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To evaluate the impact of implementing a stakeholder-informed social risk screening and social service referral system in a community hospital setting.We implemented a stakeholder-informed social care program at a community hospital in April 2022. The evaluation included patients aged 0 to 17 years admitted to the pediatric unit between April 2021 and March 2022 (1 year preimplementation) and between April 2022 and March 2023 (1 year postimplementation). For a random subset of 232 preimplementation and 218 postimplementation patients, we performed manual data extraction, documenting program process measures and preliminary effectiveness outcomes. We used χ square and Wilcoxon rank tests to compare outcomes between the preimplementation and postimplementation groups. Multivariable logistic regression was used to assess the preliminary effectiveness of the social care program in identifying social risks.Screening rates were higher in the postimplementation group for nearly all social domains. Compared with preimplementation, the postimplementation group had higher rates of social risks identified (17.4% vs 7.8% [P < .01]: adjusted odds ratio 2.9 [95% confidence interval 1.5–5.5]) on multivariate testing. Social work consults were completed more frequently and earlier for the postimplementation group (13.8.% vs 5.6% [P < .01]) and median (19 hours vs 25 hours [P = .03]), respectively. Rates of communication of social risks in discharge summaries were higher in the postimplementation group (46.8% vs 8.2% [P < .001]).The implementation of a stakeholder-informed social care program within a community hospital setting led to the increased identification of social risks and social work consultations and improved timeliness of social work consultations and written communication of social risks in discharge summaries for primary care providers.

Objective. To determine how closely a published model of navigation reflects the practice of navigation in breast cancer patient navigation programs. Data Source. Observational field notes describing patient navigator activities collected from 10 purposefully sampled, foundation-funded breast cancer navigation programs in 2008-2009. Study Design. An exploratory study evaluated a model framework for patient navigation published by Harold Freeman by using an a priori coding scheme based on model domains. Data Collection. Field notes were compiled and coded. Inductive codes were added during analysis to characterize activities not included in the original model. Principal Findings. Programs were consistent with individual-level principles representing tasks focused on individual patients. There was variation with respect to program-level principles that related to program organization and structure. Program characteristics such as the use of volunteer or clinical navigators were identified as contributors to patterns of model concordance. Conclusions. This research provides a framework for defining the navigator role as focused on eliminating barriers through the provision of individual-level interventions. The diversity observed at the program level in these programs was a reflection of implementation according to target population. Further guidance may be required to assist patient navigation programs to define and tailor goals and measurement to community needs. Key Words. Patient navigation, breast cancer, patient-centered care, disparities, Cancer care has long been documented as an arena of racial, ethnic, and socioeconomic disparities (Freeman 1989; Koh 2009). Disparities in care delivery impact patient outcomes (Battaglia et al. 2007). [...]

Objective. To develop a structured protocol for observing patient navigators at work, describing and characterizing specific activities related to their goals. Data Sources/Setting. Fourteen extended observations of navigators at three programs within a national trial of patient navigation. Study Design. Preliminary observations were guided by a conceptual model derived from the literature and expert consensus, then coded to develop and refine observation categories. These findings were then used to develop the protocol. Methods. Observation fieldnotes were coded, using both a priori codes and new codes based on emergent themes. Using these codes, the team refined the model and constructed an observation tool that enables consistent categorization of the observed range of navigator actions. Findings. Navigator actions across a wide variety of settings can be categorized in a matrix with two dimensions. One dimension categorizes the individuals and organizational entities with whom the navigator interacts; the other characterizes the types of tasks carried out by the navigators in support of their patients. Conclusions. Use of this protocol will enable researchers to systematically characterize and compare navigator activities within and across programs. Key Words. Continuity of patient care, social support, health services needs and demands, case management, patient navigation, Challenges arise when people contemplate cancer screening. They multiply when tests suggest a threatening disease and indicate the need for follow-up investigations. And the challenges expand dramatically when such investigations [...]

Social determinants of health have been demonstrated to be important drivers of health outcomes and disparities. Screening for social needs has been routinely performed and shown to be beneficial in ambulatory settings, but little is known regarding parent perspectives on screening during pediatric hospitalizations. This study sought to determine parental attitudes surrounding inpatient screening and screening process preferences in the hospital setting.We conducted 17 semistructured interviews with English- and Spanish-speaking parents of hospitalized children at 1 tertiary and 2 community hospitals between July 2020 and February 2021, with questions probing opinions and experiences with social needs screening, comfort level with discussing social needs with hospital providers, and screening process preferences in the hospital setting. Interviews were recorded, professionally transcribed, and analyzed thematically.Participants were median age 32 years, with majority female and English-speaking, and nearly one-half with children admitted to a community hospital. Emergent themes included (1) importance of screening for social needs across multiple health care settings, (2) hospitals viewed as capable systems to respond to social needs, (3) most parents comfortable discussing social needs with inpatient providers, (4) appreciation for providers expressing caring and desire to help during inpatient screening, and (5) importance of a family-centered approach to inpatient screening.Parents reported positive perceptions regarding pediatric inpatient social needs screening importance and hospitals’ ability to address social needs and identified multiple screening process preferences for the hospital setting that can inform the development of family-centered inpatient social needs screening strategies.

Racial/ethnic disparities in glycemic control—a key diabetes outcome measure—continue to widen, even though the overall prevalence of glycemic control in the US has improved. Health insurance coverage may be associated with improved glycemic control, but few studies examine effects during a period of policy change. We assessed changes in glycemic control by racial/ethnic groups following the Massachusetts Health Insurance Reform for patients at two urban safety-net academic health systems between January 2005 and December 2013. We analyzed outcomes for three measures of poor glycemic control: 1) lack of a hemoglobin A1C (A1C) measure during a 6-month period; 2) A1C >8%; 3) A1C >9% before, during, and after implementation of insurance reform. We did not find increased rates of A1C monitoring or control following insurance reform overall or for specific racial/ethnic groups. We found evidence of worsened, not improved, glycemic control in some racial/ethnic groups in the post-reform period. The expansion of affordable insurance coverage was not associated with improved glycemic control in vulnerable populations.

Important research in women's health published in 2001 is reviewed. Topics include postmenopausal hormone therapy, the diagnosis and treatment of osteoporosis, screening women for breast and cervical cancer, fitness counseling, domestic violence, urinary tract infections, and unplanned pregnancy.

Older women who undergo regular mammography are diagnosed with an earlier stage of breast cancer and are less likely to die from it based on findings of a retrospective cohort study using the Linked Medicare Tumor Registry Database. Use of regular mammograms in older women is beneficial and can reduce death, even for those over age 84. Women over age 64 account for most newly diagnosed cases and deaths, but are least likely to have mammograms. Data are from three geographic areas and are from women older than 66 having a first primary breast cancer.

Gender differences in the treatment of cerebrovascular disease for Medicare beneficiaries have been studied using secondary database analyses with an all-strokes group made up of 3356 women and 2927 men, with 1009 women and 990 men in the carotid disease subgroup. Women hospitalized for strokes were found to undergo fewer carotid endarterectomies than men.

Background: Older black women are less likely to undergo mammography and are more often given a diagnosis of advanced-stage breast cancer than older white women. Objective: To investigate the extent to which previous mammography explains observed differences in cancer stage at diagnosis between older black and white women with breast cancer. Design: Retrospective cohort study using the Linked Medicare-Tumor Registry Database. Setting: Population-based data from three geographic areas of the United States included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program (Connecticut; metropolitan Atlanta, Georgia; and Seattle-Puget Sound, Washington). Participants: Black and white women 67 years of age and older in whom breast cancer was diagnosed between 1987 and 1989. Measurements: Medicare claims were used to classify women according to mammography use in the 2 years before diagnosis as nonusers (no previous mammography), regular users ([is greater than or equal to] 2 mammographies done at least 10 months apart), or peri-diagnosis users (mammography done only within 3 months before diagnosis). Information on mammography use was linked with SEER data to determine cancer stage at diagnosis. Stage was classified as early (in situ or local) or late (regional or distant). Results: Black women were more likely to not undergo mammography (odds ratio [OR], 3.00 [95% Cl, 2.41 to 3.75]) and to be given a diagnosis of late-stage disease (OR, 2.49 [Cl, 1.59 to 3.92]) than white women. When women were stratified by previous mammography use, the black-white difference in cancer stage occurred only among nonusers (adjusted OR, 2.54 [Cl, 1.37 to 4.71]). Among regular users, cancer was diagnosed in black and white women at similar stages (adjusted OR, 1.34 [Cl, 0.40 to 4.51]). In logistic modeling, previous mammography alone explained about 30% of the excess late-stage disease in black women. In a separate model, previous mammography explained 12% of the excess late-stage disease among black women after adjustment for sociodemographic and comorbidity information. Conclusion: Differences in breast cancer stage at diagnosis between older black and white women are related to previous mammography use. Increased regular use of mammography may result in a shift toward earlier-stage disease at diagnosis and narrow the observed differences in stage at diagnosis between older black and white women., The higher rates of late-stage breast cancer at diagnosis in elderly black women compared to white women probably occur because black women are less likely to get regular mammograms. An analysis of Medicare claims for mammography in three regions revealed that elderly black women were three times less likely to have regular mammograms and more likely to be diagnosed with late-stage disease than white women. The racial difference in cancer stage was only seen in women who did not get regular mammograms. Mammography explained 12% to 30% of the late-stage diagnoses in black women.

BACKGROUND: To determine if physician specialty, length of time in practice, and fear of malpractice influence the diagnosis and management of breast cancer in older women. METHODS: We used a fractional factorial design that controlled for patient age 165 or 80 years), race, socioeconomic status, mobility, comorbidity, and assertive behavior through 2 videotaped scenarios (a potential breast cancer [no. 1] and a known stage IIA breast cancer [no. 2]). One hundred twenty-eight white male physicians equally divided by specialty (surgeon versus nonsurgeon) and time in practice (c15 or [is greater than] 15 years) viewed the videotapes and made recommendations. RESULTS: The physician subjects saw 46 patients per week, 59% female, and 47% age [is greater than or equal to] 65. Their concern over malpractice was 4.7 (on a 10-point Likert scale with a higher score indicating more concern) and did not differ by specialty or time in practice (P values [is greater than] 0.7). After viewing scenario no. 1, surgeons were less likely than nonsurgeons to consider breast cancer as the principal diagnosis (odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.2 to 0.9) and to obtain a tissue diagnosis (OR = 0.3, 95% CI = 0.1 to 0.9). However, in scenario no. 2, surgeons were more likely to offer reconstruction (OR = 3.8, 95% CI = 1.4 to 10.4). Physicians in practice [is less than or equal to] 15 years were more likely than those in practice [is less than] 15 years to obtain a tissue diagnosis in scenario no. 1 (OR = 6.1, 95% CI = 1.9 to 19.2) and to perform full primary therapy in scenario no. 2 (OR = 2.8, 95% CI = 1.2 to 6.9). Physicians who performed an extensive metastatic evaluation (bone or computer tomography [CT] scan) had greater concern over malpractice than those who did not, as did physicians who performed an axillary node dissection (OR = 2.1, 95% CI 1.3 to 3.4 and 0R = 1.8, 95% CI = 1.1 to 3.0). CONCLUSIONS: With the uncertainty of how to diagnose and treat older women with breast cancer, physician specialty, length of time in practice, and concern over malpractice do influence clinical decisions. Am J Med. 1997;103:263-269. [C] 1997 by Excerpta Medica, Inc.

Objective. To study nonmedical influences on the doctor-patient interaction. A technique using simulated patients and "real" doctors is described. Data Sources. A random sample of physicians, stratified on such characteristics as demographics, specialty, or experience, and selected from commercial and professional listings. Study Design. A medical appointment is depicted on videotape by professional actors. The patient&apos;s presenting complaint (e.g., chest pain) allows a range of valid interpretation. Several alternative versions are taped, featuring the same script with patient-actors of different age, sex, race, or other characteristics. Fractional factorial design is used to select a balanced subset of patient characteristics, reducing costs without biasing the outcome. Data Collection. Each physician is shown one version of the videotape appointment and is asked to describe how he or she would diagnose or treat such a patient. Principal Findings. Two studies using this technique have been completed to date, one involving chest pain and dyspnea and the other involving breast cancer. The factorial design provided sufficient power, despite limited sample size, to demonstrate with statistical significance various influences of the experimental and stratification variables, including the patient&apos;s gender and age and the physician&apos;s experience. Persistent recruitment produced a high response rate, minimizing selection bias and enhancing validity. Conclusion. These techniques permit us to determine, with a degree of control unattainable in observational studies, whether medical decisions as described by actual physicians and drawn from a demographic or professional group of interest, are influenced by a prescribed set of nonmedical factors. Key Words. Medical decision making, simulated patients, experimental design, medical sociology, Numerous reports suggest that medical decision making - ideally a matter of symptoms, tests, and probabilities - is in fact a social transaction prone to medically extraneous influences. These nonmedical [...]

BACKGROUND: Physicians need to be aware of their patients' attitudes toward menopause when counseling women regarding hormone therapy, because menopausal attitudes may affect women's satisfaction with their decisions to use or not to use hormone therapy. Our objectives were to assess physician awareness of patient attitudes on issues surrounding the menopause and hormone therapy, and to determine the prevalence and correlates of hormone use. METHODS: This cross-sectional survey study was conducted in the primary care outpatient practices of an academic medical center. Surveys were simultaneously administered to female patients aged 50 to 70 years (n = 182) and their primary care physicians immediately after clinical encounters. The surveys contained questions from four established (five-point) attitudinal scales (autonomy, desire for information, philosophy of the menopause, barriers to use of hormone therapy), and questions addressing patients' degree of concern about developing various conditions. Physicians were asked to estimate their patients' altitudes. PATIENTS AND METHODS: Physicians were generally aware of patients' desire for autonomy (3.2 versus 3.2, P = 1.0), but tended to underestimate patients' desire for information (3.7 versus 4.5, P = 0.0001) and patients' perceptions of barriers to using hormone therapy (3.2 versus 3.4, P = 0.0001). They also underestimated the extent to which patients view menopause as a medical problem (3.0 versus 3.2, P = 0.0001). Physicians overestimated patients' general concern about heart disease (scale difference 0.40, P = 0.0001) and breast cancer (difference 0.23, P = 0.02). Physicians were less aware of their patients' attitudes when they were male (versus female), interns/residents (versus faculty/ fellows), and less knowledgeable about menopausal hormone therapy (versus more knowledgeable). The significant predictors of hormone use on multivariate analysis were past hysterectomy, urinary incontinence, alcohol intake, and possession of knowledge regarding hormone therapy. CONCLUSIONS: Physicians incorrectly estimate some aspects of their patients' attitudes regarding menopause and hormone therapy, and certain physician characteristics may be associated with decreased awareness. To optimize hormone therapy counseling, physicians may need to increase their attention to patients' menopausal attitudes. Am J Med. 1997;103:3-10. [C] 1997 by Excerpta Medica, Inc.

Background: Black women with breast cancer have a decreased 5-year survival rate in comparison with white women, possibly because of less frequent use of mammography. Having a regular provider or source of health care is the most important determinant of mammography use. Objective: To examine whether the difference in mammography use between elderly black women and elderly white women is related to the number of visits made to a primary care physician. Design: Retrospective review of 1990 Health Care Financing Administration billing files (Medicare part B) from 10 states. Setting: Outpatient mammography services in 10 states. Participants: Black women and white women, 65 years of age and older, residing in one of the 10 states. Measurements: Any mammogram. Predictors included race, number of visits to a primary care physician (0,1, 2, or 3 or more), median income of ZIP code of residence (a surrogate measure of income), and state. Results: The following are findings from Georgia; similar results were found in each state studied. The mean age of the 335 680 women was 75 years; 20% were black. Sixty-eight percent of the black women and 69% of the white women made at least one visit to a primary care physician. Overall, 14% of the women had had mammography; black women had mammography less often than white women (9% compared with 15%). At each primary care visit level (1, 2, or 3 or more visits), black women had mammography less often than white women (1 visit, 7% compared with 15%; 2 visits, 12% compared with 21%; and 3 or more visits, 12% compared with 20%). Even among women who had made at least one visit to a primary care physician, a deficit for blacks occurred in each income quintile (lowest quintile, 13% compared with 20%; low, 10% compared with 18%; middle, 12% compared with 18%; high, 10% compared with 19%; and highest, 12% compared with 22%) and in each state (in Georgia, for example, the percentages were 14% compared with 21%). An age-, income-, and state-adjusted logistic model predicting mammography use for 2.9 million white women in all 10 states shows the powerful effect of primary care use on mammography (odds ratios for 1, 2, and 3 or more visits were, respectively, 2.73 [95% CI, 2.70 to 2.77]; 3.98 [CI, 3.93 to 4.031; and 4.62 [CI, 4.58 to 4.67!). The same model fit to 250000 black women shows a lesser effect (analogous odds ratios were 1.77 [CI, 1.67 to 1.87]; 2.49 [CI, 2.36 to 2.63]; and 3.15 [CI, 3.04to 3.25]). Conclusions: Among older women, mammography is used less often for blacks than for whites. More frequent use of mammography is associated with more visits to a primary care physician in both groups, but the deficit for black women persists at each income level and in each state, even after primary care use is considered. Primary care visits are less likely to 'boost' mammography use for black women than for white women., Doctors appear to perform fewer mammograms on older black women than older white women even among those who see their doctors equally regularly. Ten states' Medicare billing files during 1990 on 335,680 elderly women showed that, overall, 15% of the white women had mammograms while only 9% of the black women had mammograms. Women who saw their primary doctor more regularly had a greater chance of receiving a mammogram. However, more white women received mammograms than black women when comparing equal numbers of doctor visits and at equivalent income levels.

Objective: To explore use of clinical breast examination (CBE) among women receiving mammography. Methods: A retrospective cohort analysis of 100 women aged 50 years or older with at least one bilateral mammogram. Chart review documented demographic information, severity of illness, and performance of CBE (from 1 year prior to 18 months after the mammogram). Results: The mean age of the 100 women was 63 years. They were predominantly unmarried (60%), nonwhite 58%), and not currently employed (57%). Three quarters (76%) had mammography and CBE (comprehensive screening), while the remaining 24% had mammography only. Sociodemographic factors did not differ for women with and without comprehensive screening (P>. 1). However, patients of female providers were more likely to receive comprehensive screening than patients of male providers. Specifically, 95% of women seen by female attending physicians or fellows had comprehensive screening vs 67% for male attending physicians or fellows and 61% for residents (P=.008). Conclusions: Mammography may be replacing CBE especially among patients of male providers. Interventions targeted to these providers could help improve the use of CBE and mammography. (Arch Intern Med. 1996;156:741-744)

ABSTRACTObjectiveMeasure effect of late-afternoon communication and patient planning (CAPP) rounds to increase early electronic discharge orders (EDO).MethodsWe enrolled 4485 patients discharged from six subspecialty medical services. We implemented late-afternoon CAPP rounds to identify patients who could have morning discharge the subsequent day. After an initial successful implementation of the intervention, we identified lack of sustainability. We made changes with sustained implementation of the intervention. This is a before-after study of a quality improvement intervention.Program evaluationPrimary measures of intervention effectiveness were percentage of patients who received EDO by 11 am and patients discharged by noon. Additional measure of effectiveness were percent of patients admitted to the correct ward, emergency department (ED)-to-ward transfer time compared between intervention and nonintervention periods. We compared the overall expected LOS and the average weekly discharges to assess for comparability across the control and intervention time periods. We used the readmission rate as balancing measure to ensure that the intervention was not have unintended negative patients consequences.ResultsExpected length of stay based upon discharge diagnosis/comorbidities and readmission rates were similar across the intervention and control time periods. The average weekly discharges were not statistically significant. Percentage of EDO by 11 am was higher in the first intervention period, second intervention period and combined intervention periods (28.9% vs. 21.8%, P< 0.001) compared with the respective control periods. Percent discharged before noon increased in the first intervention period, second intervention period and for the combined intervention periods (17 vs. 11.8%, P< 0.001). There was no difference in the percent admitted to the correct ward and ED-to-ward transfer time.ConclusionAfternoon CAPP rounds to identify early patient discharges the following day led to increase in EDO entered by 11 am and discharges by noon without an adverse change in readmission rates and LOS.

Faculty training awards are an important means of advancing early career faculty in research. The National Institutes of Health (NIH) Building Interdisciplinary Research Careers in Women's Health (BIRCWH) is a long-running K12 career development program and has been integral in promoting the research success of faculty nationally. We surveyed BIRCWH program directors to understand factors likely to influence long-term research careers and funding success.

In this Perspective, the authors review Association of American Medical Colleges data on gender parity and intersectionality, consider the literature on gender parity in academic medicine and the underlying gender norms that explain these statistics, and offer recommendations for moving past indicators of parity to achieve gender and social equality.Improvements in gender parity among medical school graduates have not translated to gender parity among practicing physicians or medical school faculty, particularly for racial/ethnic minorities. Further, gender parity does not correspond to gender equality, such that gender-based disparities in salaries and advancement persist. In addition, social norms related to traditional gender role expectations reinforce existing biases and lead to sexual harassment and discrimination against women in the workplace.Building on their analysis of existing data and the literature, the authors offer concrete recommendations to achieve gender equality in academic medicine that not only improve parity but also support policies and practices to address the norms that further bias and discrimination. These recommendations include the collection, monitoring, and open reporting of data on salaries as well as on sex and race/ethnicity; stronger policies related to family leave and sexual discrimination and harassment; and accountability structures to ensure that policies are enforced. While these efforts alone cannot eliminate gender inequalities, academic medicine should be at the forefront of creating a climate in medicine that is supportive of gender equality as part of their larger goal of promoting social equality.

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Despite individual and institutional awareness of the inequity in retention, promotion and leadership of racially and ethnically underrepresented minority faculty in academic medicine, the number of such faculty remains unacceptably low. The authors explored challenges to the recruitment, retention and promotion of underrepresented faculty among a sample of leaders at academic medical centers.

Patient navigation—the provision of logistical, educational, and emotional support needed to help patients “navigate around” barriers to high-quality cancer treatment offers promise. No patient-reported outcome measures currently exist that assess patient navigation from the patient’s perspective. We use a partial independence item response theory model to report on the psychometric properties of the Patient Satisfaction with Navigation, Logistical measure developed for this purpose.

Prior research on decision-making for reconstructive surgery after mastectomy has not addressed the specific considerations of sexual minority women (women who partner with women, and lesbian or bisexual identified women). The purpose of this study is to explore which issues sexual minority women considered when making decisions on reconstructive surgery and to understand the influence and perspectives of these women’s most important support persons.

Objective. Given limited prior evidence of high rates of cervical cancer in Haitian immigrant women in the U.S., this study was designed to examine self-reported Pap smear screening rates for Haitian immigrant women and compare them to rates for women of other ethnicities.Methods. Multi-ethnic women at least 40 years of age living in neighborhoods with large Haitian immigrant populations in eastern Massachusetts were surveyed in 2000–2002. Multivariate logistic regression analyses were used to examine the effect of demographic and health care characteristics on Pap smear rates.Results. Overall, 81% (95% confidence interval 79%, 84%) of women in the study sample reported having had a Pap smear within three years. In unadjusted analyses, Pap smear rates differed by ethnicity (p=0.003), with women identified as Haitian having a lower crude Pap smear rate (78%) than women identified as African American (87%), English-speaking Caribbean (88%), or Latina (92%). Women identified as Haitian had a higher rate than women identified as non-Hispanic white (74%). Adjustment for differences in demographic factors known to predict Pap smear acquisition (age, marital status, education level, and household income) only partially accounted for the observed difference in Pap smear rates. However, adjustment for these variables as well as those related to health care access (single site for primary care, health insurance status, and physician gender) eliminated the ethnic difference in Pap smear rates.Conclusions. The lower crude Pap smear rate for Haitian immigrants relative to other women of color was in part due to differences in (1) utilization of a single source for primary care, (2) health insurance, and (3) care provided by female physicians. Public health programs, such as the cancer prevention programs currently utilized in eastern Massachusetts, may influence these factors. Thus, the relatively high Pap rate among women in this study may reflect the success of these programs. Public health and elected officials will need to consider closely how implementing or withdrawing these programs may impact immigrant and minority communities.

Medical providers often fail to treat depression. We examined whether treatment is more aggressive in a setting with accessible mental health resources, the Veterans Health Administration (VA). VA and non-VA primary care physicians and medical specialists viewed a videotape vignette portraying a patient meeting criteria for major depression and then answered interviewer-administered questions about management. We found that 24% of VA versus 15% of non-VA physicians would initiate guideline-recommended treatment (antidepressants or mental health referral, or both) (P= .09). Among those who identified depression as likely, 42% of VA versus 19%of non-VA physicians would treat (P= .002): 23% versus 3%recommended mental health referral (P< .001) and 21% versus 17% an antidepressant (P= .67). Although many patients with major depression may not receive guideline-recommended management, VA physicians do initiate mental health referral more often than do non-VA physicians. Access to mental health services may prove valuable in the campaign to increase physician adherence to depression clinical guidelines.

OBJECTIVE:To determine rates of and explore factors associated with mammography use among older women.

Testing asymptomatic women for chlamydial infection is advocated for high-risk populations, but testing criteria in low-risk settings are less clear. To determine whether findings from Papanicolaou (Pap) smears could identify women at risk for Chlamydia, we studied 512 women, 18 to 50 years of age, seeking routine gynecologic care. The prevalence of positive cultures for Chlamydiawas 4.7%. Three cytologic findings were independently associated with Chlamydiaon logistic regression: transformed lymphocytes, polymorphonuclear leukocytes, and squamous metaplasia. The sensitivity and the specificity of the presence of any two of these three findings were 75% and 73.6%, respectively. The prevalence of Chlamydiaif two findings were present was 12.2%, nearly three times the population prevalence. Certain findings on cervical cytology may be useful as an adjunct in preventive care for chlamydial cervicitis.

The puropse of this research was to determine the influence of patient and physician characteristics on physicians' level of variability and certainty in breast cancer care.

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbiditics, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation and treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non‐medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient‐based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision‐making process.