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Ken Langa, MD, PhD

Faculty

Dr. Langa is the Cyrus Sturgis Professor in the Department of Internal Medicine and Institute for Social Research, a Research Scientist in the Veterans Affairs Center for Clinical Management Research, and an Associate Director of the Institute of Gerontology, all at the University of Michigan. He is also Associate Director of the Health and Retirement Study (HRS), a National Institute on Aging funded longitudinal study of 20,000 adults in the United States ( http://hrsonline.isr.umich.edu ).

Last Name: 
Langa

Interactive Decision

At CBSSM, we perform the basic and applied scientific research that will improve health care policy and practice to benefit patients and their families, health care providers, third-party payers, policy makers, and the general public.  In our "Interactive Decision" web feature, we turn a recent research finding into an interactive decision that a patient or policy maker might face.  Read, decide, click—and see how your answers compare with our respondents.

Impact of the Vaccine Adverse Event Reporting System on Vaccine Acceptance and Trust (Aug-17)

Patient understanding of blood test results (Feb-17)

Attitudes toward Return of Secondary Results in Genomic Sequencing (Sep-16)

Moral concerns and the willingness to donate to a research biobank (Jun-16)

Liver Transplant Organ Quality Decision Aid: Would you consider a less than perfect liver? (Jan-16)

Blocks, Ovals, or People Icons in Icon Array Risk Graphics? (Sept-15)

Getting ahead of illness: using metaphors to influence medical decision making (May-15)

 

 

Funded by Department of Health and Human Services - Agency for Health Care Research and Quality-Subcontracts

Funding Years: 2013 - 2015.

PI(s): Angela Fagerlin

How much will chemotherapy really help you? (Dec-08)

After breast cancer surgery, additional treatments such as chemotherapy can reduce the risk of cancer coming back. But do women understand how much (or little) benefit chemotherapy provides? Imagine that you're a woman who has recently been diagnosed with breast cancer and then had the cancerous breast tumor surgically removed. While you're at an appointment about 3 weeks after your surgery, your doctor says the following to you:

"Sometimes cancer cells remain after surgery and start to grow again. To try to prevent your cancer from growing again, you should consider having some additional treatment.

"One of our test results shows that you have a type of cancer that is estrogen receptive (ER) positive. This means that your cancer needs the hormone estrogen in order to grow.

"Because you have an ER-positive tumor, you should have hormonal therapy to block estrogen and make it harder for any remaining cancer cells to grow. Hormonal therapy is usually in pill form. It does not cause hair loss or fatigue and generally has very few short-term side effects. You'll start to take hormonal therapy after all other treatments are finished and continue to take it for at least 5 years.

"Although it's clear that you should have hormonal therapy, you'll still need to make a choice about chemotherapy treatments. You could decide to have additional chemotherapy treatments for several months before starting the hormonal therapy. Sometimes, adding chemotherapy can make a big difference in decreasing the risk of dying from cancer. Other times, there's almost no benefit from adding chemotherapy.

"If you decide to have chemotherapy, you'll have 2 to 4 months of fatigue, nausea, hair loss, and other side effects. You'll also face a small risk (less than 1% or less than 1 in 100) of getting a serious infection, a bleeding problem, heart failure, or leukemia. Only you can decide if the benefit of adding chemotherapy to hormonal therapy is worth the risks and side effects."

Next, your doctor shows you a graph that may help you to decide about chemotherapy.

Your doctor says, "The graph below may help you decide if the risk reduction you would get from adding chemotherapy is worth the side effects and risks that the chemotherapy would cause.

  • The green part shows the chance that you'll be alive in 10 years.
  • The red part shows the chance that you'll die because of cancer.
  • The blue part shows the chance that you'll die from other causes.
  • The yellow part shows how much your chance of being alive in 10 years would increase if you add a therapy.
"Remember, given your situation, I think you should definitely take hormonal therapy. What you need to decide is whether to take both chemotherapy and hormonal therapy."
 
In interpreting this graph, imagine that there are two groups of 100 women each. All of these women have the same type of cancer as your hypothetical cancer.
  • The first group all decides to take hormonal therapy only.
  • The second group all decides to take both chemotherapy and hormonal therapy

How many fewer women will die from cancer in the second group, as compared with the first group?

Your doctor continues, "Now, here is another graph that shows the same information in a different way. As before,

  • The green part shows the chance that you'll be alive in 10 years.
  • The red part shows the chance that you'll die because of cancer.
  • The blue part shows the chance that you'll die from other causes.
  • The yellow part shows how much your chance of being alive in 10 years would increase if you add a therapy.
Now we asked you to consider the following question:
How many fewer women will die from cancer in the second group, as compared with the first group?
Do you want to change your answer?
 

About the study

Many participants who saw this graph in a study conducted by CBDSM researchers had similar problems. However, when study participants saw GRAPH B (with the two pictographs), many more were able to correctly calculate the difference.

The CBDSM study compared tools intended to help cancer patients make informed decisions about additional therapies (also called "adjuvant" therapies). The 4 horizontal stacked bars were taken from an online tool called "Adjuvant!" that is often used by physicians to explain risk to cancer patients. The researchers compared comprehension of risk statistics from horizontal bars and from a pictograph format.

They found that study participants who viewed a 2-option pictograph version (GRAPH B in this Decision of the Month) were more accurate in reporting the risk reduction achievable from adding chemotherapy to hormonal therapy for the hypothetical cancer scenario. With GRAPH B, 77% of participants could identify that 2 fewer women out of 100 would die from cancer with both chemotherapy and hormonal therapy. With the 4 horizontal bars (GRAPH A), only 51% of participants could make this calculation. Participants who saw GRAPH B were also much faster at answering this question than participants who saw GRAPH A.
In addition, participants in this study strongly preferred the format of the pictograph you saw (GRAPH B) to the bar graphs you saw (GRAPH A).
The researchers comment:
"While decision support tools such as Adjuvant! use graphical displays to communicate the mortality risks that patients face with different adjuvant therapy options, our research shows that women had difficulty interpreting the 4-option horizontal bar graph format currently used by Adjuvant!. Two simple changes, displaying only risk information related to treatment options that included hormonal therapy...and using pictographs instead of horizontal bars, resulted in significant improvements in both comprehension accuracy and speed of use in our demographically diverse sample....The results...support the concept that simpler information displays can make it easier for decision makers to implement optimal decision strategies. Specifically, focusing patients' attention on those treatment options currently under consideration while removing information related to options which have been already eliminated from consideration (for medically appropriate reasons) may be particularly beneficial. In the context of adjuvant therapy decisions, such an approach would imply that clinicians should discuss the decision in two stages: A first stage in which hormonal therapy is considered and a second stage in which the incremental benefit of chemotherapy is evaluated...Adjuvant! and other online risk calculators enable oncologists and patients to receive individually tailored estimates of mortality and recurrence risks, information that is essential to informed decision making about adjuvant therapy questions. Yet, the full potential of these modeling applications cannot be realized if users misinterpret the statistics provided."
 
Read the article:
Zikmund-Fisher BJ, Fagerlin A, Ubel PA. Cancer 2008;113(12):3382-3390.

 

Leaving the Emergency Room in a Fog (Sep-09)

Consider this scenario:

Alfred made a visit to his local Emergency Room. What was his diagnosis? What did the medical team do for his problem? What was he supposed to do to continue care at home? And what symptoms was he supposed to watch for to alert him to return to the ER?

Alfred woke up at 4 am on Sunday morning with pain in his left foot. That place where his new running shoes had rubbed a raw spot earlier in the week was getting worse. By 9 am, the foot was red and swollen, with a large oozing sore, and Alfred decided to go to the Emergency Room at his local hospital.

Late on Sunday afternoon, Alfred returned home from the ER. He crutched his way into the house and collapsed on the sofa. His teenage son quizzed him.

"What did they say was wrong?"
"Oh, an infection," replied Alfred.
"Well, what did they do for it?"
"I think they cut a chunk out of my foot," said Alfred.
"Whoa! Did they give you any medicine?"
"Yeah, a shot," said Alfred.
"And what’s with the crutches?"
"I’m supposed to use them for a while," said Alfred, looking annoyed.
"How long a while?"
"It’s written down," said Alfred, digging a crumpled sheet of paper out of his pocket.
"Says here you should take some prescription and elevate your left leg for two days."
"Two days? I have to go to work tomorrow," groaned Alfred.
"And you’re supposed to go back to the ER if you have a fever or pain in your leg. Where’s the prescription?"
"Here, look through my wallet. Maybe I stuck it in there," said Alfred.
The good news is that Alfred recovered completely, with some assistance and cajoling from his son. But how common is it for people who go to the Emergency Room to be foggy about what happened and what they should do once they leave the ER?
What do you think is the percentage of ER patients who do not understand at least one of the following: their diagnosis, the emergency care they received, their discharge care, or their return instructions?
 
  • 38%
  • 48%
  • 78%
  • 88%

How do your answers compare?

A recent study in the Annals of Emergency Medicine found that 78% of emergency room patients showed deficient comprehension in at least one of these areas:
 
  • Diagnosis
  • Emergency care that was given
  • Post-ER care needs
  • Symptoms that would require a return to the ER
51% of patients showed deficient comprehension in two or more areas. Only 22% of reports from patients were in complete harmony with what their care teams reported in all four areas. The biggest area of misunderstanding was in patients' post-ER care needs, such as medications, self-care steps, follow-up from their regular doctors, or follow-up with specialists.
 
Even more alarming is that, according to the study, "most patients appear to be unaware of their lack of understanding and report inappropriate confidence in their comprehension and recall." The patients were quite sure of what they knew 80% of the time—even when what they knew was not right.
 
These results suggest that Emergency Room teams need to do a better job of making sure that patients go home with clear information and instructions—and that patients and their loved ones shouldn't leave until they fully comprehend their situation.
 
Lead author Kirsten G. Engel, MD, conducted this study, "Patient Comprehension of Emergency Department Care and Instructions," with Michele Heisler, MD, Dylan M. Smith, PhD , Claire H. Robinson, MPH, Jane H.Forman, ScD, MHS, and Peter A. Ubel, MD, most of whom are affiliated with CBDSM.
 
The researchers carried out detailed interviews with 140 English-speaking patients who visited one of two Emergency Departments in southeast Michigan and were released to go home. These interviews were compared with the patients' medical records, and the comparisons revealed serious mismatches between what the medical teams found or advised and what the patients comprehended.
 
"It is critical that emergency patients understand their diagnosis, their care, and, perhaps most important, their discharge instructions," says Kirsten Engel, a former UM Robert Wood Johnson Clinical Scholar who is now at Northwestern University. "It is disturbing that so many patients do not understand their post-Emergency-Department care, and that they do not even recognize where the gaps in understanding are. Patients who fail to follow discharge instructions may have a greater likelihood of complications after leaving the Emergency Department."
 
Peter A. Ubel, the study's senior author, agrees: "Doctors need to not only ask patients if they have questions, but ask them to explain, in their own words, what they think is wrong with their health and what they can do about it. And patients need to ask their doctors more questions, and even need to explain to their doctors what they think is going on."
 
Read the article:

 

Geoff Barnes wrote a recent perspective piece and was featured in a UM Health Lab blog about anticoagulation clinic and assisting patients and providers with decision making.

Research Topics: 

PIHCD: Jacob Solomon

Wed, March 09, 2016, 2:00pm
Location: 
B004E NCRC Building 16

Jacob Solomon will be brainstorming about several ideas to study how users' ability to control decision aids affects their decision making.

Angela Fagerlin, PhD

Alumni

Dr. Fagerlin served as Co-Director of CBSSM from 2010-2015. She is currently Chair of the Department of Population Health Sciences at University of Utah School of Medicine and Research Scientist, Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS)

Last Name: 
Fagerlin
Research Projects: 

Funded by the Socirty of Family Planning

Funding Years: 2015

Women who seek abortions and the caregivers who provide them are stigmatized. Since 2007, this research team has investigated the experiences of abortion providers in the US, Latin America, and East Africa. Their narratives have informed a very successful abortion human resource intervention, the Providers Share Workshop. The goal now is to consider how these narratives might be used in service of building a new strategic communications initiative to contribute to the broader goals of reducing abortion stigma in the US and abroad. The research team will assemble an interdisciplinary group of scholars and practitioners with expertise in public communication about abortion, to identify promising communication strategies, and to craft an extramural grant proposal to test these strategies.

PI(s): Jane Hassinger, Lisa Harris, Lisa Martin

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