Cognitive Basis of CHD Disparities: Factorial Experiment

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，将重点从早期的三代工作转移到新的认知(和推理)过程的“第四代”研究。这项基于理论的研究直接(且成本效益高)建立在成功完成的研究的基础上，这些研究采用实验(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、医疗专业和多年临床经验)和医疗保健系统特征独立地影响(大多数P&lt；.001)冠心病(CHD)的诊断和治疗。与冠心病有关的临床决策(CDM)取决于患者是谁，提供者是谁，以及提供护理的环境是什么，取决于患者实际呈现的情况(CHD的体征/症状)。这项研究将描述和解释为什么不同的医生，在不同的执业环境中，证明同等患者在广泛的CHD护理中存在差异，并解释原因(不仅仅是这样)。这个项目有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)系统地替代据称与CHD相关的患者属性；对以下主要结果：CHD诊断的概率、回忆的诊断特征的数量和类型以及CHD诊断的时间。认知干预(A)对干预(B)的影响将提供由主要结果衡量的分析性推理与非分析性推理(即有意与非有意贴现)的估计效果。(2)了解患者属性如何影响医生的认知推理过程，从而产生观察到的CHD变异。(3)使用认知分析解释提供者特征如何影响记录在案的CHD变异性。(4)了解组织影响对冠心病决策的影响。来自纽约州的初级保健提供者(遇到大多数冠心病的人)将被随机抽样(n=256)，并被邀请观看临床真实的视频演示，展示具有CHD体征/症状的“患者”。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。析因设计允许估计独立(无混淆)主效应和所有双向交互作用。拟议研究的结果可以在至少两类干预措施中减少或消除卫生保健差异：(A)可以制定和评估组织和补偿政策，引导提供者远离产生卫生保健差异的决策模式；(B)在实践方式尚未牢固确立的情况下，在医学教育期间进行干预。

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.