How Does a Psychiatric Comorbidity (Schizophrenia) Affect the Management of Diabe

描述（申请人提供）：我们15年来的研究结果表明，（在诊断、药物、检查顺序和管理决策方面）同样取决于病人是谁。（年龄、性别、种族/民族），提供者是谁（性别和经验水平）和提供护理的地点（私人与公共设施，实践文化，地理位置或医疗保健系统），因为它是什么迹象和症状实际上提出。要想在这一领域取得进一步的进展，就需要超越无休止的差异记录，而要理解决策的质量--为什么这些差异会持续存在。我们提出的研究解决了在NIH计划公告中确定的关于精神疾病污名、健康差异和连接身心障碍的机制的优先事项（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，“转化研究：桥接基础和应用前景”[2006年5月]）。这里提出的研究将通过研究临床决策（CDM）过程在与潜在的污名化精神疾病同时发生的身体疾病（糖尿病）的情况下如何运作来扩展以前的工作。在这些情况下，估计非医疗影响对CDM的影响将有助于我们理解污名的产生和触发差异治疗决定的患者的具体线索（例如，诊断标签与相对于非污名化对照共病的可观察到的行为差异）。实验设计将进一步使我们能够根据患者和提供者的特征来测量临床行为的变化，而我们使用的有声思维定性数据将允许深入分析医生如何做出决策。按照优先顺序，具体目标包括：目标1：测量描述不同程度耻辱感的4种共病之一（精神分裂症伴奇异情感;精神分裂症伴正常情感;抑郁症和湿疹）的存在如何影响录像小插曲场景的临床管理。目标2：使用有声思维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）对录像小插曲场景临床管理的影响。目标4：评估医生特征（年龄/临床经验和性别）对录像小插曲场景临床管理的影响。目的5：测量医疗保健系统组织特征的影响（例如，实践的规模和所有权，实践文化）作为临床情景的协变量。这项研究的结果将有实际意义的转化研究（移动研究从“板凳到床边”），卫生政策，医学教育和讨论。公共卫生相关性：这项拟议的研究使用了一个视频小插曲析因实验和定性的有声思维数据，以研究（1）潜在的污名化合并症（精神分裂症与正常的影响，精神分裂症与奇异的影响，抑郁症和湿疹）;（2）患者;（3）医生;（4）医疗保健系统属性对诊断和治疗决策的糖尿病病例。

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.