRODUCTIONL ower cancer-screening rates among low-income and minority women may contribute to more late-stage diagnoses and higher rates of cancer mortality. [1][2][3][4][5][6] Although socioeconomic variables such as income and education may explain much of the disparity in cancer screening observed between racial and ethnic groups, 2,7,8 disparities nonetheless remain. Recent surveys in New York City found that Hispanics and African Americans were less likely to be screened for colorectal cancer than whites, 9,10 and cancer mortality rates were 1.3 times higher among residents living in low-income areas than among their counterparts in higher-income areas. 11A previously reported randomized controlled trial of a prevention care management (PCM) intervention found an improvement in cancer- 12 PCM is a telephone-based intervention delivered by trained staff to women who were not up-to-date for breast, cervical, or colorectal cancer screening, to help them overcome barriers to receiving needed tests. The intervention signifi cantly...