Social and behavioral influences on clinical communication and pain management

社会和行为对临床沟通和疼痛管理的影响

• 批准号: 8448222
• 负责人: Ronald M. Epstein
• 金额: $ 51.39万
• 依托单位: PURDUE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-03-01 至 2016-02-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8448222
• 关键词: Address; Advanced Malignant Neoplasm; Affect; Analgesics; Attenuated; Behavior; Black race; Caring; Clinical; Code; Communication; Consent; Detection; Experimental Designs; Fright; Guidelines; Implicit Association Test; Inferior; Intervention; Knowledge; Label; Learning; Malignant Neoplasms; Measures; Methodology; Methods; Observational Study; Outcome; Outcome Measure; Pain; Pain Measurement; Pain management; Patient Care; Patients; Pharmaceutical Preparations; Physicians; Primary Health Care; Race; Randomized; Recommendation; Recording of previous events; Research; Role; Specialist; Symptoms; Testing; Training; Transcript; Unconscious State; Visit; behavior influence; communication behavior; contextual factors; design; ethnic discrimination; experience; health care delivery; improved; novel; older patient; oncology; outcome forecast; patient oriented; preference; programs; public health relevance; racial difference; racial discrimination; research study; social

DESCRIPTION (provided by applicant): Compared to white patients with advanced cancer, black patients experience inferior pain control and less frequent and less effective discussions about symptoms, prognosis and treatment preferences. It is not clear the degree to which these differences are due to patient factors (e.g. asking fewer questions) or physician factors (e.g. implicit/unconscious racial bias, poor communication). Preliminary studies suggest that activating patients to be more assertive and to ask more questions during the visit can mitigate racial differences in communication and pain management. The proposed study addresses this critical question though a field experiment. Using novel standardized patient methodology, we will randomly assign black or white patients with identical cancer history and symptoms to primary care and oncology physicians to examine whether potentially mutable patient and physician behaviors (activation and patient-centered communication) might mitigate some of these racial differences, including those that are due to implicit biases. Aims: 1. To examine the magnitude of racial differences in physicians' assessment of pain, discussions about prognosis and treatment choices, and use of guideline-concordant pain management. 2. To examine whether patient activation mitigates racial differences in physician communication behaviors and pain management decisions. 3. To explore potential moderators of racial differences in physician communication behaviors and pain management decisions, such as patient-centered communication and implicit unconscious bias. Methods: We will conduct a randomized experiment examining mutable patient and physician behaviors. We will create 4 unannounced standardized patient (SP, "secret shopper") roles portraying identical scenarios - a 70-year old patient with advanced cancer and uncontrolled pain - differing only by patient race (black/white) and level of activation (high/typical). We will randomly assign 120 physicians to see 2 unannounced covert SPs of the same race over a 12-month period, but differing according to activation. Outcome measures: We will transcribe and code audio-recorded physician-SP visits. We will code the depth of physician pain assessment using the Measure of Physician Pain Assessment, developed in our pilot (Cronbach's 1 = .68). We will assess prognosis and treatment choice communication using the Prognosis and Treatment Choices measure, which we developed in our pilot (Cronbach's 1 = 0.80). We found racial differences on both of these outcomes in our pilot. We will assess guideline-concordant pain medication recommendations using chart audit and review of transcripts. We will assess Exploring and Validating Concerns a component of patient-centered communication that has been associated with prescribing behavior, and the Implicit Associations Test, a measure of implicit bias to examine their moderating effects (Aim 3).

描述(申请人提供)：与患有晚期癌症的白人患者相比，黑人患者的疼痛控制较差，关于症状、预后和治疗偏好的讨论更少、更有效。目前尚不清楚这些差异在多大程度上是由于患者因素(例如问得较少)或医生因素(例如隐含/无意识的种族偏见、沟通不良)造成的。初步研究表明，让患者在就诊期间变得更加自信并提出更多问题，可以缓解沟通和疼痛管理方面的种族差异。这项拟议的研究通过实地实验解决了这一关键问题。使用新的标准化患者方法，我们将随机将具有相同癌症病史和症状的黑人或白人患者分配给初级保健和肿瘤医生，以检查潜在的可变患者和医生行为(激活和以患者为中心的沟通)是否可能缓解其中一些种族差异，包括那些由隐性偏见引起的差异。目的：1.检验在医生对疼痛的评估、关于预后和治疗选择的讨论以及使用符合指南的疼痛管理方面的种族差异的程度。2.研究患者活动是否减轻了医生沟通行为和疼痛管理决策中的种族差异。3.探索种族差异在医生沟通行为和疼痛管理决策中的潜在调节因素，如以患者为中心的沟通和内隐的无意识偏见。方法：我们将进行一项随机实验，考察可变的患者和医生的行为。我们将创建4个未经宣布的标准化患者(SP，“秘密购物者”)角色，描述相同的场景-一名70岁的晚期癌症患者和无法控制的疼痛-只有患者种族(黑人/白人)和激活水平(高/典型)不同。我们将随机分配120名医生，让他们在12个月的时间里看两个相同种族的未经宣布的秘密SP，但根据激活情况不同。结果指标：我们将对医生-SP访问的录音进行转录和编码。我们将使用我们的飞行员开发的医生疼痛评估的测量方法(Cronbach‘s 1=.68)来编码医生疼痛评估的深度。我们将使用我们在飞行员中开发的预后和治疗选择衡量标准(Cronbach‘s 1=0.80)来评估预后和治疗选择沟通。在我们的试验中，我们发现这两个结果都存在种族差异。我们将使用图表审计和对成绩单的审查来评估与指南一致的止痛药物建议。我们将评估探索和验证担忧，这是以患者为中心的沟通的组成部分，与处方行为相关，以及内隐联想测试，内隐偏见的衡量标准，以检查其缓和效果(目标3)。