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The Medicaid Information Technology Architecture (MITA) is a roadmap and tool-kit for States to transform their Medicaid Management Information System (MMIS) into an enterprise-wide, beneficiary-centric system. MITA will enable State Medicaid agencies to align their information technology (IT) opportunities with their evolving business needs. It also addresses long-standing issues of interoperability, adaptability, and data sharing, including clinical data, across organizational boundaries by creating models based on nationally accepted technical standards. Perhaps most significantly, MITA allows State Medicaid Programs to actively participate in the DHHS Secretary's vision of a transparent health care market that utilizes electronic health records (EHRs), ePrescribing and personal health records (PHRs).

Objective: To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control., Data Sources: Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999., Study Design: Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined., Principal Findings: Increases in antiglycemic medications occurred at only 9.8 percent of visits despite 39 percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p < .001)., Conclusions: Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.

Background: Although vaginitis is a common outpatient problem, only 60% of patients can be diagnosed at the initial office visit of a primary care provider using the office procedures of pH testing, whiff tests, normal saline, and potassium hydroxide preps., Objective: To determine the most cost-effective diagnostic and treatment approach for the medical management of vaginitis., Design: Decision and cost-effectiveness analyses., Participants: Healthy women with symptoms of vaginitis undiagnosed after an initial pelvic exam, wet mount preparations, pH, and the four criteria to diagnose bacterial vaginosis., Setting: General office practice., Methods: We evaluated 28 diagnostic strategies comprised of combinations of pH testing, vaginal cultures for yeast and Trichomonas vaginalis, Gram's stain for bacterial vaginosis, and DNA probes for Neisseria gonorrhoeae and Chlamydia. Data sources for the study were confined to English language literature., Measurement: The outcome measures were symptom-days and costs., Results: The least expensive strategy was to perform yeast culture, gonorrhoeae and Chlamydia probes at the initial visit, and Gram's stain and Trichomonas culture only when the vaginal pH exceeded 4.9 (330 dollars, 7.30 symptom days). Other strategies cost 8 dollars to 76 dollars more and increased duration of symptoms by up to 1.3 days. In probabilistic sensitivity analysis, this strategy was always the most effective strategy and was also least expensive 58% of the time., Conclusions: For patients with vaginitis symptoms undiagnosed by pelvic examination, wet mount preparations and related office tests, a comprehensive, pH-guided testing strategy at the initial office visit is less expensive and more effective than ordering tests sequentially.

Purpose: To understand the views of U.S. medical school deans about their primary care faculties., Method: In 2000, the authors mailed a questionnaire containing 43 multipart items to deans of 130 U.S. allopathic medical schools. The questionnaire assessed the deans' attitudes about and evaluation of primary care at their school and their school's efforts to strengthen it. Deans were asked to compare family medicine, general internal medicine, and general pediatrics with nonprimary care clinical departments at their schools., Results: Of the 83 (64%) deans who responded, 82% reported their school had departments or divisions of family medicine, general internal medicine, and general pediatrics. Deans rated general internal medicine and general pediatrics higher than nonprimary care faculty on clinical expertise and productivity (p < .001) and family medicine equivalent to nonprimary care faculty. Deans rated all three primary care faculties superior to nonprimary care faculty for teaching skills (p < .001) and programs (p < .05), but lower than nonprimary care disciplines for research productivity (p < .01) and revenues (p < .001). They rated family medicine and general pediatrics lower for research skills (p < .001), but 73% of deans stated research was equally important for primary care and nonprimary care departments. Deans considered overall financial resources to be equivalent for primary care and nonprimary care departments, but 77% of deans felt primary care departments or divisions needed financial support from the medical school to survive. Most deans attempted to strengthen primary care by changing the curriculum to promote primary care and by providing financial support., Conclusions: Deans ranked primary care faculty high on clinical and teaching measures. Although they considered research to be an important activity for primary care faculty, they evaluated it low relative to nonprimary care departments.

Background: Women have been entering academic medicine in numbers at least equal to their male colleagues for several decades. Most studies have found that women do not advance in academic rank as fast as men and that their salaries are not as great. These studies, however, have typically not had the data to examine equity, that is, do women receive similar rewards for similar achievement?, Objective: To examine equity in promotion and salary for female versus male medical school faculty nationally., Design: Mailed survey questionnaire., Setting: 24 randomly selected medical schools in the contiguous United States., Participants: 1814 full-time U.S. medical school faculty in 1995-1996, stratified by sex, specialty, and graduation cohort., Measurements: Promotion and compensation of academic medical faculty., Results: Among the 1814 faculty respondents (response rate, 60%), female faculty were less likely to be full professors than were men with similar professional roles and achievement. For example, 66% of men but only 47% of women (P < 0.01) with 15 to 19 years of seniority were full professors. Large deficits in rank for senior faculty women were confirmed in logistic models that accounted for a wide range of other professional characteristics and achievements, including total career publications, years of seniority, hours worked per week, department type, minority status, medical versus nonmedical final degree, and school. Similar multivariable modeling also confirmed gender inequity in compensation. Although base salaries of nonphysician faculty are gender comparable, female physician faculty have a noticeable deficit (-11,691 dollars; P = 0.01). Furthermore, both physician and nonphysician women with greater seniority have larger salary deficits (-485 dollars per year of seniority; P = 0.01)., Limitations: This is a cross-sectional study of a longitudinal phenomenon. No data are available for faculty who are no longer working full-time in academic medicine, and all data are self-reported., Conclusions: Female medical school faculty neither advance as rapidly nor are compensated as well as professionally similar male colleagues. Deficits for female physicians are greater than those for nonphysician female faculty, and for both physicians and nonphysicians, women's deficits are greater for faculty with more seniority.

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.

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.

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.

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.

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.

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.

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.

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.

Objective: To explore the status and academic productivity of women compared with men in academic internal medicine., Design: Mail survey done in 1986., Setting: A total of 107 major teaching hospitals in the United States., Participants: Full-time (1693 of 2510) faculty in cardiology, rheumatology, and general internal medicine; 67% of eligible men and 70% of eligible women., Measurements: Academic productivity defined as research grants awarded, abstracts accepted, and papers published in refereed journals; academic advancement as determined by academic rank and tenure status; and monetary compensation., Results: Women entered academic medicine with shorter periods of fellowship training and were less likely to be members in the Alpha Omega Alpha honor society, but they had job descriptions similar to those of men, with similar allocation of work between research, clinical, and teaching activities. After adjustment, women and men were similar in the numbers of research grants funded as principal investigator (1.9 compared with 2.0), abstracts accepted (6.8 compared with 6.1), and papers published in refereed journals (28.8 compared with 29.2; all with P > 0.20). Women were as likely as men to have tenure, but they had lower academic rank (full or associate professor; 33% compared with 47%, P < 0.001) and received less compensation ($72,000 compared with $79,600 annually; P < 0.001)., Conclusion: Although women do similar professional tasks and achieve similar levels of academic productivity, they receive fewer rewards for their work, both in academic rank and monetary compensation.

By 1979, 77% of medical school primary teaching hospitals had functioning general internal medicine units; less than 5% had existed before 1970. These units were established to meet institutional needs for primary care internal medicine teachers and clinicians. By the end of the decade they had achieved major administrative and staffing responsibility for a wide variety of general education and service activities. The scope of general internal medicine units goes beyond the narrow definition of primary care internal medicine, to include activities traditionally considered those of the entire department of medicine.

The growth of ambulatory care delivery in the Department of Veterans Affairs (VA) has been accompanied by increasing interest in and need for ambulatory care research. Results from a national survey of academic general internal medicine units suggest that those that share VA and university affiliation tend to be more successful than those that are unaffiliated. The VA must strive to improve the environment for ambulatory care research. Among other things, this will entail providing adequate protected time to ambulatory care faculty and developing a uniform ambulatory care database to facilitate longitudinal, population-based research. Extended fellowships in ambulatory care and faculty development programs for existing staff will be required to create a core of competent investigators. The VA must also provide increased funding to the Health Services Research and Development and Cooperative Studies programs. Special funding programs targeted to key areas such as quality assurance, medical education, and direct patient care should be established. In addition, the VA should seek to develop joint ventures with other funding agencies for innovative ambulatory care initiatives.

We conducted a survey to determine the current and potential uses of computerized information systems in clinical rheumatology. One in 3 rheumatologists currently uses an office based computer, primarily for administrative functions, and at least one in 5 is likely to acquire a computer in the near future. Survey responses indicate that the increased use of office based computers will increase the willingness of community practitioners to participate in clinical research. This development will provide an opportunity to broaden the scope of clinical research participation and to increase the pool of patients available for cooperative clinical trials in rheumatology.

This article addresses cost differences between primary care physicians in private practice and hospital outpatient departments (OPD's). The analysis utilizes ambulatory visit groups (AVG's), the outpatient equivalent of diagnosis-related groups (DRG's), to adjust for case mix. Major findings are that OPD's have higher per visit costs than physicians' private offices; internists are more expensive than general practitioners regardless of site; and ancillary service costs are actually slightly higher in private practice. Any prospective payment system for ambulatory care must consider these costs differences.