The proportion of individuals developing chronic diseases is growing, particularly among the urban poor, unemployed, and immigrants. These populations experience disparities in healthcare access and treatment. Since healthcare facilities that care for these patients are often understaffed, Andrew N. de la Torre, MD, a liver transplant surgeon at UMDNJ-University Hospital, has developed a “Patient-Targeted Informatics” kiosk that uses a computer to elicit medical history and identify individuals in need of specific medical testing. The kiosk will now be expanded to elicit risk factors and screening history for other chronic diseases and to survey attitudes toward participation in clinical trials. Collaborators for this project are Stanley H. Weiss, MD, and Barbara H. Gladson, PhD.
Patients are interviewed on a touch-screen computer work-station where questions appear on the screen and are read through headphones in Spanish, English or Creole. Patients are educated about risk factors for hepatitis — including certain sexual histories and drug and alcohol use — and are then asked whether they have any of those risk factors (without having to specify which ones). Patients are more likely to divulge personal health information to a computer screen than to a healthcare practitioner. Risk based on ethnicity and country of birth is also assessed using an interactive world map. If a patient answers “yes” to risky behaviors or touches a location on the map where hepatitis is endemic, their de-identified information is electronically transmitted to Dr. de la Torre and to the health clinic. The patient is then notified to return for testing.
The kiosk is now functioning in a federally funded health clinic in East Orange and in UMDNJ-University Hospital. Between March 2008 and April 2009, 1,016 patients began, and 980 completed, the survey. The patients were ethnically and racially diverse with about 40% non-Hispanic black and about a third Hispanic of any race, and came from a broad mix of countries, with about one third from North America, 29% from the Caribbean, 23% from South and Central America, and others from Africa, Asia, the Pacific islands, Europe, and the Middle East. There were 246 patients identified as needing blood tests for chronic viral hepatitis; 150 of these had a complete chronic hepatitis screen (HCV antibody, HBV surface antigen, HBV core antibody, and HBV surface antibody). Twenty patients were found to test positive for chronic viral hepatitis (14 HCV, 6 HBV) and 96 patients were hepatitis-B naïve (i.e., all three HBV tests were negative). More than 70 patients are in the process of HBV vaccination. As an internal control, patients were asked if they had a history of viral hepatitis. Of the 66 patients noting a history of viral hepatitis, 37 (56%) acknowledged any risk factor.
Since the CDC predicts that steatohepatitis-related cirrhosis, resulting from non-alcoholic fatty liver (NAFL), will be the leading cause of liver failure by 2025, the kiosk was also programmed to calculate body mass index (BMI) to identify patients with a BMI greater than 35, or greater than 30 with concurrent diabetes. We found 27% of patients met these criteria for NAFL risk.
In addition to the two clinic locations, the kiosk was featured at the Essex County Cancer Coalition’s third annual health/cancer fair, held in the UMDNJ-New Jersey Dental School pavilion in April, in conjunction with several types of cancer screening. The response from the public was very positive and 13 individuals completed the survey.
Development of the kiosk has been facilitated by partnerships with the Health Care Foundation of New Jersey, NJMS Department of Family Medicine (Mark Johnson, MD), NJMS Department of Internal Medicine (Iris Herrera, MD), NJMS Division of Hepatology (Carroll B. Leevy, MD), and the Newark Community Health Center (Nancy Tham). Recently Dr. de la Torre and his research assistant, Ismael Castaneda, MD, partnered with Dr. Weiss and his team — including Daniel M. Rosenblum, PhD, and Christopher P. Tuohy, MPH — to expand the kiosk to include screening for cancer, cardiovascular disease, and depression. Patients will be surveyed to determine whether they are up to date with recommended screenings for breast, colon and cervical cancers and whether they have been screened for prostate cancer. The kiosk will be programmed to identify patients needing further medical testing based on their demographics, medical history, and lifestyle. For example, women younger than 26 will receive education on the human papillomavirus (HPV) and woman over 40 will receive information on mammography. Patients over 60 with a history of cigarette smoking will be informed of their risk of lung cancer and advised to discuss the need for cancer screening with their physician. Questions evaluating risk factors for cardiovascular diseases ask about the presence of hypertension, high cholesterol, and diabetes, and smoking history.
On completion of the survey, the kiosk will print summary pages of prioritized health risks for the patient and for the physician. The patient’s printout will be in his/her chosen language, at a level easily understood.
Dr. Gladson has led the development of a module to educate patients on, and measure attitudes toward, participating in a clinical trial. Clinical trials are used to identify the efficacy and safety of new drugs, but poor enrollment leads to significant delays in bringing new drugs to market. Despite governmental intervention and high rates of disease burden, minority recruitment has remained low. Barriers to enrollment may be sponsor-centered (reflecting the inclusion/exclusion criteria of a study), investigator-centered (lack of cultural competence, too few minority investigators, time constraints, and lack of funding), and subject-centered (mistrust, low health literacy, lack of access, fear of side effects, and lack of awareness). Attitudes about clinical trials among different ages, genders, and ethnicities will be identified. These results will be used to inform the development of culturally appropriate vignettes addressing some of the most significant factors influencing willingness to participate in a trial. The kiosk will then be programmed to show the appropriate vignette to future subjects based on their demographics. Ultimately, we will determine if these matched vignettes improve trial participation.
Audio-computer assisted surveys can be used to help clinicians acquire critical patient data to help assess and treat diseases while ensuring that routine health screening is up to date. Based on pilot data, our kiosk is predicted to reach more than 4,000 patients a year, improving their health and providing critical education. Preventing illness and delaying the progression of disease with our kiosk is an exciting prospect that will reach many more patients as our project expands.
Andrew N. de la Torre, MD, a graduate of Johns Hopkins Medical School, is currently associate professor of surgery at UMDNJ-New Jersey Medical School (NJMS) and director of laparoscopic and minimally invasive liver surgery and clinical director of UMDNJ-University Hospital’s (UH) hepatobiliary immunotherapy research team (HIRT). He completed his surgery residency and liver surgery training at NJMS/UH and a kidney/pancreas transplant fellowship at the University of Maryland. Among his major interests are public health education, early diagnosis of chronic viral hepatitis and prevention of hepatocellular cancer.
Stanley H. Weiss, MD, a graduate of Harvard Medical School, is professor of preventive medicine & community health at NJMS and professor of quantitative methods at UMDNJ-School of Public Health (SPH), and is board certified in medical oncology. He is a well-known researcher in the epidemiology of cancer, asthma, and infectious diseases, including HIV/AIDS. Dr. Weiss is a fellow of the American College of Epidemiology, the Cancer Liaison Physician for UH/NJMS to the American College of Surgeons’ Commission on Cancer, and the founder and director of the Essex County Cancer Coalition and the northern NJ Prostate Cancer Initiative.
Barbara H. Gladson, PhD, earned her doctorate in pharmacology from UMDNJ’s Graduate School of Biomedical Sciences (GSBS), and is currently professor of rehabilitation & movement sciences at UMDNJ-School of Health Related Professions, and associate professor of pharmacology & physiology at GSBS in Newark. She is also the Director of the UMDNJ Biopharma Educational Initiative and the MS in Clinical Trial Sciences in SHRP.
Daniel M. Rosenblum, PhD, earned his degree in public policy analysis from Carnegie Mellon University and is currently assistant professor of preventive medicine & community health at NJMS and assistant professor of quantitative methods at SPH. He analyzes epidemiologic, survey and clinical data, mostly in collaboration with Dr. Weiss. He is also co-coordinator of the Essex County Cancer Coalition.
Christopher P. Tuohy, MPH, is a graduate of UMDNJ’s School of Public Health. He is coordinator of the Essex County Cancer Coalition, and a research assistant with a lead role on many of Dr. Weiss’s projects.