Fundamental Causes of Colorectal Cancer Mortality in the United States: Understanding the Importance of Socioeconomic Status in Creating Inequality in Mortality

Objectives. We used the fundamental cause hypothesis as a framework for understanding the creation of health disparities in colorectal cancer mortality in the United States from 1968 to 2005.Methods. We used negative binomial regression to analyze trends in county-level gender-, race-, and age-adjusted colorectal cancer mortality rates among individuals aged 35 years or older.Results. Prior to 1980, there was a stable gradient in colorectal cancer mortality, with people living in counties of higher socioeconomic status (SES) being at greater risk than people living in lower SES counties. Beginning in 1980, this gradient began to narrow and then reversed as people living in higher SES counties experienced greater reductions in colorectal cancer mortality than those in lower SES counties.Conclusions. Our findings support the fundamental cause hypothesis: once knowledge about prevention and treatment of colorectal cancer became available, social and economic resources became increasingly important in influencing mortality rates.Colorectal cancer is the third leading cause of cancer-related deaths among men and women in the United States.1 In 2010 an estimated 142 570 people in the United States were diagnosed with colorectal cancer, and 50 370 people died as a result of the disease in the same year.2 Over the past 30 years, there have been significant advances in the prevention of colorectal cancer, with reductions in mortality rates due predominantly to improvements in screening and early cancer detection.One of the primary goals of colorectal cancer screening is to reduce mortality by promoting early detection of the disease. Methods used to detect colorectal cancer also aid physicians in the identification and removal of adenomas, which can give rise to colorectal cancer.3 However, because of the unequal distribution of social and economic resources in our society, knowledge about prevention and access to treatments for colorectal cancer is not universal but, rather, is unevenly distributed along the typical social cleavages of race, class, and gender. Thus, social inequalities in colorectal cancer outcomes remain remarkably evident even in an era of successful prevention and treatment strategies.4To gain a more thorough understanding of how existing social inequalities have slowed the decline in mortality attributable to colorectal cancer, we used the “fundamental cause” hypothesis to analyze almost 40 years of US death certificate data. This theoretical construct, first put forth by Link and Phelan,5 stems from the observation that adverse social conditions are repeatedly associated with higher levels of mortality in distinctly different eras and settings.5–9 According to the hypothesis, the association between socioeconomic status (SES) and mortality endures because access to resources such as knowledge, money, power, prestige, and beneficial social connections influences the extent to which people are able to avoid disease and death as well as harness protective factors that can be used to reduce morbidity and mortality.The fundamental cause hypothesis further predicts that as individuals learn how to better prevent or treat diseases, benefits stemming from these newfound abilities will not be distributed uniformly throughout a population. Instead, they will be realized to a greater extent by those who are less likely to face discrimination and stigma and are more likely to have access to socioeconomic resources such as education, money, and information,7 thus resulting in health disparities along common social divisions such as SES and race. According to the hypothesis, more advantaged individuals, relative to their less advantaged counterparts, are poised to disproportionately gain from new health-enhancing capabilities, which may translate to earlier and more rapid reductions in mortality rates.We examined SES inequalities in colorectal cancer mortality in light of major advances in preventing or delaying death, advances predominantly due to improvements in screening and associated policy recommendations. Although colorectal cancer has been surgically treated for more than a century, an emphasis on the prevention of colorectal cancer through widespread screening has become routine only in the past 30 years. In July 1980, the American Cancer Society (ACS) first published recommendations for colorectal cancer screening.10 In 1997, the US Multi-Society Task Force (MSTF), assembled by the US Agency for Health Care Policy Research in conjunction with the American Gastroenterological Association, published its first guidelines for screening for colorectal cancer.11The MSTF guidelines recommended that everyone with risk factors such as age (≥ 50 years), family or personal history of colorectal cancer, history of inflammatory bowel disease, chronic ulcerative colitis, adenomatous polyposis, juvenile polyposis, and hereditary nonpolyposis colorectal cancer be screened. Furthermore, following a positive screen, physicians should conduct a diagnostic evaluation of the colon and rectum, use recommended treatments (including the removal of adenomatous polyps), and consider follow-up surveillance after treatment. In 1997, influenced by MSTF’s recommendations, ACS revised its 1980 guidelines to include recommendations stratified by level of risk of developing colorectal cancer.11 Since then, both ACS and MSTF have issued updates on a regular basis.12The 1997 ACS guidelines recommended that all individuals at an average level of risk begin colorectal cancer screening at the age of 50 years. Individuals at moderate risk, based on a personal or family diagnosis of gastrointestinal adenomatous polyps or colorectal cancer, were recommended to initiate screening at the time of onset, the age of 40 years, or 10 years before the youngest case in the family, whichever was earlier. High-risk individuals with hereditary predispositions to colorectal cancer or a personal diagnosis of inflammatory bowel disease were recommended to initiate screening at puberty, at the age of 21 years, or 8 to 15 years after the onset of inflammatory bowel disease, depending on their individual risk factors.11According to the fundamental cause hypothesis, developments in colorectal cancer screening, such as clearly stated, evidence-based guidelines and their widespread dissemination, will benefit people of high SES more than their low-SES counterparts, thereby creating new health disparities or exacerbating existing disparities over time. Specifically, we expected individuals living in high-SES locales to benefit from recent developments in colorectal cancer screening, beginning with the release of the first colorectal cancer screening recommendations by ACS. Furthermore, given that socioeconomic inequalities are reproduced and often accentuated over time, we expected the association between SES and colorectal cancer mortality to increase over time.     

The relevance of unrelated costs internal and external to the healthcare sector to the outcome of a cost-comparison analysis of secondary prevention: the case of general colorectal cancer screening in the German population

The potential of secondary prevention measures, such as cancer screening, to produce cost savings in the healthcare sector is a controversial issue in healthcare economics. Potential savings are calculated by comparing treatment costs with the cost of a prevention program. When survivors’ subsequent unrelated health care costs are included in the calculation, however, the overall cost of disease prevention rises. What have not been studied to date are the secondary effects of fatal disease prevention measures on social security systems. From the perspective of a policy maker responsible for a social security system budget, it is not only future healthcare costs that are relevant for budgeting, but also changes in the contributions to, and expenditures from, statutory pension insurance and health insurance systems. An examination of the effect of longer life expectancies on these insurance systems can be justified by the fact that European social security systems are regulated by the state, and there is no clear separation between the financing of individual insurance systems due to cross-subsidisation. This paper looks at how the results of cost-comparison analyses vary depending on the inclusion or exclusion of future healthcare and non-healthcare costs, using the example of colorectal cancer screening in the German general population. In contrast to previous studies, not only are future unrelated medical costs considered, but also the effects on the social security system. If a German colorectal cancer screening program were implemented, and unrelated future medical care were excluded from the cost-benefit analysis, savings of up to €548 million per year would be expected. The screening program would, at the same time, generate costs in the healthcare sector as well as in the social security system of €2,037 million per year. Because the amount of future contributions and expenditures in the social security system depends on the age and gender of the recipients of the screening program (i.e. survivors of a typically fatal condition), the impact of age and gender on the results of a cost-comparison analysis of colorectal cancer screening are presented and discussed. Our study shows that colorectal cancer screening generates individual cost savings in the social security system up to a life expectancy of 60 years. Beyond that age, the balance between a recipient’s social security contributions and insurance system expenditure is negative. The paper clarifies the relevance of healthcare costs not related to the prevented disease to the economic evaluation of prevention programs, particularly in the case of fatal diseases such as colorectal cancer. The results of the study imply that, from an economic perspective, the participation of at-risk individuals in disease prevention programs should be promoted.     

Social Network Effects of Nonlifesaving Early-Stage Breast Cancer Detection on Mammography Rates

Objectives. We estimated the effect of anecdotes of early-stage, screen-detected cancer for which screening was not lifesaving on the demand for mammography.Methods. We constructed an agent-based model of mammography decisions, in which 10 000 agents that represent women aged 40 to 100 years were linked together on a social network, which was parameterized with a survey of 716 women conducted through the RAND American Life Panel. Our model represents a population in equilibrium, with demographics reflecting the current US population based on the most recent available census data.Results. The aggregate effect of women learning about 1 category of cancers—those that would be detected but would not be lethal in the absence of screening—was a 13.8 percentage point increase in annual screening rates.Conclusions. Anecdotes of detection of early-stage cancers relayed through social networks may substantially increase demand for a screening test even when the detection through screening was nonlifesaving.Women often overestimate the mortality reduction from mammograms,1–3 and anecdotes of women with early-stage breast cancer being diagnosed through mammography can serve as particularly powerful motivators in encouraging other women to have screening mammograms.4–6 Such diagnoses, which are often shared through discussions between friends, family, coworkers, and other acquaintances, are also often viewed by patients as lifesaving.7 These discussions can be viewed as the transmission of information through a social network. Typically, social networks are defined as sets of individuals with links between pairs of individuals. In this article, we define 2 individuals as linked if they discuss their health history and outcomes (such as breast cancer diagnosis and treatment) with each other.Although women often view the detection of early-stage breast cancer through mammography as lifesaving, a recent study estimated that more than three quarters of women with screen-detected cancer have not actually had their lives saved by early detection.8 Rather, these women have cancers that (1) would never have been detected clinically if not detected through screening (thus, they were overdiagnosed), (2) eventually would have been detected clinically but would not be lethal, or (3) eventually would be lethal despite being detected by screening. Physicians and epidemiologists have long understood that high rates of early-stage diagnosis through screening do not necessarily indicate that the screening reduces mortality. Furthermore, when issuing cancer screening recommendations, professional organizations generally use mortality reduction as a primary measure of the screening’s efficacy.9–12Understanding how nonlifesaving early detection of breast cancer through screening drives patient demand for screening has several important implications. First, professional organizations currently disagree about when and how frequently women should be screened for breast cancer.9,10 Those who believe that some women are screened too early and too often may find demand for mammograms driven by such nonlifesaving diagnoses problematic. Our analysis estimated how much demand for mammograms may be driven by women’s incorrect assumptions about whether breast cancer screening was lifesaving for individuals in their social networks. More generally, the fact that patients often use frequency of early detection as a proxy for the screening efficacy7 means that patients with limited time and resources might prioritize a screening test that is relatively ineffective at reducing mortality over a test that more successfully reduces mortality if the former has higher early detection rates than the latter. We examined the potential patient-driven demand for screening that is motivated by nonlifesaving screen-detected cancers discussed in a social network.It is challenging to quantify this demand through observation or experiment because it is often not possible to determine at the individual level whether early detection through screening affected mortality. If a woman with early-stage, screen-detected breast cancer does not die of breast cancer, it is usually not possible to know with certainty if she would have died from breast cancer had she not been screened. If a woman with early-stage, screen-detected breast cancer ultimately dies of breast cancer, we know that screening was not lifesaving, but there may be many years between her initial diagnosis and death from breast cancer. Therefore, we used an agent-based simulation model to estimate how nonlifesaving early-stage breast cancer detection relayed through a social network might influence mammography rates. A major advantage of using a simulation model to study this problem is that, within the model, we can distinguish between agents (individual women) whose early detection of breast cancer through screening was lifesaving and those whose early detection was not lifesaving.In our analysis, we explored how population-level mammography rates might change if individuals were able to account for the fact that not all early-stage, screen-detected cancers are lifesaving. We used the results of a customized survey conducted through RAND’s American Life Panel to inform and parameterize our behavioral model. Many individuals assume that detection of early-stage breast cancer through mammography is lifesaving,7 and we assumed that if those diagnoses were known to be nonlifesaving, they would not serve as such powerful motivators in encouraging others to screen. Mammography is lifesaving only when a cancer that would have been lethal when detected clinically is not lethal when detected by mammography. We focused our analysis on categories of cancers whose detection by screening was not lifesaving. First, we simulated changing the incidence of cancers that would not have been detected in the absence of mammography (i.e., were overdiagnosed). Second, we simulated hypothetical interventions that allowed individuals in our model to know that mammography was nonlifesaving for (1) cancers that would be detected but would not have been lethal in the absence of mammography (never-lethal cancers) and (2) cancers that were ultimately lethal despite being screen detected (always-lethal cancers).     

A review of five major community-based cardiovascular disease prevention programs. Part I: Rationale, design, and theoretical framework

Major community-based cardiovascular disease prevention programs have been conducted in North Karelia, Finland; the state of Minnesota; Pawtucket, Rhode Island; and in three communities and more recently in five cities near Stanford, California. These primary prevention programs aim to reduce cardiovascular disease incidence by reducing risk factors in whole communities. These risk factors are smoking, high blood cholesterol, diet high in cholesterol and saturated fat, hypertension, sedentary lifestyle, and obesity. This strategy may be contrasted with secondary prevention programs directed at patients who already have symptomatic cardiovascular disease and "high risk" primary prevention programs directed at individuals found through screening to have one or more risk factors. The design of the five major programs is similar in that intervention communities are matched for purposes of evaluation with nearby comparison communities. Underlying these programs are theories of community health education, social learning, communication, social marketing, and community activation, as well as more traditional biomedical and public health disciplines. This is Part I of a two-part article.     

Direct measurement of low-density-lipoprotein cholesterol is more effective than total cholesterol for the purpose of lipoprotein screening

BACKGROUND: We have developed a new method for chemically measuring blood low-density-lipoprotein (LDL) cholesterol. In the present study, we simulated guidelines of the National Cholesterol Education Program (NCEP) using our LDL cholesterol measurements. METHODS: Blood samples were collected from 1,069 individuals (519 males, 550 females) who were referred to our laboratory at Niigata University Hospital for lipoprotein analysis. LDL cholesterol levels were determined according to our assay protocol, which has been published previously. Subjects were categorized by NCEP guidelines and identified "false positives" and "false negatives" on the basis of LDL cholesterol levels measured by our method. RESULTS: The sensitivity of the NCEP guidelines is 87.5% and the specificity is 87.1%, provided we assume that every individual has fewer than two risk factors for coronary heart disease. If we assume that every individual has two or more risk factors, the sensitivity and specificity of the guidelines are 99 and 56.8%, respectively. CONCLUSION: This study presents an opportunity to reevaluate guidelines for routine lipoprotein screening. The chance that individuals with higher LDL cholesterol and lower high-density-lipoprotein cholesterol levels in serum would be missed at initial classification should be zero. The chance that individuals with desirable lipid levels would undergo further lipoprotein analysis should be decreased. Since the new method can be implemented cost-effectively in routine lipoprotein screening, direct measurement of LDL cholesterol could replace total cholesterol.     

Participation in a worksite cholesterol education program in a university setting.

Three hundred ninety-six employees of a large northeastern university participated in a blood cholesterol screening and provided follow-up data about their participation in a videotape cholesterol education program. Ten percent of these employees watched the videotape program; these individuals were significantly more likely to be at high risk for cardiovascular disease than were persons who chose not to watch the videotape. Persons participating in the cholesterol education program significantly increased their nutrition knowledge and significantly decreased their fat intake compared with nonparticipants. The most important reason given for watching the videotape was "concern about my cholesterol level." Reasons given for not watching the videotape were that it was "not well advertised" or that it was shown "at an inconvenient time." Although all 98 employees at high risk for cardiovascular disease were referred to their physicians for diagnostic evaluation, one third of these employees reported not seeing their physicians. These findings indicate that worksite cholesterol screening and education programs can improve nutrition knowledge and dietary behavior; however, these programs should develop strategies to increase participation and should follow up physician referrals.     

‘We do the impossible’: women overcoming barriers to cervical cancer screening in rural Honduras – a positive deviance analysis

Cervical cancer is the leading cause of cancer death for women in Honduras, and sexual behaviour and low screening uptake are two major factors contributing to high rates of morbidity and mortality. A qualitative study was conducted to investigate barriers that prevent rural Honduran women from engaging in screening and ways that women overcome those barriers. This study examined examples of positive deviance, or individuals engaging in the uncommon but beneficial practise of screening. Amor por sí misma (self-love), and social support were identified as two constructs women employed to overcome barriers to screening. Participants defined self-love as the act of displaying care and concern for oneself and one's health and suggested that it compels women to participate in screening. Social support was defined as receiving tangible aid and advice from others that facilitated women's screening participation. Findings suggest that the concept of self-love could be used in future screening promotion efforts and that integrating social support would also be beneficial. Engaging men in sexual and reproductive health programming is suggested in order to ensure male partners offer social support for screening and to challenge the cultural, gender and sexual norms that place women at higher risk for cervical cancer.     

Obesity,systemic inflammation,and increased risk for cardiovascular disease and diabetes among adolescents: A need for screening tools to target interventions

Cardiovascular disease (CVD) and type 2 diabetes mellitus have their roots in childhood, particularly in obese children and adolescents, raising important opportunities for early lifestyle intervention in at-risk individuals. However, not all obese individuals are at the same risk for disease progression. Accurate screening of obese adolescents may identify those in greatest need for intensive intervention to prevent or delay future disease. One potential screening target is obesity-related inflammation, which contributes to insulin resistance, metabolic syndrome, and CVD. In adults, the inflammatory marker high-sensitivity C-reactive protein (hsCRP) has utility for risk stratification and treatment initiation in individuals of intermediate CVD risk. In adolescents, hsCRP shares many of the associations of hsCRP in adults regarding the degree of insulin resistance, metabolic syndrome, and carotid artery media thickness. However, long-term data linking increased hsCRP levels—and increased insulin or decreased adiponectin—in childhood to adult disease outcomes are lacking at this time. Future efforts continue to be needed to identify childhood clinical and laboratory characteristics that could be used as screening tests to predict adult disease progression. Such tests may have utility in motivating physicians and patients’ families toward lifestyle changes, ultimately improving prevention efforts.     

A theoretical and empirical analysis of context: neighbourhoods,smoking and youth

Numerous studies are currently addressing the issue of contextual effects on health and disease outcomes. The majority of these studies fall short of providing a theoretical basis with which to explain what context is and how it affects individual disease outcomes. We propose a theoretical model, entitled collective lifestyles, which brings together three concepts from practice theory: social structure, social practices and agency. We do so in an attempt to move away from both behavioural and structural-functionalist explanations of the differential distribution of disease outcomes among areas by including a contextualisation of health behaviours that considers their meaning. We test the framework using the empirical example of smoking and pre-adolescents in 32 communities across Québec, Canada. Social structure is operationalised as characteristics and resources; characteristics are the socio-economic aggregate characteristics of individuals culled from the 1996 Canadian Census, and resources are what regulates and transforms smoking practices. Information about social practices was collected in focus groups with pre-adolescents from four of the participating communities. Using zero-order and partial correlations we find that a portrait of communities emerges. Where there is a high proportion of more socio-economically advantaged people, resources tend to be more smoking discouraging, with the opposite being true for disadvantaged communities. Upon analysis of the focus group material, however, we find that the social practices in communities do not necessarily reflect the "objectified" measures of social structure. We suggest that a different conceptualisation of accessibility and lifestyle in contextual studies may enable us to improve our grasp on how differential rates of disease come about in local areas.     

Resistance through risk: Women and cervical cancer screening

This paper explores how individual women deal with, and react to, the very general information on cervical cancer risks they receive when invited to attend for cervical screening, and the general ‘at risk’ position that is suggested to them through the official discourse on screening and re-enforced by the uniform approach taken by the UK programme. By presenting data from a qualitative interview study it demonstrates how women respond to the presentation of risk in diverse and dynamic ways, and engage in a process of ‘self-positioning’ that individualises cervical cancer risk and makes it relevant to them as individuals. Within this process women draw on a range of risk themes that they regard as relevant to cervical cancer and implicated in its development. These are discussed in a range of ways, indicating that such risk themes do not exist in a vacuum but are situated within particular social and cultural contexts. I argue that, while the conceptualisation of risk as one of the strategies employed within neo-liberal forms of government to create particular kinds of individuals is useful, it is in danger of focusing too much attention on how individuals are controlled instead of how they respond to such attempts.     

How accurately could we screen for individual risk? Using summary data to examine discriminatory accuracy of a risk marker

OBJECTIVE: While much has been written on the methodology of screening for presence of preclinical disease, correspondingly less has been written on screening for future risk of disease. Given the increasing attention paid to the concept of individualized prevention within the discipline of public health, this other type of screening warrants attention. Our aim is to demonstrate one way in which the potential accuracy of risk screening can be assessed. METHOD: In this paper, we derive a simple computational formula for the concordance statistic, a measure of the ability to separate individuals into two groups (will get disease, will not get disease), based on the presence or absence of a dichotomous risk factor. This computational formula is based on summary data (prevalence, absolute risk) pertaining to the risk factor alone. We also present simple computational formulas for the true positive fraction (the sensitivity of the "high risk" label to actual disease development) and the false positive fraction (1-specificity of the "high risk" label.). CONCLUSION: The above quantities are rarely presented when scientists make statements about the potential usefulness of a risk factor or genetic marker in screening for future disease risk. With the simple formulas offered here, readers will be better able to evaluate the accuracy of such statements.     

In-vivo and post-mortem gallstones: support for validity of the "epidemiologic necropsy" screening technique.

This research was done to evaluate the "epidemiologic necropsy" procedure as a "screening" technique for disease that has been clinically unsuspected or inactive during life. The post-mortem occurrence rates of gallstones in necropsies at Yale-New Haven Hospital were compared and found reasonably similar to the analogous rates of gallstones detected in-vivo via ultrasonographic screening of large general populations. Because the authors could not find an appropriate in-vivo screening study done in the United States, they used data mainly from screening studies in Copenhagen, Denmark, and Rome and Sirmione, Italy. Two additional ultrasonographic screening studies have been done in Norway and in populations of Hispanic Americans. Previous disparities between post-mortem and in-vivo screening results probably arose because of failure to stratify for age and sex, to remove patients with cholecystectomy from the analysis, or to account for small-size stones that would be detected at necropsy but not with ultrasonography. The current results help confirm the value of the epidemiologic necropsy procedure in estimating the size of the substantial reservoir of undetected disease that does not appear in the customary tabulations of "vital statistics."     

A profile and approach to chronic disease in Abu Dhabi

As a country, the United Arab Emirates has developed very rapidly from a developing country with a largely nomadic population, to a modern and wealthy country with a Western lifestyle. This economic progress has brought undoubted social benefits and opportunities for UAE citizens, including a high and increasing life expectancy. However, rapid modernization and urbanization have contributed to a significant problem with chronic diseases, particularly obesity-related cardiovascular risk. In response the Health Authority of Abu Dhabi has significantly strengthened its data systems to better assess the baseline and measure the impact of targeted interventions. The unique population-level Weqaya Programme for UAE Nationals living in Abu Dhabi has recruited more than 94% of adults into a screening programme for the rapid identification of those at risk and the deployment of targeted interventions to control that risk. This article describes the burden of non-communicable disease in Abu Dhabi, and the efforts made by the Health Authority of Abu Dhabi to tackle this burden including the development of a whole population cardiovascular screening programme changes to health policy, particularly in terms of lifestyle and behaviour change, and empowerment of the community to enable individuals to make healthier choices. In addition, recommendations have been made for global responsibility for tackling chronic disease.     

Meeting the challenge of epidemic infectious disease outbreaks: an agenda for research

Challenges arising from epidemic infectious disease outbreaks can be more effectively met if traditional public health is enhanced by sociology. The focus is normally on biomedical aspects, the surveillance and sentinel systems for infectious diseases, and what needs to be done to bring outbreaks under control quickly. Social factors associated with infectious disease outbreaks are often neglected and the aftermath is ignored. These factors can affect outbreak severity, its rate and extent of spread, influencing the welfare of victims, their families, and their communities. We propose an agenda for research to meet the challenges of infectious disease outbreaks. What social factors led to the outbreak? What social factors affected its severity and rate and extent of spread? How did individuals, social groups, and the state react to it? What are the short- and long-term effects on individuals, social groups, and the larger society? What programs can be put in place to help victims, their families, and affected communities to cope with the consequences--impaired mental and physical health, economic losses, and disrupted communities? Although current research on infectious disease outbreaks pays attention to social factors related to causation, severity, rate and extent of spread, those dealing with the "social chaos" arising from outbreaks are usually neglected. Inclusion, by combining traditional public health with sociological analysis, will enrich public health theory and understanding of infectious disease outbreaks. Our approach will help develop better programs to combat outbreaks and equally important, to help survivors, their families, and their communities cope better with the aftermath.     

Screening of older patients for atrial fibrillation in general practice: Current evidence and its implications for future practice

Background: Individuals with atrial fibrillation (AF) face a fivefold increased risk of ischaemic stroke compared with those without the condition. Recent studies suggest that individuals with asymptomatic AF also face an increased risk of ischaemic stroke, but their condition is often not recognized and diagnosed until an ischaemic stroke event has occurred. Identification of individuals with undiagnosed AF at increased risk for stroke is critical in promoting optimal intervention with anticoagulants.

Objectives: In this narrative review, we consider the benefits and limitations of various proposed screening strategies, whether single or multiple time-points, in addition to devices for implementation in the primary care setting.

Outcomes: Opportunistic screening via pulse palpation with subsequent referral for 12-lead electrocardiogram testing has been shown to cost-effectively identify individuals with asymptomatic AF. Some handheld devices suitable for use in primary care settings are now available and may facilitate screening of large cohorts of individuals considered to be at increased risk of AF, such as those aged ≥65 years or those diagnosed with or undergoing monitoring for hypertension.

Conclusions: It was determined that improved detection and diagnosis of AF, combined with appropriate anticoagulation strategies, will be crucial for improving stroke prevention and reducing its associated social and economic costs.     

The usefulness of bronchoalveolar lavage in identifying past occupational exposure to asbestos: a light and electron microscopy study.

Fiberoptic bronchoscopy has permitted the development of lavage procedures for the collection of lung washes. In certain disease states this material may contain large numbers of phagocytic cells (macrophages and neutrophils). Since these phagocytes are the predominant "dust scavenger cells" in the lung, the assessment of their particulate burden as well as that of the overall lavage material has been suggested as a potentially important diagnostic tool. The studies to date have shown that the presence of ferruginous bodies is an indication of past occupational exposure. In the present study, a digestion procedure was carried out on bronchoalveolar lavage material collected from individuals who were occupationally exposed to asbestos and from samples obtained from the general population. The parameters used for distinguishing the source of these samples included both light microscopy assessment of the filters for the presence of ferruginous bodies and electron microscopic screening for the presence of uncoated fibers.     

New arrows in the quiver for targeting care management: high-risk versus high-opportunity case identification

"Care management" purposefully obscures the distinctions between disease and case management and stresses their common features: action in the present to prevent adverse future outcomes and costs. It includes identifying a high-need population by referrals, screening, or data analysis, assessing those likely to benefit from interventions, intervening, evaluating the intervention, and adjusting interventions when needed. High-risk individuals can be identified using at least 9 techniques, from referrals and questionnaires to retrospective claims analysis and predictive models. Other than referrals, software based on the risk-adjustment methodology that we have adapted can incorporate all these methodologies. Because the risk adjustment employs extensive case mix and severity adjustment, it provides care managers with 3 innovative ways to identify not only high-risk individuals but also high-opportunity cases.     

Social Patterning of Screening Uptake and the Impact of Facilitating Informed Choices: Psychological and Ethical Analyses

Screening for unsuspected disease has both possible benefits and harms for those who participate. Historically the benefits of participation have been emphasized to maximize uptake reflecting a public health approach to policy; currently policy is moving towards an informed choice approach involving giving information about both benefits and harms of participation. However, no research has been conducted to evaluate the impact on health of an informed choice policy. Using psychological models, the first aim of this study was to describe an explanatory framework for variation in screening uptake and to apply this framework to assess the impact of informed choices in screening. The second aim was to evaluate ethically that impact. Data from a general population survey (n = 300) of beliefs and attitudes towards participation in diabetes screening indicated that greater orientation to the present is associated with greater social deprivation and lower expectation of participation in screening. The results inform an explanatory framework of social patterning of screening in which greater orientation to the present focuses attention on the disadvantages of screening, which tend to be immediate, thereby reducing participation. This framework suggests that an informed choice policy, by increasing the salience of possible harms of screening, might reduce uptake of screening more in those who are more deprived and orientated to the present. This possibility gives rise to an apparent dilemma where an ethical decision must be made between greater choice and avoiding health inequality. Philosophical perspectives on choice and inequality are used to point to some of the complexities in assessing whether there really is such a dilemma and if so how it should be resolved. The paper concludes with a discussion of the ethics of paternalism.     

Cervical screening, compliance and moral obligation

Cervical screening has been subject to extensive scrutiny within the social sciences over the last two decades. Moreover, it has been described, in passing, as an example of 'surveillance medicine' through which new aspects of people's lives are brought under medical scrutiny. Cervical screening is an example of secondary prevention with which women, on the whole, are expected and encouraged to comply, in what are deemed to be their best interests. However, the social science literature on cervical screening tends to present compliance as a morally neutral and unproblematic response to information about disease prevention. In contrast, this paper seeks to illustrate how women draw on specific contexts and relationships through which participation in, or compliance with screening, is given meaning. Drawing on women's accounts of their experience of screening participation, the paper suggests that compliance with cervical screening cannot be viewed exclusively as a morally neutral, if desirable, outcome of disease prevention initiatives, but may also be embedded within a moral framework of self-responsibility and social obligation.