Cognitive Basis of CHD Disparities: Factorial Experiment

描述（由申请人提供）：本研究代表了临床决策研究的范式转变，将重点从前三代工作转移到新的“第四代”认知（和推理）过程研究。这项基于理论的研究直接（且成本有效）建立在成功完成的研究基础上，这些研究使用实验（因子）设计，并证明患者属性（性别、年龄、种族和社会经济地位）、提供者特征（性别、医学专业和临床经验）和卫生保健系统特征独立影响（大多数p<.001）冠心病（CHD）的诊断和管理。与冠心病相关的临床决策（CDM）不仅取决于患者的实际表现（冠心病的体征/症状），还取决于患者是谁、提供者是谁以及提供护理的环境。该研究将描述和解释为什么（而不仅仅是）不同的医生，在不同的实践环境中，对相同的患者进行广泛的冠心病护理的证据差异。这个项目有四个目标。(1)评估两种认知实验操作的独立效应：(a)医生对冠心病可能性的认知“启动”；(b)系统地替换据称与冠心病相关的患者属性；以下主要结果：冠心病诊断的概率，可回忆的诊断特征的数量和类型，以及冠心病诊断的时间。认知干预(a)对干预(b)的影响将提供分析与非分析推理（即有意与无意的折扣）的估计效果，以主要结果来衡量。(2)了解患者属性如何干扰医生的认知推理过程，从而产生观察到的冠心病变化。(3)利用认知分析解释提供者特征如何影响记录在案的冠心病变异性。(4)了解组织影响对冠心病决策的影响。来自纽约州的初级保健提供者（遇到最多冠心病的人）将被随机抽样（n=256），并被邀请观看一段临床真实的录像，介绍一名出现冠心病体征/症状的“患者”。有关主要结局（冠心病诊断的概率）和一系列合理的次要结局的信息将通过结构化访谈得到。析因设计允许估计独立（非混杂）主效应和所有双向相互作用。拟议研究的结果可以减少或消除至少两种干预措施的保健差异：(a)可以制定和评价组织和报销政策，引导提供者远离产生保健差异的决策模式；(b)在医学教育期间，在实践风格尚未牢固确立的情况下进行干预。

DESCRIPTION (provided by applicant): This research represents a paradigm shift in studies of Clinical Decision Making by moving the focus from three earlier generations of work to a new "fourth generation" study of cognitive (and reasoning) processes. This theoretically based study builds directly (and cost efficiently) on successfully completed studies which used experimental (factorial) designs and demonstrate that patient attributes (gender, age, race and SES), provider characteristics (gender, medical specialty and years of clinical experience) and health care system characteristics independently influence (most p<.001) the diagnosis and management of Coronary Heart Disease (CHD). Clinical decision-making (CDM) with respect to CHD is shaped as much by who the patient is, who the provider is and the setting in which care is provided as it is by what the patient actually presents (the signs/symptoms of CHD). The study will describe how and explain why (and not simply that) different physicians, in different practice settings evidence variations in a broad-range of CHD care with equivalent patients. This project has 4 aims. (1) To estimate the independent effects of two cognitive experimental manipulations: (a) cognitive "priming" of physicians as to CHD possibility; and (b) systematic substitution of patient attributes purportedly associated with CHD; on the following primary outcomes: probability of a CHD diagnosis, the number and type of diagnostic features recalled, and the timing of CHD diagnosis. The impact of cognitive intervention (a) on intervention (b) will provide estimated effects of analytic vs. non- analytic reasoning (i.e., intentional vs. non-intentional discounting) as measured by the primary outcomes. (2) To understand how patient attributes intrude on physicians' cognitive reasoning processes to produce the observed CHD variations. (3) To explain, using cognitive analysis, how provider characteristics contribute to the documented CHD variability. (4) To understand how organizational influences also intrude on CHD decision-making. Primary care providers (who encounter most CHD) from New York State will be randomly sampled (n=256) and invited to view a clinically authentic videotaped presentation of a "patient" presenting with signs/symptoms of CHD. Information concerning the primary outcome (probability of CHD diagnosis) and a range of well-justified secondary outcomes will be elicited through structured interviewing. The factorial design permits estimation of independent (unconfounded) main effects and all two-way interactions. Results from the proposed research could reduce or eliminate health care variation in at least two types of interventions: (a) Organizational and reimbursement policies could be developed and evaluated which steer providers away from the patterns of decision-making which produce healthcare variations; (b) Interventions during medical education, when practice styles are not yet firmly established.