A stepped randomized trial to promote colorectal cancer screening in a nationwide sample of U.S. Veterans

BACKGROUND

Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality.

OBJECTIVES

To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1.

METHODS

Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step.

RESULTS

After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%).

CONCLUSIONS

In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.

Attitudes of Chinese health sciences postgraduate students' to the use of information and communication technology in global health research

BACKGROUND

Information and communications technology (ICT) has been suggested as an important tool for improving global health education and building research capacity in developing countries. However, the existing curricula do not have adequate emphasis on global health research and training. This study was carried out to examine health sciences postgraduates' attitudes and practices regarding curriculum for ICT use in global health research and training in China.

METHODS

A cross-sectional study was conducted among health sciences postgraduates from six universities in southern China, during December 2016 to March 2017. A self-administered online questionnaire was used to collect data through an online survey platform. Data were analyzed using SPSS for Windows 13.0.

RESULTS

A total of 1065 participants successfully completed the questionnaires. More than 90% of the students have not had any training about ICT, three quarters have not taken an online course, and 31% of the students do not use ICT in their current research. More than 65% thought that, in an ICT research training curriculum, it was important to learn: ICT utilization related knowledge, ICT research methods/resources, knowledge of databases, ways of data use and acquisition, and informatics search methods (ICT users compared to non-users were more likely to agree to these learning components (all p <  0.05)). Many of the respondents used or planned to use mobile phones (80%), Internet (59%), use computer and WeChat (> 40%), and QQ (a popular chat tool in China) (30%) as ICT tools in research activities. ICT users compared to non-users were more likely to consider using ICT and/or biomedical informatics methods in decision-support or support for information seeking, healthcare delivering, academic research, data gathering, and facilitating collaboration (all p <  0.05).

CONCLUSIONS

The findings of this study showed that ICT utilization was very important to health sciences postgraduates for their research activities in China, but they lacked ICT-related training. The results suggested the need for specialized curriculum related to ICT use in global health research for health sciences postgraduates in China.

A RCT to evaluate a totally automated, culturally-adapted telephone counselor for increasing physical activity among physically inactive individuals in China

BACKGROUND

The prevalence of diabetes in China has rapidly increased in recent years. Family history and physical inactivity are known risk factors for developing diabetes. As automated telephone-based communication is recognized as a cost-effective health promoting device, the present study aims at evaluating the efficacy of an automated telephone counselor (TLC-PA-China) for promoting physical activity to the WHO-recommended level among physically inactive family members of diabetes patients.

METHODS

This study employed a parallel, two-group, non-blinded, randomized controlled trial design with equal allocation to the intervention group (TLC-PA-China), and a control group. Voluntary participants with at least one first-degree relative diagnosed with diabetes mellitus were recruited through eight Community Health Centers in Shenzhen, China. The intervention group was requested to use the system once per week during a six-month period. The control group received an information pamphlet about the benefits of regular physical activity.

RESULTS

Two hundred ten eligible participants were randomized to TLC-PA-China (n = 109) or Control (n = 101) groups. Using intention-to-treat analysis, the TLC-PA-China group was significantly more likely to meet the WHO physical activity recommendation than the control (GEE: OR = 6.37, p < 0.001). The number of physically inactive people to intervene upon for one to become active was 2.84 at 3 months and 3.31 at 6 months.

CONCLUSIONS

TLC-PA-China increased physical activity levels among physically inactive adults in China who were at high risk of developing diabetes. This study lays the groundwork for application of behavioral informatics intervention in China.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-PRC-13003361 . Registered 15 May 2013 (Retrospectively registered).

Building capacity for information and communication technology use in global health research and training in China: a qualitative study among Chinese health sciences faculty members

Background

The demand to use information and communications technology (ICT) in education and research has grown fast among researchers and educators working in global health. However, access to ICT resources and the capacity to use them in global health research remains limited among developing country faculty members. In order to address the global health needs and to design an ICT-related training course, we herein explored the Chinese health science faculty members’ perceptions and learning needs for ICT use.

Methods

Nine focus groups discussions (FGDs) were conducted during December 2015 to March 2016, involving 63 faculty members working in areas of health sciences from six universities in China. All FGDs were audio recorded and analysed thematically.

Results

The findings suggest that the understandings of ICT were not clear among many researchers; some thought that the concept of ICT was too wide and ambiguous. Most participants were able to cite examples of ICT application in their research and teaching activities. Positive attitudes and high needs of ICT use and training were common among most participants. Recommendations for ICT training included customised training programmes focusing on a specific specialty, maintaining a balance between theories and practical applications, more emphasis on the application of ICT, and skills in finding the required information from the bulk information available in the internet. Suggestions regarding the format and offering of training included short training programmes, flexible timing, lectures with practicum opportunities, and free of charge or with very minimal cost to the participants. Two participants suggested the linking of ICT-related training courses with faculty members’ year-end assessment and promotion.

Conclusions

This study among health sciences faculty members in China demonstrated a high level of need and interest in learning about ICT use in research and training. The results have important implications for the design and implementation of ICT-related educational programmes in China and other developing countries.

Developing a Curriculum for Information and Communications Technology Use in Global Health Research and Training: A Qualitative Study Among Chinese Health Sciences Graduate Students

BACKGROUND

Rapid development of information and communications technology (ICT) during the last decade has transformed biomedical and population-based research and has become an essential part of many types of research and educational programs. However, access to these ICT resources and the capacity to use them in global health research are often lacking in low- and middle-income country (LMIC) institutions.

OBJECTIVE

The aim of our study was to assess the practical issues (ie, perceptions and learning needs) of ICT use among health sciences graduate students at 6 major medical universities of southern China.

METHODS

Ten focus group discussions (FGDs) were conducted from December 2015 to March 2016, involving 74 health sciences graduate students studying at 6 major medical universities in southern China. The sampling method was opportunistic, accounting for the graduate program enrolled and the academic year. All FGDs were audio recorded and thematic content analysis was performed.

RESULTS

Researchers had different views and arguments about the use of ICT which are summarized under six themes: (1) ICT use in routine research, (2) ICT-related training experiences, (3) understanding about the pros and cons of Web-based training, (4) attitudes toward the design of ICT training curriculum, (5) potential challenges to promoting ICT courses, and (6) related marketing strategies for ICT training curriculum. Many graduate students used ICT on a daily basis in their research to stay up-to-date on current development in their area of research or study or practice. The participants were very willing to participate in ICT courses that were relevant to their academic majors and would count credits. Suggestion for an ICT curriculum included (1) both organized training course or short lecture series, depending on the background and specialty of the students, (2) a mixture of lecture and Web-based activities, and (3) inclusion of topics that are career focused.

CONCLUSIONS

The findings of this study suggest that a need exists for a specialized curriculum related to ICT use in health research for health sciences graduate students in China. The results have important implications for the design and implementation of ICT-related educational program in China or other developing countries.

Interactive voice response version of the late-life function and disability instrument

OBJECTIVES

To develop an interactive voice response (IVR) version of the Late-Life Function and Disability Instrument Computer Adaptive Test (LLFDI-CAT) and to evaluate its reliability and acceptability in older adults.

DESIGN

The IVR system was embedded within the LLFDI-CAT program. To test the test-retest reliability and concordance of the IVR version of LLFDI-CAT with the telephone interviewer form (TIF), participants received the two versions of the LLFDI at baseline and at 1-week follow-up.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults aged 65 and older (N = 50).

MEASUREMENTS

The LLFDI is a self-reported outcome measure developed to assess function and disability in older adults.

RESULTS

The IVR version of the LLFDI-CAT showed acceptable overall test-retest reliability (intraclass correlation coefficient (ICC) = 0.79-0.80) and concordance (ICC = 0.74-0.97) with the TIF. Although most participants preferred the TIF, the majority did not find the IVR version more difficult to use.

CONCLUSION

The IVR version of the LLFDI-CAT achieved reliability levels that were comparable with those of the TIF version. Future work is needed to improve the IVR design to better fit older adults' needs and preferences.

Validation of 5 stage-of-change measures for parental support of healthy eating and activity

OBJECTIVE

To assess the validity of 5 parental stage-of-change (SOC) measures: (1) providing 5 servings/d of fruits and vegetables (FV), (2) limiting television (TV) to 2 h/d, (3) helping children achieve 1 h/d physical activity (PA), (4) limiting sugary drinks (SD) to 1 serving/wk, and (5) limiting fruit juice (FJ) to 4-6 oz/d.

DESIGN

Cross-sectional instrument development study. Construct validity was evaluated by examining whether parental self-efficacy, parental readiness ladder (ladder), and child's behavioral levels (eg, FV consumption) exhibited a theoretically consistent pattern across the SOC.

SETTING/PARTICIPANTS

Convenience sample (n = 283) of parents of children aged 4-10 years.

MEASURES

Survey assessed SOC, ladder, and child's behavioral level score for each topic (FV, TV, PA, SD, and FJ), and parental self-efficacy for measure except TV.

ANALYSIS

Analysis of variance with Tukey-Kramer post hoc tests examined whether variables differed by SOC.

RESULTS

Percentages of parents in the pre-action SOC were 34% (PA), 39% (FV), 42% (SD), 45% (TV), and 63% (FJ). Parental self-efficacy, ladder, and child's behavioral level differed significantly by SOC for each topic area (P < .001). Maintenance SOC was significantly higher than pre-action SOC.

CONCLUSIONS AND IMPLICATIONS

Measured variables exhibited a theoretically consistent pattern across SOC, suggesting construct validity and potential usefulness for obesity prevention efforts.

Comparison of two theory-based, fully automated telephone interventions designed to maintain dietary change in healthy adults: study protocol of a three-arm randomized controlled trial

Background

Health behavior change interventions have focused on obtaining short-term intervention effects; few studies have evaluated mid-term and long-term outcomes, and even fewer have evaluated interventions that are designed to maintain and enhance initial intervention effects. Moreover, behavior theory has not been developed for maintenance or applied to maintenance intervention design to the degree that it has for behavior change initiation.

Objective

The objective of this paper is to describe a study that compared two theory-based interventions (social cognitive theory [SCT] vs goal systems theory [GST]) designed to maintain previously achieved improvements in fruit and vegetable (F&V) consumption.

Methods

The interventions used tailored, interactive conversations delivered by a fully automated telephony system (Telephone-Linked Care [TLC]) over a 6-month period. TLC maintenance intervention based on SCT used a skills-based approach to build self-efficacy. It assessed confidence in and barriers to eating F&V, provided feedback on how to overcome barriers, plan ahead, and set goals. The TLC maintenance intervention based on GST used a cognitive-based approach. Conversations trained participants in goal management to help them integrate their newly acquired dietary behavior into their hierarchical system of goals. Content included goal facilitation, conflict, shielding, and redundancy, and reflection on personal goals and priorities. To evaluate and compare the two approaches, a sample of adults whose F&V consumption was below public health goal levels were recruited from a large urban area to participate in a fully automated telephony intervention (TLC-EAT) for 3-6 months. Participants who increase their daily intake of F&V by ≥1 serving/day will be eligible for the three-arm randomized controlled trial. A sample of 405 participants will be randomized to one of three arms: (1) an assessment-only control, (2) TLC-SCT, and (3) TLC-GST. The maintenance interventions are 6 months. All 405 participants who qualify for the trial will complete surveys administered by blinded interviewers at baseline (randomization), 6, 12, 18, and 24 months.

Results

Data analysis is not yet complete, but we hypothesize that (1) TLC-GST > TLC-SCT > control at all follow-up time points for F&V consumption, and (2) intervention effects will be mediated by the theoretical constructs (eg, self-efficacy, goal pursuit, conflict, shielding, and facilitation).

Conclusions

This study used a novel study design to initiate and then promote the maintenance of dietary behavior change through the use of an evidence-based fully automated telephony intervention. After the first 6 months (the acquisition phase), we will examine whether two telephony interventions built using different underlying behavioral theories were more successful than an assessment-only control group in helping participants maintain their newly acquired health behavior change.

Trial Registration

Clinicaltrials.gov NCT00148525; http://clinicaltrials.gov/ct2/show/NCT00148525 (Archived by Webcite at http://www.webcitation.org/6TiRriJOs).

Assessing parental self-efficacy for obesity prevention related behaviors

Background

Reliable, valid and theoretically consistent measures that assess a parent’s self-efficacy for helping a child with obesity prevention behaviors are lacking.

Objectives

To develop measures of parental self-efficacy for four behaviors: 1) helping their child get at least 60 minutes of moderate intensity physical activity every day, 2) helping one’s child consume five servings of fruits and vegetables each day, 3) limiting sugary drinks to once a week, and 4) limiting consumption of fruit juice to 6 ounces every day.

Methods

Sequential methods of scale development were used. An item pool was generated based on theory and qualitative interviews, and reviewed by content experts. Scales were administered to parents or legal guardians of children 4–10 years old. The item pool was reduced using principal component analysis. Confirmatory factor analysis tested the resulting models in a separate sample.

Subjects

304 parents, majority were women (88%), low-income (61%) and single parents (61%). Ethnic distribution was 40% Black and 37% white.

Results

All scales had excellent fit indices: Comparative fit index > .98 and chi-squares (Pediatrics 120 Suppl 4:S229-253, 2007) = .85 – 7.82. Alphas and one-week test-retest ICC’s were ≥ .80. Significant correlations between self-efficacy scale scores and their corresponding behaviors ranged from .13-.29 (all p < .03).

Conclusions

We developed four, four-item self-efficacy scales with excellent psychometric properties and construct validity using diverse samples of parents.

Trial registration

Clinical trial registration: NCT01768533.

A cost-effectiveness analysis of a telephone-linked care intervention for individuals with Type 2 diabetes

AIM

To assess the cost-effectiveness of an automated telephone-linked care intervention, Australian TLC Diabetes, delivered over 6 months to patients with established Type 2 diabetes mellitus and high glycated haemoglobin level, compared to usual care.

METHODS

A Markov model was designed to synthesize data from a randomized controlled trial of TLC Diabetes (n=120) and other published evidence. The 5-year model consisted of three health states related to glycaemic control: 'sub-optimal' HbA1c ≥58mmol/mol (7.5%); 'average' ≥48-57mmol/mol (6.5-7.4%) and 'optimal' <48mmol/mol (6.5%) and a fourth state 'all-cause death'. Key outcomes of the model include discounted health system costs and quality-adjusted life years (QALYS) using SF-6D utility weights. Univariate and probabilistic sensitivity analyses were undertaken.

RESULTS

Annual medication costs for the intervention group were lower than usual care [

INTERVENTION

£1076 (95%CI: £947, £1206) versus usual care £1271 (95%CI: £1115, £1428) p=0.052]. The estimated mean cost for intervention group participants over five years, including the intervention cost, was £17,152 versus £17,835 for the usual care group. The corresponding mean QALYs were 3.381 (SD 0.40) for the intervention group and 3.377 (SD 0.41) for the usual care group. Results were sensitive to the model duration, utility values and medication costs.

CONCLUSION

The Australian TLC Diabetes intervention was a low-cost investment for individuals with established diabetes and may result in medication cost-savings to the health system. Although QALYs were similar between groups, other benefits arising from the intervention should also be considered when determining the overall value of this strategy.

The interaction between dietary and life goals: using goal systems theory to explore healthy diet and life goals

Objective: To examine the types of life and dietary goals individuals report and how these goal domains interact as framed by goal systems theory. Methods: This work is a cross-sectional survey study. Measures included the incidence of common life and dietary goals and how these goals interact with and facilitate each other. Results: The results of a quantitative survey (n = 46 participants), which was informed by two focus groups (n = 17 participants), showed that participants are trying to achieve several different life (e.g. achieving financial success) and dietary goals (e.g. eating more fruits and vegetables, drinking more water, and losing weight) and that these two types of goals interact to both facilitate and conflict with each other. Having a life goal of exercising was significantly associated with healthy eating goals when compared with other life goals (p's < .05), suggesting these goals may be linked and help to facilitate one another. Being in the maintenance phase with the goal of healthy eating was associated with participants feeling like they were more successful in their other non-diet-related health goals (p < .05), suggesting maintenance of goals can facilitate success in achieving other goals. Conclusions: Life goals can have an impact on a person's ability to achieve and maintain dietary and other health goals. Health educators may help to facilitate long-term behavior change by examining a person's life goals as well as dietary goals.

Determining who responds better to a computer- vs. human-delivered physical activity intervention: results from the community health advice by telephone (CHAT) trial

BACKGROUND

Little research has explored who responds better to an automated vs. human advisor for health behaviors in general, and for physical activity (PA) promotion in particular. The purpose of this study was to explore baseline factors (i.e., demographics, motivation, interpersonal style, and external resources) that moderate intervention efficacy delivered by either a human or automated advisor.

METHODS

Data were from the CHAT Trial, a 12-month randomized controlled trial to increase PA among underactive older adults (full trial N = 218) via a human advisor or automated interactive voice response advisor. Trial results indicated significant increases in PA in both interventions by 12 months that were maintained at 18-months. Regression was used to explore moderation of the two interventions.

RESULTS

Results indicated amotivation (i.e., lack of intent in PA) moderated 12-month PA (d = 0.55, p < 0.01) and private self-consciousness (i.e., tendency to attune to one's own inner thoughts and emotions) moderated 18-month PA (d = 0.34, p < 0.05) but a variety of other factors (e.g., demographics) did not (p > 0.12).

CONCLUSIONS

Results provide preliminary evidence for generating hypotheses about pathways for supporting later clinical decision-making with regard to the use of either human- vs. computer-delivered interventions for PA promotion.

Exercise advice by humans versus computers: maintenance effects at 18 months

OBJECTIVE

An automated telehealth counseling system, aimed at inactive midlife and older adults, was shown previously to achieve 12-month physical activity levels similar to those attained by human advisors. This investigation evaluated the sustained 18-month impacts of the automated advisor compared with human advisors.

METHODS

Following the end of the 12-month randomized, controlled trial, participants who had been randomized to either the human advisor (n = 73) or automated advisor (n = 75) arms were followed for an additional 6 months. During that period, human or automated advisor-initiated telephone contacts ceased and participants were encouraged to initiate contact with their advisor as deemed relevant. The primary outcome was moderate-to-vigorous physical activity (MVPA), measured using the Stanford Physical Activity Recall and validated during the major trial via accelerometry.

RESULTS

The two arms did not differ significantly in 18-month MVPA or the percentage of participants meeting national physical activity guidelines (ps >.50). No significant within-arm MVPA differences emerged between 12 and 18 months. Evaluation of the trajectory of physical activity change across the 18-month study period indicated that, for both arms, the greatest physical activity increases occurred during the first 6 months of intervention, followed by a relatively steady amount of physical activity across the remaining months.

CONCLUSIONS

The results provide evidence that an automated telehealth advice system can maintain physical activity increases at a level similar to that achieved by human advisors through 18 months. Given the accelerated use of mobile phones in developing countries, as well as industrialized nations, automated telehealth systems merit further evaluation.

Workplace Telecommunications Technology to Identify Mental Health Disorders and Facilitate Self-Help or Professional Referrals

Purpose.

Test the feasibility and impact of an automated workplace mental health assessment and intervention.

Design.

Efficacy was evaluated in a randomized control trial comparing employees who received screening and intervention with those who received only screening.

Setting.

Workplace.

Subjects.

463 volunteers from Boston Medical Center, Boston University, and EMC and other employed adults, among whom 164 were randomized to the intervention (N = 87) and control (N = 77) groups.

Intervention.

The system administers a panel of telephonic assessment instruments followed by tailored information, education, and referrals.

Measures.

The Work Limitation Questionnaire, the Medical Outcomes Questionnaire Short Form-12, the Patient Health Questionnaire-9, question 10 from the Patient Health Questionnaire to measure functional impairment, and the Perceived Stress Scale-4 and questions written by study psychiatrists to measure emotional distress and social support respectively. The WHO-Five Well-being Index was administered to measure overall well-being.

Analysis.

Independent sample t-tests and χ2 tests as well as mean change were used to compare the data.

Results.

No significant differences on 16 of the 20 comparisons at 3- and 6-month time points. The intervention group showed a significant improvement in depression (p ≤ .05) at 3 months and on two Work Limitation Questionnaire subscales, the Mental-Interpersonal Scale (p ≤ .05) and the Time and Scheduling Scale (p ≤ .05), at 3 and 6 months respectively with a suggestive improvement in mental health at 6 months (p ≤ .10).

Conclusions.

This is a potentially fruitful area for research with important implications for workplace behavioral interventions. (Am J Health Promot 2011;25[3]:207–216.)

Randomised controlled trial of an automated, interactive telephone intervention to improve type 2 diabetes self-management (Telephone-Linked Care Diabetes Project): study protocol

Background

An estimated 285 million people worldwide have diabetes and its prevalence is predicted to increase to 439 million by 2030. For the year 2010, it is estimated that 3.96 million excess deaths in the age group 20-79 years are attributable to diabetes around the world. Self-management is recognised as an integral part of diabetes care. This paper describes the protocol of a randomised controlled trial of an automated interactive telephone system aiming to improve the uptake and maintenance of essential diabetes self-management behaviours.

Methods/Design

A total of 340 individuals with type 2 diabetes will be randomised, either to the routine care arm, or to the intervention arm in which participants receive the Telephone-Linked Care (TLC) Diabetes program in addition to their routine care. The intervention requires the participants to telephone the TLC Diabetes phone system weekly for 6 months. They receive the study handbook and a glucose meter linked to a data uploading device. The TLC system consists of a computer with software designed to provide monitoring, tailored feedback and education on key aspects of diabetes self-management, based on answers voiced or entered during the current or previous conversations. Data collection is conducted at baseline (Time 1), 6-month follow-up (Time 2), and 12-month follow-up (Time 3). The primary outcomes are glycaemic control (HbA1c) and quality of life (Short Form-36 Health Survey version 2). Secondary outcomes include anthropometric measures, blood pressure, blood lipid profile, psychosocial measures as well as measures of diet, physical activity, blood glucose monitoring, foot care and medication taking. Information on utilisation of healthcare services including hospital admissions, medication use and costs is collected. An economic evaluation is also planned.

Discussion

Outcomes will provide evidence concerning the efficacy of a telephone-linked care intervention for self-management of diabetes. Furthermore, the study will provide insight into the potential for more widespread uptake of automated telehealth interventions, globally.

Trial Registration Number

ACTRN12607000594426

Usability testing of an electronic health record form to support physician-based counseling and self-management of overweight children

Overweight management is challenging due to time constraints and minimal training in nutrition, physical activity and brief counseling. The Telephone-linked Care for Healthy Eating and Activity Today system may help physicians counsel by providing home data and effective behavioral theory-based counseling. Incorporating Goal Directed Task Analysis, Display Task Description and usability testing helped align the interface with the user's needs and workflow. We recommend routine use of these approaches to improve interface quality and usability.

TLC-HEAT: Telephony-based self-care for overweight children

Efforts to use information technology (IT) to link pediatric primary care patients in the home with their clinicians have been rudimentary to date. We have developed a model information system that uses a ubiquitous user-interface, the telephone, and the electronic health record (EHR) to support health behavior change and weight loss for overweight urban children and their parents. In this paper, we present the technical architecture and underlying psychological theories used to build the system.

How to write health dialog for a talking computer

Automated dialogue systems delivered over the telephone offer a promising approach to delivering health-related interventions to populations of individuals at low-cost. Over the past two decades, an automated telephone system called Telephone-Linked Care or TLC has been successfully designed and evaluated by the authors and their colleagues. This work has resulted in over twenty systems for various health-related conditions and lifestyle behaviors. This paper describes our approach to developing and writing dialogue for these automated telephone systems, including determining the program objectives, defining the target population, and selecting a theory of behavior change to guide the intervention. Both macro and micro issues are considered in constructing dialogue systems that are engaging for the target population, easy to use, and effective at promoting positive health behaviors and outcomes.

Automated telephone screening for problem drinking

OBJECTIVE

This study assessed test-retest reliability and criterion validity for an automated version of the Alcohol Use Disorders Identification Test (AUDIT), a screening tool for alcohol-related problems. Participants' willingness to use such a system to learn about and change their drinking behavior was also assessed.

METHOD

Participants were 202 callers recruited through newspaper ads and flyers asking for volunteers concerned about their drinking and willing to help test a new method of screening and referral for alcohol problems. Participants were divided into two groups. The first group of subjects recruited received the Telephone-Linked Communications (TLC)-AUDIT twice, administered a week apart. The second group received the TLC-AUDIT once and a human-administered AUDIT once, also a week apart.

RESULTS

Test-retest reliability was assessed in 102 participants; the intraclass correlation of AUDIT scores between both administrations was .87; kappa for nonproblem versus problem drinking (AUDIT score of 8 or above) was .89. The validity study compared the TLC-AUDIT scores of the next 100 participants to AUDIT questions administered by a human interviewer. The intraclass correlation was .94; kappa was .75. Seventy-five percent of all participants who screened positive for problem drinking agreed they would "talk to a computer again to learn more about your drinking pattern and how to deal with it".

CONCLUSIONS

Automated telephone technology can be used to administer the AUDIT instrument with high levels of reliability and validity. This technology could be used to deliver behavioral change interventions.

Developing a quality measure for clinical inertia in diabetes care

OBJECTIVE

To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control.

DATA SOURCES

Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999.

STUDY DESIGN

Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined.

PRINCIPAL FINDINGS

Increases in antiglycemic medications occurred at only 9.8 percent of visits despite 39 percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p < .001).

CONCLUSIONS

Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.

Evaluating nicotine replacement therapy and stage-based therapies in a population-based effectiveness trial

Pharmacological interventions for smoking cessation are typically evaluated using volunteer samples (efficacy trials) but should also be evaluated in population-based trials (effectiveness trials). Nicotine replacement therapy (NRT) alone and in combination with behavioral interventions was evaluated on a population of smokers from a New England Veterans Affairs Medical Center. Telephone interviews were completed with 3,239 smokers, and 2,054 agreed to participate (64%). Participants were randomly assigned to one of four conditions: stage-matched manuals (MAN); NRT plus manuals (NRT + MAN); expert system plus NRT and manuals (EXP + NRT + MAN); and automated counseling plus NRT, manuals, and expert system (TEL + EXP + NRT + MAN). Assessments were completed at baseline, 10, 20, and 30 months. The point prevalence cessation rates at final follow-up (30 months) were MAN, 20.3%; NRT + MAN, 19.3%; EXP + NRT + MAN, 17.6%; and TEL + EXP + NRT + MAN, 19.9%. Stage-matched manuals provided cessation rates comparable with previous studies. The addition of NRT, expert system interventions, and automated telephone counseling failed to produce a further increase in intervention effectiveness.

Comparing participants and nonparticipants recruited for an effectiveness study of nicotine replacement therapy

BACKGROUND

Interventions for smoking cessation have been typically evaluated on reactively recruited samples in clinical trials (efficacy trials). However, to have an impact on smoking rates in a general population, the intervention should also be evaluated with proactively recruited representative samples (effectiveness trials).

PURPOSE

The characteristics of participants and two groups of nonparticipants recruited for a population-based nicotine replacement therapy study were compared.

METHODS

All members of a large New England Veterans' Administration Medical Center were contacted, and interviews were completed with 3,239 identified smokers (at least 10 cigarettes per day). At the end of the interview, all smokers were offered participation in a multiple intervention study. Of the interviewed smokers, 2,915 verbally agreed to participate in the study (90%). Of those who gave initial verbal consent, 2,054 returned the written informed consent form and became participants (70%).

RESULTS

The participants (full consent group) differed significantly from both nonparticipant groups-that is, the smokers who were interviewed but declined participation by active refusal (survey only group) and those who gave verbal consent but passively refused participation by failing to return the written consent form (verbal consent only group). Participants were more likely to be married, younger, and female; to live with others; and to have previously used or considered using nicotine replacement therapy. The survey only group was also more likely to be in the precontemplation stage (54%), whereas the participants were more likely to be in the contemplation (46%) or preparation stage (35%). The verbal consent only group was intermediate of the other two groups in stage-of-change characteristics.

CONCLUSIONS

An important finding was that it is possible to recruit a large proportion of a sample of identified smokers to an nicotine replacement therapy study. However, the participants are likely to differ in significant ways from those who either actively or passively decline participation.

"Shotgun" versus sequential testing. Cost-effectiveness of diagnostic strategies for vaginitis

BACKGROUND

Although vaginitis is a common outpatient problem, only 60% of patients can be diagnosed at the initial office visit of a primary care provider using the office procedures of pH testing, whiff tests, normal saline, and potassium hydroxide preps.

OBJECTIVE

To determine the most cost-effective diagnostic and treatment approach for the medical management of vaginitis.

DESIGN

Decision and cost-effectiveness analyses.

PARTICIPANTS

Healthy women with symptoms of vaginitis undiagnosed after an initial pelvic exam, wet mount preparations, pH, and the four criteria to diagnose bacterial vaginosis.

SETTING

General office practice.

METHODS

We evaluated 28 diagnostic strategies comprised of combinations of pH testing, vaginal cultures for yeast and Trichomonas vaginalis, Gram's stain for bacterial vaginosis, and DNA probes for Neisseria gonorrhoeae and Chlamydia. Data sources for the study were confined to English language literature.

MEASUREMENT

The outcome measures were symptom-days and costs.

RESULTS

The least expensive strategy was to perform yeast culture, gonorrhoeae and Chlamydia probes at the initial visit, and Gram's stain and Trichomonas culture only when the vaginal pH exceeded 4.9 (330 dollars, 7.30 symptom days). Other strategies cost 8 dollars to 76 dollars more and increased duration of symptoms by up to 1.3 days. In probabilistic sensitivity analysis, this strategy was always the most effective strategy and was also least expensive 58% of the time.

CONCLUSIONS

For patients with vaginitis symptoms undiagnosed by pelvic examination, wet mount preparations and related office tests, a comprehensive, pH-guided testing strategy at the initial office visit is less expensive and more effective than ordering tests sequentially.

The views of U.S. medical school deans toward academic primary care

PURPOSE

To understand the views of U.S. medical school deans about their primary care faculties.

METHOD

In 2000, the authors mailed a questionnaire containing 43 multipart items to deans of 130 U.S. allopathic medical schools. The questionnaire assessed the deans' attitudes about and evaluation of primary care at their school and their school's efforts to strengthen it. Deans were asked to compare family medicine, general internal medicine, and general pediatrics with nonprimary care clinical departments at their schools.

RESULTS

Of the 83 (64%) deans who responded, 82% reported their school had departments or divisions of family medicine, general internal medicine, and general pediatrics. Deans rated general internal medicine and general pediatrics higher than nonprimary care faculty on clinical expertise and productivity (p < .001) and family medicine equivalent to nonprimary care faculty. Deans rated all three primary care faculties superior to nonprimary care faculty for teaching skills (p < .001) and programs (p < .05), but lower than nonprimary care disciplines for research productivity (p < .01) and revenues (p < .001). They rated family medicine and general pediatrics lower for research skills (p < .001), but 73% of deans stated research was equally important for primary care and nonprimary care departments. Deans considered overall financial resources to be equivalent for primary care and nonprimary care departments, but 77% of deans felt primary care departments or divisions needed financial support from the medical school to survive. Most deans attempted to strengthen primary care by changing the curriculum to promote primary care and by providing financial support.

CONCLUSIONS

Deans ranked primary care faculty high on clinical and teaching measures. Although they considered research to be an important activity for primary care faculty, they evaluated it low relative to nonprimary care departments.

Testing the usability of two automated home-based patient-management systems

To explore to what extent observation and semistructured in-depth interviews provide effective tools for usability testing of two automated home-based systems aimed at monitoring patients' health status at home and improving self-care. Telephone-Linked Care for Diet Adherence in Dyslipidemia (TLC-DietAid) used computer telephony to interact with users and Home Asthma Telemonitoring System (HAT System) used a combination of Personal Digital Assistant (palmtops) and the Internet for similar purposes. Both systems were evaluated in two separate pilot studies. Our pilot studies uncovered "medium-specific" and "content-specific" issues that addressed either the process of the interaction or its content. The results demonstrated that patient-users tended to evaluate each system on the basis of how it fit into everyday life and corresponded to personal preferences. The methodology also allowed the system designers to understand users' concerns and the context of adoption in order to introduce necessary changes to the design to address such concerns.

Compensation and advancement of women in academic medicine: is there equity?

BACKGROUND

Women have been entering academic medicine in numbers at least equal to their male colleagues for several decades. Most studies have found that women do not advance in academic rank as fast as men and that their salaries are not as great. These studies, however, have typically not had the data to examine equity, that is, do women receive similar rewards for similar achievement?

OBJECTIVE

To examine equity in promotion and salary for female versus male medical school faculty nationally.

DESIGN

Mailed survey questionnaire.

SETTING

24 randomly selected medical schools in the contiguous United States.

PARTICIPANTS

1814 full-time U.S. medical school faculty in 1995-1996, stratified by sex, specialty, and graduation cohort.

MEASUREMENTS

Promotion and compensation of academic medical faculty.

RESULTS

Among the 1814 faculty respondents (response rate, 60%), female faculty were less likely to be full professors than were men with similar professional roles and achievement. For example, 66% of men but only 47% of women (P < 0.01) with 15 to 19 years of seniority were full professors. Large deficits in rank for senior faculty women were confirmed in logistic models that accounted for a wide range of other professional characteristics and achievements, including total career publications, years of seniority, hours worked per week, department type, minority status, medical versus nonmedical final degree, and school. Similar multivariable modeling also confirmed gender inequity in compensation. Although base salaries of nonphysician faculty are gender comparable, female physician faculty have a noticeable deficit (-11,691 dollars; P = 0.01). Furthermore, both physician and nonphysician women with greater seniority have larger salary deficits (-485 dollars per year of seniority; P = 0.01).

LIMITATIONS

This is a cross-sectional study of a longitudinal phenomenon. No data are available for faculty who are no longer working full-time in academic medicine, and all data are self-reported.

CONCLUSIONS

Female medical school faculty neither advance as rapidly nor are compensated as well as professionally similar male colleagues. Deficits for female physicians are greater than those for nonphysician female faculty, and for both physicians and nonphysicians, women's deficits are greater for faculty with more seniority.

Faculty self-reported experience with racial and ethnic discrimination in academic medicine

BACKGROUND

Despite the need to recruit and retain minority faculty in academic medicine, little is known about the experiences of minority faculty, in particular their self-reported experience of racial and ethnic discrimination at their institutions.

OBJECTIVE

To determine the frequency of self-reported experience of racial/ethnic discrimination among faculty of U.S. medical schools, as well as associations with outcomes, such as career satisfaction, academic rank, and number of peer-reviewed publications.

DESIGN

A 177-item self-administered mailed survey of U.S. medical school faculty.

SETTING

Twenty-four randomly selected medical schools in the contiguous United States.

PARTICIPANTS

A random sample of 1,979 full-time faculty, stratified by medical school, specialty, graduation cohort, and gender.

MEASUREMENTS

Frequency of self-reported experiences of racial/ethnic bias and discrimination.

RESULTS

The response rate was 60%. Of 1,833 faculty eligible, 82% were non-Hispanic white, 10% underrepresented minority (URM), and 8% non-underrepresented minority (NURM). URM and NURM faculty were substantially more likely than majority faculty to perceive racial/ethnic bias in their academic environment (odds ratio [OR], 5.4; P <.01 and OR, 2.6; P <.01, respectively). Nearly half (48%) of URM and 26% of NURM reported experiencing racial/ethnic discrimination by a superior or colleague. Faculty with such reported experiences had lower career satisfaction scores than other faculty (P <.01). However, they received comparable salaries, published comparable numbers of papers, and were similarly likely to have attained senior rank (full or associate professor).

CONCLUSIONS

Many minority faculty report experiencing racial/ethnic bias in academic medicine and have lower career satisfaction than other faculty. Despite this, minority faculty who reported experiencing racial/ethnic discrimination achieved academic productivity similar to that of other faculty.

Personal relationships with an intelligent interactive telephone health behavior advisor system: a multimethod study using surveys and ethnographic interviews

The burgeoning of consumer health informatics and virtual health care can help people improve their health. However, little is known about individuals' reactions to such systems. We conducted an evaluation of the telephone-linked care (TLC) system, a computer-based telecommunications system, that functions as an at home monitor, educator, and counselor for patients with chronic health conditions. Our multimethod assessment of individuals' reactions to using TLC included both quantitative and qualitative methods. Ethnographic in-depth open-ended interviews indicated more subtle and surprising reactions to TLC than the overall positive responses from surveys: individuals formed personal relationships with this technology. This relationship formation suggests that TLC designers may have been successful in their attempts to emulate a conversation with a human being. Our study adds to evidence that technology can serve as a projective device for peoples' values and psychological issues. Both designers and users project values and goals onto computer-based technologies and take on different identities through it. Different groups of users, therefore, may see the same technology differently. People also form relationships with technologies, as they did with TLC. These findings, as well as implications for system design and health outcomes, need to be explored in additional studies.

Participant reactions to a computerized telephone system for nutrition and exercise counseling

This paper reports on an evaluation of the reactions of participants in a computer-controlled telephone conversation system (telephone-linked care, TLC) designed to offer nutrition and exercise counseling. After 6 months in the study, subjects were asked a series of questions about their opinions of the TLC system, including overall satisfaction and the system's helpfulness. One hundred and ninety individuals completed the attitude survey. On a scale of 0-100, respondents rated the overall satisfaction and helpfulness of the system at 63.6 and 62.3. Subjects using the nutrition counseling version of TLC rated it significantly higher on satisfaction (73.0 versus 52.4) and helpfulness (70.3 versus 53.7) than did subjects using the exercise version. Satisfaction and helpfulness were correlated with perceived usability, amount of contact, realism, and credibility (P < 0.01). Multivariate analyses showed that treatment group and number of calls made accounted for the greatest amount of variance in ratings of satisfaction and helpfulness. The findings suggest that the amount of contact with this technology, reflected by the number of calls, and the treatment group, nutrition or exercise, were significant predictors of reported satisfaction and perceived helpfulness of the system.

TLC-Asthma: an integrated information system for patient-centered monitoring, case management, and point-of-care decision support

A great deal of successful work has been done in the area of EMR development, implementation, and evaluation. Less work has been done in the area of automated systems for patients. Efforts to link data at multiple levels - the patient, the case manager, and the clinician have been rudimentary to-date. In this paper we present a model information system that integrates patient health information across multiple domains to support the monitoring and care of children with persistent asthma. The system has been developed for use in a multi-specialty group practice and includes three primary components: 1) a patient-centered telephone-linked communication system; 2) a web-based alert reporting and nurse case-management system; and 3) EMR-based provider communication to support clinical decision making at the point-of-care. The system offers a model for a new level of connectivity for health information that supports customized monitoring, IT-enabled nurse case-managers, and the delivery of longitudinal data to clinicians to support the care of children with persistent asthma. Systems like the one described are well-suited, perhaps essential, technologies for the care of children and adults with chronic conditions such as asthma.

The use of computer telephony to provide interactive health information

The use of information technology to provide health information to the public has grown at a rapid pace. Numerous sources of health care information within both the print and Internet media are now available. Yet, their availability raises concerns about the quality of the information provided and questions about which is the most effective method for transmitting health information to consumers. We present an interactive method of presenting high-quality health information that uses a new approach: an integration of the telephone and the computer also called computer telephony. Telephone-Linked Communication for Health Information (TLC-HI) is a computer-based telecommunications system that functions as an educator to people in search of answers to health-related issues. To create TLC-HI, we converted validated print-based consumer information into computer-controlled conversational dialogues. We discuss the potential that the TLC-HI approach holds for improving the way health information is communicated.

Telephone-linked care for cancer symptom monitoring: a pilot study

PURPOSE

The purpose of this pilot project was to explore the feasibility of using a telephone-based computerized system to monitor postchemotherapy symptoms and to test the mechanism of generating alert communications to healthcare providers about symptoms that are poorly controlled.

DESCRIPTION OF STUDY

Twenty-seven patients with cancer participated in the study by calling the telephone-linked care (TLC) system daily during a single cycle of chemotherapy and reporting on seven common chemotherapy-related symptoms. Using selected symptom data, symptoms that met a preset threshold for severity generated a fax notification of the patient's symptom pattern to the physician. Patients then were interviewed about their satisfaction with TLC and about suggestions for improvement.

RESULTS

The study demonstrated that TLC is easy to learn and use and that it captures daily symptom information from patients in their homes. A majority of patients experienced symptoms that were severe enough to generate symptom-alert faxes. Patient satisfaction with TLC was high. The technique, TLC voice, and the duration of the calls were acceptable to patients. There were few technical problems.

CLINICAL IMPLICATIONS

The TLC system has the potential to improve dramatically symptom monitoring and symptom care of patients with cancer at home. Further testing is needed, but the TLC chemotherapy monitoring application shows promise for improving supportive-care service delivery for cancer patients. In its initial test, the TLC chemotherapy monitoring application has been shown to be highly acceptable to patients, able to generate useful symptom data, and able to generate faxed alerts to healthcare providers, thus improving communication about poorly controlled symptoms.

Randomized trial of a "talking computer" to improve adults' eating habits

PURPOSE

To assess efficacy of an intervention delivered by an interactive, computer-controlled telephone system to improve individuals' diets.

DESIGN

Randomized controlled trial.

SETTING

Large multispecialty group practice.

SUBJECTS

Two hundred ninety-eight adults who were both sedentary and had suboptimal diet quality.

INTERVENTION

Weekly communication for 6 months via a totally automated, computer-based voice system. Among intervention group subjects, the system monitored dietary habits and provided educational feedback, advice, and behavioral counseling. Control group subjects received physical activity promotion counseling.

MEASURES

Daily intake of fruits, vegetables, red and processed meats, whole fat dairy foods, and whole grain foods estimated from a food frequency questionnaire.

RESULTS

Mean age 45.9 years, 72% women, 45% white, and 45% African-American. Among participants who completed diet assessments, compared with the control group, the intervention raised fruit intake a mean of 1.1 servings per day (95% confidence interval [CI] .4, 1.7). On a 0 to 100 global diet quality score combining all five food groups, intervention participants improved their mean score 9 (95% CI 4, 13) points more than in the control group. The intervention also raised dietary fiber intake 4.0 g/d (95% CI .1, 7.8) and decreased saturated fat, as a proportion of energy intake, by 1.7% (95% CI -2.7, -.7).

CONCLUSIONS

This computer-based telecommunications dietary behavior intervention helped improve participants' overall diet.

Fellowship training and career outcomes for primary care physician-faculty

PURPOSE

To examine associations between fellowship training and career outcomes among primary care physician-faculty.

METHOD

A total of 821 full-time primary care physician-faculty from 24 representative U.S. medical schools were surveyed using a self-administered questionnaire. Primary outcomes were recent grant submissions and funding, career referred publications, rank, and salary. Findings were adjusted for demographic and professional characteristics.

RESULTS

Of the 500 respondents, 234 of the physician-faculty had completed a fellowship and 266 had not. Fellowship-trained physician-faculty were more than four times as likely to have submitted a grant proposal and to have had a grant funded (both p < 0.0001) than were physician-faculty without fellowship training. They were also more likely to have had any refereed publications (OR 3.8, p < 0.0001) and to have achieved senior academic rank (OR = 1.9, p = 0.02). Among those with fellowship experience, the amount of research training was important. Those with at least one year of research experience in their fellowship program had more grant proposal submissions (OR = 1.9, p = 0.02), more grants funded (OR = 2.9, p = 0.0003), more publications (OR = 2.4, p = 0.02), and higher academic ranks (OR 2.3, p = 0.03) than did those with less research training. Salaries were similar in every comparison.

CONCLUSION

Fellowship-trained primary care physician-faculty were more productive researchers and were more likely to have achieved senior academic rank than were their no-fellowship-trained peers. Even among physician-faculty with fellowship experience, more research training was associated with higher productivity and rank. Salaries were not affected by training experience.

Relationships of physical activity with dietary behaviors among adults

BACKGROUND

Physical activity and diet are important influences on health, but few data are available about the relationship between these two factors. The purpose of this study was to examine relationships between physical activity and dietary quality and to identify determinants of the combination of sedentary behavior and suboptimal diet.

METHODS

The design of this study was cross-sectional. The setting was a large managed-care organization and the participants were 1,322 racially diverse men and women ages 25-91 years. We categorized subjects' physical activity into vigorous, moderate, and sedentary based on answers to two validated interviewer-administered questions about intensity and duration of specified activities. Dietary assessment was by means of a validated short food frequency questionnaire. We defined suboptimal diet as consuming unhealthful quantities of at least two of the following five food groups: fruits, vegetables, whole grain foods, whole-fat dairy foods, and red and processed meats.

RESULTS

Seven hundred fifty-four (57%) subjects were sedentary and 617 (47%) consumed a suboptimal diet. Using multiple linear regression, we found that sedentary individuals consumed smaller amounts of foods and nutrients considered to be healthful, such as fruits and vegetables, fiber, calcium, folate, and vitamins A, C, and E, than more active participants. For nutrients considered to be harmful, such as saturated fat, trans fat, and dietary cholesterol, the association with physical activity was inverse. In multiple logistic regression analyses, the strongest sociodemographic correlates of the joint presence of inactivity and poor diet were less education [odds ratio for 1-year decrease 1.14 (95% confidence interval 1.06, 1.22)], nonwhite race [1.48 (1.05, 2.07)], and nonmarried status [1.49 (1.06, 2.10)].

CONCLUSIONS

Physical activity and diet quality are correlated behaviors. Suboptimal diet and sedentary behavior tend to cluster in individuals who are less educated, not married, and of nonwhite race. Programs that target diet and activity together, informed by their joint determinants, may attain enhanced outcomes.

Faculty perceptions of gender discrimination and sexual harassment in academic medicine

BACKGROUND

Gender-based discrimination and sexual harassment are common in medical practice and may be even more prevalent in academic medicine.

OBJECTIVE

To examine the prevalence of gender-based discrimination and sexual harassment among medical school faculty and the associations of gender-based discrimination with number of publications, career satisfaction, and perceptions of career advancement.

DESIGN

A self-administered mailed questionnaire of U.S. medical school faculty that covered a broad range of topics relating to academic life.

SETTING

24 randomly selected medical schools in the contiguous United States.

PARTICIPANTS

A random sample of 3332 full-time faculty, stratified by specialty, graduation cohort, and sex.

MEASUREMENTS

Prevalence of self-reported experiences of discrimination and harassment, number of peer-reviewed publications, career satisfaction, and perception of career advancement.

RESULTS

Female faculty were more than 2.5 times more likely than male faculty to perceive gender-based discrimination in the academic environment (P < 0.001). Among women, rates of reported discrimination ranged from 47% for the youngest faculty to 70% for the oldest faculty. Women who reported experiencing negative gender bias had similar productivity but lower career satisfaction scores than did other women (P< 0.001). About half of female faculty but few male faculty experienced some form of sexual harassment. These experiences were similarly prevalent across the institutions in the sample and in all regions of the United States. Female faculty who reported being sexually harassed perceived gender-specific bias in the academic environment more often than did other women (80% compared with 61 %) and more often reported experiencing gender bias in professional advancement (72% compared with 47%). Publications, career satisfaction, and professional confidence were not affected by sexual harassment, and self-assessed career advancement was only marginally lower for female faculty who had experienced sexual harassment (P = 0.06).

CONCLUSION

Despite substantial increases in the number of female faculty, reports of gender-based discrimination and sexual harassment remain common.

Contributions of general internal medicine teaching units: a national survey

OBJECTIVE

To identify and describe general internal medicine teaching units and their educational activities.

DESIGN

A cross-sectional mailed survey of heads of general internal medicine teaching units affiliated with U.S. internal medicine training programs who responded between December 1996 and December 1997.

MEASUREMENTS AND MAIN RESULTS

Responses were received from 249 (61%) of 409 eligible programs. Responding and nonresponding programs were similar in terms of university affiliation, geographic region, and size of residency program. Fifty percent of faculty received no funding from teaching units, 37% received full-time (50% or more time), and 13% received part-time (under 50% time) funding from units. Only 23% of faculty were primarily located at universities or medical schools. The majority of faculty were classified as clinicians (15% or less time spent in teaching) or clinician-educators (more than 15% time spent in teaching), and few were clinician-researchers (30% or more time spent in research). Thirty-six percent of faculty were internal medicine subspecialists. All units were involved in training internal medicine residents and medical students, and 21% trained fellows of various types. Half of the units had teaching clinics located in underserved areas, and one fourth had teaching clinics serving more than 50% managed care patients. Heads of teaching units reported that 54% of recent graduating residents chose careers in general internal medicine.

CONCLUSIONS

General internal medicine teaching units surveyed contributed substantial faculty effort, much of it unfunded and located off-campus, to training medical students, residents, and fellows. A majority of their graduating residents chose generalist careers.

Specialty choices, compensation, and career satisfaction of underrepresented minority faculty in academic medicine

PURPOSE

Despite efforts to increase the numbers of underrepresented minorities (URMs), only 3.9% of medical school faculty are URMs. The authors compared the specialty choices, compensation, and career satisfaction of minority faculty with those of their majority counterparts to determine whether there were differences that might affect the recruitment and retention of minority faculty.

METHOD

In 1995, the authors mailed a self-administered survey to a stratified random sample of 3,013 eligible full-time salaried faculty in 24 randomly selected medical schools. Those schools, which had at least 200 faculty, did not include the Puerto Rican or historically black medical schools.

RESULTS

Of the eligible faculty surveyed, 1,807 (60%) responded; 1,463 were majority faculty, 195 were URM faculty, and 149 were other-minority faculty. Similar proportions of the three groups were in the primary care specialties. Only 11% of the URM respondents were in basic science departments. There was no significant difference in adjusted mean compensation between majority, URM, and other-minority faculty. However, URM faculty were significantly less satisfied with their careers (adjusted scores: 60 versus > 65; p = .001) and more often considered leaving academic medicine within five years (58% versus < 45%).

CONCLUSION

Given the demographic changes of the U.S. population, these issues should be addressed by deans and department heads in order to enhance recruitment and facilitate retention of URM faculty in academic medicine.

Microcystic adnexal carcinoma: collaborative series review and update

BACKGROUND

Microcystic adnexal carcinoma (MAC) is a malignant appendageal tumor first described in 1982. It can be clinically and histologically confused with other malignant and benign cutaneous neoplasms, leading to inadequate initial treatment. This neoplasm is locally aggressive and deeply infiltrating, characterized by high morbidity and frequent recurrence. Mohs micrographic surgery has been used to conserve tissue and improve the likelihood for cure.

OBJECTIVE

We report our experience using Mohs micrographic surgery for the treatment of MAC and compare with earlier reports in the literature. In addition, we review the epidemiology, clinical and histologic characteristics, and optimal treatment of this rare neoplasm. We also describe a 15-year-old white male patient with MAC on the scalp occurring only 7 years after radiation exposure.

METHODS

The medical records of 11 patients with MAC who were treated by Mohs micrographic surgery were reviewed at both departments, and follow-up data were obtained.

RESULTS

In all patients treated with Mohs micrographic surgery, there were no recurrences after a mean follow-up of 5 years.

CONCLUSION

Mohs technique enables the detection of clinically unrecognizable tumor spread and perineural invasion often encountered with MAC. Aggressive initial treatment by microscopically controlled excision appears to offer the greatest likelihood of cure for this neoplasm, while providing conservation of normal tissue. In addition, we describe the second youngest patient with MAC and readdress the issue of previous radiotherapy as an important predisposing factor.

A telecommunications system to manage patients with chronic disease

The care of patients with chronic disease is a large and growing problem in the United States and other industrialized countries.' it is expensive, and the quality of care received by patients is often sub-optimal, resulting in poor health outcomes. We developed a totally automated computer-controlled telecommunications system, called TLC, that provides--frequent, close monitoring of patients with chronic disease and reports the results to the patients' physicians on a timely basis, so that they can intervene appropriately. TLC also monitors the patients' important self care activities, such as medication-taking, and provides education and counseling to improve the patients' performance of these activities. The system operates through regularly scheduled telephone conversations with patients' in their homes. An evaluation of a TLC chronic disease application for patients with hypertension demonstrated that use of the system was associated with significant improvement of the patients' adherence to their medication regimens and significantly improved blood pressure control. These results show that it is possible to design an information science-based health care delivery system that performs functions usually performed only by health care professionals, and suggests that information science will become an important means of delivering health care services in the next millennium.

An automated telephone-based smoking cessation education and counseling system

Automated patient education and counseling over the telephone is a convenient and inexpensive method for modifying health-related behaviors. A computer-controlled, telecommunications technology called Telephone-Linked Care (TLC) was used to develop a behavioral intervention to assist smokers to quit and to prevent relapse. The education and counseling is offered through a series of interactive telephone conversations which can take place in the smoker's home. The system's automated dialogues are driven by an expert system that controls the logic. The content is derived from the Transtheoretical Model of behavioral change, principles of Social Cognitive Theory, strategies of patient-centered counseling and recommendations of clinical experts in smoking cessation. The system asks questions, provides information, gives positive reinforcement and feedback, and makes suggestions for behavioral change. Information that the patient communicates is stored and is used to influence the content of subsequent conversations.

Ethnographic interviews to elicit patients' reactions to an intelligent interactive telephone health behavior advisor system

Information technology is being used to collect data directly from patients and to provide educational information to them. Concern over patient reactions to this use of information technology is especially important in light of the debate over whether computers dehumanize patients. This study reports reactions that patient users expressed in ethnographic interviews about using a computer-based telecommunications system. The interviews were conducted as part of a larger evaluation of Telephone-Linked Care (TLC)-HealthCall, an intelligent interactive telephone advisor, that advised individuals about how to improve their health through changes in diet or exercise. Interview findings suggest that people formed personal relationships with the TLC system. These relationships ranged from feeling guilty about their diet or exercise behavior to feeling love for the voice. The findings raise system design and user interface issues as well as research and ethical questions.

Inadequate management of blood pressure in a hypertensive population

BACKGROUND

Many patients with hypertension have inadequate control of their blood pressure. Improving the treatment of hypertension requires an understanding of the ways in which physicians manage this condition and a means of assessing the efficacy of this care.

METHODS

We examined the care of 800 hypertensive men at five Department of Veterans Affairs sites in New England over a two-year period. Their mean (+/-SD) age was 65.5+/-9.1 years, and the average duration of hypertension was 12.6+/-5.3 years. We used recursive partitioning to assess the probability that antihypertensive therapy would be increased at a given clinic visit using several variables. We then used these predictions to define the intensity of treatment for each patient during the study period, and we examined the associations between the intensity of treatment and the degree of control of blood pressure.

RESULTS

Approximately 40 percent of the patients had a blood pressure of > or =160/90 mm Hg despite an average of more than six hypertension-related visits per year. Increases in therapy occurred during 6.7 percent of visits. Characteristics associated with an increase in antihypertensive therapy included increased levels of both systolic and diastolic blood pressure at that visit (but not previous visits), a previous change in therapy, the presence of coronary artery disease, and a scheduled visit. Patients who had more intensive therapy had significantly (P<0.01) better control of blood pressure. During the two-year period, systolic blood pressure declined by 6.3 mm Hg among patients with the most intensive treatment, but increased by 4.8 mm Hg among the patients with the least intensive treatment.

CONCLUSIONS

In a selected population of older men, blood pressure was poorly controlled in many. Those who received more intensive medical therapy had better control. Many physicians are not aggressive enough in their approach to hypertension.

Relation of family responsibilities and gender to the productivity and career satisfaction of medical faculty

BACKGROUND

Studies have found that female faculty publish less, have slower career progress, and generally have a more difficult time in academic careers than male faculty. The relation of family (dependent) responsibilities to gender and academic productivity is unclear.

OBJECTIVE

To describe dependent responsibilities by gender and to identify their relation to the aspirations, goals, rate of progress, academic productivity, and career satisfaction of male and female medical school faculty.

DESIGN

177-item survey questionnaire.

SETTING

24 randomly selected medical schools in the contiguous United States.

PARTICIPANTS

1979 respondents from a probability sample of full-time academic medical school faculty.

MEASUREMENTS

The main end point for measuring academic productivity was the total number of publications in refereed journals. Perceived career progress and career satisfaction were assessed by using Likert scales.

RESULTS

For both male and female faculty, more than 90% of time devoted to family responsibilities was spent on child care. Among faculty with children, women had greater obstacles to academic careers and less institutional support, including research funding from their institutions (46% compared with 57%; P < 0.001) and secretarial support (0.68 full-time equivalents compared with 0.83 full-time equivalents; P = 0.003), than men. Compared with men with children, women with children had fewer publications (18.3 compared with 29.3; P < 0.001), slower self-perceived career progress (2.6 compared with 3.1; P < 0.001), and lower career satisfaction (5.9 compared with 6.6; P < 0.001). However, no significant differences between the sexes were seen for faculty without children.

CONCLUSIONS

Compared with female faculty without children and compared with men, female faculty with children face major obstacles in academic careers. Some of these obstacles can be easily modified (for example, by eliminating after-hours meetings and creating part-time career tracks). Medical schools should address these obstacles and provide support for faculty with children.