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Background. Modeling breast cancer progression and the effect of various risk is helpful in deciding when a woman should start and end screening, and how often the screening should be undertaken. Methods. We modeled the natural progression of breast cancer using a hidden Markov process, and incorporated the effects of covariates. Patients are women aged 50–59 (older) and 40–49 (younger) years from the Canadian National Breast Screening Studies. We included prevalent cancers, estimated the screening sensitivities and rates of over-diagnosis, and validated the models using simulation. Results. We found that older women have a higher rate of transition from a healthy to preclinical state and other causes of death but a lower rate of transition from preclinical to clinical state. Reciprocally, younger women have a lower rate of transition from a healthy to preclinical state and other causes of death but a higher rate of transition from a preclinical to clinical state. Different risk factors were significant for the age groups. The mean sojourn times for older and younger women were 2.53 and 2.96 years, respectively. In the study group, the sensitivities of the initial physical examination and mammography for older and younger women were 0.87 and 0.81, respectively, and the sensitivity of the subsequent screens were 0.78 and 0.53, respectively. In the control groups, the sensitivities of the initial physical examination for older and younger women were 0.769 and 0.671, respectively, and the sensitivity of the subsequent physical examinations for the control group aged 50–59 years was 0.37. The upper-bounds for over-diagnosis in older and younger women were 25% and 27%, respectively. Conclusions. The present work offers a basis for the better modeling of cancer incidence for a population with the inclusion of prevalent cancers. [ABSTRACT FROM AUTHOR]

We thank Corber, (1) Dunkley (2) and Moloughney (3) for their thoughtful responses to our commentary, (4) with each further expanding the understanding and appreciation of public health medicine's past, [...]

The article announces that physician Flo Witte will be recognized with the American Medical Writers Association's 2016 Harold Swanberg Distinguished Service Award.

Presents letters to the editor on a number of medical topics as of January 22, 2002. Breast self-examination; Assessment of the quality of clinical practice guidelines; Gaining a history of illness from a patient.

A letter to the editor and a response by Bart J. Harvey and Thomas A. Lang to the letter about their article "Hypothesis Testing, Study Power and Sample Size" in the September 2010 issue are presented.

Competing Interests: Competing interests: No competing interests were declared.

Objective: To study the effect of electronic medical record (EMR) implementation on preventive services covered by Ontario's pay-for-performance program., Design: Prospective double-cohort study., Participants: Twenty-seven community-based family physicians., Setting: Toronto, Ont., Intervention: Eighteen physicians implemented EMRs, while 9 physicians continued to use paper records., Main Outcome Measure: Provision of 4 preventive services affected by pay-for-performance incentives (Papanicolaou tests, screening mammograms, fecal occult blood testing, and influenza vaccinations) in the first 2 years of EMR implementation., Results: After adjustment, combined preventive services for the EMR group increased by 0.7%, a smaller increase than that seen in the non-EMR group (P = .55, 95% confidence interval -2.8 to 3.9)., Conclusion: When compared with paper records, EMR implementation had no significant effect on the provision of the 4 preventive services studied.

Objective: To apply the diffusion-of-innovations theory to the examination of factors that are perceived by family physicians as influencing the implementation of electronic medical records (EMRs)., Design: Qualitative study with 2 focus groups 18 months after EMR implementation; participants also took part in a concurrent quantitative study examining EMR implementation and preventive services., Setting: Toronto, Ont., Participants: Twelve community-based family physicians., Methods: We employed a semistructured interview guide. The interviews were audiotaped and transcribed verbatim; 2 researchers independently categorized and coded the transcripts and then met to compare and contrast their findings, category mapping, and interpretations. Findings were then mapped to an existing theoretical framework., Main Findings: Multiple barriers to EMR implementation were described. These included lack of relative advantage for many processes, high complexity of the system, low compatibility with physician needs and past experiences, difficulty with adaptation of the EMR to the organization and adaptation of the organization to the EMR, and lack of organizational slack. Positive factors were the presence of a champion and relative advantages for some processes., Conclusion: Early EMR implementation experience is consistent with theoretical concepts associated with implementation of innovations. A problematic implementation process helps to explain, at least in part, the lack of improvement in preventive services in our quantitative results.

Objective: To assess the concerns of adult patients with spine-related complaints during the period between referral to and consultation with a spine surgeon., Design: Prospective survey., Setting: Toronto, Ont., Participants: A total of 338 consecutive, nonemergent patients before consultation with a single spine surgeon over a 5-month period., Main Outcome Measures: Patient concerns, effect of referral to a spine surgeon, and effect of waiting to see a spine surgeon., Results: The issues patients reported to be most concerning were ongoing pain (45.6% rated this as most concerning), loss of function (23.4%), need for surgery (12.1%), and permanence of the condition (9.6%). Regression analysis demonstrated that older age was an independent predictor of increased level of concern regarding pain (P=.01) and disability (P=.04). Forty-seven percent of all patients listed the need for surgery among their top 3 concerns. Mere referral to a spine surgeon (P=.03) was an independent predictor of increased concern regarding the need for surgery. Sex, diagnosis, surgical candidacy, and actual wait time were not predictive of increased concerns. Patients reported family physicians to be their most influential information source regarding spinal conditions., Conclusion: Timely provision of more specific information regarding the benign and non-surgical nature of most degenerative spinal conditions might substantially reduce patients' exaggerated concerns regarding the probability of surgery for a considerable number of patients referred to spine surgeons.

Objective: To evaluate family physicians' enjoyment of and knowledge gained from game-based learning, compared with traditional case-based learning, in a continuing medical education (CME) event on stroke prevention and management., Design: An equivalence trial to determine if game-based learning was as effective as case-based learning in terms of attained knowledge levels. Game questions and small group cases were developed. Participants were randomized to either a game-based or a case-based group and took part in the event., Setting: Ontario provincial family medicine conference., Participants: Thirty-two family physicians and 3 senior family medicine residents attending the conference., Intervention: Participation in either a game-based or a case-based CME learning group., Main Outcome Measures: Scores on 40-item immediate and 3-month posttests of knowledge and a satisfaction survey., Results: Results from knowledge testing immediately after the event and 3 months later showed no significant difference in scoring between groups. Participants in the game-based group reported higher levels of satisfaction with the learning experience., Conclusion: Games provide a novel way of organizing CME events. They might provide more group interaction and discussion, as well as improve recruitment to CME events. They might also provide a forum for interdisciplinary CME. Using games in future CME events appears to be a promising approach to facilitate participant learning.