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.

A pilot study of a telehealth intervention for persons with spinal cord dysfunction.

STUDY DESIGN: Single-blind randomized controlled trial of 6 months' duration. OBJECTIVES: To evaluate the efficacy of a novel telehealth intervention, 'CareCall', on reducing pressure ulcers and depression and enhancing the use of appropriate health care. SETTING: General community, Massachusetts and Connecticut, United States METHODS: 'CareCall' is an automated, interactive voice response system that combines patient education, cognitive behavioral interventions, screening and referrals, with alerts to a nurse telerehabilitation coordinator for direct non-emergent phone follow up. Participants consisted of a convenience sample of 142 persons with multiple sclerosis or spinal cord injury using a wheelchair >6 h per day. The intervention group received CareCall (n=71) The control group received usual care (n=71). The main outcome measures were: The pressure ulcer scale for healing tool, Patient Health Questionnaire-9 depression scale, Cornell Services Index and Craig Hospital Inventory of Environmental Factors-Short Form Question 5. RESULTS: CareCall achieved a reduction in presence of pressure ulcers at 6 months in women (P<0.0001). Among those with baseline depression, CareCall reduced 6-month severity of depression, adjusting for age and gender (P<0.047). CareCall did not have a significant impact on health-care utilization (OR=1.8, P=0.07), but did significantly improve participants' report of health-care availability (OR=2.03, P<0.04). CONCLUSION: This is the first study to demonstrate the efficacy of a largely automated telehealth intervention for adults with spinal cord dysfunction. Future research needs to replicate this study in a larger, multisite trial.

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.

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.

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.

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.

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.

Minority faculty and academic rank in medicine.

CONTEXT: Previous studies have found that fewer minority medical school faculty hold senior professorial ranks than do majority faculty and may not be promoted as rapidly. OBJECTIVE: To determine whether minority faculty were as likely as majority faculty to have attained senior rank (associate professor or full professor) after adjusting for other factors that typically influence promotion. DESIGN: A self-administered mailed survey of US medical school faculty using the Association of American Medical Colleges database. The sample was stratified by department, graduation cohort, and sex. PARTICIPANTS: A stratified random sample of 3013 full-time faculty at 24 representative US medical schools. All underrepresented minority faculty at these schools were sampled. MAIN OUTCOME MEASURE: Attainment of senior academic rank (associate professor or full professor). RESULTS: Of 3013 faculty surveyed, 1807 (60.0%) responded, including 1463 white (81.0%), 154 black (8.5%), 136 Asian (7.5%), and 54 Hispanic (3.0%). Overall, 980 faculty (54%) had attained senior academic rank, including 47 (30.5%) of 154 black faculty, 59 (43.4%) of 136 Asian faculty, 22 (40.8%) of 54 Hispanic faculty, and 852 (58.3%) of 1463 white faculty. White faculty had significantly more first-authored and total peer-reviewed publications than the other groups. After adjusting for the medical school, department, years as medical school faculty, number of peer-reviewed publications, receipt of research grant funding, proportion of time in clinical activities, sex, and tenure status, we found that the odds ratios of holding senior rank relative to white faculty were 0.33 (95% confidence interval [CI], 0.17-0.63) for black faculty, 0.36 (95% CI, 0.12-1.08) for Hispanic faculty, and 0.58 (95% CI, 0.30-1.12) for Asian faculty. CONCLUSIONS: Minority faculty were less likely than white faculty to hold senior academic rank. This finding was not explained by potential confounders such as years as a faculty member or measures of academic productivity.

Evaluation and management of vaginitis.

OBJECTIVE: To evaluate recent advances in our understanding of the clinical relevance, diagnosis, and treatment of vaginal infections, and to determine an efficient and effective method of evaluating this clinical problem in the outpatient setting. DATA SOURCES: Relevant papers on vaginitis limited to the English language obtained through a MEDLINE search for the years 1985 to 1997 were reviewed. DATA SYNTHESIS: Techniques that enable the identification of the various strains of candida have helped lead to a better understanding of the mechanisms of recurrent candida infection. From this information a rationale for the treatment of recurrent disease can be developed. Bacterial vaginosis has been associated with complications, including upper genital tract infection, preterm delivery, and wound infection. Women undergoing pelvic surgery, procedures in pregnancy, or pregnant women at risk of preterm delivery should be evaluated for bacterial vaginosis to decrease the rate of complications associated with this condition. New, more standardized criteria for the diagnosis of bacterial vaginosis may improve diagnostic consistency among clinicians and comparability of study results. Use of topical therapies in the treatment of bacterial vaginosis are effective and associated with fewer side effects than systemic medication. Trichomonas vaginalis, although decreasing in incidence, has been associated with upper genital tract infection. Therapy of T. vaginalis infection has been complicated by an increasing incidence of resistance to metronidazole. CONCLUSIONS: Vaginitis is a common medical problem in women that is associated with significant morbidity and previously unrecognized complications. Research in recent years has improved diagnostic tools as well as treatment modalities for all forms of vaginitis.

Automated telephone conversations to assess health behavior and deliver behavioral interventions.

The medical care system is not very effective in modifying health behavior of individuals, in particular, ensuring patient compliance with medication regimens, healthy diets, regular physical activity, and regular health screening, and in the avoidance of substance abuse. Telephone-Linked Care (TLC) is a telecommunications technology that enables computer-controlled telephone counseling with patients in their homes. It has been applied to the task of improving a number of different health behaviors. Randomized controlled studies suggest that use of the system for as little as 3 months is associated with improvement in adherence to medication regimens, dietary change in hypercholesterolemia, and increased physical activity among sedentary individuals. Future work involves applying the technology to other important health behaviors, optimally using health behavior theory in the system design, targeting use of TLC to the most appropriate patient groups, incorporating new computer and telecommunications technology into the system, and interfacing TLC into the health care delivery system.

Junior faculty members' mentoring relationships and their professional development in U.S. medical schools.

PURPOSE: To determine (1) the prevalence of mentoring relationships for U.S. medical school junior faculty; (2) the quality of these mentoring relationships; (3) any variation by gender or race; and (4) the relationship between mentoring and junior faculty members' perceptions of institutional professional support; research-, teaching-, and clinical-skills development; allocation of time to professional activities; and career satisfaction. METHOD: In 1995 a 177-item survey was mailed to 3,013 full-time faculty at 24 randomly selected U.S. medical schools stratified on an area of medical specialization, graduation cohort, and gender. Mentoring was defined as "dynamic reciprocal relationship between an advanced career incumbent (the mentor) and a junior faculty member (the protégé) aimed at fostering the development of the junior person/protégé." Because mentoring is most crucial for junior faculty, the study focused on mentoring relationships within the previous three years ("recent mentoring") for faculty who were not full professors. Chisquare tests, analysis of variance, and principal-components analysis were used to analyze the data. RESULTS: In all, 1,808 (60%) of the 3,013 faculty surveyed, of whom 72% were junior faculty, returned completed questionaires. Fifty-four percent of the junior faculty had had a recent mentoring relationship. There was no significant difference between the men and the women faculty or between majority and minority faculty in the prevalence and quality of the mentoring relationships. The faculty with mentors rated their research preparation and research skills higher than did the faculty without mentors. Most of the women faculty (80%) and the minority faculty (86%) who had had mentors reported that it was not important to have a mentor of the same gender or minority group. CONCLUSION: Mentoring relationships are prevalent in academic medicine and should be promoted to support the career growth of junior faculty.

Relationships of gender and career motivation to medical faculty members' production of academic publications.

PURPOSE: To evaluate the relationships between both internal and external career-motivating factors and academic productivity (as measured by the total numbers of publications) among full-time medical faculty, and whether these relationships differ for men and women. METHOD: In 1995 a 177-item survey was mailed to 3,013 full-time faculty at 24 randomly selected U.S. medical schools stratified on area of medical specialization, length of service, and gender. Two-tailed t-tests and regression analyses were used to study the data. RESULTS: A total of 1,764 faculty were used in the final analyses. The women had published two thirds as many articles as had the men (mean, 24.2 vs. 37.8). Intrinsic and extrinsic career motivation were rated similarly (on a three-point scale) by the women and the men: intrinsic career motivation was rated higher (women's mean rating: 2.8, men's mean rating: 2.9) than was extrinsic career motivation (mean rating: 2.1 for both). The main findings of the regression analyses were (1) intrinsic career motivation was positively associated, and extrinsic career motivation was negatively associated, with the number of publications; (2) publication rates were higher for the men than for the women after controlling for career motivation; and (3) there was no significant effect of gender on these relationships. CONCLUSION: The women faculty published less than did their men colleagues, but this difference cannot be accounted for by gender differences in career motivation. Further research on institutional support, family obligations, harassment, and other factors that could affect academic productivity is necessary to understand the gender difference in numbers of publications.

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.