Statistics for weighing benefits and harms in a proposed genetic substudy of a randomized cancer prevention trial

Summary.  When evaluating potential interventions for cancer prevention, it is necessary to compare benefits and harms. With new study designs, new statistical approaches may be needed to facilitate this comparison. A case in point arose in a proposed genetic substudy of a randomized trial of tamoxifen versus placebo in asymptomatic women who were at high risk for breast cancer. Although the randomized trial showed that tamoxifen substantially reduced the risk of breast cancer, the harms from tamoxifen were serious and some were life threaten-ing. In hopes of finding a subset of women with inherited risk genes who derive greater bene-fits from tamoxifen, we proposed a nested case–control study to test some trial subjects for various genes and new statistical methods to extrapolate benefits and harms to the general population. An important design question is whether or not the study should target common low penetrance genes. Our calculations show that useful results are only likely with rare high penetrance genes.     

The ascendancy of primary care: permanent or temporary?

The conventional wisdom strongly suggests a health care provider food chain for the future: Primary care physicians (PCPs), principally family practitioners, on the top playing the lead role, distantly followed by specialists, with hospitals and other ancillary services even further down the line. Is this a reasonable expectation? Will PCPs dominate the new systems? Or will they be but one of many equally necessary components of these developing integrated health care delivery organizations? Looking at the various models now developing, it would seem that future integrated delivery systems will utilize both PCPs and specialists, but with strong augmentation from a diverse assortment of other health care professionals, including nonphysician providers, educators, and administrators. To separate the illusion of primary care dominance of the coming health care system from the likely reality, we should first determine what is driving the apparent present demand for primary care physicians. Next, we will examine the possible and probable reactions to that demand from an economic standpoint and from the points of view of both health care professionals and the public. Finally, we must try to picture how health care provider organizations of the future are likely to look and how they will integrate their health care professionals.     

Using relative utility curves to evaluate risk prediction

Summary.  Because many medical decisions are based on risk prediction models that are constructed from medical history and results of tests, the evaluation of these prediction models is important. This paper makes five contributions to this evaluation: the relative utility curve which gauges the potential for better prediction in terms of utilities, without the need for a reference level for one utility, while providing a sensitivity analysis for misspecification of utilities, the relevant region, which is the set of values of prediction performance that are consistent with the recommended treatment status in the absence of prediction, the test threshold, which is the minimum number of tests that would be traded for a true positive prediction in order for the expected utility to be non-negative, the evaluation of two-stage predictions that reduce test costs and connections between various measures of performance of prediction. An application involving the risk of cardiovascular disease is discussed.     

Mother and Grandmother Parenting in Low‐Income Three‐Generation Rural Households

This study draws data from the Family Life Project to examine parenting behaviors observed for 105 mothers and grandmothers raising an infant in rural low‐income multigenerational households. Multilevel models are used to examine the relationships between maternal age and psychological distress and parenting of the infant by both generations. The findings indicate that young maternal age is a risk factor for less sensitive parenting in the presence of other risks, including psychological distress. Further, young maternal age is associated with negative parenting behaviors by grandmothers only. Grandmothers and mothers displayed similar levels of negative intrusive parenting, but different factors were linked to the observed parenting of each generation. These findings contribute to understanding the benefits and risks of three‐generation households.     

Dual-earner couples and the decision to work less: A conceptual model

This paper examines the factors that affect the decision made by dual-earner couples concerning the possibility of one (or both) partners working a reduced-hours schedule. We rely on a comprehensive review of the literature on part-time work among dual-earner couples and on the factors that affect the decisions couples make about their work hours as well as preliminary findings from our ongoing study to consider two key questions: (1) What factors do dual-earner couples take into account when they consider whether one or both might work a reduced-hours schedule? (2) If the couple decides that one partner will work a reduced-hours schedule, how do they decide which partner reduces the hours of employment? Most previous research has focused on the centrality of gender in the decisions that couples make concerning the hours that they work. However, our review of the literature and the preliminary findings of our current research suggest that there are other factors that affect (directly or indirectly) the couples' decisions related to part-time options. Based on this review we present a new decision-making model for two-earner couples that will have implications for future research and policy initiatives. This paper is particularly timely for several reasons: the number of dual-earner couples continues to increase; there is some indication that more employees would choose to reduce their work hours if that were a viable option; and recently, managers and professional workers have become more vocal about their interest in part-time career options.     

Preface: Women and Work: Where Are We, Where Did We Come From, and Where Are We Going?

The obstacles faced by today's women in the workplace bear out the truth in the old adage that history repeats itself. The maternal wall, the ideal worker, and the ideal homemaker beliefs are current iterations of the century-old tendency to mark women as suited for the home and men as suited for the workplace ( Albee & Perry, 1998 ; Coltrane, 1996 ; Mintz, 2000 ). The belief that the sexes are vastly different—with different needs, values, and abilities—has been a hallmark throughout the history of both women and men in both the workplace and the home ( Ferree, 1990 ; Williams, 2000 ). Generally speaking, these beliefs have been detrimental to all concerned ( Barnett & Rivers, 2004 ).     

When Precaution Creates Misunderstandings: The Unintended Effects of Precautionary Information on Perceived Risks,the EMF Case

In the past decade, growing public concern about novel technologies with uncertain potential long‐term impacts on the environment and human health has moved risk policies toward a more precautionary approach. Focusing on mobile telephony, the effects of precautionary information on risk perception were analyzed. A pooled multinational experimental study based on a 5 × 2 × 2 factorial design was conducted in nine countries. The first factor refers to whether or not information on different types of precautionary measures was present, the second factor to the framing of the precautionary information, and the third factor to the order in which cell phones and base stations were rated by the study participants. The data analysis on the country level indicates different effects. The main hypothesis that informing about precautionary measures results in increased risk perceptions found only partial support in the data. The effects are weaker, both in terms of the effect size and the frequency of significant effects, across the various precautionary information formats used in the experiment. Nevertheless, our findings do not support the assumption that informing people about implemented precautionary measures will decrease public concerns.     

Child sexual abuse in Leeds before and after Cleveland

We report a retrospective cohort study in which clinical and outcome features of 237 cases of child sexual abuse diagnosed by Leeds paediatricians after Cleveland in 1989 were compared with previously published characteristics of 337 children diagnosed by the same paediatricians before Cleveland in 1985 and 1986. Clinical and diagnostic features also were analysed in two subgroups of the 1989 cohort, those for whom there was no case conference and those in whom further abuse was detected at follow-up examination. The number of cases diagnosed annually remained high, and source of referrals and age and sex distribution were similar. Most suspected perpetrators were from within the home in both cohorts. Some clinical features of the 1989 cohort suggested more physically severe abuse. In 1989 fewer children were registered as sexually abused, or were taken into care, and fewer suspected perpetrators were convicted. From the 1989 cohort those children for whom there was no case conference tended to be older, to disclose and were abused less severely by someone outside their home as compared to those for whom a case conference was held. The children in whom further abuse was detected tended to be younger, to not disclose. to be more severely abused by a perpetrator within the home and to be taken into care as compared to those in whom further abuse was not detected. One or more case conferences were held for nearly all of the children in whom further abuse was detected. For most of the 1989 children no evidence was found indicating receipt of mental health services from other than the key social worker. Implications of these findings are discussed in terms of professional and public knowledge and attitudes regarding children's and parental rights and family preservation.