Race-Associated Genomic Correlates of Therapeutic Response in African American Patients With Non-Small-Cell Lung Cancer

PURPOSE

African American individuals are disproportionately affected by lung cancer in terms of incidence and mortality. In oncogene-driven non-small-cell lung cancer (NSCLC), emerging evidence indicates that underlying molecular heterogeneity, which can be affected by ancestry, contributes to variable drug sensitivity and therapeutic responses. The purpose of this study was to evaluate race-associated differences in reported treatment decisions, therapeutic outcomes, and molecular features in KRAS- and EGFR-mutant NSCLC.

MATERIALS AND METHODS

This is a retrospective study using real-world clinical-genomic data from health systems in the United States to evaluate race-associated outcomes in advanced-stage KRAS- or EGFR-driven NSCLC. Our overall objectives were to evaluate race-associated therapeutic outcomes and to describe molecular features in non-Hispanic Black (NHB) and non-Hispanic White (NHW) patients with NSCLC.

RESULTS

A total of 723 NSCLC patients with KRAS and 315 patients with EGFR oncogenic mutations were evaluated. In KRAS-mutant patients, variable outcomes were observed in NHB and NHW patients on the basis of receiving chemotherapy alone or in combination with immune checkpoint inhibitors. NHB patients received treatment at significantly lower rates compared with NHW patients. In the EGFR-mutant cohort, NHB and NHW patients received EGFR-targeted agents at similar rates, and overall survival was not significantly different. Race-associated differences in molecular features included a higher frequency of TP53 comutation in KRAS-mutant NHB patients and higher prevalence of EGFR G719S subtype in NHB patients.

CONCLUSION

In a real-world cohort of patients with NSCLC, we identified race-associated differences in therapeutic outcomes and described molecular characteristics in NHB and NHW patients with NSCLC. To proactively identify patients most likely to respond to systemic therapies, a more comprehensive approach is needed to help guide therapy selection in individualized patient populations.

Abstract 6259: Molecular biomarker testing and targeted therapy patterns in patients with acute myelogenous leukemia (AML): A real-world data analysis

Background and Objective: Molecular testing and targeted treatments for patients (pts) diagnosed with AML have evolved in recent years. Real-world testing patterns, including next-generation sequencing (NGS), and clinical management of pts with AML were analyzed in 2 large U.S. community health systems.

Methods: Pts >18 years, diagnosed with AML from January 1, 2015 to December 31, 2020, were identified in a database containing clinical and genomic data from integrated community delivery networks. Study end was March 31, 2021, allowing for 3 months minimum follow up. Actionable biomarkers were defined by NCCN guidelines version 3, 2021.

Results: The study included 685 pts, median age of 70 and median follow up of 5.4 months; 55% were male, 73% non-Hispanic White (NHW), 10% non-Hispanic Black (NHB). 69% had de novo AML. Cytogenetic prognostic classification was: 4% favorable; 33% intermediate; 30% adverse; and 33% unknown. 541 (79%) pts, median age of 69, received NGS or single gene/small panel tests. 144 (21%) pts with no testing had a median age of 78. Pts with de novo AML were more likely to be tested compared to secondary AML (84% vs. 67%, p<0.001). No significant difference was found in testing receipt between NHW and NHB pts (82% vs. 76%, p=0.3). 80% of pts received NGS testing in upfront setting, 15% in relapse setting (>30 days after diagnosis), 5% were unknown. 77% of pts diagnosed in 2020 received NGS tests (Table 1). 52/100 (52%) of pts with FLT3 (ITD or TKD) mutation, 5/27 (19%) with IDH1 mutation and 11/44 (25%) with IDH2 mutation received targeted therapy.

Conclusions: Molecular biomarker testing has increased over time with NGS becoming the dominant modality. Testing uptake did not differ by race. Half of pts with FLT3 mutation received targeted therapy, one fifth with IDH1 and one quarter with IDH2 mutations. Future research should explore targeted therapy receipt over time and address gaps in uptake for pts with AML in the community setting.

Table 1. Proportion of patients with molecular biomarker testing by diagnosis year among (n=685) Diagnosis Year 2015(N = 77) 2016(N = 92) 2017(N = 113) 2018(N = 138) 2019(N = 129) 2020(N = 136) Overall(N = 685) NGS testing, n (%) 7 (9%) 17 (18%) 46 (41%) 100 (72%) 100 (78%) 105 (77%) 375 (55%) Other non-NGS molecular biomarker testing only, n (%) 48 (62%) 52 (57%) 38 (34%) 14 (10%) 14 (11%) 0 (0%) 166 (24%) Molecular biomarker testing (NGS and/or other), n (%) 55 (71%) 69 (75%) 84 (74%) 114 (83%) 114 (88%) 105 (77%) 541 (79%) Proportion tested by actionable biomarker, n (%) FLT3-ITD 51 (66%) 64 (70%) 77 (68%) 108 (78%) 106 (82%) 94 (69%) 500 (73%) FLT3-TKD 50 (65%) 63 (68%) 76 (67%) 105 (76%) 106 (82%) 90 (66%) 490 (72%) IDH2 5 (6%) 10 (11%) 34 (30%) 95 (69%) 100 (78%) 102 (75%) 346 (51%) IDH1 5 (6%) 10 (11%) 28 (25%) 91 (66%) 101 (78%) 102 (75%) 337 (49%)

Citation Format: Jeanna Wallenta Law, Zartash Gul, Anna Berry, Michael A. Thompson, Christopher Willner, Sowjanya Vuyyala, Haley McCracken, Katherine Geverd, Frank M. Wolf, Thomas D. Brown, Philip Kuriakose. Molecular biomarker testing and targeted therapy patterns in patients with acute myelogenous leukemia (AML): A real-world data analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6259.

Race-specific genomic determinants of therapeutic response in African American NSCLC patients

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Background: African American (AA) individuals are disproportionately affected by lung cancer in terms of incidence and mortality, despite lower tobacco exposure compared to Caucasian Americans (CA). Since molecular profiling is critically important to guide therapy selection in non-small cell lung cancer (NSCLC), we compared treatment-relevant molecular data in a cohort of AA and CA patients with EGFR or KRAS-driven NSCLC. Methods: This is a retrospective study using a clinicogenomic electronic medical record database from health systems in the United States designed to evaluate outcomes in advanced stage NSCLC. Eligibility criteria for analysis included a diagnosis of NSCLC between 2010 and 2020, stage III or IV, available race/ethnicity data, and identification of common KRAS or EGFR activating variant within 60 days of diagnosis. The primary objective was to define the type of EGFR or KRAS activating variant and determine the frequency of co-occurring alterations in NSCLC-associated genes by cohort (AA and CA). Secondary objectives included examining the timing of genetic testing and use of targeted therapy in these cohorts. Results: A total of 642 NSCLC patients with KRAS (15.0% AA; 81.6% CA) and 348 patients with EGFR oncogenic mutations (13.8% AA; 70.1% CA) met inclusion criteria. Mean time from diagnosis to first molecular test result was 20.9 days for AA vs. 19.9 days for CA (p = 0.5). The EGFR G719S variant was more prevalent in the AA cohort (6.3% AA v 0.4%) with no significant differences observed in the most common KRAS or EGFR variants tested (Table). A total of 100 KRAS-mutant patients (16 AA, 86 CA) had a reported result in at least one co-mutation of interest. The most frequent co-mutations were TP53 (81.3% AA v 65% CA, p = 0.92); KEAP1 (18.8% AA v 8.3% CA, p = 0.52); ATM (18.8% AA v 9.5% CA, p = 0.54); and PTEN (0% AA v 8.3% CA, p = 0.5). A total of 35 EGFR-mutant patients (4 AA, 31 CA) had a co-mutation reported in TP53 (75% AA v 65% CA, p = 0.77). EGFR targeted therapy was reported in 47.9% of AA and 52.9% of CA (p = 0.639). In the KRAS-mutant cohort, delivery of immune checkpoint inhibitors (ICIs) was reported in 29.2% of AA and 39.3% of CA (p = 0.08); chemotherapy was reported in 36.5% AA and 45.2% of CA (p = 0.14). Delivery of both ICI and chemotherapy was reported in 13.5% of AA and 21.9% of CA (p = 0.08). Conclusions: In a real-world cohort of NSCLC patients, we found similar frequencies of common KRAS and EGFR variants in AA and CA, but higher rates of EGFR G719S variant in AA patients. A more comprehensive analysis is needed to further evaluate the trends in co-mutations observed in our analysis, to determine the race-specific impact of these alterations in EGFR and KRAS-driven NSCLC.[Table: see text]

Abstract P3-14-17: Exploring racial disparities in BRCA testing for triple negative breast cancer patients: A real-world data analysis

Background and Objective: BRCA testing for patients (pts) with triple negative breast cancer (TNBC) is important because it has secondary prevention implications for patients and multigenerational implications allowing for earlier detection of BRCA gene carriers in the family and enabling primary prevention. And with the advent of PARP inhibitors it also has treatment implications. The NCCN guidelines recommended in January 2015 that BRCA testing be performed for all pts with TNBC diagnosed at age 60 or younger regardless of race, ethnicity or family history. To understand disparities in BRCA testing among TNBC pts we analyzed the proportion tested, explored barriers to testing, and made comparisons by race, ethnicity, and socioeconomic status (SES). Methods: Adult pts with TNBC diagnosed at or under age 60 between January 1, 2015 and December 31, 2020 were identified in the Syapse Learning Health Network, a real-world database with clinical and genomic data from community health systems. Study end was June 1, 2021, allowing for a minimum follow up of 5 months. Electronic health records were reviewed to calculate proportion tested and barriers to testing. SES was estimated using zip code level median household income from the 2010 census and stratified based on the national poverty level (low <150%, middle 150-299%, high 300%+). χ;2 statistics were used to assess differences between groups. Results: 577 pts with a median age at TNBC of 50 and median follow up of 18 months were included. 65.2% self-identified as white, 27.9% as Black or African American (AA), 1.4% Asian, 1.4% American Indian or Alaska Native, and 4.2% other. 8% identified as Hispanic/Latino. Due to relative size of racial/ethnic groups, the stratified analyses focused on comparisons between white and AA pts. Overall, 459 (79.5%) pts received a test, but with 83% of white pts receiving tests as compared to 72.7% of AA pts (p=0.009). 71.4% of pts with low SES received a test vs. 81.8% for middle and 79.4% with high SES (p=0.068). Among the 118 pts with no test, 48 (40.7%) did not have documentation of a test referral or evidence of testing offered in clinician notes. This differed by race with white pts less likely to have test offer documented vs. AA pts (53.1% vs. 72.7%, p=0.064). Among the 48 pts with no evidence of test offer, additional details were often not documented. However some clinician notes cited a perceived ineligibility due to lack of family history, transferring out or move to hospice, and pt refusal. Among the 70 (59.3%) pts who were offered a test but did not receive it, reasons included 37.1% choosing not to be tested, 11.4% due to early death, loss to follow up or transferring away, and 7.1% lacked adequate health insurance. These reasons varied by race, with 59.4% of AA pts choosing not to be tested vs. 20.6% of white pts (p=0.003) (Table 1). Conclusions: Real-world data provides insight into BRCA testing patterns in routine clinical practice where racial disparities are well documented and persistent. While the overall proportion of pts who received BRCA testing was high, AA pts experienced more barriers. Despite AA pts having greater evidence of a test offer vs. white pts, there was a significant gap in testing favoring white pts, with the most notable reason for lack of testing being pt choice. The clinical significance of BRCA testing in TNBC indicates a need to create targeted strategies to close gaps in education, confidence and access among patients and providers to improve testing levels.

Table 1.BRCA testing barriers among patients who were offered a test but did not receive it (N=70)Total (n=70)White (n=34)Black or African American (n=32)Low SES (n=19)Middle SES (n=43)High SES (n=8)Lack of adequate health insurance, n (%)5 (7.1)3 (8.8)1 (3.1)3 (15.8)1 (2.3)1 (12.5)Patient chose not to be tested, n (%)26 (37.1)7 (20.6)19 (59.4)8 (42.1)14 (32.6)4 (50.0)Deceased before testing occurred, n (%)5 (7.1)3 (8.8)2 (6.3)1 (5.3)4 (9.3)0 (0)LTFU/Transferred, n (%)3 (4.3)2 (5.9)1 (3.1)1 (5.3)1 (2.3)1 (12.5)Other, n (%)7 (10.0)6 (17.6)1 (3.1)1 (5.3)6 (14.0)0 (0)Unknown, n (%)24 (34.3)13 (38.2)8 (25.0)5(26.3)17 (39.5)2 (25.0)

Citation Format: Jeanna Wallenta Law, Hanadi BuAli, Sherri Costa, Michael P. Mullane, Mohamed Hendawi, Michael McPhee, Bryanne Collini, Mahder Teka, Francesca Coutinho, Ronda Broome, Frank M. Wolf, Liz Toland, Trista Weber, Anna Berry, Thomas D. Brown, Haythem Ali. Exploring racial disparities in BRCA testing for triple negative breast cancer patients: A real-world data analysis [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-14-17.

Genomic markers associated with hyperprogression in patients with lung cancer treated with immune checkpoint inhibitors

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Background: Immune checkpoint inhibitor (ICI) therapy has become a mainstay of non-small cell lung cancer (NSCLC) treatment. However, not all patients (pts) benefit with a subset paradoxically experiencing accelerated tumor growth while on ICI. Hyperprogression (HP) refers to accelerated tumor growth on ICI with worsening clinical status. Various gene alterations may be associated with HP including MDM2/MDM4 amplifications, EGFR alterations, and STK11/LKB1 mutations. Kato et al. (doi: 10.1158/1078-0432.CCR-16-3133 ) showed HP in 6/6 pts with MDM2/MDM4 amplification and in 2/10 pts with EGFR alterations. This report describes HP in pts with NSCLC treated with ICIs in a large health system. Methods: Pts with NSCLC treated with ICIs from Jan 2012 to Jan 2021 at Advocate Aurora Health were reviewed after IRB approval. Pts with NSCLC histology (ICD diagnosis codes and/or manual chart review), ICI treatment, and molecular testing were identified via the real world data integrated within the Syapse Learning Health Network platform. Additional chart review to ascertain HP was performed, and molecular results were analyzed. HP criteria include: 1) time-to-treatment failure < 2 months (from start to discontinuation of ICI for any reason), 2) > 50% increase in tumor burden by RECIST, 3) spread of the disease to a new organ between baseline and first radiologic evaluation or clinical deterioration, and 4) ECOG PS ≥ 2 during the first 2 months of treatment. Based on the number of criteria fulfilled, HP = > 3, Progression = 1-2, and non-progressor = 0. Pts with and without HP were compared using Chi-squared and Fisher Exact tests. T-tests were performed for continuous variables. Results: Out of 7,078 NSCLC pts, 1,389 (20%) were treated with ICI including atezolizumab (40 pts, 3%), durvalumab (17 pts, 1%), nivolumab (167 pts, 12%), pembrolizumab (190 pts, 14%), and multiple ICIs (12 pts, 1%). Of those pts treated with ICIs, molecular testing was performed in 427 (31%). 98 of 427 pts (23%)had HP and an additional 86 pts (20%) had progressive disease without meeting the definition of HP. Biomarker associations with HP are shown in the table. By tumor gene alterations, HP was seen in pts with: EGFR (20/60), STK11/LKB1 (16/25); and MDM2/4 (4/7). Conclusions: EGFR, STK11/LKB1, and MDM2/4 gene alterations were all statistically significantly associated with HP. Clinical and molecular predictors of HP need to be explored in order to optimize selection of pts for ICI therapy.[Table: see text]

Rapid real-world data analysis of patients with cancer, with and without COVID-19, across distinct health systems

Background

The understanding of the impact of COVID‐19 in patients with cancer is evolving, with need for rapid analysis.

Aims

This study aims to compare the clinical and demographic characteristics of patients with cancer (with and without COVID‐19) and characterize the clinical outcomes of patients with COVID‐19 and cancer.

Methods and Results

Real‐world data (RWD) from two health systems were used to identify 146 702 adults diagnosed with cancer between 2015 and 2020; 1267 COVID‐19 cases were identified between February 1 and July 30, 2020. Demographic, clinical, and socioeconomic characteristics were extracted. Incidence of all‐cause mortality, hospitalizations, and invasive respiratory support was assessed between February 1 and August 14, 2020. Among patients with cancer, patients with COVID‐19 were more likely to be Non‐Hispanic black (NHB), have active cancer, have comorbidities, and/or live in zip codes with median household income <$30 000. Patients with COVID‐19 living in lower‐income areas and NHB patients were at greatest risk for hospitalization from pneumonia, fluid and electrolyte disorders, cough, respiratory failure, and acute renal failure and were more likely to receive hydroxychloroquine. All‐cause mortality, hospital admission, and invasive respiratory support were more frequent among patients with cancer and COVID‐19. Male sex, increasing age, living in zip codes with median household income <$30 000, history of pulmonary circulation disorders, and recent treatment with immune checkpoint inhibitors or chemotherapy were associated with greater odds of all‐cause mortality in multivariable logistic regression models.

Conclusion

RWD can be rapidly leveraged to understand urgent healthcare challenges. Patients with cancer are more vulnerable to COVID‐19 effects, especially in the setting of active cancer and comorbidities, with additional risk observed in NHB patients and those living in zip codes with median household income <$30 000.

Myocarditis as a rare, yet serious adverse event associated with immune checkpoint inhibitors in patients with non-small cell lung cancer: Case series from a large community-based cancer center

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Background: Patients (pts) with lung cancer and other cancers treated with immune checkpoint inhibitors (ICI) may experience immune related adverse events (irAE). These can present with variable severity and with single- or multi-organ involvement including pneumonitis, colitis, hepatitis, and myocarditis/pericarditis. The incidence of myocarditis has been reported between 0.06% and 2.4% and is associated with a high mortality (25% to 50%). This retrospective review of real-world data (RWD) investigates myocarditis as a high-grade adverse event in pts with lung cancer treated with ICIs. Methods: Pts were identified and characterized using RWD in the Syapse Learning Health Network platform from 2010 to 2020 at Advocate Aurora Health Care. Eligible pts included: ≥18 years old; histologically confirmed NSCLC; and myocarditis diagnosis by ICD codes. Additional chart review was performed to confirm timing of ICI treatment and myocarditis. All pts identification and review were performed after IRB review. Results: 12,686 pts with non-small cell lung cancer were eligible for review. The median age at diagnosis was 70; 54% were female; 86% were White and 12% were Black; 1,975 (15.6%) were treated with an ICI and of those 4 cases (0.2%) of myocarditis were identified. All 4 pts were White females, ages 46, 59, 65, and 74 years. Pathology included lung adenocarcinoma (3) and an undifferentiated lung carcinoma (1). All pts had metastatic disease, and none had a prior history of cardiac disease. ICIs were pembrolizumab (2), durvalumab (1), and nivolumab (1). Median time from initial dose of ICI to diagnosis of myocarditis was 62 days [range: 42-185]. All 4 pts presented with chest pain and elevated troponin T [median 0.07 ng/ml (range: 0.06-0.08)]. All pts had echocardiography at the time of diagnosis, and 2 pts had cardiac MRI that confirmed myocarditis. 3 pts were treated with a prednisone taper. 1 pt died of recurrent congestive heart failure and ventricular tachycardia despite rescue attempt with high dose corticosteroids. 2 pts had additional concomitant irAEs of hypothyroidism/colitis, and thyroiditis/pneumonitis, respectively. Conclusions: Many irAEs are reversible. This RWD analysis confirms that clinically evident myocarditis is a rare but serious adverse event of ICI therapy. Early consideration, diagnosis, and intervention may help prevent poor outcomes. Termination of ICI therapy along with initiation of corticosteroids constitute the current standard of management. Further research is warranted to better identify high risk groups, surveillance measures, and improved management of ICI associated myocarditis.

Abstract S10-02: Using real-world data (RWD) from an integrated platform for rapid analysis of patients with cancer with and without COVID-19 across distinct health systems

Introduction: Reports suggest worsened outcomes in patients with cancer (pts) and COVID-19 (Cov), varying by geography and local peak dynamics. We describe characteristics and clinical outcomes of pts with and without Cov.

Methods: RWD at 2 Midwestern health systems from the Syapse Learning Health Network were used to identify adults with active cancer (AC) or past history of cancer (PHC). AC pts were identified by encounters with ICD-10 code for malignant neoplasm or receipt of an anticancer agent within 12 months prior to February 15, 2020; PHC pts were identified by encounters with an active cancer code from May 15, 2015 to February 15, 2019 and no receipt of anticancer therapy within the prior 12 months. Cov was defined by diagnostic codes and laboratory results from February 15 to May 13, 2020. Comorbidities were assessed prior to February 15, 2020; hospitalizations (hosp), invasive mechanical ventilation (IMV), and all-cause mortality (M) were assessed from February 15 to May 27, 2020.

Results: We identified 800 pts with Cov (0.5%) out of a total of 154,585 pts with AC or PHC. Compared to AC pts without Cov (AC WO, 39,402), AC pts with Cov (AC Cov, 388) were more likely to be non-Hispanic Black (NHB, 39% vs. 9%), have renal failure (RF, 24% vs. 12%), cardiac arrhythmias (33% vs. 19%), congestive heart failure (CHF, 16% vs. 8%), obesity (19% vs. 14%), pulmonary circulation disorder (PCD, 9% vs. 4%), and a zip code with median annual household income (ZMI) &lt;$30k (18% vs. 5%). Comorbidity and income were similarly distributed for PHC pts with Cov (PHC Cov, 412). Compared to PHC pts without Cov (PHC WO, 114,383), coagulopathy (coag) was more common in PHC Cov pts (10% vs. 5%). Hosp for AC Cov pts was higher than for AC WO pts (81% vs. 15%). Hosp for PHC Cov pts was also higher than for PHC WO pts (68% vs. 6%). Hosp was highest for NHB pts in both AC Cov and PHC Cov groups (88% and 72%) and for AC Cov pts in low ZMI (94% in &lt;$30K). Pts &lt;50 years old had hosp rates of 79% (AC Cov) and 49% (PHC Cov). IMV rate for AC Cov pts was higher than for PHC Cov pts (21% vs. 14%). Rates of IMV for AC Cov pts were highest in low ZMI (27%) and in pts with coag (36%). M by group was: AC Cov 16%; AC WO 1%; PHC Cov 11%; PHC WO 1%. Among AC Cov pts, M was higher for men (19% vs. 13%) and pts with PCD (31%), RF (25%), or diabetes (DM, 24%); among PHC Cov pts, M was also higher for men (14% vs. 8%) and pts with coag (30%), valvular disease (27%), or PCD (24%). Increasing age, DM, RF, and PCD were associated with increased risk of M for AC Cov pts in age, race/ethnicity, and comorbidity-adjusted logistic regression; increasing age and coag were associated with M in PHC Cov pts.

Conclusion: In this rapid characterization from RWD, pts with Cov have higher rates of pre-existing cardiopulmonary/vascular and renal conditions and increased risk of hospitalization, IMV, and mortality than pts without Cov. Higher Cov risk and worse outcomes in NHB and lower-income pts suggest health care disparities. Whether these outcomes are due to comorbidities or acute sequelae merits further study, as does investigation of alternative definitions for real-world populations and outcomes.

Citation Format: Shirish M. Gadgeel, Michael A. Thompson, Monika A. Izano, Clara Hwang, Tom Mikkelsen, James L. Weese, Frank M. Wolf, Andrew Schrag, Sheetal Walters, Harpreet Singh, Jonathan Hirsch, Thomas D. Brown, Paul G. Kluetz. Using real-world data (RWD) from an integrated platform for rapid analysis of patients with cancer with and without COVID-19 across distinct health systems [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S10-02.

Educational interventions for asthma in children

BACKGROUND

Self-management education programs have been developed for children with asthma, but it is unclear whether such programs improve outcomes.

OBJECTIVES

To determine the efficacy of asthma self-management education on health outcomes in children.

SEARCH STRATEGY

Systematic search of the Cochrane Airways Group's and Cochrane Schizophrenia Group's Special Registers of Controlled Trials and hand searches of the reference lists of relevant review articles.

SELECTION CRITERIA

Randomized and controlled clinical trials of asthma self-management education programs in children and adolescents aged 2 -18 years.

DATA COLLECTION AND ANALYSIS

All studies were assessed independently by two reviewers. Disagreements were settled by consensus. Study authors were contacted for missing data or to verify methods. Subgroup analyses examined the impact of type and intensity of educational intervention, self-management strategy, trial type, asthma severity, adequacy of follow-up, and study quality.

MAIN RESULTS

Of 45 trials identified, 32 studies involving 3706 patients were eligible. Asthma education programs were associated with moderate improvement in measures of airflow (standardized mean difference [SMD] 0.50, 95% confidence interval [CI] 0.25 to 0.75) and self-efficacy scales (SMD 0.36, 95% CI 0.15 to 0.57). Education programs were associated with modest reductions in days of school absence (SMD -0.14, 95% CI -0.23 to -0.04), days of restricted activity (SMD -0.29, 95% CI -0.49 to -0.08), and emergency room visits (SMD -0.21, 95% CI -0.33 to -0.09). There was a reduction in nights disturbed by asthma when pooled using a fixed-effects but not a random-effects model. Effects of education were greater for most outcomes in moderate-severe, compared with mild-moderate asthma, and among studies employing peak flow versus symptom-based strategies. Effects were evident within the first 6 months, but for measures of morbidity and health care utilization, were more evident by 12 months.

REVIEWER'S CONCLUSIONS

Asthma self-management education programs in children improve a wide range of measures of outcome. Self-management education directed to prevention and management of attacks should be be incorporated into routine asthma care. Conclusions about the relative effectiveness of the various components are limited by the lack of direct comparisons. Future trials of asthma education programs should focus on morbidity and functional status outcomes, including quality of life, and involve direct comparisons of the various components of interventions.

Toward setting a research agenda for systematic reviews of evidence of the effects of medical education

PURPOSE

To provide an update on, and a preliminary research agenda for, best evidence medical education (BEME).

SUMMARY

Efforts related to evidence-based medical education are summarized briefly, including BEME, the newly formed Campbell Collaboration, and the Cochrane Collaboration's Effective Practice and Organization of Care review group. A list of topics and priorities for which evidence of effectiveness in medical education should be systematically reviewed is provided based on the results of a session at the July 2000 annual meeting of the Society of Directors of Research in Medical Education. The highest ranked topics clustered around four major conceptual areas: (a) curricular design, (b) learning and instructional methods, (c) testing and assessment, and (d) outcomes.

CONCLUSIONS

BEME is gaining momentum with growing numbers of people becoming involved as well as an increased number of pertinent workshops, publications, and Web sites. The work of creating pertinent systematic reviews of the medical education literature is at hand.

Working conditions and adverse pregnancy outcome: a meta-analysis

OBJECTIVE

To evaluate the association between working conditions and adverse pregnancy outcomes by performing a meta-analysis of published studies.

DATA SOURCES

We searched the English-language literature in MEDLINE through August 1999 using the terms standing, posture, work, workload, working conditions, shift, occupational exposure, occupational diseases, lifting, pregnancy complications, pregnancy, small for gestational age (SGA), fetal growth retardation (FGR), preterm, and labor.

METHODS OF STUDY SELECTION

We included observational studies evaluating the effect of one or more of the following work-related exposures on adverse pregnancy outcome: physically demanding work, prolonged standing, long work hours, shift work, and cumulative work fatigue score. Outcomes of interest were preterm birth, hypertension or preeclampsia, and SGA.We conducted a meta-analysis based on 160,988 women in 29 studies to evaluate the association of physically demanding work, prolonged standing, long working hours, shift work, and cumulative work fatigue score with preterm birth. Also analyzed were the associations of physically demanding work with hypertension or preeclampsia and SGA infants. The data were analyzed using the Peto-modified Mantel-Haenszel method to estimate the pooled odds ratios (ORs) and 95% confidence intervals (CIs).

TABULATION, INTEGRATION, AND RESULTS

Physically demanding work was significantly associated with preterm birth (OR 1.22, 95% CI 1.16, 1. 29), SGA (OR 1.37, 95% CI 1.30, 1.44), and hypertension or preeclampsia (OR 1.60, 95% CI 1.30, 1.96). Other occupational exposures significantly associated with preterm birth included prolonged standing (OR 1.26, 95% CI 1.13, 1.40), shift and night work (OR 1.24, 95% CI 1.06, 1.46), and high cumulative work fatigue score (OR 1.63, 95% CI 1.33, 1.98). We found no significant association between long work hours and preterm birth (OR 1.03, 95% CI 0.92, 1.16).

CONCLUSION

Physically demanding work may significantly increase a woman's risk of adverse pregnancy outcome.

The importance of race in medical student performance of an AIDS risk assessment interview with simulated patients

INTRODUCTION

This study was done to ascertain the effect of race on medical student-patient communication. The primary hypothesis was that interviewing performance scores would be higher when race of student and race of simulated patient instructor (SPI) were concordant than when they were discordant.

METHODS

Data obtained from student interactions with four Caucasian and four African American female SPIs participating in a case involving an AIDS risk assessment interview were analysed. Performance was assessed using two instruments: an 8-item behaviourally anchored interviewing skills scale and a 14-item checklist reflecting content relevant to sexual behaviour and AIDS risk. SPI groups were comparable and SPIs were trained to a high level of inter-rater reliability. Students (24 African American and 180 non-African American) were assigned to SPIs based on the spelling of the student's name. Performance was scored independently at the conclusion of each interview by both the SPI and the student her/himself.

RESULTS

African American students had lower scale scores than non-African American students in interactions with Caucasian (but not African American) SPIs; and all student scores, both on the skills scale and the content checklist, were higher with African American than with Caucasian SPIs (as assessed by both SPI and student). Women students had higher scores than men.

CONCLUSIONS

Race of SPI has an influence on student performance of an AIDS risk assessment interview. Further studies focusing on racial interactions in the medical interview are required. It appears that race of SPI may need to be accounted for in the development and interpretation of SPI-based clinical competence exams.

Near-infrared spectroscopy for fetal assessment during labour

BACKGROUND

Over the past four decades, continuous electronic fetal monitoring (EFM) has been increasingly employed to detect fetal acidemia in labor, with a view toward prevention of hypoxic ischemic encephalopathy, permanent neurologic injury, and death. Although very sensitive, this technology has low specificity, and a high false positive rate. This false positive rate has resulted in operative intervention on behalf of many fetuses who were not in fact in danger of neurologic injury or death. Near-infrared spectroscopy has been developed to directly measure fetal cerebral oxygenation, with a view toward identification of those fetuses truly at risk.

OBJECTIVES

To determine the effects of the use of near-infrared spectroscopy (NIRS) to assess fetal condition during labour, on maternal and perinatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: November 1999.

SELECTION CRITERIA

Randomized trials comparing near-infrared spectroscopy with continuous EFM alone or continuous EFM and scalp pH.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed by one reviewer.

MAIN RESULTS

No randomized trials were identified. Thus no studies were included.

REVIEWER'S CONCLUSIONS

There is currently insufficient evidence to assess the efficacy of fetal surveillance by near-infrared spectroscopy.

Enhancement of clinicians' diagnostic reasoning by computer-based consultation: a multisite study of 2 systems

CONTEXT

Computer-based diagnostic decision support systems (DSSs) were developed to improve health care quality by providing accurate, useful, and timely diagnostic information to clinicians. However, most studies have emphasized the accuracy of the computer system alone, without placing clinicians in the role of direct users.

OBJECTIVE

To explore the extent to which consultations with DSSs improve clinicians' diagnostic hypotheses in a set of diagnostically challenging cases.

DESIGN

Partially randomized controlled trial conducted in a laboratory setting, using a prospective balanced experimental design in 1995-1998.

SETTING

Three academic medical centers, none of which were involved in the development of the DSSs.

PARTICIPANTS

A total of 216 physicians: 72 at each site, including 24 internal medicine faculty members, 24 senior residents, and 24 fourth-year medical students. One physician's data were lost to analysis.

INTERVENTION

Two DSSs, ILIAD (version 4.2) and Quick Medical Reference (QMR; version 3.7.1), were used by participants for diagnostic evaluation of a total of 36 cases based on actual patients. After training, each subject evaluated 9 of the 36 cases, first without and then using a DSS, and suggested an ordered list of diagnostic hypotheses after each evaluation.

MAIN OUTCOME MEASURE

Diagnostic accuracy, measured as the presence of the correct diagnosis on the hypothesis list and also using a derived diagnostic quality score, before and after consultation with the DSSs.

RESULTS

Correct diagnoses appeared in subjects' hypothesis lists for 39.5% of cases prior to consultation and 45.4% of cases after consultation. Subjects' mean diagnostic quality scores increased from 5.7 (95% confidence interval [CI], 5.5-5.9) to 6.1 (95% CI, 5.9-6.3) (effect size: Cohen d = 0.32; 95% CI, 0.23-0.41; P<.001). Larger increases (P = .048) were observed for students than for residents and faculty. Effect size varied significantly (P<.02) by DSS (Cohen d = 0.20; 95% CI, 0.08-0.32 for ILIAD vs Cohen d = 0.45; 95% CI, 0.31-0.59 for QMR).

CONCLUSIONS

Our study supports the idea that "hands-on" use of diagnostic DSSs can influence diagnostic reasoning of clinicians. The larger effect for students suggests a possible educational role for these systems.

Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?

CONTEXT

Although physicians report spending a considerable amount of time in continuing medical education (CME) activities, studies have shown a sizable difference between real and ideal performance, suggesting a lack of effect of formal CME.

OBJECTIVE

To review, collate, and interpret the effect of formal CME interventions on physician performance and health care outcomes.

DATA SOURCES

Sources included searches of the complete Research and Development Resource Base in Continuing Medical Education and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group, supplemented by searches of MEDLINE from 1993 to January 1999.

STUDY SELECTION

Studies were included in the analyses if they were randomized controlled trials of formal didactic and/or interactive CME interventions (conferences, courses, rounds, meetings, symposia, lectures, and other formats) in which at least 50% of the participants were practicing physicians. Fourteen of 64 studies identified met these criteria and were included in the analyses. Articles were reviewed independently by 3 of the authors.

DATA EXTRACTION

Determinations were made about the nature of the CME intervention (didactic, interactive, or mixed), its occurrence as a 1-time or sequenced event, and other information about its educational content and format. Two of 3 reviewers independently applied all inclusion/exclusion criteria. Data were then subjected to meta-analytic techniques.

DATA SYNTHESIS

The 14 studies generated 17 interventions fitting our criteria. Nine generated positive changes in professional practice, and 3 of 4 interventions altered health care outcomes in 1 or more measures. In 7 studies, sufficient data were available for effect sizes to be calculated; overall, no significant effect of these educational methods was detected (standardized effect size, 0.34; 95% confidence interval [CI], -0.22 to 0.97). However, interactive and mixed educational sessions were associated with a significant effect on practice (standardized effect size, 0.67; 95% CI, 0.01-1.45).

CONCLUSIONS

Our data show some evidence that interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and, on occasion, health care outcomes. Based on a small number of well-conducted trials, didactic sessions do not appear to be effective in changing physician performance.

Training students in education of the hypertensive patient: enhanced performance after a simulated patient instructor (SPI)-based exercise

The process whereby a physician explains to the ill patient what has gone wrong and what can be done about it can be taught and evaluated by simulated patients (SPIs). This study was designed to determine whether a training experience in educating a diabetic SPI improves subsequent performance with a hypertensive SPI. Competence in educating a hypertensive SPI by students who had no prior training experience (n = 26) was compared to that of an experimental group (n = 20) that had a prior training session. Performance was assessed with a counseling skills scale and a case-specific content checklist (1 = poor to 5 = excellent). Students in the experimental group performed better than controls in both counseling skills (4.46 v 3.86, P < .01) and completeness of coverage of content (3.28 v 2.65, P < .01). Students in both groups focused more on clinical features and treatment than on laboratory testing and follow-up. The ability to counsel "patients" with hypertension can be enhanced by a prior learning experience with a diabetic SPI. Clinical application of knowledge about hypertension can be assessed by SPIs.

Development and evaluation of an instrument to assess medical students' cultural attitudes

This paper describes the development and psychometric evaluation of an instrument designed to assess medical students' comfort with a range of sociocultural issues and intercultural experiences. Each survey item obliged students to reflect on their own sociocultural identities and academic status in relation to others', and to judge how comfortable they would be interacting across perceived boundaries based on sociocultural identity and academic status. More than 90% of University of Michigan first-year medical students (n=153) completed the survey just before classes began. Principal components analysis of the survey's 26 items identified 7 interpretable factors or subscales; the Cronbach alpha reliability coefficients for the 7 subscales and the total scale ranged from .73 to .92. T-tests were used to investigate differences in average ratings among student subgroups (based on gender and ethnicity). To assess the magnitude of the effect of the differences between groups, effect size was computed for each of the means comparisons. Psychometric analyses indicated that this survey was both reliable and valid for assessing students' cultural attitudes. Further, analyses by gender and ethnic subgroup identified meaningful ratings differences in men's and women's reported comfort levels. Our findings suggest that this instrument is useful for assessing students' openness to developing cultural awareness and competence. Educators at other medical schools may find this instrument useful as a needs assessment tool for planning educational programs designed to increase students' cultural competence.

Premature rupture of membranes at term: a meta-analysis of three management schemes

OBJECTIVE

To compare rates of cesarean birth, endometritis, chorioamnionitis, and serious neonatal infections among pregnancies complicated by premature rupture of membranes (PROM) at term and managed by immediate oxytocin induction, by conservative management (or delayed oxytocin induction), or by vaginal (or endocervical) prostaglandin E2, gel, suppositories, or tablets.

DATA SOURCES

The English-language literature in MLD, LINE and other databases was searched through April 1996 using the terms "fetal membranes," "premature rupture," and "term."

METHODS OF STUDY SELECTION

We included randomized trials comparing two or more management schemes for PROM at term.

TABULATION, INTEGRATION, AND RESULTS

Twenty-three studies with a total of 7493 subjects met the inclusion criteria and were included for analysis. Data regarding chorioamnionitis, endometritis, neonatal infections, and cesarean delivery were extracted. Meta-analyses were performed for the three interventions for these outcomes of interest using the Der-Simonian and Laird and Mantel-Haenszel techniques to estimate the pooled odds ratios (ORs). No statistically significant differences in cesarean deliveries or neonatal infections were noted among management schemes. Vaginal prostaglandins resulted in more chorioamnionitis than immediate oxytocin (OR 1.55, 95% confidence interval [CI] 1.09, 2.21), but less chorioamnionitis than conservative management (OR 0.68, 95% CI 0.51, 0.91). Immediate oxytocin induction resulted in fewer cases of chorioamnionitis (OR 0.67, 95% CI 0.52, 0.85) and endometritis (OR 0.71, 95% CI 0.51, 0.99) than conservative management, although these results achieved significance only with the Mantel-Haenszel technique.

CONCLUSION

Conservative management may result in more maternal infections than immediate induction with oxytocin or prostaglandins.

Teaching smoking-cessation counseling to medical students using simulated patients

OBJECTIVE

Our objective was to evaluate the effectiveness of using simulated patient instructors and the Ockene method to instruct third-year medical students in smoking-cessation counseling techniques.

DESIGN

We used a clinical exercise with self-study preparation and simulated patient instructors.

METHODS

One hundred fifty-nine students participated in a smoking-cessation counseling session in which cognitive and behavioral endpoints were assessed by simulated patient instructors and the students themselves.

RESULTS

Student performance in the cognitive and behavioral components of model smoking-cessation counseling was acceptable. Specific areas of weakness, such as the tendency of students to underemphasize the personal and social benefits of smoking cessation, and to overestimate their competence on a number of skill items, were identified. Student evaluation of the exercise was positive.

CONCLUSIONS

Smoking-cessation counseling can be taught effectively to third-year medical students by simulated patient instructors during a clinical clerkship.

Teaching skills for accessing and interpreting information from systematic reviews/meta-analyses, practice guidelines, and the Internet

Skills and practice related to accessing and interpreting clinical information from systematic reviews/meta-analyses, practice guidelines, and the Internet have been integrated into a new senior year elective designed to teach medical students how to critically appraise information from a variety of sources and evaluate it's applicability to patient care. Small groups of senior medical students under the direction of a multidisciplinary team (behavioral scientist, information specialist, physician) facilitate discussions of clinical articles using checklists designed to evaluate their quality. The central feature of the course is a demonstration of the Cochrane Database of Systematic Reviews (CDSR), an electronic journal distributed by BMJ Publishing, and the requirement that students conduct a literature review on a topic of their choice and present an oral and written summary in the form of a "draft" meta-analysis. Students are provided with strategies to "surf" the Internet/WWW for information, e.g., practice guidelines/treatment protocols, descriptions of on-going clinical trials. A total of 52 students have participated to date. Students have selected project topics across a wide range of medical disciplines, including internal medicine, family practice, OB/GYN, pediatrics, surgery, neurology, emergency medicine, and psychiatry. The course is one of the most favorably evaluated of all senior electives and rated more favorably than the overall mean ratings for all electives combined on 8 of 9 scales, including "Quality of course overall" (4.39 vs. 3.92 on 5-point scale).

Changes in diagnostic decision-making after a computerized decision support consultation based on perceptions of need and helpfulness: a preliminary report

We examined the degree to which attending physicians, residents, and medical students' stated desire for a consultation on difficult-to-diagnose patient cases is related to changes in their diagnostic judgments after a computer consultation, and whether, in fact, their perceptions of the usefulness of these consultations are related to these changes. The decision support system (DSS) used in this study was ILIAD (v4.2). Preliminary findings based on 16 subjects' (6 general internists, 4 second-year residents in internal medicine, and 6 fourth-year medical students) workup of 136 patient cases indicated no significant main effects for 1) level of experience, 2) whether or not subjects indicated they would seek a diagnostic consultation before using the DSS, or 3) whether or not they found the DSS consultation in fact to be helpful in arriving at a diagnosis (p > .49 in all instances). Nor were there any significant interactions. Findings were similar using subjects or cases as the unit of analysis. It is possible that what may appear to be counter-intuitive, and perhaps irrational, may not necessarily be so. We are currently examining potential explanatory hypotheses in our ongoing current, larger study.

Exercise participation in a frail elderly population

A low-intensity exercise demonstration project was developed jointly by researchers, social service practitioners, and program participants to actively involve frail older people in their own health maintenance. This article describes this collaborative process and its impact on the success of the health promotion program, which was conducted at three senior centers serving a low-income, urban elderly population. Participants were predominantly sedentary women over age 70 with multiple chronic conditions. The program was conducted with peer leaders to facilitate its continuation after the research demonstration phase. In addition to positive health outcomes related to functional mobility, blood pressure maintenance, and overall well-being, this intervention was successful in sustaining active participation in regular physical activity through the use of peer leaders selected by the program participants. The planning, implementation, and outcomes of this project illustrate the benefits and challenges of combining research and practice perspectives in conducting health promotion interventions with older populations.

The influence of a decision support system on the differential diagnosis of medical practitioners at three levels of training

As computer-based diagnostic consultation systems become, available, their influence and usefulness need to be evaluated. This report, based on partial data from a larger study, examines the influence of Iliad, a diagnostic consultation system, on the differential diagnosis of fourth year medical students, residents in medicine, and attendings in general internal medicine. Our results show that when faced with difficult diagnostic cases, medical students add significantly more diagnoses from Iliad's differential than do residents or attendings. However, the quality of Iliad's diagnostic advice in terms of the presence of the correct diagnosis, is no better for consultations done by students or residents compared to attendings.

Effects of a decision support system on the diagnostic accuracy of users: a preliminary report

OBJECTIVES

To assess the effects of incomplete data upon the output of a computerized diagnostic decision support system (DSS), to assess the effects of using the system upon the diagnostic opinions of users, and to explore if these effects vary as a function of clinical experience.

DESIGN

Experimental pilot study. Four clusters of nine cases each were constructed and equated for case difficulty. Definitive findings were omitted from the case abstracts. Subjects were randomly assigned to one of four clusters and were trained on the DSS prior to use.

SUBJECTS

The study involved 16 physicians at three levels of clinical experience (six general internists, four residents in internal medicine, and six fourth-year medical students), from three academic medical centers.

PROCEDURE

Each subject worked up nine cases, first without and then with ILIAD consultation. They were asked to offer up to six potential diagnoses and to list up to three steps that should be the next items in the diagnostic workup. Effects of DSS consultation were measured by changes in the position of the correct diagnosis in the lists of differential diagnoses, pre- and post-consultation.

RESULTS

The DSS lists of diagnostic possibilities contained the correct diagnosis in 38% of cases, about midway between the levels of accuracy of residents and attending general internists. In over 70% of cases, the DSS output had no effect on the position of the correct diagnosis in the subjects' lists. The system's diagnostic accuracy was unaffected by the clinical experience of the users.

Strategies for integrating computer-based activities into your educational environment: a practical guide

Strategies for implementing instructional technology are based on recent experiences at the University of Michigan Medical Center. The issues covered include 1) addressing facilities, hardware, and staffing needs, 2) determining learners' skill requirements and appropriate training activities, and 3) selecting and customizing educational software. Many examples are provided, and nine key points for success are emphasized.

Adaptation of a general optimism scale for use with older women

The Life Orientation Test has been widely used with various populations since its development, but its psychometric properties among older adults have not been assessed. This study employed exploratory factor analysis to examine the factor structure of a modified version of the test for 90 frail older women. The results do not support a unidimensional conceptualization of optimism. Internal consistency reliability was lower for the entire scale than for separate factors representing positively versus negatively framed questions. Some support for construct validity was shown by small to moderate correlations with several related constructs. The results were likely to have been affected both by the modification of the test to simplify data collection with an elderly population and by a differing manifestation of the construct among functionally impaired older adults as compared to previous research with younger, healthier samples.

A prospective study identifying risk factors for discontinuance of insulin pump therapy

OBJECTIVE

To identify characteristics of adult patients at baseline associated with duration of subsequent, continuous, subcutaneous infusion of insulin treatment (pump therapy) of type I diabetes.

RESEARCH DESIGN AND METHODS

For 6 wk, patients followed a standardized conventional therapy and kept a record of insulin dosages, capillary blood glucose concentrations, and symptomatic hypoglycemia. They were then hospitalized. Additional baseline data were obtained and pump therapy was started. Survival analysis was used to determine the relationship between baseline independent variables or risk factors and duration of pump therapy, which is the dependent variable.

RESULTS

Of the 68 participants, 33 (49%) terminated pump therapy after an average of 9.9 mo of treatment. Two models (each P < 0.00005) were developed that exhibited a high degree of consistency. Of the 6 variables, 5 were common to both models (HbA1, autonomic neuropathy, mean amplitude of glycemic excursions, frequency of symptoms of hypoglycemia when blood glucose was < 70 mg/dl, and erythema at injection sites). The sixth variable in model 1 (insulin dosage) was replaced in model 2 by a variable, Adult Self-Efficacy for Diabetes, which was obtained on the 33 more recently enrolled patients; this variable related to patient perceptions of self-care behaviors.

CONCLUSIONS

We found that, at baseline, the presence of a high concentration of HbA1 and a low estimation by the patient of their ability to treat the disease portend failure of insulin pump therapy as evidenced by its discontinuation. This effect is accentuated when clinical evidence of autonomic neuropathy is observed. These findings offer guidance in selecting patients with type I diabetes for insulin pump therapy.

Medical student use of history and physical information in diagnostic reasoning

Clinical data gathering is central to clinical competence. Although research has demonstrated the value to experienced clinicians of information obtained from the history, little is known of how medical students use this information. In the present study, two case simulations (in rheumatoid arthritis and systemic lupus erythematosis) were developed to assess medical student information gathering and utilization. The results indicate that most of the students were already considering the correct diagnosis as a possibility after the presenting complaint and patient description. However, the medical history exerted the strongest influence on transforming the correct diagnosis from just another diagnostic possibility into the favored diagnostic candidate. Students who failed to list the correct diagnosis in the differential diagnosis after obtaining the history were significantly less likely to reach the correct diagnosis at the end of the case. These results confirm the critical importance of the history in medical problem solving.

ATLAS-plus: multimedia instruction in embryology, gross anatomy, and histology

ATLAS-plus [Advanced Tools for Learning Anatomical Structure] is a multimedia program used to assist in the teaching of anatomy at the University of Michigan Medical School. ATLAS-plus contains three courses: Histology, Embryology, and Gross Anatomy. In addition to the three courses, a glossary containing terms from the three courses is available. All three courses and the glossary are accessible in the ATLAS-plus environment. The ATLAS-plus environment provides a consistent set of tools and options so that the user can navigate easily and intelligently in and between the various courses and modules in the ATLAS-plus world. The program is a collaboration between anatomy and cell biology faculty, medical students, graphic artists, systems analysts, and instructional designers.

Information gathering and integration as sources of error in diagnostic decision making

This research examined the relative importance of information gathering versus information utilization in accounting for errors in diagnostic decision making. Two experiments compared physicians' performances under two conditions: one in which they gathered a limited amount of diagnostic information and then integrated it before making a decision, and the other in which they were given all the diagnostic information and needed only to integrate it. The physicians: 1) frequently failed to select normatively optimal information in both experimental conditions; 2) were more confident about the correctness of their information selection when their task was limited to information integration than when it also included information gathering; and 3) made diagnoses in substantial agreement with those indicated by applying normative procedures to the same data. Physicians appear to have difficulties recognizing the diagnosticity of information, which often results in decisions that are pseudodiagnostic or based on diagnostically worthless information.

The effect of training on medical students' responses to geriatric patient concerns: results of a linguistic analysis

The results of a randomized, controlled study indicated that an experience-based educational intervention in which medical students interview volunteer nursing home residents significantly changed medical students' responses to two geriatric patient vignettes. Despite prevailing ageist biases, the intervention enhanced students' abilities to identify and respond therapeutically to hypothetical elderly patients' underlying expressions of concern and, furthermore, prepared students for patient-centered geriatric interviewing. The use of elderly volunteers to assist in practice interview sessions helps sensitize future physicians to the problems of aging and teaches them empathic communication skills.

Effects of peer-group intervention on metabolic control of adolescents with IDDM. Randomized outpatient study

In children with insulin-dependent diabetes mellitus (IDDM), deterioration in metabolic control frequently occurs during early adolescence. To prevent this predictable increase in blood glucose levels, we randomly assigned young adolescents with IDDM to an intervention based on problem solving with self-monitoring of blood glucose (SMBG) integrated into standard outpatient care or to standard care only for an 18-mo period. At follow-up, 50% of the standard-care adolescents exhibited greater than 1% increase in glycosylated hemoglobin (HbA1) levels over baseline values, indicating a deterioration in metabolic control, compared to only 23% of the intervention group. Follow-up HbA1 means +/- SD were 10.10 +/- 2.00% for intervention and 11.04 +/- 2.28% for standard-care adolescents, indicating a significantly lower value in the intervention group (P = .04). At follow-up, a greater percentage of intervention than standard-care adolescents reported using SMBG information when they exercised (60.0 vs. 33.3%, chi 2 = 4.29, P = .04). Our data suggest that clinic-based problem-solving groups can be more effective with young adolescents with IDDM than conventional treatment in preventing the expected deterioration in blood glucose.

Quality of life activities associated with adherence to insulin infusion pump therapy in the treatment of insulin dependent diabetes mellitus

The impact of continuous subcutaneous insulin infusion (CSII) pump therapy on patients' activities of daily living and the prevalence of acute complications were examined in order to characterize patients' experience while on CSII, and to ascertain whether any of these factors could be associated with continued use of CSII. Fifty-one of 55 patients (93%) identified as initiating CSII in our medical center patient population completed retrospective surveys; 37 individuals (73%) were still using pumps and 14 individuals (27%) had discontinued pump use. CSII appeared to affect the quality of daily activities only modestly, neither improving nor interfering with many activities to any great degree. Activities associated with greatest improvements were eating, working, traveling, sleeping, and exercising. Results of logit analyses adjusting for duration of pump therapy indicated that the prevalence of six different acute complications (skin infections at the needle site, mild insulin reactions, more severe insulin reactions requiring assistance, hypoglycemic coma, asymptomatic hypoglycemia, and ketoacidosis) was not statistically associated with patients' decisions to continue or to stop CSII. In contrast, significant differences (p less than 0.05) between the groups continuing and discontinuing CSII were found in 11 of 18 activities of daily living. In general, patients continuing CSII, in contrast to those discontinuing CSII, found that many of their activities were improved significantly during pump therapy. There were few differences between groups in the degree to which CSII was perceived to interfere with daily activities. However, those continuing CSII found it significantly less necessary to take the pump off while doing some activities than did those discontinuing CSII.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of general and case-related experience on primary care treatment decision making

In an effort to examine how general vs case-related clinical experience influenced physicians' treatment decisions, four clinical case vignettes (rheumatoid arthritis, fever of undetermined origin, exercise-induced asthma, and cor pulmonale) were presented to 387 primary care physicians. For each case, physicians indicated (1) their willingness to proceed with treatment without seeking additional information, (2) their preferences for sources of supplementary information, and (3) their preferences for continued care responsibility. The results indicated that the nature of the particular vignette had a major impact on how physicians made treatment decisions. Also, having greater case-related experience and being younger led to greater willingness to proceed with treatment and preferences for continued care responsibility. Preferences for information sources were largely independent of either form of experience. Treatment decision making appears to be quite dependent on experience with similar problems and being up-to-date on current treatment procedures.

Development and evaluation of diabetes continuing education courses for health professionals: a synthesis of eight years of experience

Fifteen continuing education courses in diabetes care attended by 943 health professionals were evaluated and synthesized using meta-analytic techniques. Objective and subjective evalu ation results were used to monitor and improve the quality of the programs. Participants' knowl edge of diabetes care issues improved an average of 36 percentile points (P<.001), providing objective evidence of the positive impact of the courses. Favorable ratings by participants of the usefulness of the course content in meeting their own learning needs provided subjec tive evidence of the value of the courses. A follow-up survey of participants six months later indicated that more than 80 % were successful in changing the educational and psychosocial aspects of their health care practices as a result of course attendance. Many reported increased understanding of the psychosocial aspects of diabetes and compliance problems, greater confidence in their dietary recom mendations and patient education skills, and increased personal satisfaction from their diabetes patient care.

Confrontation and politeness strategies in physician-patient interactions

The therapeutic success of physician-patient interactions depends in large part on how physicians interpret and respond to patients' implicit and explicit messages. Using a hypothetical vignette, in which a patient refuses to comply with a recommended therapeutic regimen, we found that first-year medical students with no classroom training in medical interviewing implicitly recognized that the situation called for face preserving or polite linguistic behavior. Ninety percent of them used culturally sanctioned politeness forms to repair the conversational breakdown depicted in the vignette. They responded to this clinical scenario, however, with linguistic behaviors borrowed from their everyday interactions, some of which were culturally appropriate, but not necessarily therapeutic. We suggest that students can learn to adapt their culturally appropriate behaviors and engage in therapeutic communication as physicians if they are given the necessary conceptual tools. We discuss how Brown and Levinson's theories of politeness and strategic language usage can (1) provide a framework for interpreting communication in general and physician-patient interaction in particular, (2) illuminate some of the problems inherent in doctor-patient encounters, and (3) be used prescriptively for teaching students and health professionals how to avoid some communication difficulties.

The effects of a cost-education program on hospital charges

An educational intervention designed to change physicians' use of inpatient services was implemented on two general medical services for a year. The intervention consisted of a brief orientation to cost containment issues, a pamphlet that outlined practical cost containment strategies and listed the charges for commonly ordered tests and services, and access to detailed interim patients' bills generated during the hospitalization. Two concurrent control services received no intervention. Over 1,600 admissions were evaluated. The geometric mean length of stay was 0.61 days shorter on intervention services compared with control (5.15 vs. 5.76 days, p less than 0.01). The geometric mean hospital charges were $388 less for intervention patients ($3,199 vs. $3,587, p less than 0.005). Neither patients' demographic characteristics nor case mix could explain the reductions. The authors conclude that a simple program utilizing information already in existence in most hospitals can result in a significant and meaningful reduction in length of stay and charges.

Information-seeking strategies and differences among primary care physicians

Differences in the sources of information that physicians utilize in their practice have several implications for the quality of care delivered and the dissemination of medical information. In order to examine the extent of differences in information preferences in primary care settings, 98 general internal medicine physicians and 73 family physicians were asked to indicate which of six alternative information sources they relied on most when faced with difficult medical problems. The alternatives were: journals, textbooks, informal consultations with colleagues, consultations with community specialists, consultations with outside specialists, and transfer of the patient to another physician. The results indicated that primary care internists have a greater preference for consulting the medical literature, while family physicians more often rely on colleagues and specialists as sources of information. These differences suggest that the focus of information dissemination through journals or textbooks may be more effective for internists, while colleagues or "educationally influential" physicians in the community may be more effective vehicles for information dissemination to family physicians.