Cognitive Basis of CHD Disparities: Factorial Experiment

这项研究代表了临床决策研究的范式转变， 从前三代的工作到新的“第四代”认知（和推理）研究 流程.这项基于理论的研究直接建立在成功完成的基础上（并且具有成本效益） 使用实验（析因）设计的研究表明，患者属性（性别、年龄， 种族和社会经济地位），提供者特征（性别，医学专业和临床经验年数）和 卫生保健系统特征独立影响（大多数p<.001）的诊断和管理， 冠心病（CHD）。关于CHD的临床决策（CDM）同样受到以下因素的影响 病人是谁，提供者是谁，以及提供护理的环境是由什么病人提供的。 实际上存在（CHD的体征/症状）。这项研究将描述如何并解释为什么（和不 简单地说，不同的医生，在不同的实践环境中，在广泛的冠心病中存在差异 与同等的患者进行护理。 这个项目有四个目标。(1)估计两个认知实验的独立效应 操作：（a）医生对CHD可能性的认知“启动”;和（B）系统性替代 据称与CHD相关的患者属性;以下主要结局：CHD的概率 诊断，回顾的诊断特征的数量和类型，以及CHD诊断的时间。的 认知干预（a）对干预（B）的影响将提供分析与非分析的估计效果， 分析推理（即，故意与非故意折扣），由主要结果衡量。 (2)为了了解患者属性如何侵入医生的认知推理过程，以产生 观察CHD变异。(3)使用认知分析来解释供应商特征如何有助于 记录的CHD变异性。(4)了解组织的影响如何也侵入冠心病 决策的来自纽约州的初级保健提供者（遇到最多CHD的人）将被随机 抽样（n=256），并邀请观看临床上真实的录像介绍的“病人”， CHD的体征/症状。关于主要结局的信息（CHD诊断概率） 并通过结构化面试得出一系列合理的次要结果。的 析因设计允许估计独立（无混杂）主效应和所有双向交互作用。 这项研究的结果可以减少或消除至少两种类型的医疗保健差异。 干预措施：（a）可以制定和评价组织和偿还政策， 提供者远离产生医疗保健变化的决策模式;（B）干预措施 在医学教育中，当实践风格尚未牢固确立时。

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 theproposed research could reduce or eliminate health care variation in at least two types of interventions: (a) Organizational and reimbursement policies couldbe developedand evaluated which steer providers away from thepatterns of decision-making which produce healthcare variations; (b) Interventions during medical education, when practice styles are not yet firmly established.