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）：本研究代表了临床决策研究的范式转移，该研究通过将重点从三代工作转移到对认知（和推理）过程的新“第四代”研究。这项基于理论上的研究直接（并有效地）在成功完成的研究（阶乘设计）设计上建立了（并表明患者属性（性别，年龄，种族和SES），提供者特征（性别，医学专业和临床经验年度）和卫生保健系统特征独立影响（大多数p <.001）诊断和管理型心脏病（CH）。关于冠心病的临床决策（CDM）由患者是谁，提供者是谁以及患者实际表现出的护理的设置所塑造的（冠心病的体征/症状）。该研究将描述与同等患者的广泛冠心病护理中的不同练习环境中的不同医生的方式和解释为什么（而不是简单地）不同的医生。该项目有4个目标。 （1）估计两种认知实验操作的独立影响：（a）医生对CHD可能性的认知“启动”； （b）据称与CHD相关的患者属性的系统取代；关于以下主要结果：冠心病诊断的概率，召回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）对干预的影响（b）将提供分析性与非分析推理的估计效果（即，由主要结果衡量。 （2）了解患者如何归因于医生的认知推理过程以产生观察到的CHD变异。 （3）使用认知分析解释提供商特征如何促进已记录的CHD变异性。 （4）了解组织的影响如何也侵入了CHD决策。来自纽约州的初级保健提供者（遇到大多数CHD）将随机取样（n = 256），并邀请观看临床上真实的录像带的“患者”呈现的“患者”呈现，其中呈现了CHD的体征/症状。有关主要结果（CHD诊断的概率）和一系列正式结构的次要结果的信息将通过结构化访谈引起。阶乘设计允许估计独立（无共同）的主要效应和所有双向相互作用。拟议的研究的结果可以减少或消除至少两种干预措施的医疗保健差异：（a）可以制定和评估组织和报销政策，从而远离产生医疗保健变化的决策模式； （b）在医学教育期间的干预措施尚未牢固确定。