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Medication for opioid use disorder (MOUD) improves treatment retention and reduces illicit opioid use. A-CHESS is an evidence-based smartphone intervention shown to improve addiction-related behaviors. The authors tested the efficacy of MOUD alone versus MOUD plus A-CHESS to determine whether the combination further improved outcomes. In an unblinded parallel-group randomized controlled trial, 414 participants recruited from outpatient programs were assigned in a 1:1 ratio to receive either MOUD alone or MOUD+A-CHESS for 16 months and were followed for an additional 8 months. All participants were on methadone, buprenorphine, or injectable naltrexone. The primary outcome was abstinence from illicit opioid use; secondary outcomes were treatment retention, health services use, other substance use, and quality of life; moderators were MOUD type, gender, withdrawal symptom severity, pain severity, and loneliness. Data sources were surveys comprising multiple validated scales, as well as urine screens, every 4 months. There was no difference in abstinence between participants in the MOUD+A-CHESS and MOUD-alone arms across time (odds ratio=1.10, 95% CI=0.90–1.33). However, abstinence was moderated by withdrawal symptom severity (odds ratio=0.95, 95% CI=0.91–1.00) and MOUD type (odds ratio=0.57, 95% CI=0.34–0.97). Among participants without withdrawal symptoms, abstinence rates were higher over time for those in the MOUD+A-CHESS arm than for those in the MOUD-alone arm (odds ratio=1.30, 95% CI=1.01–1.67). Among participants taking methadone, those in the MOUD+A-CHESS arm were more likely to be abstinent over time (b=0.28, SE=0.09) than those in the MOUD-alone arm (b=0.06, SE=0.08), although the two groups did not differ significantly from each other (∆b=0.22, SE=0.11). MOUD+A-CHESS was also associated with greater meeting attendance (odds ratio=1.25, 95% CI=1.05–1.49) and decreased emergency department and urgent care use (odds ratio=0.88, 95% CI=0.78–0.99). Overall, MOUD+A-CHESS did not improve abstinence relative to MOUD alone. However, MOUD+A-CHESS may provide benefits for subsets of patients and may impact treatment utilization. [ABSTRACT FROM AUTHOR]

Background and Aims: Management of alcohol use disorder (AUD) could be enhanced by effective remote treatments. This study tested whether supplementing intensive outpatient programs (IOPs) with continuing care delivered via (1) telephone, (2) smartphone or (3) their combination improves outcomes relative to (4) IOP only. Continuing care conditions were also compared. Design Randomized controlled trial of four groups with 3‐, 6‐, 9‐, 12‐ and 18‐month follow‐ups. Setting: University research center in Philadelphia, PA, USA. Participants: Participants (n = 262) met DSM‐V criteria for AUD, were largely male (71%) and African American (82%). Interventions and Comparator: Telephone monitoring and counseling (TMC; n = 59), addiction comprehensive health enhancement support system (ACHESS; n = 68) and TMC + ACHESS (n = 70) provided for 12 months. The control condition received IOP only (TAU; n = 65). Measurement The primary outcome was percentage of days heavy drinking (PDHD) in months 1–12. Secondary outcomes were any drinking, any drug use, drinking consequences and quality of life. Findings Mean PDHD in months 1–12 was 10.29 in TAU, 5.41 in TMC, 6.80 in ACHESS and 5.99 in TMC + ACHESS. PDHD was lower in TMC [Cohen's d = 0.35, P = 0.018, 95% confidence interval (CI) = (−1.42, −0.20)], ACHESS [d = 0.31, P = 0.031, 95% CI = (−1.27, −0.06)] and TMC + ACHESS [d = 0.36, P = 0.009, 95% CI = (−1.40, −0.20)] than in TAU. Differences between TMC + ACHESS, TMC and ACHESS were small (d ≤ 0.06) and non‐significant. Findings were inconclusive as to whether or not the treatment conditions differed on PDHD at 18 months. A significant effect was obtained on any drinking, which was higher in months 1–12 in TAU than in TMC [odds ratio (OR) = 3.02, standard error (SE) = 0.43, 95% CI = (1.30, 6.99), P = 0.01] and TMC + ACHESS [OR = 2.43, SE = 0.39, 95% CI = (1.12, 5.27), P = 0.025). No other significant effects were obtained on other secondary outcomes during or after treatment. Conclusions: A telephone‐delivered intervention and a smartphone‐delivered intervention, alone and in combination, provided effective remote continuing care for alcohol use disorder. The combination of both interventions was not superior to either alone and effects did not persist post‐treatment. [ABSTRACT FROM AUTHOR]

Background: Family members absorb much of the care of dementia patients. The burden of care substantially impacts caregivers' health, further straining our healthcare system. By 2050, the incidence of Alzheimer's disease will more than double, increasing the numbers of family caregivers proportionally. Interventions that reduce their burden are needed to preserve their health as well as the viability of the healthcare system.Objective: This paper reports on the development and feasibility testing of a computer-based system intended to improve the lives of caregivers. D-CHESS (Dementia-Comprehensive Health Enhancement Support System) allows users to obtain information, communicate with other caregivers, get help with care decisions, and share information with experts.Method: Thirty-one caregivers were randomly assigned to an intervention group receiving D-CHESS for 6 months or to a control group receiving a caregiving book. Surveys at 0, 2, 4, and 6 months evaluated caregiver burden, family conflict, satisfaction with decisions, social support, loneliness, anxiety, depression, and coping competence.Results: Survey findings suggest D-CHESS participants may perform better on measures of social support, anxiety, loneliness, and coping competence; the groups were equivalent on caregiver burden, decision satisfaction, and depression, and the control group reported less family conflict than the intervention. D-CHESS use data suggested enhancements to system design and content to increase awareness and use of various features.Conclusion: This study suggests that D-CHESS has potential to positively impact family caregivers and that the system merits further development and investigation with a full-scale clinical trial. [ABSTRACT FROM AUTHOR]

Background: New smartphone communication technology provides a novel way to provide personalized continuing care support following alcohol treatment. One such system is the Addiction version of the Comprehensive Health Enhancement Support System (A-CHESS), which provides a range of automated functions that support patients. A-CHESS improved drinking outcomes over standard continuing care when provided to patients leaving inpatient treatment. Effective continuing care can also be delivered via telephone calls with a counselor. Telephone Monitoring and Counseling (TMC) has demonstrated efficacy in two randomized trials with alcohol-dependent patients. A-CHESS and TMC have complementary strengths. A-CHESS provides automated 24/7 recovery support services and frequent assessment of symptoms and status, but does not involve regular contact with a counselor. TMC provides regular and sustained contact with the same counselor, but no ongoing support between calls. The future of continuing care for alcohol use disorders is likely to involve automated mobile technology and counselor contact, but little is known about how best to integrate these services.Methods/design: To address this question, the study will feature a 2 × 2 design (A-CHESS for 12 months [yes/no] × TMC for 12 months [yes/no]), in which 280 alcohol-dependent patients in intensive outpatient programs (IOPs) will be randomized to one of the four conditions and followed for 18 months. We will determine whether adding TMC to A-CHESS produces fewer heavy drinking days than TMC or A-CHESS alone and test for TMC and A-CHESS main effects. We will determine the costs of each of the four conditions and the incremental cost-effectiveness of the three active conditions. Analyses will also examine secondary outcomes, including a biological measure of alcohol use, and hypothesized moderation and mediation effects.Discussion: The results of the study will yield important information on improving patient alcohol use outcomes by integrating mobile automated recovery support and counselor contact.Trial Registration: ClinicalTrials.gov, NCT02681406 . Registered on 2 September 2016. [ABSTRACT FROM AUTHOR]

Background: Millions of Americans need but don't receive treatment for substance use, and evidence suggests that addiction-focused interventions on smart phones could support their recovery. There is little research on implementation of addiction-related interventions in primary care, particularly in Federally Qualified Health Centers (FQHCs) that provide primary care to underserved populations. We used mixed methods to examine three FQHCs' implementation of Seva, a smart-phone app that offers patients online support/discussion, health-tracking, and tools for coping with cravings, and offers clinicians information about patients' health tracking and relapses. We examined (a) clinicians' initial perspectives about implementing Seva, and (b) the first year of implementation at Site 1. Methods: Prior to staggered implementation at three FQHCs (Midwest city in WI vs. rural town in MT vs. metropolitan NY), interviews, meetings, and focus groups were conducted with 53 clinicians to identify core themes of initial expectations about implementation. One year into implementation at Site 1, clinicians there were re-interviewed. Their reports were supplemented by quantitative data on clinician and patient use of Seva. Results: Clinicians anticipated that Seva could help patients and make behavioral health appointments more efficient, but they were skeptical that physicians would engage with Seva (given high caseloads), and they were uncertain whether patients would use Seva. They were concerned about legal obligations for monitoring patients' interactions online, including possible "cries for help" or inappropriate interactions. One year later at Site 1, behavioral health care providers, rather than physicians, had incorporated Seva into patient care, primarily by discussing it during appointments. Given workflow/load concerns, only a few key clinicians monitored health tracking/relapses and prompted outreach when needed; two researchers monitored the discussion board and alerted the clinic as needed. Clinician turnover/leave complicated this approach. Contrary to clinicians' initial concerns, patients showed sustained, mutually supportive use of Seva, with few instances of misuse. Conclusions: Results suggest the value of (a) focusing implementation on behavioral health care providers rather than physicians, (b) assigning a few individuals (not necessarily clinicians) to monitor health tracking, relapses, and the discussion board, (c) anticipating turnover/leave and having designated replacements. Patients showed sustained, positive use of Seva. [ABSTRACT FROM AUTHOR]

Background: Hospitals frequently evaluate their service quality based on the care and services provided to patients by their clinical and non‐clinical staff.1,2 However, such evaluations do not take into consideration the many interactions that patients have in online patient communities with the health‐care organization (HCO) as well as with peer patients. Patients' interactions in these online communities could impact their perceptions regarding the HCO's service quality. Purposes: The objective of this pilot study was to evaluate the impact of social support and responsiveness that patients experience in an HCO's online community on patients' perceptions regarding the HCO's service quality. Method: The study data are collected from CHESS, a health‐care programme (Comprehensive Health Enhancement Support System) run by the Centre for Health Enhancement System Studies at the University of Wisconsin–Madison. Findings: Findings show that the social support and the responsiveness received from peer patients in the online patient communities will impact patients' perceptions regarding the service quality of the HCO even when the organizational members themselves do not participate in the online discussions. Practice implications: The results indicate that interactions in such HCO‐provided online patient communities should not be ignored as they could translate into patients' perceptions regarding HCOs' service quality. Ways to improve responsiveness and social support in an HCO's online patient community are discussed. [ABSTRACT FROM AUTHOR]

Background Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary-care practices to integrate treatment for addiction and other behavioral health conditions into their practices. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these settings is substantial but largely untested. This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones, called Seva, into primary-care settings. Seva is an evidence-based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians. Methods/Design Our implementation strategy uses three models of organizational change: the Program Planning Model to promote acceptance and sustainability, the NIATx quality improvement model to create a welcoming environment for change, and Rogers's diffusion of innovations research, which facilitates adaptations of innovations to maximize their adoption potential. We will implement Seva and conduct an intensive, mixed-methods assessment at three diverse Federally Qualified Healthcare Centers in the United States. Our non-concurrent multiple-baseline design includes three periods — pretest (ending in four months of implementation preparation), active Seva implementation, and maintenance — with implementation staggered at six-month intervals across sites. The first site will serve as a pilot clinic. We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, including effects on clinicians, patients, and practices. Our mixedmethods approach will include quantitative (e.g., interrupted time-series analysis of treatment attendance, with clinics as the unit of analysis) and qualitative (e.g., staff interviews regarding adaptations to implementation protocol) methods, and assessment of implementation costs. Discussion If implementation is successful, the field will have a proven technology that helps Federally Qualified Health Centers and affiliated organizations provide addiction treatment and recovery support, as well as a proven strategy for implementing the technology. Seva also has the potential to improve core elements of addiction treatment, such as referral and treatment processes. A mobile technology for addiction treatment and accompanying implementation model could provide a cost-effective means to improve the lives of patients with drug and alcohol problems. Trial registration ClinicalTrials.gov (NCT01963234). [ABSTRACT FROM AUTHOR]

Aims Improvement collaboratives consisting of various components are used throughout health care to improve quality, but no study has identified which components work best. This study tested the effectiveness of different components in addiction treatment services, hypothesizing that a combination of all components would be most effective. Design An unblinded cluster-randomized trial assigned clinics to one of four groups: interest circle calls (group teleconferences), clinic-level coaching, learning sessions (large face-to-face meetings) and a combination of all three. Interest circle calls functioned as a minimal intervention comparison group. Setting Out-patient addiction treatment clinics in the United States. Participants Two hundred and one clinics in five states. Measurements Clinic data managers submitted data on three primary outcomes: waiting-time (mean days between first contact and first treatment), retention (percentage of patients retained from first to fourth treatment session) and annual number of new patients. State and group costs were collected for a cost-effectiveness analysis. Findings Waiting-time declined significantly for three groups: coaching (an average of 4.6 days/clinic, P = 0.001), learning sessions (3.5 days/clinic, P = 0.012) and the combination (4.7 days/clinic, P = 0.001). The coaching and combination groups increased significantly the number of new patients (19.5%, P = 0.028; 8.9%, P = 0.029; respectively). Interest circle calls showed no significant effect on outcomes. None of the groups improved retention significantly. The estimated cost per clinic was $2878 for coaching versus $7930 for the combination. Coaching and the combination of collaborative components were about equally effective in achieving study aims, but coaching was substantially more cost-effective. Conclusions When trying to improve the effectiveness of addiction treatment services, clinic-level coaching appears to help improve waiting-time and number of new patients while other components of improvement collaboratives (interest circles calls and learning sessions) do not seem to add further value. [ABSTRACT FROM AUTHOR]

Background: In this study, the authors examined the effectiveness of an online support system (Comprehensive Health Enhancement Support System [CHESS]) versus the Internet in relieving physical symptom distress in patients with non-small cell lung cancer (NSCLC).Methods: In total, 285 informal caregiver-patient dyads were assigned randomly to receive, for up to 25 months, standard care plus training on and access to either use of the Internet and a list of Internet sites about lung cancer (the Internet arm) or CHESS (the CHESS arm). Caregivers agreed to use CHESS or the Internet and to complete bimonthly surveys; for patients, these tasks were optional. The primary endpoint-patient symptom distress-was measured by caregiver reports using a modified Edmonton Symptom Assessment Scale.Results: Caregivers in the CHESS arm consistently reported lower patient physical symptom distress than caregivers in the Internet arm. Significant differences were observed at 4 months (P = .031; Cohen d = .42) and at 6 months (P = .004; d = .61). Similar but marginally significant effects were observed at 2 months (P = .051; d = .39) and at 8 months (P = .061; d = .43). Exploratory analyses indicated that survival curves did not differ significantly between the arms (log-rank P = .172), although a survival difference in an exploratory subgroup analysis suggested an avenue for further study.Conclusions: The current results indicated that an online support system may reduce patient symptom distress. The effect on survival bears further investigation. [ABSTRACT FROM AUTHOR]

BACKGROUND: In this study, the authors examined the effectiveness of an online support system (Comprehensive Health Enhancement Support System [CHESS]) versus the Internet in relieving physical symptom distress in patients with non-small cell lung cancer (NSCLC). METHODS: In total, 285 informal caregiver-patient dyads were assigned randomly to receive, for up to 25 months, standard care plus training on and access to either use of the Internet and a list of Internet sites about lung cancer (the Internet arm) or CHESS (the CHESS arm). Caregivers agreed to use CHESS or the Internet and to complete bimonthly surveys; for patients, these tasks were optional. The primary endpoint-patient symptom distress-was measured by caregiver reports using a modified Edmonton Symptom Assessment Scale. RESULTS: Caregivers in the CHESS arm consistently reported lower patient physical symptom distress than caregivers in the Internet arm. Significant differences were observed at 4 months ( P = .031; Cohen d = .42) and at 6 months ( P = .004; d = .61). Similar but marginally significant effects were observed at 2 months ( P = .051; d = .39) and at 8 months ( P = .061; d = .43). Exploratory analyses indicated that survival curves did not differ significantly between the arms (log-rank P = .172), although a survival difference in an exploratory subgroup analysis suggested an avenue for further study. CONCLUSIONS: The current results indicated that an online support system may reduce patient symptom distress. The effect on survival bears further investigation. Cancer 2013. © 2013 American Cancer Society. [ABSTRACT FROM AUTHOR]

Background: Dissemination is a critical facet of implementing quality improvement in organizations. As a field, addiction treatment has produced effective interventions but disseminated them slowly and reached only a fraction of people needing treatment. This study investigates four methods of disseminating quality improvement (QI) to addiction treatment programs in the U.S. It is, to our knowledge, the largest study of organizational change ever conducted in healthcare. The trial seeks to determine the most cost-effective method of disseminating quality improvement in addiction treatment. Methods: The study is evaluating the costs and effectiveness of different QI approaches by randomizing 201 addiction-treatment programs to four interventions. Each intervention used a web-based learning kit plus monthly phone calls, coaching, face-to-face meetings, or the combination of all three. Effectiveness is defined as reducing waiting time (days between first contact and treatment), increasing program admissions, and increasing continuation in treatment. Opportunity costs will be estimated for the resources associated with providing the services. Outcomes: The study has three primary outcomes: waiting time, annual program admissions, and continuation in treatment. Secondary outcomes include: voluntary employee turnover, treatment completion, and operating margin. We are also seeking to understand the role of mediators, moderators, and other factors related to an organization's success in making changes. Analysis: We are fitting a mixed-effect regression model to each program's average monthly waiting time and continuation rates (based on aggregated client records), including terms to isolate state and intervention effects. Admissions to treatment are aggregated to a yearly level to compensate for seasonality. We will order the interventions by cost to compare them pair-wise to the lowest cost intervention (monthly phone calls). All randomized sites with outcome data will be included in the analysis, following the intent-to-treat principle. Organizational covariates in the analysis include program size, management score, and state. Discussion: The study offers seven recommendations for conducting a large-scale cluster-randomized trial: provide valuable services, have aims that are clear and important, seek powerful allies, understand the recruiting challenge, cultivate commitment, address turnover, and encourage rigor and flexibility. Trial Registration: ClinicalTrials. govNCT00934141 [ABSTRACT FROM AUTHOR]

Self-management of chronic diseases has been a research focus for years. Information and communication technologies (ICTs) have played a significant role in aiding patients and their families with that management task. The recent dramatic increase in smartphone capabilities has expanded the potential of these technologies by facilitating the integration of features specific to cell phones with advanced capabilities that extend the reach of what type of information can be assessed and which services can be provided. A recent review of the literature covering the use of ICTs in managing chronic diseases, including addiction, has examined the effectiveness of ICTs, with an emphasis on technologies tested in randomized controlled trials. One example of an addiction-relapse prevention system currently being tested is the Alcohol Comprehensive Health Enhancement Support System (ACHESS) Program. [ABSTRACT FROM AUTHOR]

Post-treatment relapse to uncontrolled alcohol use is common. Currently available communication technology can use existing models for relapse prevention to cost-effectively improve long-term relapse prevention. This paper describes: (1) research-based elements of alcohol consumption-related relapse prevention and how they can be encompassed in self-determination theory (SDT) and Marlatt's cognitive behavioral relapse prevention model, (2) how technology could help address the needs of people seeking recovery, (3) a technology-based prototype, organized around sexual transmitted disease and Marlatt's model, and (4) how we are testing a system based on the ideas in this article and related ethical and operational considerations. [ABSTRACT FROM AUTHOR]

Objective: We evaluated the association between physicians' communication behavior and breast cancer patients' trust in their physicians.Design: Longitudinal survey conducted at baseline, 2-month, and 5-month follow-up during first year of diagnosis.Participants: Newly diagnosed breast cancer patients (N = 246).Measurements: We collected data on patient perceptions of the helpfulness of informational, emotional, and decision-making support provided by physicians and patients' trust. Linear regression models evaluated the association of concurrent and prior levels of physician support with patients' trust.Results: At baseline, patients who received helpful informational, emotional, and decision-making support from physicians reported greater trust (p < 0.05, p < 0.001, and p < 0.01, respectively). At the 2-month assessment, baseline informational support and informational and emotional support at 2-months were associated with greater trust (p < 0.05, p < 0.01, and p < 0.05, respectively). At the 5-month assessment, only helpful emotional support from physicians at 5 months was associated with greater trust (p < 0.01). Interestingly, while perceived helpfulness of all three types of physician support decreased significantly over time, patient trust remained high and unchanged.Conclusions: Findings suggest that while informational and decision-making support may be more important to patient trust early in the course of treatment, emotional support from physicians may be important to maintain trust throughout the initial year of diagnosis. [ABSTRACT FROM AUTHOR]

To compare the benefits of the Internet generally versus a focused system of services, 257 breast cancer patients were randomly assigned to a control group, access to the Internet with links to high-quality breast cancer sites, or access to an eHealth system (Comprehensive Health Enhancement Support System, CHESS) that integrated information, support, and decision and analysis tools. The intervention lasted 5 months, and self-report data on quality of life, health-care competence, and social support were collected at pretest and at 2-, 4-, and 9-month posttests. CHESS subjects logged on more overall than Internet subjects and accessed more health resources, but the latter used non health-related sites more. Subjects with access to the Internet alone experienced no better outcomes than controls at any of the 3 time points, compared to pretest levels. Subjects with CHESS experienced greater social support during the intervention period and had higher scores on all 3 outcomes at 9 months, 4 months after the intervention ended. CHESS subjects also scored higher than those with Internet access during the intervention period but not significantly after the intervention ended. Thus, CHESS (with one simple interface and integrated information, communication, and skills services) helped newly diagnosed breast cancer patients even after computers were removed. In contrast, patients received little benefit from Internet access, despite having links to a variety of high-quality sites. [ABSTRACT FROM AUTHOR]

Abstract: The Network for the Improvement of Addiction Treatment (NIATx) teaches participating treatment centers to use process improvement strategies. A cross-site evaluation monitored impacts on days between first contact and first treatment and percent of patients who started treatment and completed two, three and four units of care (i.e., one outpatient session, 1 day of intensive outpatient care, and 1 week of residential treatment). The analysis included 13 agencies that began participation in August 2003, submitted 10–15 months of data, and attempted improvements in outpatient (n =7), intensive outpatient (n =4) or residential treatment services (n =4) (two agencies provided data for two levels of care). Days to treatment declined 37% (from 19.6 to 12.4 days) across levels of care; the change was significant overall and for outpatient and intensive outpatient services. Significant overall improvement in retention in care was observed for the second unit of care (72–85%; 18% increase) and the third unit of care (62–73%; 17% increase); when level of care was assessed, a significant gain was found only for intensive outpatient services. Small incremental changes in treatment processes can lead to significant reductions in days to treatment and consistent gains in retention. [Copyright &y& Elsevier]

This article consolidates insights from 15 years of research examining how the medically underserved use and benefit from an eHealth program, the Comprehensive Health Enhancement Support System (CHESS). The authors outline results from early feasibility tests to determine if the underserved would use CHESS. Distinctive behaviors of underserved populations who have used CHESS are reported with a focus on how online health information and computer-mediated support groups are used. The article then reports on how the underserved benefit from using CHESS. Best practice recommendations for recruitment and training the underserved are offered, and implications for closing the digital divide are discussed. [ABSTRACT FROM AUTHOR]

Background: The assessment of needs for cancer care is a critical step in providing high quality care and achieving cancer patients' and families' satisfaction. Instruments can be used to assess needs and guide cancer care planning. This study discusses the importance of the needs assessment, relationships between needs, satisfaction and quality of life; and reviews the assessment instruments of needs experienced by cancer patients and their families. Methods: A systematic search was conducted in MEDLINE and CANCERLIT data bases. Instruments were evaluated based on their conceptual and measurement models as well as their demonstrated reliability and validity. The authors also sought information pertaining to instruments' burden of administration and responsiveness. Measures compromised by a lack of published psychometric description were not included. Results: This search identified 17 patient needs assessment instruments and seven family needs assessment instruments. The development and psychometric proprieties of most of these instruments were well documented. However, data on their responsiveness and burden of administration were scarce. Conclusions: Each selected instrument meets some but not all of our criteria for validity, reliability, responsiveness and burden. It is questionable whether any instrument can be developed meeting all the requirements. However, there is still a need to continue researching and developing needs assessment instruments leading to effective intervention and improving quality of cancer care. [ABSTRACT FROM AUTHOR]

Objective. To test the effectiveness of a Bayesian model employing subjective probability estimates for predicting success and failure of health care improvement projects. Data Sources. Experts' subjective assessment data for model development and independent retrospective data on 221 healthcare improvement projects in the United States, Canada, and the Netherlands collected between 1996 and 2000 for validation. Methods. A panel of theoretical and practical experts and literature in organizational change were used to identify factors predicting the outcome of improvement efforts. A Bayesian model was developed to estimate probability of successful change using subjective estimates of likelihood ratios and prior odds elicited from the panel of experts. A subsequent retrospective empirical analysis of change efforts in 198 health care organizations was performed to validate the model. Logistic regression and ROC analysis were used to evaluate the model's performance using three alternative definitions of success. Data Collection. For the model development, experts' subjective assessments were elicited using an integrative group process. For the validation study, a staff person intimately involved in each improvement project responded to a written survey asking questions about model factors and project outcomes. Results. Logistic regression chi-square statistics and areas under the ROC curve demonstrated a high level of model performance in predicting success. Chi-square statistics were significant at the 0.001 level and areas under the ROC curve were greater than 0.84. Conclusions. A subjective Bayesian model was effective in predicting the outcome of actual improvement projects. Additional prospective evaluations as well as testing the impact of this model as an intervention are warranted. [ABSTRACT FROM AUTHOR]

This study identified the key Unmet Needs of men with localized prostate cancer. A series of Nominal Groups were used to identify needs, from which a 135-item survey was developed to assess both the Importance and Unmet Need of each item. An Importance-Weighted Unmet Need score was calculated for each item, incorporating both the Importance and the degree to which the need was unmet. Surveys (n=500) were distributed in four geographically distinct areas, with a response rate of 46%. Respondents were 90% Caucasian, 80% married, with a mean age of 66 years, and mean education of 14 years. Care delivery needs were most important and least unmet, while Support needs were least important and most unmet. However, when degree to which needs were unmet was weighted by Importance, information needs had the highest Importance-Weighted Unmet Need scores. The greatest Unmet Needs for information were in knowledge of recurrence issues and in side effects of the illness and its treatment. [Copyright &y& Elsevier]

This paper reviews the research and development around a consumer health informatics system CHESS (The Comprehensive Health Enhancement Support System) developed and tested by the Center for Health Systems Research and Analysis at the University of Wisconsin. The review places particular emphasis on what has been found with regard to the acceptance and use of such systems by high risk and underserved groups. [ABSTRACT FROM AUTHOR]

The objective of this paper is to examine group polarization in subjects who have access to a quantitative decision aid, comparing to subjects who do not. Group polarization indicates the opinion of a group involved in a decision process will tend to be more extreme in the direction of the norm than the initial opinions of its members. Most of previous studies were focused on the theoretical explanation of this effect. Two theories are generally proposed to explain it: social comparison (SC) and persuasive arguments (PA). As we know, no study has been worked on how it can be dealt with. In this study, we use Analytic Hierarchy Process (AHP) as a quantitative decision aid in a group process to examine the changes of this effect. Two hundred and forty undergraduate students participated in this study. Results show that persuasive argument was significantly reduced by the use of AHP, while no significant effect was found in group polarization and social comparison. The implications of the findings are further discussed. [ABSTRACT FROM AUTHOR]

Objective: Assess impact of a computer-based patient support system on quality of life in younger women with breast cancer, with particular emphasis on assisting the underserved.Design: Randomized controlled trial conducted between 1995 and 1998.Setting: Five sites: two teaching hospitals (Madison, Wis, and Chicago, Ill), two nonteaching hospitals (Chicago), and a cancer resource center (Indianapolis, Ill). The latter three sites treat many underserved patients.Participants: Newly diagnosed breast cancer patients (N = 246) under age 60.Interventions: Experimental group received Comprehensive Health Enhancement Support System (CHESS), a home-based computer system providing information, decision-making, and emotional support.Measurements and Main Results: Pretest and two post-test surveys (at two- and five-month follow-up) measured aspects of participation in care, social/information support, and quality of life. At two-month follow-up, the CHESS group was significantly more competent at seeking information, more comfortable participating in care, and had greater confidence in doctor(s). At five-month follow-up, the CHESS group had significantly better social support and also greater information competence. In addition, experimental assignment interacted with several indicators of medical underservice (race, education, and lack of insurance), such that CHESS benefits were greater for the disadvantaged than the advantaged group.Conclusions: Computer-based patient support systems such as CHESS may benefit patients by providing information and social support, and increasing their participation in health care. These benefits may be largest for currently underserved populations. [ABSTRACT FROM AUTHOR]

This study investigated the goodness of one behavioral and five mathematical aggregation rules for combining likelihood ratio estimates given by a group of experts. Behavioral aggregation required only that all four members of the group agree to use a single estimate. All mathematical aggregation rules used the geometric mean of the estimates. However, five methods were used to weight the estimates of each "expert." The methods used were equal weights, peer-assigned weights, self-assigned weights, group (combined peer and self) assigned weights and an average between self- and group-assigned weights. Statistical differences were found in favor of mathematical consensus for likelihood ratios from size 2 to 15. No differences were found for smaller or larger likelihood ratios, or between the various weighting methods. Equal weighting of experts was the simplest method to use. Estimates were obtained at a rate of 3.25 mm per group per estimate. [ABSTRACT FROM AUTHOR]

This research evaluated four methods of eliciting subjective likelihood ratio estimates. The methods differed in terms of amount and structure of interaction permitted between estimators. These processes were individual estimates, and three group processes: a Talk-Estimate process approximating an interacting group, an Estimate-Feedback-Estimate process as an approximation of a Delphi group, an Estimate-Talk-Estimate process as combination of nominal and interacting groups. In this study the Estimate-Talk-Estimate group process was superior in approaching correct estimates in this judgmental task. This is consistent with the long research tradition which favors group as opposed to individual problem-solving in judgmental situations. The individual Estimate process and the Estimate-Feedback-Estimate technique performed about equally well with respect to both error and variability. If anything, written feedback appeared to lead to a reduction in the quality of estimates. Finally, the relatively poor results from the Talk-Estimate process are consistent with other studies which have pointed out dysfunctions of inter- acting group processes for judgmental tasks. [ABSTRACT FROM AUTHOR]

A Bayesian probabilistic information processing system (PIP) was compared, in field and laboratory tests, with four other forecasting methodologies. The influence of amount of information and conditional dependence of data on forecaster performance was investigated. PIP performed at least as well as any other technique in terms of magnitude of error and was superior to all techniques in terms of frequency of error. However PIP also required the most physician time per estimate. [ABSTRACT FROM AUTHOR]

A personal narrative is presented which explores the author's experience of having a heart transplant.

Background: A key component of relapse prevention is to self-monitor the internal (feelings or cravings) and external (people, places, activities) factors associated with relapse. Smartphones can deliver ecological momentary assessments (EMA) to help individuals self-monitor. The purpose of this exploratory study was to develop a model for predicting an individual's risk of future substance use after each EMA and validate it using a multi-level model controlling for repeated measures on persons.Methods: Data are from 21,897 observations from 43 adults following their initial episode of substance use treatment in Chicago from 2015 to 2016. Participants were provided smartphones for six months and asked to complete two to three minute EMAs at five random times per day (81% completion). In any given EMA, 2.7% reported substance use and 8% reported any use in the next five completed EMA. Chi-square Automatic Interaction Detector (CHAID) was used to classify EMAs into six levels of risk and then validated with a hierarchical linear model (HLM).Results: The major predictors of substance use in the next five completed EMAs were substance use pattern over the current and prior five EMAs (no recent/current use, either recent or current use [but not both], continued use [both recent and current]), negative affect (feelings), and craving (rating). Negative affect was important for EMAs with no current or recent use reported; craving was important for EMAs with either recent or current use; and neither mattered for EMAs with continued use. The CHAID gradated EMA risk from 0.7% to 36.6% of the next five completed EMAs with substance use reported. It also gradated risk of "any" use in the next five completed EMAs from 3% to 82%.Conclusions: This study demonstrated the potential of using smartphone-based EMAs to monitor and provide feedback for relapse prevention in future studies. [ABSTRACT FROM AUTHOR]

Background: A key component of relapse prevention is to self-monitor the internal (feelings or cravings) and external (people, places, activities) factors associated with relapse. Smartphones can deliver ecological momentary assessments (EMA) to help individuals self-monitor. The purpose of this exploratory study was to develop a model for predicting an individual's risk of future substance use after each EMA and validate it using a multi-level model controlling for repeated measures on persons.Methods: Data are from 21,897 observations from 43 adults following their initial episode of substance use treatment in Chicago from 2015 to 2016. Participants were provided smartphones for six months and asked to complete two to three minute EMAs at five random times per day (81% completion). In any given EMA, 2.7% reported substance use and 8% reported any use in the next five completed EMA. Chi-square Automatic Interaction Detector (CHAID) was used to classify EMAs into six levels of risk and then validated with a hierarchical linear model (HLM).Results: The major predictors of substance use in the next five completed EMAs were substance use pattern over the current and prior five EMAs (no recent/current use, either recent or current use [but not both], continued use [both recent and current]), negative affect (feelings), and craving (rating). Negative affect was important for EMAs with no current or recent use reported; craving was important for EMAs with either recent or current use; and neither mattered for EMAs with continued use. The CHAID gradated EMA risk from 0.7% to 36.6% of the next five completed EMAs with substance use reported. It also gradated risk of "any" use in the next five completed EMAs from 3% to 82%.Conclusions: This study demonstrated the potential of using smartphone-based EMAs to monitor and provide feedback for relapse prevention in future studies. [ABSTRACT FROM AUTHOR]

This study investigates how social support and family relationship perceptions influence breast cancer patients' online communication networks in a computer-mediated social support (CMSS) group. To examine social interactions in the CMSS group, we identified two types of online social networks: open and targeted communication networks. The open communication network reflects group communication behaviors (i.e., one-to-many or "broadcast" communication) in which the intended audience is not specified; in contrast, the targeted communication network reflects interpersonal discourses (i.e., one-toone or directed communication) in which the audience for the message is specified. The communication networks were constructed by tracking CMSS group usage data of 237 breast cancer patients who participated in one of two National Cancer Institute-funded randomized clinical trials. Eligible subjects were within 2 months of a diagnosis of primary breast cancer or recurrence at the time of recruitment. Findings reveal that breast cancer patients who perceived less availability of offline social support had a larger social network size in the open communication network. In contrast, those who perceived less family cohesion had a larger targeted communication network in the CMSS group, meaning they were inclined to use the CMSS group for developing interpersonal relationships. [ABSTRACT FROM AUTHOR]

Background: Alcohol abuse, other substance use disorders, and risk behaviors associated with the human immunodeficiency virus (HIV) represent three of the top 10 modifiable causes of mortality in the US. Despite evidence that continuing care is effective in sustaining recovery from substance use disorders and associated behaviors, patients rarely receive it. Smartphone applications (apps) have been effective in delivering continuing care to patients almost anywhere and anytime. This study tests the effectiveness of two components of such apps: ongoing self-monitoring through Ecological Momentary Assessments (EMAs) and immediate recovery support through Ecological Momentary Interventions (EMIs).Methods/design: The target population, adults enrolled in substance use disorder treatment (n = 400), are being recruited from treatment centers in Chicago and randomly assigned to one of four conditions upon discharge in a 2 × 2 factorial design. Participants receive (1) EMAs only, (2) EMIs only, (3) combined EMAs + EMIs, or (4) a control condition without EMA or EMI for 6 months. People in the experimental conditions receive smartphones with the apps (EMA and/or EMI) specific to their condition. Phones alert participants in the EMA and EMA + EMI conditions at five random times per day and present participants with questions about people, places, activities, and feelings that they experienced in the past 30 min and whether these factors make them want to use substances, support their recovery, or have no impact. Those in the EMI and EMA + EMI conditions have continual access to a suite of support services. In the EMA + EMI condition, participants are prompted to use the EMI(s) when responses to the EMA(s) indicate risk. All groups have access to recovery support as usual. The primary outcome is days of abstinence from alcohol and other drugs. Secondary outcomes are number of HIV risk behaviors and whether abstinence mediates the effects of EMA, EMI, or EMA + EMI on HIV risk behaviors.Discussion: This project will enable the field to learn more about the effects of EMAs and EMIs on substance use disorders and HIV risk behaviors, an understanding that could potentially make treatment and recovery more effective and more widely accessible.Trial Registration: ClinicalTrials.gov, ID: NCT02132481 . Registered on 5 May 2014. [ABSTRACT FROM AUTHOR]

Background: Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary-care practices to integrate treatment for addiction and other behavioral health conditions into their practices. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these settings is substantial but largely untested. This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones, called Seva, into primary-care settings. Seva is an evidence-based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians.Methods/design: Our implementation strategy uses three models of organizational change: the Program Planning Model to promote acceptance and sustainability, the NIATx quality improvement model to create a welcoming environment for change, and Rogers's diffusion of innovations research, which facilitates adaptations of innovations to maximize their adoption potential. We will implement Seva and conduct an intensive, mixed-methods assessment at three diverse Federally Qualified Healthcare Centers in the United States. Our non-concurrent multiple-baseline design includes three periods - pretest (ending in four months of implementation preparation), active Seva implementation, and maintenance - with implementation staggered at six-month intervals across sites. The first site will serve as a pilot clinic. We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, including effects on clinicians, patients, and practices. Our mixed-methods approach will include quantitative (e.g., interrupted time-series analysis of treatment attendance, with clinics as the unit of analysis) and qualitative (e.g., staff interviews regarding adaptations to implementation protocol) methods, and assessment of implementation costs.Discussion: If implementation is successful, the field will have a proven technology that helps Federally Qualified Health Centers and affiliated organizations provide addiction treatment and recovery support, as well as a proven strategy for implementing the technology. Seva also has the potential to improve core elements of addiction treatment, such as referral and treatment processes. A mobile technology for addiction treatment and accompanying implementation model could provide a cost-effective means to improve the lives of patients with drug and alcohol problems.Trial Registration: ClinicalTrials.gov (NCT01963234). [ABSTRACT FROM AUTHOR]

The social mediation role of mobile technology is typified by mHealth apps designed to connect individuals to others and support substance use disorder (SUD) recovery. In this study, we examined the use and utility of one such app designed to support people living with HIV (PLWH) and SUD. Drawing on Ling's emphasis on reciprocity and micro-coordination in mobile telephony as a social mediation technology, we gathered digital trace data from app logs to construct two metrics, initiation (i.e. whether a particular feature is engaged on a given day) and intensity (i.e. degree of involvement in the activity when engaged on that day), at three levels of communication—networked (one-to-many), dyadic (one-to-one), and intraindividual (self-to-self). We consider these system features alongside use of information resources, games and relaxation links, a meeting and events calendar, and support tools to address use urges. We found few differences in patterns of use by race, sex, and age, though African Americans were less likely to engage in intraindividual expression, whereas women and older users were more likely to make use of this feature. The initiation and intensity of network and dyadic reception, as well as the intensity of network expression, predicts recovery outcomes as measured on a weekly "check-in" survey, suggesting the utility of mobile log data for digital phenotyping in mHealth. By implementing this app during the COVID-19 pandemic, the study also found the disruption caused by national lockdown was negatively related to the app use. [ABSTRACT FROM AUTHOR]

Background: Substance use disorders (SUDs) lead to tens-of-thousands of overdose deaths and other forms of preventable deaths in the USA each year. This results in over $500 billion per year in societal and economic costs as well as a considerable amount of grief for loved ones of affected individuals. Despite these health and societal consequences, only a small percentage of people seek treatment for SUDs, and the majority of those that seek help fail to achieve long-term sobriety. E-health applications in healthcare have proven to be effective at sustaining treatment and reaching patients traditional treatment pathways would have missed. However, e-health adoption and sustainment rates in healthcare are poor, especially in the SUD treatment sector. Implementation engineering can address this gap in the e-health field by augmenting existing implementation models, which explain organizational and individual e-health behaviors retrospectively, with prospective resources that can guide implementation.Methods: This cluster randomized control trial is designed to test two implementation strategies at adopting an evidence-based mobile e-health technology for SUD treatment. The proposed e-health implementation model is the Network for the Improvement of Addiction Treatment-Technology Implementation (NIATx-TI) Framework. This project, based in Iowa, will compare a control condition (using a typical software product training approach that includes in-person staff training followed by access to on-line support) to software implementation utilizing NIATx-TI, which includes change management training, followed by coaching on how to implement and use the mobile application. While e-health spans many modalities and health disciplines, this project will focus on implementing the Addiction Comprehensive Health Enhancement Support System (A-CHESS), an evidence-based SUD treatment recovery app framework. This trial will be conducted in Iowa at 46 organizational sites within 12 SUD treatment agencies. The control arm consists of 23 individual treatment sites based at five organizations, and the intervention arm consists of 23 individual SUD treatment sites based at seven organizations DISCUSSION: This study addresses an issue of substantial public health significance: enhancing the uptake of the growing inventory of patient-centered evidence-based addiction treatment e-health technologies.Trial Registration: ClinicalTrials.gov , NCT03954184 . Posted 17 May 2019. [ABSTRACT FROM AUTHOR]

Background: We estimated the efficacy of the Addiction-Comprehensive Health Enhancement Support System (A-CHESS) in increasing the use of services for addiction and examined the extent to which this use of services mediated the effects of A-CHESS on risky drinking days and abstinence from drinking.Methods: We conducted secondary data analyses of the A-CHESS randomized controlled trial. Recruitment occurred in five residential treatment programs operated by two addiction treatment organizations. Participants were 349 adults with alcohol use disorders recruited two weeks before discharge from residential treatment. We provided intervention arm participants with a smartphone, the A-CHESS application, and an 8-month service plan. Control arm participants received treatment as usual. Telephone interviews at 4, 8, and 12-month follow-ups assessed past-month risky drinking days, past-month abstinence, and post-discharge service utilization (past-month outpatient addiction treatment and past-week mutual help including Alcoholics Anonymous and Narcotics Anonymous). Using mixed effects latent variable models, we estimated the indirect effects of A-CHESS on drinking outcomes, as mediated by post-discharge service utilization.Results: Approximately 50.5% of participants reported outpatient addiction treatment and 75.5% reported mutual help at any follow-up interview in the year following randomization. Assignment to the A-CHESS intervention was associated with an increased odds of outpatient addiction treatment across follow-ups, but not mutual help. This use of outpatient addiction treatment mediated the effect of A-CHESS on risky drinking days, but not abstinence. The effect of A-CHESS through outpatient addiction treatment appeared to reduce the expected number of risky drinking days across follow-ups by 11%.Conclusions: The mobile health (mHealth) intervention promoted the use of outpatient addiction treatment, which appeared to contribute to its efficacy in reducing risky drinking. Future research should investigate how mHealth interventions could link patients to needed treatment services and promote the sustained use of these services. [ABSTRACT FROM AUTHOR]

Context: Palliation in patient care is under-utilized in part because many patients have insufficient knowledge about this management option. Information technology can improve awareness by providing access to numerous sources of trustworthy information. Evidence acquisition: To estimate what a patient interested in palliation might find online, online resources were searched in July 2010, using terms relevant to palliation. PubMed was searched for publications relevant to discussed topics. Evidence synthesis: Search engines returned vast numbers of hits, and identifying trustworthy sites was difficult. Products judged as trustworthy were classified as information, decision tool, or extended interaction tool. Sites with useful educational material were relatively plentiful; decision guides or interactive tools were much rarer. Available consumer informatics did not address some terminal illnesses very well, and some subpopulations such as children, nor was there sufficient attention to literacy levels or principles of instructional design. Online or published information about usage numbers, effectiveness, and cost/benefit considerations was scant. Many sectors, including commercial, government, healthcare, research, and wellness/advocacy groups, have created consumer informatics for palliation. Conclusions: Online information about palliation is available, although identifying trustworthy sources can be problematic. General information sites are relatively plentiful, but more tools for decision making, and interaction would increase value of web resources. More attention to literacy levels, instructional principles, and needs of special populations would improve products. Research to measure usage of such tools, ability to influence behavior, and cost/benefit issues is needed. [ABSTRACT FROM AUTHOR]

Objective: In 1996, 2001, and 2010, the Consolidated Standards of Reporting Trials (CONSORT) group released criteria for reporting critical information about randomized clinical trials . These criteria were intended to improve the quality and completeness of reporting of RCTs in health care research. This paper discusses the relevance of the CONSORT recommendations for the reporting and design of eHealth research. Methods: We reviewed the CONSORT recommendations and discussed their particular relevance to eHealth (electronic information, support and/or communication resources designed to promote health) research. This review focuses on such issues as recruitment and screening of participants, description of treatment elements, and reporting of outcome data and adverse events. Results: eHealth research presents special challenges regarding the comprehensive and effective reporting of research information. However, the strategic application of CONSORT recommendations holds great promise for improving the quality and informativeness of eHealth research. Conclusion: Investigators need to consider CONSORT recommendations at all stages of the research enterprise, including planning, execution and reporting in order to increase the informativeness of their research efforts. Practice implications: The recommendations contained in this paper have the potential to enhance the public health and scientific value of eHealth research. [Copyright &y& Elsevier]

Presents an editorial on the evaluation of ehealth systems and services. Need for ehealth developers to first evaluate the users' needs, then the product's risks and benefits, then its feasibility and its acceptability to the user; Way that web sites should include content that is of high quality and useful to the user; Cost implications of ehealth programs; View that evaluations need to determine how people use various ehealth features and how such use relates to health outcomes.

A letter to the editor is presented regarding a local survey of HIV infections among men.

Background: Due to the COVID-19 pandemic, healthcare providers were forced to shift many services quickly from in-person to virtual, including substance use disorder (SUD) and mental health (MH) treatment services. This led to a sharp increase in telehealth services, with health systems seeing patients virtually at hundreds of times the rate as before the onset of the COVID-19 pandemic. By analyzing qualitative data about SUD and MH care organizations' experiences using telehealth, this study aims to elucidate emergent themes related to telehealth use by the front-line behavioral health workforce.Methods: This study uses qualitative data from large-scale web surveys distributed to SUD and MH organizations between May and August 2020. At the end of these surveys, the following question was posed in free-response form: "Is there anything else you would like to say about use of telehealth during or after the COVID-19 pandemic?" Respondents were asked to answer on behalf of their organizations. The 391 responses to this question were analyzed for emergent themes using a conventional approach to content analysis.Results: Three major themes emerged: COVID-specific experiences with telehealth, general experiences with telehealth, and recommendations to continue telehealth delivery. Convenience, access to new populations, and lack of commute were frequently cited advantages of telehealth, while perceived ineffectiveness of and limited access to technology were frequently cited disadvantages. Also commonly mentioned was the relaxation of reimbursement regulations. Respondents supported continuation of relaxed regulations, increased institutional support, and using a combination of telehealth and in-person care in their practices.Conclusions: This study advanced our knowledge of how the behavioral health workforce experiences telehealth delivery. Further longitudinal research comparing treatment outcomes of those receiving in-person and virtual services will be necessary to undergird organizations' financial support, and perhaps also legislative support, for virtual SUD and MH services. [ABSTRACT FROM AUTHOR]

Communicating within digital health interventions involves a range of behaviors that may contribute to the management of chronic illnesses in different ways. This study examines whether communication within a smartphone-based application for addiction recovery produces distinct effects depending on 1) the "level" of communication, defined as intraindividual communication (e.g., journal entries to oneself); dyadic communication (e.g., private messaging to other individuals); or network communication (e.g., discussion forum posts to all group members), and 2) whether individuals produce or are exposed to messages. We operationalize these communication levels and behaviors based on system use logs as the number of clicks dedicated to each activity and assess how each category of system use relates to changes in group bonding and substance use after 6 months with the mobile intervention. Our findings show that (1) intraindividual exposure to one's own past posts marginally predicts decreased drug use; (2) dyadic production predicts greater perceived bonding; while dyadic exposure marginally predicts reduced drug use; (3) network production predicts decreased risky drinking. Implications for digital health interventions are discussed. [ABSTRACT FROM AUTHOR]

Scholars have adopted Street's (2003) ecological model of communication in medical encounters to investigate the factors promoting patient participation in health care. However, factors demonstrated in the ecological model were bounded in the context of medical care primarily focusing on health care providers and patients. Social factors, such as patients' relationships and supportive communication with others outside the context of health care remain relatively unexplored. To expand the purview of our understanding of factors that influence patient participation, this research integrated social support literature into the research on physician-patient communication and proposed a model which described a process through which social support can enhance patient participation in health care. The data analyzed in this study were a part of two larger clinical trials in which 661 women with breast cancer were recruited from three cancer institutions in the United States. The results from structural equation modeling analysis from cross-sectional and longitudinal data provided strong evidence for the hypotheses predicting that perceived social support was positively associated with health information competence, which in turn fully mediated the association between social support and patient participation in health care. Theoretical and practical implications are discussed. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To examine how psychosocial variables predicted use of an online health consultation service among low-income breast cancer patients and in turn how using this service affected these same psychosocial outcomes. Method: This retrospective study included 231 recently diagnosed, low-income (at or below 250% of the federal poverty level) breast cancer patients provided a free computer with 16 weeks of access to the Internet-based ‘Ask an Expert’ service offered as part of the Comprehensive Health Enhancement Support System (CHESS) “Living with Breast Cancer” program. The use activity included a total of 502 messages submitted to the online health consultation service. The data included five psychosocial variables: information seeking, social support, health self efficacy, participation in health care, and doctor–patient relationship, were collected at both the pre-test and 16-week post-test after using the service. Correlation tests were conducted to examine the relationship between pre- and post-test, and use activity. A multiple regression model was formed for each of five psychosocial variables to examine how use activity of the consultation service was associated with various psychosocial measurements. Results: In total, 865 distinct consulting queries from 502 messages were identified as measurement of patients’ use activities (3.74 consulting queries per participant). Use activity had significant negative relationships with pre-test scores across all five psychosocial variables. The regression models found significant positive main effects (use activity) associated with three of these psychosocial variables: health self efficacy, participation in health care and doctor–patient relationship. Use activity of the online consultation service did not have significant relationships with the dependent variables of information seeking and perceived social support. Conclusion: Low-income breast cancer patients sought out information from an online cancer information expert. Patients with more negative perceptions at pre-test tended to use the service more. Greater use of the service was associated with improvement in patients’ perception of health self-efficacy, participation in health care and doctor–patient relationship. Moreover, use of online health consultation appears to level the differences, narrowing the gaps between those who were worse and better off at pre-test. These findings suggest that online health consultation can serve as an effective complement to other resources, which help low-income, breast cancer patients feel more confident to participate more actively in their health care, become more actively involved in making decisions about their treatments and enhance the relationship with their doctors. [Copyright &y& Elsevier]