The case for frugal default options in patient–doctor communication

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79400/1/j.1365-2753.2010.01404.x.pd

Enough: The Failure of the Living Will

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90575/1/3527683.pd

The Death of the Living Will

Enough. The living will has failed, and it is time to say so. We should have known it would fail: A notable but neglected psychological literature always provided arresting reasons to expect the policy of living wills to misfire. Given their alluring potential, perhaps they were worth trying. But a crescendoing empirical literature and persistent clinical disappointments reveal that the rewards of the campaign to promote living wills do not justify its costs

Racial/Ethnic Disparities in Knowledge about Risks and Benefits of Breast Cancer Treatment: Does It Matter Where You Go?

To evaluate the association between provider characteristics and treatment location and racial/ethnic minority patients' knowledge of breast cancer treatment risks and benefits. Data Sources/Data Collection . Survey responses and clinical data from breast cancer patients of Detroit and Los Angeles SEER registries were merged with surgeon survey responses ( N =1,132 patients, 277 surgeons). Study Design . Cross-sectional survey. Multivariable regression was used to identify associations between patient, surgeon, and treatment setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast conserving surgery with radiation. Principal Findings . Half (51 percent) of respondents had survival knowledge, while close to half (47.6 percent) were uncertain regarding recurrence knowledge. Minority patients and those with lower education were less likely to have adequate survival knowledge and more likely to be uncertain regarding recurrence risk than their counterparts ( p <.001). Neither surgeon characteristics nor treatment location attenuated racial/ethnic knowledge disparities. Patient–physician communication was significantly ( p <.001) associated with both types of knowledge, but did not influence racial/ethnic differences in knowledge. Conclusions . Interventions to improve patient understanding of the benefits and risks of breast cancer treatments are needed across surgeons and treatment setting, particularly for racial/ethnic minority women with breast cancer.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/71991/1/j.1475-6773.2008.00843.x.pd

A Matter of Perspective: Choosing for Others Differs from Choosing for Yourself in Making Treatment Decisions

Many people display omission bias in medical decision making, accepting the risk of passive nonintervention rather than actively choosing interventions (such as vaccinations) that result in lower levels of risk. OBJECTIVE : Testing whether people's preferences for active interventions would increase when deciding for others versus for themselves. RESEARCH DESIGN : Survey participants imagined themselves in 1 of 4 roles: patient, physician treating a single patient, medical director creating treatment guidelines, or parent deciding for a child. All read 2 short scenarios about vaccinations for a deadly flu and treatments for a slow-growing cancer. PARTICIPANTS : Two thousand three hundred and ninety-nine people drawn from a demographically stratified internet sample. MEASURES : Chosen or recommended treatments. We also measured participants' emotional response to our task. RESULTS : Preferences for risk-reducing active treatments were significantly stronger for participants imagining themselves as medical professionals than for those imagining themselves as patients (vaccination: 73% [physician] & 63% [medical director] vs 48% [patient], P s<.001; chemotherapy: 68% & 68% vs 60%, P s<.012). Similar results were observed for the parental role (vaccination: 57% vs 48%, P =.003; chemotherapy: 72% vs 60%, P <.001). Reported emotional reactions were stronger in the responsible medical professional and parental roles yet were also independently associated with treatment choice, with higher scores associated with reduced omission tendencies (OR=1.15 for both regressions, P s<.01). CONCLUSIONS : Treatment preferences may be substantially influenced by a decision-making role. As certain roles appear to reinforce “big picture” thinking about difficult risk tradeoffs, physicians and patients should consider re-framing treatment decisions to gain new, and hopefully beneficial, perspectives.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72417/1/j.1525-1497.2006.00410.x.pd

Anxiety symptoms prior to a prostate cancer diagnosis: Associations with knowledge and openness to treatment

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135536/1/bjhp12222.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135536/2/bjhp12222_am.pd

Risk, Benefit, and Cost Thresholds for Emergency Department Testing: A Cross‐sectional, Scenario‐based Study

BackgroundWhile diagnostic testing is common in the emergency department, the value of some testing is questionable. The purpose of this study was to assess how varying levels of benefit, risk, and costs influenced an individual’s desire to have diagnostic testing.MethodsA survey through Amazon Mechanical Turk presented hypothetical clinical situations: low‐risk chest pain and minor traumatic brain injury. Each scenario included three given variables (benefit, risk, and cost), that was independently randomly varied over four possible values (0.1, 1, 5, and 10% for benefit and risk and $0,$100, $500, and$1,000 for the individual’s personal cost for receiving the test). Benefit was defined as the probability of finding the target disease (traumatic intracranial hemorrhage or acute coronary syndrome).ResultsOne‐thousand unique respondents completed the survey. With an increased benefit from 0.1% to 10%, the percentage of respondents who accepted a diagnostic test went from 28.4% to 53.1%. (odds ratio [OR] = 3.42; 95% confidence interval [CI] = 2.57–4.54). As risk increased from 0.1% to 10%, this number decreased from 52.5% to 28.5%. (OR = 0.33; 95% CI = 0.25–0.44). Increasing cost from $0 to$1,000 had the greatest change of those accepting the test from 61.1% to 21.4%, respectively (OR = 0.15; 95% CI = 0.11–0.2).ConclusionsThe desire for testing was strongly sensitive to the benefits, risks, and costs. Many participants wanted a test when there was no added cost, regardless of benefit or risk levels, but far fewer elected to receive the test as cost increased incrementally. This suggests that out‐of‐pocket costs may deter patients from undergoing diagnostic testing with low potential benefit.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137417/1/acem13148_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137417/2/acem13148.pd

Decision aid use during postâ biopsy consultations for localized prostate cancer

BackgroundDecision Aids (DAs) effectively translate medical evidence for patients but are not routinely used in clinical practice. Little is known about how DAs are used during patientâ clinician encounters.ObjectiveTo characterize the content and communicative function of highâ quality DAs during diagnostic clinic visits for prostate cancer.Participants252 men newly diagnosed with localized prostate cancer who had received a DA, 45 treating physicians at 4 US Veterans Administration urology clinics.MethodsQualitative analysis of transcribed audio recordings was used to inductively develop categories capturing content and function of all direct references to DAs (booklet talk). The presence or absence of any booklet talk per transcript was also calculated.ResultsBooklet talk occurred in 55% of transcripts. Content focused on surgical procedures (36%); treatment choice (22%); and clarifying risk classification (17%). The most common function of booklet talk was patient corroboration of physiciansâ explanations (42%), followed by either physician or patient acknowledgement that the patient had the booklet. Codes reflected the absence of DA use for shared decisionâ making. In regression analysis, predictors of booklet talk were fewer years of patient education (P = .027) and more time in the encounter (P = .027). Patient race, DA type, time reading the DA, physician informing quality and physician age did not predict booklet talk.ConclusionsResults show that good decision aids, systematically provided to patients, appeared to function not to open up deliberations about how to balance benefits and harms of competing treatments, but rather to allow patients to ask narrow technical questions about recommended treatments.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141531/1/hex12613_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/141531/2/hex12613.pd

It Must be Awful for Them: Perspective and Task Context Affects Ratings for Health Conditions

When survey respondents rate the quality of life (QoL) associated with a health condition, they must not only evaluate the health condition itself, but must also interpret the meaning of the rating scale in order to assign a specific value. The way that respondents approach this task depends on subjective interpretations, resulting in inconsistent results across populations and tasks. In particular, patients and non-patients often give very different ratings to health conditions, a discrepancy that raises questions about the objectivity of either groups\u27 evaluations. In this study, we found that the perspective of the raters (i.e., their own current health relative to the health conditions they rated) influences the way they distinguish between different health states that vary in severity. Consistent with prospect theory, a mild and a severe lung disease scenario were rated quite differently by lung disease patients whose own health falls between the two scenarios, whereas healthy non-patients, whose own health was better than both scenarios, rated the two scenarios as much more similar. In addition, we found that the context of the rating task influences the way participants distinguish between mild and severe scenarios. Both patients and non-patients gave less distinct ratings to the two scenarios when each were presented in isolation than when they were presented alongside other scenarios that provided contextual information about the possible range of severity for lung disease. These results raise continuing concerns about the reliability and validity of subjective QoL ratings, as these ratings are highly sensitive to differences between respondent groups and the particulars of the rating task