The Role of Future Orientation and Decision Regret in Health Care Decision Making

描述（由申请人提供）：改善各种肺部疾病患者护理的一个关键挑战是帮助他们在面临多种合理的诊断或治疗方案时做出最能促进其潜在价值的选择。 不幸的是，患者和他们的代理决策者常常因为正常人类决策心理学的缺陷而无法做出这种“最佳选择”。例如，一名前吸烟者患有孤立性肺结节，经过多次计算机断层扫描后情况稳定，但他可能会选择进行活检，因为他担心如果他选择监测但后来发现结节是恶性的，他会感到后悔。即使像他这样的患者实际上更有可能后悔进行活检的决定，这也可能是正确的，因为当结果显示正常时，这种方法存在可避免的风险、负担和成本。 这种预期的遗憾——也就是说， 患者或其代理决策者担心他们稍后会将实际结果与如果他们做出其他选择可能会发生的更好结果进行比较，这可能会影响肺病患者及其代理做出的广泛决策。 这可能会阻碍最佳决策的制定，因为决策者对后悔可能性的估计可能不准确，或者可能会过度分散决策者对决策中更重要因素的注意力。然而，这种后悔的影响也可能被利用，这样向患者或代理人提供有关决策后悔的数据可能会帮助他们将注意力集中在与他们最相关的结果上。 在这一假设的指导下，我试图构建一个概念框架，说明肺病患者及其替代决策者在决策时如何思考未来，并评估决策后悔信息对此类患者及其替代者的治疗选择和决策过程质量的具体影响。 为了实现这些目标，我将进行两项研究，以探讨肺病患者和从学术医疗中心门诊招募的潜在代理人的后悔情况。首先，我将通过对肺病患者及其潜在替代者进行​​基于小插曲的半结构化访谈来制定概念框架。 其次，我将进行一项随机析因实验，其中参与者考虑医学上相关的假设情况，并在描述为同样合适但预期后悔的几率和严重程度各不相同的两种管理选项之间进行选择。 半结构化访谈将引出对决策过程的描述、对治疗决策结果信息寻求的偏好、决策时对未来反事实的考虑、所考虑结果的相对接近性以及作为决策因素的遗憾的概念。 根据这些定性数据，随后的随机实验将确定为每个选项提供操纵后悔数据的具体影响，并不仅衡量所做的选择，还衡量决策过程的质量。 该项目将为计划中的 NIH K23 职业发展奖提供必要的初步数据，该奖项将 (1) 收集类似肺部疾病患者实际选择后的真实决策后悔数据，(2) 开发一种决策辅助工具，其中包含患者及其代理人可以理解的决策后悔数据，以及 (3) 测试这种增强型决策辅助工具在真实肺部实践中的有效性。

DESCRIPTION (provided by applicant): A key challenge in improving the care of patients with a variety of pulmonary diseases is to help them make choices that best promote their underlying values when faced with multiple reasonable diagnostic or therapeutic options. Unfortunately, patients and their surrogate decision makers are often diverted from making such "optimal choices" by the foibles of normal human decision psychology. For example, a former smoker with a solitary pulmonary nodule that has been stable on repeated computed tomography may nonetheless choose to have it biopsied because he fears feeling regret if he chooses surveillance and later finds that it is malignant. This may be true even if patients like him are i fact more likely to regret decisions to pursue biopsy, due to the avoidable risks, burdens, and costs of this approach when the results turn out to be normal. Such anticipated regret - that is, the fear among patients or their surrogate decision makers that they will later compare the actual outcomes with better outcomes that might have happened if they had made an alternative choice - may influence a broad range of decisions made by patients with pulmonary diseases and their surrogates. This may deter optimal decision making, as the decision maker's estimation of the likelihood of regret may be inaccurate or may unduly distract decision makers from more important elements of the decision. However, the effects of such regret might also be harnessed, such that providing patients or surrogates with data on decision regret may help them focus their attention on the outcomes most relevant to them. Guided by this hypothesis, I seek to construct a conceptual framework for how patients with lung disease and their surrogate decision makers think about the future at the time of decision making, and to evaluate the specific effects of decision regret information on the treatment selections and decision process quality of such patients and their surrogates. To accomplish these goals, I will conduct two studies to explore regret among patients with pulmonary disease and potential surrogates recruited from outpatient settings at an academic medical center. First, I will produce the conceptual framework by conducting and analyzing vignette- based semi-structured interviews among patients with pulmonary diseases and their potential surrogates. Second, I will conduct a randomized factorial experiment in which participants consider medically relevant hypothetical situations, and choose between two management options described as being equally appropriate but in which the odds and severity of anticipated regret vary. Semi-structured interviews will elicit descriptions of the decision making process, preferences regarding information-seeking about outcomes of treatment decisions, consideration of future counterfactuals at the time of decision making, the relative proximity of the outcomes considered, and the concept of regret as a factor in decision making. Informed by these qualitative data, the subsequent randomized experiment will determine the specific influence of providing manipulated regret data for each option, and measure not only the choices made but the quality of the decision-making process. This project will provide essential preliminary data for a planned NIH K23 Career Development Award that would (1) collect real decision regret data following actual choices by similar patients with pulmonary diseases, (2) develop a decision aid that incorporates decision regret data that is understandable for patients and their surrogates, and (3) test the effectiveness of this enhanced decision aid in real pulmonary practice.