Comparison of measures to assess change in diagnostic performance due to a decision support system.

Little has been done to examine the relative merit of measures used to assess the impact of diagnostic decision support systems (DDSS) on physician performance. In this study, 10 different single-measures of diagnostic performance were compared empirically. The measures were of three types: rank-order, all-or-none, and appropriateness. The responsiveness (RESP) of each measure was estimated under two repeated-measures experimental conditions. RESP is the degree to which a measure could detect differences between conditions of low and high performance. The diagnostic performance of 108 physicians was compared on medical cases of varying diagnostic difficulty and with or without a high level of assistance from a DDSS. The results showed that the RESP among the measures varied nearly tenfold. The rank-order measures tended to provide the highest RESP values (maximum = 2.14) while appropriateness measures provided the lowest RESP values (maximum = 1.41). The most responsive measures were rank-orders of the correct diagnosis within the top 5 to 10 listed diagnoses.

Effects of a decision support system on physicians' diagnostic performance.

PURPOSE: This study examines how the information provided by a diagnostic decision support system for clinical cases of varying diagnostic difficulty affects physicians' diagnostic performance. METHODS: A national sample of 67 internists, 35 family physicians, and 6 other physicians used the Quick Medical Reference (QMR) diagnostic decision support system to assist them in the diagnosis of written clinical cases. Three sets of eight cases, stratified by diagnostic difficulty and the potential of QMR to produce high-quality information, were used. The effects of using QMR on three measures of physicians' diagnostic performance were analyzed using analyses of variance. RESULTS: Physicians' diagnostic performance was significantly higher (p < 0.01) on the easier cases and the cases for which QMR could provide higher-quality information. CONCLUSIONS: Physicians' diagnostic performance can be strongly influenced by the quality of information the system produces and the type of cases on which the system is used.

Influence of case and physician characteristics on perceptions of decision support systems.

OBJECTIVE: This study examines how characteristics of clinical cases and physician users relate to the users' perceptions of the usefulness of the Quick Medical Reference (QMR) and their confidence in their diagnoses when supported by the decision support system. METHODS: A national sample (N = 108) of 67 internists, 35 family physicians, and 6 other U.S. physicians used QMR to assist in the diagnosis of written clinical cases. Three sets of eight cases stratified by diagnostic difficulty and the potential of QMR to produce high-quality information were used. A 2 x 2 repeated-measures analysis of variance was used to test whether these factors were associated with perceived usefulness of QMR and physicians' diagnostic confidence after using QMR. Correlations were computed among physician characteristics, ratings of QMR usefulness, and physicians' confidence in their own diagnoses, and between usefulness or confidence and actual diagnostic performance. RESULTS: The analyses showed that QMR was perceived to be significantly more useful (P < 0.05) on difficult cases, on cases where QMR could provide high-quality information, by non-board-certified physicians, and when diagnostic confidence was lower. Diagnostic confidence was higher when comfort with using certain QMR functions was higher. The ratings of usefulness or diagnostic confidence were not consistently correlated with diagnostic performance. CONCLUSIONS: The results suggest that users' diagnostic confidence and perceptions of QMR usefulness may be associated more with their need for decision support than with their actual diagnostic performance when using the system. Evaluators may fail to find a diagnostic decision support system useful if only easy cases are tested, if correct diagnoses are not in the system's knowledge base, or when only highly trained physicians use the system.

Disability caused by work-related musculoskeletal disorders.

This article describes the magnitude, extent, and economic consequences of some of the more common, work-related musculoskeletal disorders. In addition, it provides a brief historic overview of the state-federal vocational rehabilitation program in the United States. It identifies and considers a constellation of risk factors for work-related disability because of musculoskeletal disorders, and it discusses phases of physical rehabilitation as that process relates to injured workers. The shifting disability paradigm is examined, and attention is given to terminology that has become fashionable since passage of the landmark Americans with Disabilities Act of 1990. Finally, various factors and conditions that often become barriers to an injured person's successful return to the workforce are briefly discussed.

Medical status of adolescents at time of admission to a juvenile detention center.

PURPOSE: To examine the medical status and history of health care utilization of adolescents at the time of their admission to a juvenile detention facility. METHODS: Data were collected over an 18-month period on all detainees admitted for the first time to a juvenile detention facility in a major southeastern city in the United States. Information was gathered through a private, confidential interview completed by a medical social worker and a physical examination by a physician. Information was obtained regarding past medical history, complaints at the time of admission, health care utilization, and physical examination. RESULTS: Approximately 10% of teenagers admitted to a detention facility have a significant medical problem (excluding drug/alcohol abuse, or uncomplicated sexually transmitted diseases) that requires medical follow-up. The majority of these conditions were known to the adolescent at the time of admission. Only a third of adolescents admitted to the detention facility reported a regular source of medical care, and only about 20% reported having a private physician. A majority of all the detainees had already fallen behind in or dropped out of school. More than half of the families of the adolescents with a medical problem appeared to be unable or unwilling to assist in ensuring proper medical follow-up. CONCLUSIONS: A significant percentage of adolescents entering a detention facility have a medical problem requiring health care services. Detention facilities offer an opportunity to deliver and coordinate medical care to high-risk adolescents. Programs linking public and private health care providers with the correctional care system may provide juveniles with an acceptable option for obtaining needed health care services.

Health outcome improvements in patients with systemic lupus erythematosus using two telephone counseling interventions.

OBJECTIVE: To examine the effectiveness of two telephone intervention strategies for improving the health outcomes of patients with systemic lupus erythematosus (SLE). METHODS: Fifty-eight SLE patients were randomly assigned to receive a 6-month telephone counseling intervention using either a treatment counseling (TC) or symptom monitoring (SM) strategy. Health outcomes were assessed using the Fatigue Severity Scale (FSS) and the Arthritis Impact Measurement Scales 2 (AIMS2). RESULTS: At the 6-month followup, the mean AIMS2 Physical Function scale and AIMS2 Social Support scale scores were significantly improved (P < 0.05) for the TC group compared to the SM groups. The mean FSS score, AIMS2 Affect score, and AIMS2 Pain score were significantly improved (P < 0.05) for both groups. CONCLUSIONS: Telephone interventions, especially using the TC approach, can be effective for improving the functional status of persons with SLE.

Health outcomes of two telephone interventions for patients with rheumatoid arthritis or osteoarthritis.

OBJECTIVE: The effects of treatment counseling or symptom monitoring telephone intervention strategies on the health outcomes of patients with rheumatoid arthritis (RA) or osteoarthritis (OA), compared with usual care, were assessed. METHODS: A 3-group, randomized, controlled 9-month trial was conducted incorporating 405 patients with RA or OA and using the Arthritis Impact Measurement Scales (AIMS2) as the outcome measure. RESULTS: Analyses of covariance showed that the AIMS2 total health status of the treatment counseling group (effect size = 33, P < 0.01), but not the symptom monitoring group (effect size = 0.21, P = 0.10), was significantly improved, compared with usual care, for both RA and OA patients. The specific types of benefits differed significantly between RA and OA patients. The mean number of medical visits by OA patients in the treatment counseling group was also significantly reduced (P < 0.01). CONCLUSION: Telephone contact using the treatment counseling strategy produced significant, but different, health status benefits for RA and OA patients. The symptom monitoring strategy produced modest benefits.

The effect of person-centered counseling on the psychological status of persons with systemic lupus erythematosus or rheumatoid arthritis: a randomized, controlled trial.

OBJECTIVE: We tested the effectiveness of a 6-month person-centered (PC), nondirective, telephone-based counseling intervention for improving the psychological status of persons with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA). METHODS: The design was a parallel-group, randomized, controlled study comparing a PC counseling intervention (8 SLE, 28 RA patients) with usual care (7 SLE, 30 RA patients). The Arthritis Impact Measurement Scales was used to measure psychological dysfunction, physical dysfunction, and pain at baseline and at followup. RESULTS: The main finding was that the PC counseling intervention significantly improved the psychological status of the SLE patients (P < 0.05, effect size = 1.13, responsiveness = 0.77) in comparison to usual care. There was no evidence of a benefit for persons with RA or of improvements in physical function or pain for persons with either disease. CONCLUSIONS: PC counseling may be an effective intervention for improving the psychological status of persons with SLE, but may not be for those with RA.

Barriers to return to work among persons unemployed due to arthritis and musculoskeletal disorders.

OBJECTIVE: To identify barriers to return to work (RTW) among persons likely to be seen in a clinician's practice who are unemployed due to arthritis and musculoskeletal disorders. METHODS: Two hundred eighteen persons unemployed due to arthritis and musculoskeletal disorders were interviewed at baseline and followed up for 1 year, at which time their work status was ascertained. Backward stepwise logistic regression was used to determine the association of baseline clinical, sociodemographic, and work-related factors to their work status at 1 year of followup. RESULTS: Fifty-one (24%) of 216 initially unemployed subjects had returned to permanent paid employment of > or = 20 hours/week after 1 year. Having rheumatoid arthritis, Social Security Disability Insurance (SSDI) status, a high pain level, older age, and lower education were barriers to reemployment. CONCLUSION: This study establishes the importance of chronic pain and having rheumatoid arthritis as factors independently associated with failure to RTW among persons unemployed due to arthritis and musculoskeletal disorders. The importance of SSDI beneficiary status, age, and education level in RTW is further confirmed. Duration of unemployment or previous work factors were not predictors of RTW in this group.

Musculoskeletal disability, employment, and rehabilitation.

OBJECTIVE: To determine which, if any, baseline social and disease characteristics can be used to identify persons with musculoskeletal disabilities accepted for state-federal vocational rehabilitation services who are most likely to return to work. METHODS: A database of case closures from the Alabama Vocational Rehabilitation Service was analyzed using segmentation modelling. This included all persons (n = 4093) with musculoskeletal disability who were accepted by the Alabama Vocational Rehabilitation Agency in 1987-91. Demographics, income, type of disability, severity of disability, medical insurance, similar benefits, benefit status, and referral source were independent variables. Outcome (dependent) variable was work status at end of agency services. RESULTS: Overall, 71% of persons with arthritis and musculoskeletal disorders who were accepted for vocational rehabilitation services in 1987-91 returned to work at the end of agency services. Segmentation modelling created a tree in which certain baseline characteristics formed subgroups with differing rates of successful rehabilitation. Social Security Disability Insurance (SSDI) status was the single best predictor of rehabilitation. Seventy-three percent of nonbeneficiaries were rehabilitated compared to 55% of beneficiaries (p < 0.00001). For non-SSDI beneficiaries, education level > or = grade 12 was associated with better rehabilitation outcome (p < 0.00001). SSDI beneficiaries with nonback disorders fared better than those with back disorders (p < 0.05). Disease severity, assessed by Federal Special Programs criteria, was not associated with rehabilitation outcome at any level of the tree. CONCLUSION: Simple baseline social and disease characteristics can be used to identify groups of persons accepted for vocational rehabilitation services with musculoskeletal disability with differing rates of vocational rehabilitation. Disability benefit status and education level are important predictors of return to work after agency services. These findings can lead to the development of strategies to improve the efficacy of vocational rehabilitation services.

Treatment regimen and side effects of treatment measures.

The severity of asthma can be judged by many features, including the need for medication and associated side effects. Since asthma has both acute and chronic characteristics, therapeutic regimens should be valuable as an instrument to define disease severity and the consequence of intervention. However, because of the variability of asthma severity within each patient, medication quantitation as an index of asthma severity is not without difficulty and limitation. Furthermore, the philosophy of asthma therapy has undergone changes over the past decade. Previously, anti-inflammatory therapy was reserved for only the most severely ill patients. Now, inflammation is recognized as a critical component of asthma, and all patients with active asthma (other than mild symptoms) are recommended to use anti-inflammatory therapy. Although there is little published experience with treatment regimens as an index of disease severity, those that have been used have found validity and reproducibility with this approach. In this paper, a scoring approach to medication use is recommended. Medication is classified into bronchodilator (beta-agonists, theophylline, and anticholinergic) or anti-inflammatory (corticosteroid and cromolyn sodium). Medication scores are given on either a per-use or a new-dosage basis. Furthermore, the eight medications are stratified according to potency (i.e., inhaled corticosteroid < oral corticosteroid < parenteral corticosteroid). From this approach, the severity of an individual patient's asthma can be quantitated, and this value can serve as one instrument to assess disease severity.

Factors associated with successful vocational rehabilitation in persons with arthritis.

OBJECTIVE: The objective of this study was to analyze factors associated with successful vocational rehabilitation (return to work) among persons receiving state-federal vocational rehabilitation services because of work disability from arthritis. METHODS: Multivariate analyses were used to determine the association of sociodemographic, disease-related, and agency factors with work outcome among a group of 456 persons with arthritis receiving state-federal vocational rehabilitation services during 1985-1988. RESULTS: Agency-sponsored physical restoration services (P less than 0.0001) and retraining (P less than 0.0001) were the variables most strongly correlated with return to work. Age, sex, race, disease severity, financial status, and educational level assessed at intake were not significantly associated with work rehabilitation outcome. CONCLUSION: Factors potentially amenable to agency intervention were more strongly associated with work rehabilitation outcome than were sociodemographic or disease-related variables.

Subsequent behavior of users of an arthritis information telephone service.

Followup telephone interviews were conducted with a stratified random sample of 305 users of a prototype telephone information service for arthritis 2-4 months after their initial contact with the service. The percentage of respondents who reported taking at least 1 positive action for their arthritis because of service usage was 79%. The most frequently reported actions of users were asking their doctor more questions and greater compliance with their doctor's orders. About one-half of the respondents felt more in control of their arthritis because of service usage. Both the taking of at least 1 action and the taking of certain specific actions were significantly correlated with feeling more in control of the arthritis (P less than 0.01). Respondents who were less than 60 years old, black, or symptomatic were significantly more likely to take an action and took significantly more actions (P less than 0.01). This minimal intervention may stimulate positive behaviors for individuals with arthritis.

A curriculum in clinical sexuality for arthritis health care professionals.

The results of an experimental training program in sexologic interviewing for a multidisciplinary arthritis patient care team are reported. The program included didactic instruction, observation and practice of interviewing skills, a seminar, and a case presentation. Trainees had gained more knowledge than control subjects at one year. Both groups improved their interviewing skills, but trainees showed more improvement than controls on problem-list generation. All participants showed more improvement when interviewing male than female patients. The data show that training programs in sexologic interviewing can improve both knowledge and skills. Programs should include actual practice interviewing patients.

Users of a public arthritis information service and their needs.

Brief interviews were conducted with 1670 users of the Arthritis Information Service of Alabama, a statewide toll-free telephone information service. The results showed the service users were significantly (p less than 0.01) different from both the adult population and from the estimated symptomatic population of the service area. Users tended to be female, symptomatic, white, older, and better educated than the adult population. The most frequent category of need was emotional support, followed by referral, symptom/test explanation, treatment explanation, self-help method, medication, and physician-patient communication. Informational needs were significantly related to the gender, age, and the reported diagnoses of the user. Our results suggested that telephone services for health promotion may need to make special efforts to reach nonwhite and less educated persons and to provide emotional support.

User evaluation of an arthritis information telephone service.

Arthritis patients are prone to misperceptions, forgetfulness, and the use of unproven remedies. They also may become noncompliant and be unaware of community resources. Informational or educational programs such as the Arthritis Information Service of Alabama may be useful for reducing these problems. There have been several reports concerning the use of telephone services (e.g.), for providing information about specific diseases but few concerning arthritis. An important step in the evaluation of a telephone information service is the surveying of user opinions concerning the service's procedures and its benefits. The purposes of the present study were to estimate the percentage of users who believed they had benefited from service usage, to identify the potential benefits of service usage, and to identify the groups most likely to report benefits.

Sexual dysfunction among patients with arthritis.

The relationship of arthritis and sexual dysfunction was investigated among 169 patients with rheumatoid arthritis, osteoarthritis and spondyloarthropathy, 130 of whom were pair-matched to controls. Assessments of marital happiness and depressed mood were also made using the CES-D and the Azrin Marital Happiness Scale (AMHS). Sexual dysfunctions were found to be common among patients and controls, the majority in both groups reporting one or more dysfunctions. Impotence was more common among male patients than controls and was found to be associated with co-morbidity and the taking of methotrexate. Depressed mood was more common among patients and was associated with certain sexual difficulties, but not with impotence. Marital unhappiness, as indicated by AMHS scores, was not associated with arthritis but was associated with sexual dysfunction, sexual dissatisfaction and being female.

Sexual quality-of-life of patients with arthritis compared to arthritis-free controls.

The influence of arthritis upon sexual satisfaction and activity and patient receptivity to sexual rehabilitation was investigated by interviewing 169 patients with arthritis and 130 controls. Patients differed from controls in their greater loss of sexual satisfaction over time, but they were comparably satisfied with their current sexual adjustment. They reported similar reductions in frequency of intercourse over time. Joint symptoms and fatigue disturbed the sexual adjustment of patients more than controls, but damaged body image, worry about partner interest, loss of libido and loss of lubrication did not. There was receptivity to a program of sexual rehabilitation among patients and controls that was not dependent upon sexual dissatisfaction.