Cognitive Basis of CHD Disparities: Factorial Experiment

CHD 差异的认知基础：阶乘实验

• 批准号: 7048016
• 负责人: John B McKinlay
• 金额: $ 44.52万
• 依托单位: NEW ENGLAND RESEARCH INSTITUTES, INC.
• 依托单位国家: 美国
• 财政年份: 2006
• 资助国家: 美国
• 起止时间: 2006-03-20 至 2009-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7048016
• 关键词: age difference; behavior test; behavioral /social science research tag; bias; clinical research; coronary disorder; decision making; diagnosis design /evaluation; diagnosis quality /standard; gender difference; health care personnel performance; health care service evaluation; health disparity; health services research tag; heart disorder diagnosis; human subject; patient care personnel attitude; patient care planning; patient oriented research; racial /ethnic difference; socioeconomics; videotape /videodisc

DESCRIPTION (provided by applicant): This research represents a paradigm shift in studies of Clinical Decision Making by moving the focus from three earlier generations of work to a new "fourth generation" study of cognitive (and reasoning) processes. This theoretically based study builds directly (and cost efficiently) on successfully completed studies which used experimental (factorial) designs and demonstrate that patient attributes (gender, age, race and SES), provider characteristics (gender, medical specialty and years of clinical experience) and health care system characteristics independently influence (most p<.001) the diagnosis and management of Coronary Heart Disease (CHD). Clinical decision-making (CDM) with respect to CHD is shaped as much by who the patient is, who the provider is and the setting in which care is provided as it is by what the patient actually presents (the signs/symptoms of CHD). The study will describe how and explain why (and not simply that) different physicians, in different practice settings evidence variations in a broad-range of CHD care with equivalent patients. This project has 4 aims. (1) To estimate the independent effects of two cognitive experimental manipulations: (a) cognitive "priming" of physicians as to CHD possibility; and (b) systematic substitution of patient attributes purportedly associated with CHD; on the following primary outcomes: probability of a CHD diagnosis, the number and type of diagnostic features recalled, and the timing of CHD diagnosis. The impact of cognitive intervention (a) on intervention (b) will provide estimated effects of analytic vs. non- analytic reasoning (i.e., intentional vs. non-intentional discounting) as measured by the primary outcomes. (2) To understand how patient attributes intrude on physicians' cognitive reasoning processes to produce the observed CHD variations. (3) To explain, using cognitive analysis, how provider characteristics contribute to the documented CHD variability. (4) To understand how organizational influences also intrude on CHD decision-making. Primary care providers (who encounter most CHD) from New York State will be randomly sampled (n=256) and invited to view a clinically authentic videotaped presentation of a "patient" presenting with signs/symptoms of CHD. Information concerning the primary outcome (probability of CHD diagnosis) and a range of well-justified secondary outcomes will be elicited through structured interviewing. The factorial design permits estimation of independent (unconfounded) main effects and all two-way interactions. Results from the proposed research could reduce or eliminate health care variation in at least two types of interventions: (a) Organizational and reimbursement policies could be developed and evaluated which steer providers away from the patterns of decision-making which produce healthcare variations; (b) Interventions during medical education, when practice styles are not yet firmly established.

描述（由申请人提供）：这项研究代表了临床决策研究的范式转变，将重点从前三代的工作转移到了认知（和推理）过程的新“第四代”研究。这项基于理论的研究直接（且具有成本效益）建立在成功完成的研究的基础上，这些研究使用实验（析因）设计，并证明患者属性（性别、年龄、种族和社会经济地位）、提供者特征（性别、医学专业和多年的临床经验）和医疗保健系统特征独立影响（大多数 p<.001）冠心病 (CHD) 的诊断和管理。有关 CHD 的临床决策 (CDM) 不仅取决于患者身份、提供者身份以及提供护理的环境，还取决于患者实际表现（CHD 的体征/症状） 。该研究将描述并解释为什么（而不仅仅是）不同的医生在不同的实践环境中证明对同等患者的广泛的先心病护理存在差异。该项目有 4 个目标。 (1) 评估两种认知实验操作的独立效果： (a) 医生对 CHD 可能性的认知“启动”； (b) 系统地替换据称与先心病相关的患者属性；以下主要结局：冠心病诊断的概率、回忆起的诊断特征的数量和类型以及冠心病诊断的时间。认知干预 (a) 对干预 (b) 的影响将提供通过主要结果衡量的分析推理与非分析推理（即有意贴现与非有意贴现）的估计效果。 (2) 了解患者属性如何干扰医生的认知推理过程以产生观察到的 CHD 变化。 (3) 使用认知分析来解释提供者特征如何影响记录的 CHD 变异性。 (4) 了解组织影响力如何影响 CHD 决策。来自纽约州的初级保健提供者（遇到大多数冠心病）将被随机抽样（n = 256），并被邀请观看具有冠心病体征/症状的“患者”的临床真实录像。有关主要结果（冠心病诊断的概率）和一系列合理的次要结果的信息将通过结构化访谈获得。因子设计允许估计独立（无混杂）主效应和所有双向相互作用。拟议研究的结果可以减少或消除至少两种干预措施中的医疗保健差异： (a) 可以制定和评估组织和报销政策，引导提供者远离产生医疗保健差异的决策模式； (b) 在医学教育期间，当实践方式尚未牢固确立时进行干预。