OBJECTIVES: A randomized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older in a Medicaid health maintenance organization (HMO). METHODS: Half of 52 primary care sites received the intervention, which included written feedback and a financial bonus. Mammography, breast exam, colorectal screening, and Pap testing compliance rates were evaluated. RESULTS: From 1993 to 1995, screening rates doubled overall (from 24% to 50%), with no significant differences between intervention and control group sites. CONCLUSIONS: Financial incentives and feedback did not improve physician compliance with cancer screening guidelines in a Medicaid HMO.

Prospective studies of the general population have isolated specific social and psychological factors as independent predictors of longevity. This study assesses the ability of these factors, plus two others said to influence survival in patients with cancer, to predict survival and the time to relapse after a diagnosis of cancer. Patients with unresectable cancers (n = 204) were followed to determine the length of survival. Patients with Stage I or II melanoma or Stage II breast cancer (n = 155) were followed to determine the time to relapse. Analysis of data on these 359 patients indicates that social and psychological factors individually or in combination do not influence the length of survival or the time to relapse (P less than 0.10). The specific diagnosis (F = 2.0, P = 0.06), performance status (F = 0.66, P = 0.62), extent of disease (F = 1.12, P = 0.89), and therapy (F = 1.08, P = 0.35) were also unrelated to the psychosocial factors studied. Although these factors may contribute to the initiation of morbidity, the biology of the disease appears to predominate and to override the potential influence of life-style and psychosocial variables once the disease process is established.

Feedback to physicians, with or without financial incentives, did not improve pediatric preventive care in this Medicaid HMO during a time of rapid, secular improvements in care. Possible explanations include the context and timing of the intervention, the magnitude of the financial incentives, and lack of physician awareness of the intervention.

Thrombosis of popliteal artery aneurysms can produce limb-threatening ischemia. In this setting we have found preoperative thrombolytic therapy to be beneficial. Methods: Thirty-three patients with 54 popliteal artery aneurysms were studied (mean follow-up 62 months). Twenty-one patients (62%) had bilateral popliteal artery aneurysms, and 20 patients (61%) had extrapopliteal arterial aneurysms. Thirty-three (61 %) aneurysms had symptoms of compression or ischemia, and 21 (39%) aneurysms had thrombosis. A trend toward thrombosis for larger aneurysms was noted (p < 0.068). Results: Forty-five aneurysms were treated with bypass grafting. Five-year graft patency and limb salvage rates were 71% and 90%, respectively. Factors favoring graft patency and limb salvage included presence of two-or three-vessel runoff compared with patients with single-or no-vessel runoff (p < 0.025 graft patency;p < 0.003 limb salvage) and presence of a patent aneurysm (p < 0.005 graft patency and limb salvage). Seven patients diagnosed with thrombosis of their aneurysm and all runoff vessels were treated with preoperative thrombolytic therapy. Complete clearing of thrombus from these arteries was achieved in six of these patients (and from two of these runoff vessels in the remaining patient). These patients had better graft patency (p < 0.005) and limb salvage (p < 0.01) than comparable patients treated with emergency operations. Six amputations were performed in the follow-up interval, none of which were performed in patients having undergone thrombolytic therapy. Conclusions: It is concluded that popliteal aneurysms are managed best by elective repair of patent aneurysms with good runoff. In that difficult situation of the thrombosed popliteal artery aneurysm associated with acute leg ischemia, thrombolytic therapy safely and effectively provides patients with a more favorable alternative than emergency surgery.

A supportive family environment is thought to enhance the capacity of cancer patients to adapt to their illness and treatment. But families, like patients, vary in their ability to cope with the impact of a cancer diagnosis in a family member and in their ability to fulfill the patient's needs. Increased understanding of the interrelationships between the family's and patient's responses to illness is of fundamental importance to the care of the patient with cancer. A heterogeneous sample of 201 cancer patients and their relatives were studied to determine compatibility of psychological status and to isolate clinical and demographic variables associated with psychological distress. Self‐report tests of anxiety, mood disturbance, and mental health were applied. Despite large individual variation, the psychological status of patients and their matched relatives was closely correlated. The patient's treatment status affected both patients and their next‐of‐kin. Psychological well‐being worsened according to whether patients were receiving follow‐up care, active treatment, or palliative therapy. These data suggest a mutuality of psychological response between patients and their families. Supportive intervention for the patient or relative who manifests distress, therefore, should benefit both. Because patients and relatives involved with palliative treatment are most in need of psychological assistance, particular attention should be paid to this group, as is attempted in hospice care.