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

描述（由申请人提供）：我们自己超过15年的研究结果表明，患者得到什么（在诊断、药物、测试和管理决策方面），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）、在哪里提供护理（私立还是公立机构、实践文化、地理位置或医疗保健系统）一样重要，也与实际出现的体征和症状有关。这一领域的进一步发展需要超越无休止的差异记录，而转向理解决策的质量——为什么这些差异会持续存在。我们提出的研究解决了美国国立卫生研究院关于精神疾病耻辱、健康差异和生理与精神障碍联系机制的项目公告中确定的优先事项（PA-07-027, PA-07- 212， IOM报告跨越质量鸿沟和不平等待遇，以及最近的NIMH会议，“转化研究：桥梁基础和应用前景”[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共同发生的情况下运作来扩展先前的工作。在这种情况下，估计非医学因素对CDM的影响将有助于我们理解病耻感的产生，以及患者触发不同治疗决策的具体线索（例如，诊断标签与相对于非病耻感对照合并症的可观察行为差异）。实验设计将进一步允许我们根据患者和提供者的特征测量临床行为的变化，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。根据优先顺序，具体目标包括：目的1：衡量描述不同程度耻辱的4种共病（精神分裂症怪异影响、精神分裂症正常影响、抑郁症和湿疹）之一的存在如何影响录像小片段场景的临床管理。目标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）对录像情景临床管理的影响。目的4：评估医生特征（年龄/临床经验和性别）对录像情景临床管理的影响。目标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）作为协变量对临床情景的影响。本研究的结果将对转化研究（将研究从“实验室转移到床边”）、卫生政策和医学教育具有实际意义，并进行了讨论。公共卫生相关性：本研究采用视频小片段析因实验和定性的有声思考数据来研究以下因素的影响：(1)潜在的污名化合并症（正常情感的精神分裂症、怪异情感的精神分裂症、抑郁症和湿疹）；(2)病人;(3)医生;(4)医疗保健系统属性对诊断糖尿病患者的诊断和治疗决策的影响。

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.