Does a Psychiatric Comorbidity Affect the Management of Diabetes

描述(由申请人提供)：我们15年来的研究结果表明，患者得到的东西(在诊断、药物治疗、订购的测试和管理决定方面)与患者是谁(年龄、性别、种族/民族)、提供者是谁(性别和经验水平)以及在哪里提供护理(私人与公共设施、执业文化、地理位置或医疗保健系统)一样重要，因为它是实际呈现的迹象和症状的函数。要在这一领域取得进一步进展，就需要超越无休止地记录分歧，并朝着理解决策的质量--为什么这些分歧持续存在--的方向迈进。我们提议的研究解决了NIH项目公告中关于精神疾病污名、健康差距以及将身体和精神疾病联系起来的机制的优先事项(PA-07-027，PA-07-212，IOM报告跨越质量鸿沟和不平等治疗，以及最近的NIMH会议，“翻译研究：弥合基础和应用视角”[2006年5月])。这里提出的研究将通过检查临床决策(CDM)过程如何在身体疾病(糖尿病)与潜在的污名化精神疾病并存的情况下运行来扩展先前的工作。在这种情况下估计非医学影响对CDM的影响将有助于我们理解耻辱的产生和来自患者的触发差别治疗决定的特定线索(例如，诊断标签与相对于非污名对照共病的可观察到的行为差异)。实验设计将进一步允许我们根据患者和提供者的特征来衡量临床行为的差异，而我们使用有声思考的定性数据将允许对医生如何做出决定进行深入分析。按照优先顺序，具体目标包括：目标1：衡量描述不同程度耻辱的4种共病情况(具有奇怪影响的精神分裂症；具有正常情感的精神分裂症；抑郁和湿疹)的存在如何影响录像幻影情景的临床管理。目的2：使用有声思考数据和定性分析来理解产生我们观察到的临床决策的潜在的认知推理和心理过程。目的3：评估“患者”属性(种族/民族、性别和年龄)对录像幻灯情景的临床处理的影响。目的4：评估医生特征(年龄/临床经验和性别)对录像幻灯情景临床管理的影响。目的5：衡量卫生保健系统的组织特征(例如，实践的规模和所有权、实践文化)作为与临床情景相关的协变量的影响。这项研究的发现将对转化性研究(将研究从“长凳上移到床边”)、卫生政策和医学教育具有实际意义，并将进行讨论。公共卫生相关性：这项拟议的研究使用视频片段析因实验和定性有声思考数据来研究(1)潜在的污名化共病(情感正常的精神分裂症、具有奇怪情感的精神分裂症、抑郁和湿疹)；(2)患者；(3)医生；以及(4)医疗系统属性对诊断和治疗糖尿病病例的影响。

DESCRIPTION (provided by applicant): Results from our own research over 15 years shows that what a patient gets (in terms of diagnosis, medications, tests ordered and management decisions) is as much a function of who the patient is (age, gender, race/ethnicity), who the provider is (gender and level of experience) and where the care is delivered (private vs. public facility, practice culture, geographic location, or health care system), as it is of what signs and symptoms are actually presented. Further progress in the field requires moving beyond endless documentation of differences and toward understanding the quality of decision making-why these differences persist. Our proposed study addresses priorities identified across NIH program announcements on mental illness stigma, health disparities, and mechanisms linking physical and mental disorders (PA-07-027, PA-07- 212, IOM reports Crossing the Quality Chasm and Unequal Treatment, and a recent NIMH meeting, "Translational Research: Bridging Basic and Applied Perspectives" [May 2006]). The research proposed here would extend previous work by examining how clinical decision making (CDM) processes operate in the case of a physical illness (diabetes) that is co-occurring with potentially stigmatizing mental illness conditions. Estimating the influence of nonmedical influences on CDM under these circumstances will help us understand stigma production and the specific cues from patients that trigger differential treatment decisions (e.g., diagnostic labels versus observable behavioral differences relative to a non-stigmatizing control comorbidity). An experimental design will further allow us to measure variation in clinical behavior according to patient and provider characteristics, while our use of think-aloud qualitative data will allow for in-depth analyses of how physicians make decisions. In order of priority, specific aims include: AIM 1: To measure how the presence of one of 4 comorbid conditions depicting varying levels of stigma (schizophrenia with bizarre affect; schizophrenia with normal affect; depression, and eczema) influence clinical management of the videotaped vignette scenario. AIM 2: To use think-aloud data and qualitative analyses to understand the underlying cognitive reasoning and mental processes that produce the clinical decisions we observe. AIM 3: To estimate the influence of "patient" attributes (race/ethnicity, gender, and age) on clinical management of the videotaped vignette scenario. AIM 4: To estimate the influence of physician characteristics (age/clinical experience and gender) on clinical management of the videotaped vignette scenario. AIM 5: To measure the influence of organizational features of the health care system (e.g., size and ownership of practice, practice culture) as covariates with respect to the clinical scenario. Findings from this research will have practical implications for translational research (moving research from "bench to bedside"), health policy, and medical education and are discussed. PUBLIC HEALTH RELEVANCE: This proposed study uses a video vignette factorial experiment and qualitative think-aloud data to study the influence of (1) potentially stigmatizing comorbidities (schizophrenia with normal affect, schizophrenia with bizarre affect, depression, and eczema); (2) patient; (3) physician; and (4) healthcare system attributes on diagnostic and treatment decisions for a case of diagnosed diabetes.