Alice J. Watson

The Role of Online Support Communities: Benefits of Expanded Social Networks to Patients With Psoriasis

OBJECTIVE To determine the demographics, usage patterns, attitudes, and experiences of online support site users. DESIGN Online survey. Patients A total of 260 subjects recruited from 5 online psoriasis support groups. MAIN OUTCOME MEASURES An exploratory analysis was performed to determine demographic and disease characteristics of online support site users. Perceived benefits were also documented. RESULTS The mean (SD) age of respondents was 40.1 (11.5) years (range, 18-75 years), most (75.7%) were white, female (60.4%), and college educated (84.3%). Key factors associated with use of online support sites included availability of resources (95.3%), convenience (94.0%), access to good advice (91.0%), and the lack of embarrassment when dealing with personal issues (90.8%). The most common activities were posting messages (65.0%) and searching for information (63.1%). Nearly half of all respondents perceived improvements in their quality of life (49.5%) and psoriasis severity (41.0%) since joining the site. Intensity of participation in online support activities was associated with improved quality of life (P = .002), but not with improvements in psoriasis severity. CONCLUSIONS Our data demonstrate that psoriasis virtual communities offer users both a valuable educational resource and a source of psychological and social support. Such benefits could be further enhanced by physician engagement within these communities.

How Doctors Choose Medications to Treat Type 2 Diabetes A national survey of specialists and academic generalists

OBJECTIVE—Glycemic control remains suboptimal despite the wide range of available medications. More effective medication prescription might result in better control. However, the process by which physicians choose glucose-lowering medicines is poorly understood. We sought to study the means by which physicians choose medications for type 2 diabetic patients. RESEARCH DESIGN AND METHODS—We surveyed 886 physician members of either the Society of General Internal Medicine (academic generalists, response rate 30%) or the American Diabetes Association (specialists, response rate 23%) currently managing patients with type 2 diabetes. Respondents weighed the importance of 15 patient, physician, and nonclinical factors when deciding which medications to prescribe for type 2 diabetic subjects at each of three management stages (initiation, use of second-line oral agents, and insulin). RESULTS—Respondents reported using a median of five major considerations (interquartile range 4–6) at each stage. Frequently cited major considerations included overall assessment of the patients health/comorbidity, A1C level, and patients adherence behavior but not expert guidelines/hospital algorithms or patient age. For insulin initiation, academic generalists placed greater emphasis on patient adherence (76 vs. 60% of specialists, P < 0.001). These generalists also identified patient fear of injections (68%) and patient desire to prolong noninsulin therapy (68%) as major insulin barriers. Overall, qualitative factors (e.g., adherence, motivation, overall health assessment) were somewhat more highly considered than quantitative factors (e.g., A1C, age, weight) with mean aggregate scores of 7.3 vs. 6.9 on a scale of 0–10, P < 0.001. CONCLUSIONS—The physicians in our survey considered a wide range of qualitative and quantitative factors when making medication choices for hyperglycemia management. The apparent complexity of the medication choice process contrasts with current evidence-based treatment guidelines.

An Internet-Based Virtual Coach to Promote Physical Activity Adherence in Overweight Adults: Randomized Controlled Trial

Background Addressing the obesity epidemic requires the development of effective, scalable interventions. Pedometers and Web-based programs are beneficial in increasing activity levels but might be enhanced by the addition of nonhuman coaching. Objectives We hypothesized that a virtual coach would increase activity levels, via step count, in overweight or obese individuals beyond the effect observed using a pedometer and website alone. Methods We recruited 70 participants with a body mass index (BMI) between 25 and 35 kg/m2 from the Boston metropolitan area. Participants were assigned to one of two study arms and asked to wear a pedometer and access a website to view step counts. Intervention participants also met with a virtual coach, an automated, animated computer agent that ran on their home computers, set goals, and provided personalized feedback. Data were collected and analyzed in 2008. The primary outcome measure was change in activity level (percentage change in step count) over the 12-week study, split into four 3-week time periods. Major secondary outcomes were change in BMI and participants’ satisfaction. Results The mean age of participants was 42 years; the majority of participants were female (59/70, 84%), white (53/70, 76%), and college educated (68/70, 97%). Of the initial 70 participants, 62 completed the study. Step counts were maintained in intervention participants but declined in controls. The percentage change in step count between those in the intervention and control arms, from the start to the end, did not reach the threshold for significance (2.9% vs –12.8% respectively, P = .07). However, repeated measures analysis showed a significant difference when comparing percentage changes in step counts between control and intervention participants over all time points (analysis of variance, P = .02). There were no significant changes in secondary outcome measures. Conclusions The virtual coach was beneficial in maintaining activity level. The long-term benefits and additional applications of this technology warrant further study. Trial Registration ClinicalTrials.gov NCT00792207; http://clinicaltrials.gov/ct2/show/NCT00792207 (Archived by WebCite at http://www.webcitation.org/63sm9mXUD)

A randomized trial to evaluate the efficacy of online follow-up visits in the management of acne.

OBJECTIVE To evaluate whether delivering acne follow-up care via an asynchronous, remote online visit (e-visit) platform produces equivalent clinical outcomes to office care. DESIGN A prospective, randomized controlled study. SETTING Two teaching hospitals in Boston between September 2005 and May 2007. PARTICIPANTS A total of 151 patients with mild to moderate facial acne. INTERVENTIONS Subjects were asked to carry out 4 follow-up visits using either an e-visit platform or conventional office care. At 6-week intervals, subjects in the e-visit group were prompted to send images of their skin and an update, via a secure Web site, to their dermatologist. Dermatologists responded with advice and electronic prescriptions. MAIN OUTCOME MEASURES The primary outcome measure was change in total inflammatory lesion count between the first and last visit. The major secondary outcomes were subject and dermatologist satisfaction with care and length of time to complete visits. RESULTS The mean age of subjects was 28 years; most were female (78%), white (65%), and college educated (69%). One hundred twenty-one of the initial 151 subjects completed the study. The decrease in total inflammatory lesion count was similar in the e-visit and office visit groups (6.67 and 9.39, respectively) (P = .49). Both subjects and dermatologists reported comparable satisfaction with care regardless of visit type (P = .06 and P = .16, respectively). Compared with office visits, e-visits were time saving for subjects and time neutral for dermatologists (4 minutes, 8 seconds vs 4 minutes, 42 seconds) (P = .57). CONCLUSION Delivering follow-up care to acne patients via an e-visit platform produced clinical outcomes equivalent to those of conventional office visits.

Diabetes Connected Health: A Pilot Study of a Patient- and Provider-Shared Glucose Monitoring Web Application

Background: Real-time sharing of blood glucose results with providers could improve communication and lead to more timely medication titration. New technology platforms are available to support the delivery of innovative models of care delivery. Methods: In the Diabetes Connected Health (DCH) pilot study, patients with diabetes received access to an online application that stored and graphed glucose readings uploaded from a standard glucometer. Both patients and providers had access to this Web site, where data could be viewed, analyzed, and discussed. To examine the impact of the DCH program, we assessed adoption of the program, patient and provider satisfaction, frequency of use, and changes in glucose levels over a period of 3 months. Results: The mean age of the 7 pilot participants was 51 (range 35–65). Participants sent in an average of 50 readings in Month 1 and 38 readings in Month 3 and made, on average, 6 comments in Months 1 and 12 comments in Month 3. The mean blood glucose range decreased in Month 3 versus Month 1 (141.1 and 146.5, respectively). Self-reported HbA1c fell from 6.8% at the start of the study to 5.8% at the end. Five/seven participants described the site as excellent or good. Qualitative data analysis highlighted key benefits of the program as well as areas for improvement. Conclusions: This pilot study of a shared glucose monitoring Web application was well received by patients. Programs like this may lead to improvements in the quality of clinical care delivered to people with type 2 diabetes.

Cutaneous fungal infections in the United States: analysis of the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1995-2004.

Background  Dermatophyte infections lead to high costs and differentially affect certain groups. Previous population studies have been limited in size, duration, and representativeness.

Linking Electronic Health Record-Extracted Psychosocial Data in Real-Time to Risk of Readmission for Heart Failure

BACKGROUND Knowledge of psychosocial characteristics that helps to identify patients at increased risk for readmission for heart failure (HF) may facilitate timely and targeted care. OBJECTIVE We hypothesized that certain psychosocial characteristics extracted from the electronic health record (EHR) would be associated with an increased risk for hospital readmission within the next 30 days. METHODS We identified 15 psychosocial predictors of readmission. Eleven of these were extracted from the EHR (six from structured data sources and five from unstructured clinical notes). We then analyzed their association with the likelihood of hospital readmission within the next 30 days among 729 patients admitted for HF. Finally, we developed a multivariable predictive model to recognize individuals at high risk for readmission. RESULTS We found five characteristics-dementia, depression, adherence, declining/refusal of services, and missed clinical appointments-that were associated with an increased risk for hospital readmission: the first four features were captured from unstructured clinical notes, while the last item was captured from a structured data source. CONCLUSIONS Unstructured clinical notes contain important knowledge on the relationship between psychosocial risk factors and an increased risk of readmission for HF that would otherwise have been missed if only structured data were considered. Gathering this EHR-based knowledge can be automated, thus enabling timely and targeted care.

Use of remote monitoring to improve outcomes in patients with heart failure: a pilot trial

Remote monitoring (RM) of homebound heart failure (HF) patients has previously been shown to reduce hospital admissions. We conducted a pilot trial of ambulatory, non-homebound patients recently hospitalized for HF to determine whether RM could be successfully implemented in the ambulatory setting. Eligible patients from Massachusetts General Hospital (n = 150) were randomized to a control group (n = 68) or to a group that was offered RM (n = 82). The participants transmitted vital signs data to a nurse who coordinated care with the physician over the course of the 6-month study. Participants in the RM program had a lower all-cause per person readmission rate (mean = 0.64, SD ± 0.87) compared to the usual care group (mean = 0.73, SD ± 1.51; P-value = .75) although the difference was not statistically significant. HF-related readmission rate was similarly reduced in participants. This pilot study demonstrates that RM can be successfully implemented in non-homebound HF patients and may reduce readmission rates.

Text Messages as a Reminder Aid and Educational Tool in Adults and Adolescents with Atopic Dermatitis: A Pilot Study

Optimal management of atopic dermatitis (AD) requires patients to adhere to self-care behaviors. Technologies, such as cell phones, have been widely adopted in the USA and have potential to reinforce positive health behaviors. We conducted a pilot study with 25 adolescents and adults age 14 years and older [mean 30.5 yrs, SD 13.4] with AD. Daily text messages (TMs) that provided medication reminders and AD education were sent for six weeks to participants. Our goals were to (1) measure changes in pre- and posttest scores in treatment adherence, self-care behaviors, disease severity, and quality of life and (2) assess the usability and satisfaction of the TM system. Significant improvements in treatment adherence, self-care behaviors, skin severity, and quality of life (P ≤ .001, .002, <.001, and .014, resp.) were noted postintervention. User feedback on the TM system was positive with 88% and 92% of participants reporting that the reminder TMs and educational TMs were helpful, respectively. In conclusion, study participants were receptive to using TMs as a reminder aid and educational tool. The positive trends observed are promising and lay the ground work for further studies needed to elucidate the full potential of this simple and cost-effective intervention.

The feasibility and impact of delivering a mind-body intervention in a virtual world.

Introduction Mind-body medical approaches may ameliorate chronic disease. Stress reduction is particularly helpful, but face-to-face delivery systems cannot reach all those who might benefit. An online, 3-dimensional virtual world may be able to support the rich interpersonal interactions required of this approach. In this pilot study, we explore the feasibility of translating a face-to-face stress reduction program into an online virtual setting and estimate the effect size of the intervention. Methods and Findings Domain experts in virtual world technology joined with mind body practitioners to translate an existing 8 week relaxation response-based resiliency program into an 8-week virtual world-based program in Second Life™ (SL). Twenty-four healthy volunteers with at least one months experience in SL completed the program. Each subject filled out the Perceived Stress Scale (PSS) and the Symptom Checklist 90- Revised (SCL-90-R) before and after taking part. Participants took part in one of 3 groups of about 10 subjects. The participants found the program to be helpful and enjoyable. Many reported that the virtual environment was an excellent substitute for the preferred face-to-face approach. On quantitative measures, there was a general trend toward decreased perceived stress, (15.7 to 15.0), symptoms of depression, (57.6 to 57.0) and anxiety (56.8 to 54.8). There was a significant decrease of 2.8 points on the SCL-90-R Global Severity Index (p<0.05). Conclusions This pilot project showed that it is feasible to deliver a typical mind-body medical intervention through a virtual environment and that it is well received. Moreover, the small reduction in psychological distress suggests further research is warranted. Based on the data collected for this project, a randomized trial with less than 50 subjects would be appropriately powered if perceived stress is the primary outcome.