Cognitive Basis of CHD Disparities: Factorial Experiment

这项研究通过转移焦点，代表了临床决策研究的范式转移 从早期的三代工作到认知(和推理)的新“第四代”研究 流程。这项以理论为基础的研究直接建立在成功完成的基础上(且具有成本效益) 使用实验(析因)设计并证明患者属性(性别、年龄、 种族和SES)、提供者特征(性别、医疗专业和多年临床经验)以及 医疗保健系统的特性独立影响(大多数P&lt；.001)的诊断和管理 冠心病(CHD)。与冠心病相关的临床决策(CDM)的形成与 谁是病人，提供者是谁，以及由什么病人提供照护的环境 实际存在(CHD的体征/症状)。这项研究将描述如何并解释原因(和不 简单地说)不同的医生，在不同的执业环境中，证据在广泛的CHD范围内是不同的 对同等的病人进行护理。 这个项目有4个目标。(1)估计两个认知实验的独立效应 操作：(A)对医生进行关于冠心病可能性的认知“启动”；和(B)系统地替代 据称与CHD有关的患者属性；基于以下主要结果：发生CHD的可能性 诊断，回忆的诊断特征的数量和类型，以及冠心病诊断的时间。这个 认知干预的影响(A)对干预(B)将提供分析性与非分析性的估计效果 以主要结果衡量的分析推理(即有意与非有意的折现)。 (2)了解患者属性如何影响医生的认知推理过程，以产生 观察CHD的变化。(3)使用认知分析解释提供商特征如何有助于 记录的CHD变异性。(4)了解组织影响对CHD的影响 决策。来自纽约州的初级保健提供者(遇到大多数冠心病)将随机 抽样(n=256)，并被邀请观看临床上真实的“病人”陈述的录像带 有冠心病的体征/症状。有关主要结果的信息(诊断为冠心病的概率) 并将通过结构化面试得出一系列合理的次要结果。这个 析因设计允许估计独立(无混淆)主效应和所有双向交互作用。 拟议的研究结果可以减少或消除至少两种类型的医疗保健差异 干预措施：(A)可以制定和评估组织和补偿政策，以指导 远离造成医疗保健变化的决策模式；(B)干预措施 在医学教育期间，当实习方式尚未牢固确立时。

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 theproposed research could reduce or eliminate health care variation in at least two types of interventions: (a) Organizational and reimbursement policies couldbe developedand evaluated which steer providers away from thepatterns of decision-making which produce healthcare variations; (b) Interventions during medical education, when practice styles are not yet firmly established.