Involvement In Treatment Decisions Research Articles

Treatment decision-making among breast cancer patients in Malaysia.

PurposeThis study investigated breast cancer patients’ involvement level in the treatment decision-making process and the concordance between patients’ and physician’s perspectives in decision-making.Participants and methodsA cross-sectional study was conducted involving physicians and newly diagnosed breast cancer patients from three public/teaching hospitals in Malaysia. The Control Preference Scale (CPS) was administered to patients and physicians, and the Krantz Health Opinion Survey (KHOS) was completed by the patients alone. Binary logistic regression was used to determine the association between sociodemographic characteristics, the patients’ involvement in treatment decision-making, and patients’ preference for behavioral involvement and information related to their disease.ResultsThe majority of patients preferred to share decision-making with their physicians (47.5%), while the second largest group preferred being passive (42.6%) and a small number preferred being active (9.8%). However, the physicians perceived that the majority of patients preferred active decision-making (56.9%), followed by those who desired shared decision-making (32.8%), and those who preferred passive decision-making (10.3%). The overall concordance was 26.5% (54 of 204 patient–physician dyads). The median of preference for information score and behavioral involvement score was 4 (interquartile range [IQR] =3–5) and 2 (IQR =2–3), respectively. In univariate analysis, the ethnicity and educational qualification of patients were significantly associated with the patients’ preferred role in the process of treatment decision-making and the patients’ preference for information seeking (p>0.05). However, only educational qualification (p=0.004) was significantly associated with patients’ preference for information seeking in multivariate analysis.ConclusionPhysicians failed to understand patients’ perspectives and preferences in treatment decision-making. The concordance between physicians’ perception and patients’ perception was quite low as the physicians perceived that more than half of the patients were active in treatment decision-making. In actuality, more than half of patients perceived that they shared decision-making with their physicians.

Shared decision making after severe stroke-How can we improve patient and family involvement in treatment decisions?

People who are well may regard survival with disability as being worse than death. However, this is often not the case when those surviving with disability (e.g. stroke survivors) are asked the same question. Many routine treatments provided after an acute stroke (e.g. feeding via a tube) increase survival, but with disability. Therefore, clinicians need to support patients and families in making informed decisions about the use of these treatments, in a process termed shared decision making. This is challenging after acute stroke: there is prognostic uncertainty, patients are often too unwell to participate in decision making, and proxies may not know the patients' expressed wishes (i.e. values). Patients' values also change over time and in different situations. There is limited evidence on successful methods to facilitate this process. Changes targeted at components of shared decision making (e.g. decision aids to provide information and discussing patient values) increase patient satisfaction. How this influences decision making is unclear. Presumably, a "shared decision-making tool" that introduces effective changes at various stages in this process might be helpful after acute stroke. For example, by complementing professional judgement with predictions from prognostic models, clinicians could provide information that is more accurate. Decision aids that are personalized may be helpful. Further qualitative research can provide clinicians with a better understanding of patient values and factors influencing this at different time points after a stroke. The evaluation of this tool in its success to achieve outcomes consistent with patients' values may require more than one clinical trial.

Cardiologists' experiences and perceptions of patient involvement and communication related to shared decision-making regarding atrial fibrillation treatment.

To feel involved in decisions about atrial fibrillation (AF) treatment, patients need supportive communication from cardiologists. Shedding light on cardiologists' perceptions of patient involvement in AF care settings is thus of importance. We examine (1) how cardiologists describe patient involvement and communication related to shared decisionmaking regarding AF treatment, and (2) their perceptions of efforts to involve patients in the treatment decisions. Ten cardiologists were interviewed in four Swedish hospitals. A qualitative content analysis was performed on the interview data. Cardiologists' perceptions of patient involvement in treatment decisions are framed in terms of (1) ideology, (2) experience, and (3) responsibility. By taking into account patients' feelings in the consultations, and by actively encouraging patients to be involved, the cardiologists contributed to patient involvement. One key to improving compliance with legislation aimed at increasing patient involvement in treatment decisions could lie in paying attention to physician-patient communication and the conditions for patient involvement in decision-making about treatment.

Patient's Cognitive Function and Attitudes towards Family Involvement in Cancer Treatment Decision Making: A Patient-Family Caregiver Dyadic Analysis.

PurposeOlder patient populations commonly have cognitive impairment, which might impact decisional capacity. We examined patients and family caregivers preferences for family involvement in treatment decision making assuming different level of cognitive impairment, and sought to explore the factors associated with the preferences and the degree to which patients and family members agree on preferences.Materials and MethodsA total of 358 elderly cancer patient and caregiver dyads were recruited from the 11 cancer centers in Korea andwere asked to express their preferences forfamily involvement in treatment decision making using hypothetical scenarios with three different levels of cognitive status (intact, mild impairment, and severe impairment).ResultsBoth patients and family caregivers preferred greater family dominance in treatment decision makingwith the increasing the level of cognitive impairment (39.7%, 60.9%, and 86.6% for patients and 45.0%, 66.2%, and 89.7% for caregivers in each scenarios). Patient and family caregiver concordance in decisional control preference was small for all three scenarios (weighted κ=0.32, κ=0.26, and κ=0.36, respectively). Higher patient education was associated with preference for patient dominance in treatment decision in conditions of both mild and severe cognitive impairment. The association of higher patient education and patient-caregiver preference concordance was positive with intact cognition, while it was negative with severe cognitive impairment.ConclusionDecision control preferences were affected by hypothesized cognitive status of the patients. Findings from our study would be helpful to develop effective strategy for optimizing family involvement in cancer treatment decision in the context of deteriorating cognitive function of the patients.

Ethical considerations in dental plan claims adjudication

Ethical considerations in dental plan claims adjudication

Shared Decision-Making in Patients With Prostate Cancer in Japan: Patient Preferences Versus Physician Perceptions.

This article adds the Japanese perspective to our knowledge of shared decision-making (SDM) preferences by surveying patients with prostate cancer (PCA) and physicians in Japan. In 2015, 103 Japanese patients with PCA were asked about their SDM preferences by using an Internet-based 5-point-scale questionnaire. Concurrently, 127 Japanese physicians were surveyed regarding their perceptions of patient preferences on SDM. Drivers of preferences and perceptions were analyzed using univariable ordinal logistic regression and graphing the fitted response probabilities. Although 41% of both patients and physicians expressed and expected a desire for active involvement in treatment decisions (a higher rate than in a similar study for the United States in 2001), almost half the Japanese patients preferred SDM, but only 33% of physicians assumed this was their choice. That is, 29% of Japanese physicians underestimated patients’ preference for involvement in making treatment decisions. Patients with lower health-related quality of life (as measured by the Functional Assessment of Cancer Therapy-Prostate [FACT-P]) expressed a stronger preference for SDM. The study shows that the worse the medical situation, the more patients with PCA prefer to be involved in the treatment decision, yet physicians tend to underestimate the preferences of their patients. Perhaps in contrast to common assumptions, Japanese patients are as interested in being involved in decision making as are patients in the United States.

Influence of patient perceived relationship with pharmacist and physician and its association with beliefs in medicine

Objectives The purpose of this study was to evaluate the association between patients’ perceived relationship with their pharmacist and physicians and its association with their beliefs in medicine. Methods A cross-sectional design was used and 307 self-administered surveys were collected from adults, 45 years and above, in Houston, Texas via convenience sampling. Participants reported their general beliefs in medicine (perceived harm, perceived benefit and perceived medication overuse), perceived patient–pharmacist relationship, and perceived patient–physician relationship using a previously validated instrument adapted for this research. Perceived relationship constructs consisted of three domains each for pharmacist and physicians, namely trust/satisfaction, information sharing and patient involvement in treatment. Key findings The study participants were white (46.25%) females (54.72%) with a mean age of 58 (±13) years. The results indicate that the participants trusted and were satisfied with both their pharmacist and physician. Participants with higher trust/satisfaction with pharmacist consider medications as more beneficial. While participants with higher trust/satisfaction with their physicians were less likely to believe that doctors over-prescribe medicines, which may lead to medication over use. Information sharing by pharmacists was associated with a significant decrease in perception of general benefits of medications. Further participant's involvement in treatment decisions by the physician had a significant association with increased perceptions of benefits of medications. Conclusions Patients trust/satisfaction with their pharmacist leads to the belief that medications are more beneficial while a higher trust/satisfaction with physicians leads to lower beliefs in medicine, especially patients less likely to be adherent with appropriate medications.

EHealth Literacy and Partner Involvement in Treatment Decision Making for Men With Newly Diagnosed Localized Prostate Cancer

To examine how the eHealth literacy of partners of patients with newly diagnosed prostate cancer affects their involvement in decision making, and to identify the factors that influence their eHealth literacy. . Cross-sectional exploratory study. . North Carolina. . 142 partners of men with newly diagnosed localized prostate cancer. . A telephone survey and descriptive and multiple linear regression analyses were used. . The partners' eHealth literacy, involvement in treatment decision making, and demographics, and the health statuses of the patients and their partners. . Higher levels of eHealth literacy among partners were significantly associated with their involvement in getting a second opinion, their awareness of treatment options, and the size of the social network they relied on for additional information and support for treatment decision making for prostate cancer. The factor influencing eHealth literacy was the partners' access to the Internet for personal use, which explained some of the variance in eHealth literacy. . This study described how partners' eHealth literacy influenced their involvement in treatment decision making for prostate cancer and highlighted the influencing factors (i.e., partners' access to the Internet for personal use). . When helping men with prostate cancer and their partners with treatment decision making, nurses need to assess eHealth literacy levels to determine whether nonelectronically based education materials are needed and to provide clear instructions on how to use eHealth resources.

Abstract A53: Racial and ethnic disparities in prostate cancer survivors' perceived engagement in treatment decision making

Abstract Objective: Shared decision making is especially important in prostate cancer as treatment decisions are inherently demanding and complex. There are multiple treatment options in which none are superior for survival. The complexity of treatment decision making in weighing pros and cons, considering patients' values and personal preferences, and physicians' recommendations is even more challenging for patients of low health literacy and/or limited English proficiency, both of which are disproportionately represented among racial and ethnic minorities. However, research is scant regarding the extent of minority patients' involvement in treatment decision making, particularly in prostate cancer where treatment options remain controversial and conflict of interest is inherent in clinical decision making. This study examines racial and ethnic disparities in prostate cancer survivors'perceived engagement in treatment decision making with their doctors, and factors associated with racial and ethnic disparities in a multiethnic sample. Methods: Racially and ethnically diverse prostate cancer patients, age 18-75 years old, were identified through the California Cancer Registry. Participants completed a cross-sectional 30-minute telephone interview in English, Spanish, Cantonese, or Mandarin (N=855). Multivariable logistic regression models were used to investigate racial and ethnic disparities in (1) doctors asking patients to help decide treatment plan, (2) patients and doctors working out a treatment plan together, and (3) factors significantly associated with patient's perceived involvement in decision making, by race/ethnicity. Results: Participants included African American (19%), Asian American (15%), Latino (24%), and White (42%) participants diagnosed with stage I or II prostate cancer. More than half were married/living with a partner (76%), college graduates (51%), from Northern California (59%), and English speakers (83%). A smaller portion of participants had public or no health insurance (20%), were of low health literacy (19%), and received treatment with hormone therapy or chemotherapy (15%). Asian American participants were less likely than Whites to have their doctors ask them to help decide on a treatment plan (OR=0.31; 95% CI=0.18-0.53), with Cantonese/Mandarin language being a significant contributing factor for these participants (OR=0.08; 95% CI=0.01-0.63). Similarly, Asian Americans were also less likely to work out their treatment plan with their doctors (OR=0.54; 95% CI=0.33-0.90), and Cantonese/Mandarin language was also significantly associated (OR=0.04; 95% CI=0.01-0.25). There were no significant differences in outcomes comparing African Americans or Latinos to White participants. Conclusion: Asian American prostate cancer patients report less engagement in treatment decision making, with language being a significant contributing factor. This is concerning because patients' values and preferences need to be considered and weigh heavily in the decision. Providers should consider potential language barriers for newly diagnosed patients and seek resources to support these patients (e.g., translators, patient navigators, etc.). Additionally, providers may require additional training and resources to help them engage vulnerable patients, particularly Asian American cancer patients, in shared decision making, which requires skills in elicitation and risk communication. Future research is needed to explore strategies to best engage underserved patients and effectively support healthcare providers in shared treatment decision making. Citation Format: Nynikka R.A. Palmer, Steven Gregorich, Jennifer Livaudais-Toman, Celia Kaplan. Racial and ethnic disparities in prostate cancer survivors' perceived engagement in treatment decision making. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A53.

What are the decision-making preferences of patients in vascular surgery? A mixed-methods study

ObjectivesShared decision-making (SDM) has been advocated as the preferred method of choosing a suitable treatment option. However, patient involvement in treatment decision-making is not yet common practice in the field...

Long-term persistence and adherence on urate-lowering treatment can be maintained in primary care-5-year follow-up of a proof-of-concept study.

To evaluate the persistence and adherence on urate-lowering treatment (ULT) in primary care 5 years after an initial nurse-led treatment of gout. One hundred gout patients initiated on up-titrated ULT between March and July 2010 were sent a questionnaire that elicited information on current ULT, reasons for discontinuation of ULT if applicable, medication adherence and generic and disease-specific quality-of-life measures in 2015. They were invited for one visit at which height and weight were measured and blood was collected for serum uric acid measurement. Seventy-five patients, mean age 68.13 years ( s . d . 10.07) and disease duration 19.44 years ( s . d . 13), returned completed questionnaires. The 5-year persistence on ULT was 90.7% (95% CI 81.4, 91.6) and 85.3% of responders self-reported taking ULT ⩾6 days/week. Of the 65 patients who attended the study visit, the mean serum uric acid was 292.8 μmol/l ( s . d . 97.2). An initial treatment that includes individualized patient education and involvement in treatment decisions results in excellent adherence and persistence on ULT >4 years after the responsibility of treatment is taken over by the patient's general practitioner, suggesting that this model of gout management should be widely adopted.

Factors associated with oncology patients' involvement in shared decision making during chemotherapy.

Oncology patients are increasingly encouraged to play an active role in treatment decision making. While previous studies have evaluated relationships between demographic characteristics and decision-making roles, less is known about the association of symptoms and psychological adjustment characteristics (eg, coping styles and personality traits) and decision-making roles. As part of a larger study of symptom clusters, patients (n=765) receiving chemotherapy for breast, gastrointestinal, gynecological, or lung cancer provided information on demographic, clinical, symptom, and psychological adjustment characteristics. Patient-reported treatment decision-making roles (ie, preferred role and role actually played) were assessed using the Control Preferences Scale. Differences among patients, who were classified as passive, collaborative, or active, were evaluated using χ2 analyses and analyses of variance. Over half (56.3%) of the patients reported that they both preferred and actually played a collaborative role. Among those patients with concordant roles, those who were older, those with less education and lower income, and those who were less resilient were more likely to prefer a passive role. Several psychological adjustment characteristics were associated with decision-making role, including coping style, personality, and fatalism. Oncology patients' preferences for involvement in treatment decision making are associated with demographic characteristics as well as with symptoms and psychological adjustment characteristics, such as coping style and personality. These results reaffirm the complexities of predicting patients' preferences for involvement in decision making. Further study is needed to determine if role or coping style may be influenced by interventions designed to teach adaptive coping skills.

Involving Patients in Weighting Benefits and Harms of Treatment in Parkinson's Disease.

IntroductionLittle is known about how patients weigh benefits and harms of available treatments for Parkinson’s Disease (oral medication, deep brain stimulation, infusion therapy). In this study we have (1) elicited patient preferences for benefits, side effects and process characteristics of treatments and (2) measured patients’ preferred and perceived involvement in decision-making about treatment.MethodsPreferences were elicited using a best-worst scaling case 2 experiment. Attributes were selected based on 18 patient-interviews: treatment modality, tremor, slowness of movement, posture and balance problems, drowsiness, dizziness, and dyskinesia. Subsequently, a questionnaire was distributed in which patients were asked to indicate the most and least desirable attribute in nine possible treatment scenarios. Conditional logistic analysis and latent class analysis were used to estimate preference weights and identify subgroups. Patients also indicated their preferred and perceived degree of involvement in treatment decision-making (ranging from active to collaborative to passive).ResultsTwo preference patterns were found in the patient sample (N = 192). One class of patients focused largely on optimising the process of care, while the other class focused more on controlling motor-symptoms. Patients who had experienced advanced treatments, had a shorter disease duration, or were still employed were more likely to belong to the latter class. For both classes, the benefits of treatment were more influential than the described side effects. Furthermore, many patients (45%) preferred to take the lead in treatment decisions, however 10.8% perceived a more passive or collaborative role instead.DiscussionPatients weighted the benefits and side effects of treatment differently, indicating there is no “one-size-fits-all” approach to choosing treatments. Moreover, many patients preferred an active role in decision-making about treatment. Both results stress the need for physicians to know what is important to patients and to share treatment decisions to ensure that patients receive the treatment that aligns with their preferences.

Subjective and objective knowledge and decisional role preferences in cerebrovascular patients compared to controls.

BackgroundRisk knowledge and active role preferences are important for patient involvement in treatment decision-making and adherence. Although knowledge about stroke warning signs and risk factors has received considerable attention, objective knowledge on secondary prevention and further self-esteem subjective knowledge have rarely been studied. The aim of our study was to investigate knowledge and treatment decisional role preferences in cerebrovascular patients compared to controls.MethodsWe performed a survey on subjective and objective stroke risk knowledge and autonomy preferences in cerebrovascular patients from our stroke outpatient clinic (n=262) and from pedestrians on the street taken as controls during a “World Stroke Day” (n=274). The questionnaire includes measures for knowledge and decisional role preferences from previously published questionnaires and newly developed measures, for example, subjective knowledge, revealed on a visual analog scale.ResultsThe overall stroke knowledge was low to moderate, with no differences between patients and controls. Knowledge about secondary prevention was particularly low. Only 10%–15% of participants correctly estimated the stroke absolute risk reduction potential of aspirin. The medical data interpretation competence was moderate in both groups. Age and basic mathematical and statistical understanding (numeracy) were the only independent predictors of objective stroke knowledge, whereas previous stroke had no impact on stroke knowledge. However, patients were thought to be better informed than controls. Approximately 60% of both patients and controls claimed to prefer a shared decision-making approach in treatment decisions.ConclusionThe level of stroke risk knowledge in patients with cerebrovascular diseases was as low as in randomly selected pedestrians, although patients felt better informed. Both groups preferred involvement in treatment decision-making. We conclude that educational concepts for increasing awareness of knowledge gaps as well as for stroke risk and for prevention strategies are needed.

Increasing patient involvement in the diabetic foot pathway: a pilot randomized controlled trial.

This pilot study aimed to explore whether the use of an intervention to increase shared decision-making (Decision Navigation) increased decision self-efficacy and foot-treatment adherence in patients with a diabetic foot ulcer. Fifty-six patients with a diabetic foot ulcer were randomized to receive Decision Navigation (N = 30) or usual care (N = 26). Primary outcomes included decision self-efficacy, adherence to foot treatment as reported by the participant and adherence to foot treatment as reported by the clinician. Secondary outcomes included foot ulcer healing rate, health-related quality of life, decision conflict and decision regret. Despite participants rating Decision Navigation as very helpful, mixed analyses of variance revealed no differences in decision self-efficacy or adherence between those receiving Decision Navigation and those receiving usual care. There were no differences between groups with regards to the secondary outcomes, with the exception of decision conflict which increased over time (12 weeks) for those receiving Decision Navigation. An intervention that facilitated patient involvement in treatment decisions did not have any impact on decisional confidence or adherence to foot treatment. This does not provide support for the suggestion that personalized care can improve health-related outcomes at this progressed stage of the patient's disease trajectory. We suggest that the diabetic foot population may benefit from interventions aimed at increasing motivation to engage with care pathways, centred on challenging personal controllability beliefs.

A Successful Implementation Strategy to Support Adoption of Decision Making in Mental Health Services.

Individual involvement in treatment decisions with providers, often through the use of decision support aids, improves quality of care. This study investigates an implementation strategy to bring decision support to community mental health centers (CMHC). Fifty-two CMHCs implemented a decision support toolkit supported by a 12-month learning collaborative using the Breakthrough Series model. Participation in learning collaborative activities was high, indicating feasibility of the implementation model. Progress by staff in meeting process aims around utilization of components of the toolkit improved significantly over time (p < .0001). Survey responses by individuals in service corroborate successful implementation. Community-based providers were able to successfully implement decision support in mental health services as evidenced by improved process outcomes and sustained practices over 1year through the structure of the learning collaborative model.

Desired Involvement in Treatment Decisions Among Adults with PTSD Symptoms.

Most medical patients want to be involved in decisions about their care. Whether this is true for people with posttraumatic stress disorder (PTSD)-a disorder characterized by avoidance of trauma-related discussions-is unknown. We conducted an online survey assessing preferences for involvement in PTSD treatment decisions (level of control, timing) and information about PTSD treatment (content, format). Adults who screened positive for possible PTSD (N = 301) were recruited from a large online survey panel representative of the U. S. Virtually all respondents (97.3%) desired involvement in treatment decisions; two thirds (67.8%) wanted primary responsibility for decisions. Most (64.2%) wanted 30-60 minutes to learn about treatments and 80.1% wanted at least 1-3 days to consider their options. Respondents expressed more interest in informational content on treatment effectiveness and side effects than any other topic. In-person discussion with a provider was preferred more than other learning formats (e.g., websites, brochures). Results suggested that people with symptoms of PTSD want involvement in decisions about their treatment and want to discuss treatment options with their provider. Providers may wish to prioritize information about effectiveness and side effects, and should expect that many patients will need several days after their visit to make a decision.

Decision Making Among Persons Living With Heart Failure.

Persons with heart failure (HF) are required to make decisions on a daily basis related to their declining health and make urgent decisions during acute illness exacerbations. However, little is known about the types of decisions patients make. The aims of this study were to critically evaluate the current quantitative literature related to decision making among persons with HF and identify research gaps in HF decision-making research. A systematic search of literature about decisions persons with HF make was conducted using PubMed, CINAHL, and PsychINFO databases. The following inclusion criteria were used: sample composed of at least 50% HF participants, concrete decisions were made, and a quantitative study design was used. Two authors performed title, abstract, and full-text reviews independently to identify eligible articles. Twelve quantitative articles were included. Study samples were predominately older, white, male, and married. Two-thirds of the articles focused on decisions related to the end-of-life topics (ie, resuscitation decisions, advanced care planning). The other one-third focused on decisions about care seeking, participant's involvement in treatment decisions during their last clinic visit, and self-care behaviors. Within the HF literature, the term decision is often ill-defined or not defined. Limitations in methodological rigor limit definitive conclusions about HF decision making. Future studies should consider strengthening study rigor and examining other decision topics such as inclusion of family in making decisions as HF progresses. Research rigorously examining HF decision making is needed to develop interventions to support persons with HF.

Can we routinely measure patient involvement in treatment decision-making in chronic kidney care? A service evaluation in 27 renal units in the UK.

BackgroundShared decision making is considered an important aspect of chronic disease management. We explored the feasibility of routinely measuring kidney patients' involvement in making decisions about renal replacement therapy (RRT) in National Health Service settings.MethodsWe disseminated a 17-item paper questionnaire on involvement in decision-making among adult patients with established kidney failure who made a decision about RRT in the previous 90 days (Phase 1) and patients who had been receiving RRT for 90–180 days (Phase 2). Recruitment rates were calculated as the ratio between the number of included and expected eligible patients (I : E ratio). We assessed our sample's representativeness by comparing demographics between participants and incident patients in the UK Renal Registry.ResultsThree hundred and five (Phase 1) and 187 (Phase 2) patients were included. For Phase 1, the I : E ratio was 0.44 (range, 0.08–2.80) compared with 0.27 (range, 0.04–1.05) in Phase 2. Study participants were more likely to be white compared with incident RRT patients (88 versus 77%; P < 0.0001). We found no difference in age, gender or social deprivation. In Phases 1 and 2, the majority reported a collaborative decision-making style (73 and 69%), and had no decisional conflict (85 and 76%); the median score for shared decision-making experience was 12.5 (Phase 1) and 10 (Phase 2) out of 20.ConclusionOur study shows the importance of assessing the feasibility of data collection in a chronic disease context prior to implementation in routine practice. Routine measurement of patient involvement in established kidney disease treatment decisions is feasible, but there are challenges in selecting the measure needed to capture experience of involvement, reducing variation in response rate by service and identifying when to capture experience in a service managing people's chronic disease over time.

Abstract IA14: Multilevel sources of bias as determinants of treatment disparities

Abstract Race disparities in cancer incidence and mortality continue to persist. Unequal treatment (IOM, 2003) for Blacks compared to Whites, is a key factor driving disparities in survivorship and mortality. Research documenting disparities in cancer treatment has shown, for example, that when compared to Whites, Black patients have less access and/or information about clinical trials, are more likely to be under dosed when receiving chemotherapy for breast cancer, are less likely to receive chemotherapy for leukemia, are given less information about hospice care, are less likely to receive adequate levels of pain medication, among others. Social psychological theories of intergroup relations have been helpful for understanding unequal treatment as an outcome of individual level factors associated with physician and patient race related thoughts and feelings, (e.g., White physicians' prejudice or explicit/implicit bias regarding Black patients and Black patients' mistrust or suspicion of White physicians and the healthcare system.) These individual level factors may be expressed in the treatment setting because most Black cancer patients are treated by non-Black oncologists and experience race-discordant clinical interactions. The interaction occurs at the relational level, which, thus, presents a second set of factors related to poor communication and errors in understanding that also potentially contribute to treatment disparities. This presentation will include research showing how social psychological theories of intergroup relations are helping to explain how individual level race-related thoughts and feelings and relational level communication factors that arise in race-discordant clinical interactions result in treatment disparities. The discussion will include initial results from a current study at two comprehensive cancer centers in an urban Midwestern city that included Black cancer patients (n=112) and non-Black oncologists (n=18). Baseline information collected before the initial clinic visit to discuss treatment options included measures of physicians' explicit and implicit racial bias and patients' perceived past discrimination, and group-based suspicion of healthcare. The clinic visit was then video recorded and digitally coded for verbal and nonverbal behavior, information exchange, physician/patient talk time, interaction length, patient centeredness, behavioral synchronicity, etc. Measures administered to patients after the visit included perceived patient centeredness, trust, distress, difficulty in remembering the content of the interaction, and expectations about recommended treatments. Physician measures included perceptions of patient involvement in treatment decisions, and the patients' personal attributes, and expectations about patient responses to treatments. Appropriateness of actual treatment received was later abstracted from the patient's medical record. Early findings show that higher oncologist implicit bias is associated with less reported patient involvement in treatment decisions, less time spent with the patient, lower blind observers' ratings of physician supportiveness, and less smiling and shorter gaze towards patient. Patients interacting with higher implicit oncologists reported less patient centeredness, less trust in the oncologist (one week later), and more difficulty remembering and understanding the conversation (one week later). Indirect effects show that higher implicit physician bias results in lower patient perceived patient centeredness (during the interaction), which subsequently causes patients to be more distressed following the interaction and to expect the recommended treatment to be more difficult to complete. Interventions to reduce the negative impacts of individual level race related thoughts and feelings and race-discordant interactions will be described during the talk. Unfortunately, race-discordant clinical interactions are unlikely to change in the near-term given the major shortage of Black oncologists (e.g., only about 172 Black medical oncologists practice in the U.S.) and low percentage of Black medical trainees. However, other multilevel approaches are being tested, including patient activation techniques, such as the use of question prompt lists to improve communication patterns in the visit, which may enhance the quality of the interaction and the treatment decision making process. In addition, physician-focused interventions are being created to increase relational communication skills and alliance building. One unique strategy is to increase mindfulness and behavior modeling. The study authors are testing this by using direct observations of video recorded oncology interactions. The project involves having professional actors re-enact the actual clinical interactions that we have video recorded of high-implicit bias physicians and low implicit bias physicians. Fidelity studies comparing our re-enacted (but de-identified) clinical interactions with the original video recordings show strong concordance. Using re-enactments to show physicians, especially less experienced physicians, how such verbal and nonverbal behavioral patterns differ may provide effective training. Citation Format: Terrance L. Albrecht. Multilevel sources of bias as determinants of treatment disparities. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr IA14.