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Funding: NIH/Virginia Commonwealth University

Patient-physician racial discordance is strongly associated with patient dissatisfaction and mistrust in physicians, which is further associated with poor treatment adherence and suboptimal healthcare utilization. This poses serious public health challenges because approximately 80-90% of Black patients see physicians from different racial groups. Patient dissatisfaction and mistrust have been recently found to be particularly magnified when physicians hold high levels of automatic, implicit bias toward Black Americans, suggesting that physicians’ implicit racial bias impacts physician communication behaviors during medical interactions and ultimately Black patient outcomes. The overall goal of this research is to identify physicians’ communication behaviors during medical interactions that are associated with physicians’ implicit racial bias and Black patients’ immediate (satisfaction, trust) as well as clinically important longer-term outcomes (adherence, healthcare utilization). To achieve this goal, we target medical interactions involving Black patients with Type 2 diabetes mellitus (T2DM) because nonadherence in Black patients with T2DM is particularly prevalent. Additionally, the patient-physician communication quality has been found to predict patient adherence to T2DM treatment regimens. We will use a mixed-methods design that integrates the strengths of inductive reasoning to explore which physicians’ communication behaviors during medical interactions matter from Black patients’ perspectives and deductive reasoning to identify theoretically and clinically important behaviors. Our aims are: Aim 1) to explore which physician communication behaviors during medical interactions are perceived negatively or positively by Black patients and why; Aim 2) to identify which physician communication behaviors identified in Aim 1 are associated with physicians’ implicit racial bias; and Aim 3) to examine how physicians’ implicit racial bias impacts Black patients’ satisfaction, trust, adherence, and healthcare utilization through physicians’ communication behaviors. We will use an innovative integration of multiple methods (interviews, video-recorded medical interactions, surveys, medical record reviews). Findings from this research will enable researchers to identify physician communication behaviors during medical interactions that are problematic and beneficial to the immediate and longer-term outcomes among Black patients with T2DM. Such an ability is needed to develop personally-tailored, targeted communication skills training and other interventions targeting patient-provider interactions to overcome racial disparities in diabetes treatment adherence, outcomes, and beyond. Additionally, upon completion of this project, we will have a Medical Interaction involving Black Patients Coding System (MIBPCS) that differs from prior patient-physician communication coding systems in that it: (1) will focus on physicians’ communication behaviors during medical interactions that can predict Black patients’ outcomes; and (2) places an unprecedented importance on the patients’ point of view.

UM PI: Michael Fetters

In the January-February issue of IRB: Ethics & Human Research, Scott Y.H. Kim, Raymond de Vries, Renee Wilson, Sonali Parnami, Samuel Frank, Karl Kieburtz, and Robert G. Holloway present results of a study about the therapeutic orientation of research participants.

The authors examined the relationship between understanding and appreciation of randomization probabilities in 29 individuals recruited for a sham surgery controlled intervention study in Parkinson's disease. 83% provided the correct, quantitative answer to the understanding question; of those, one group (55%) answered the appreciation question correctly using quantitative terms, whereas the remaining group (45%) provided only qualitative comments.

The therapeutic orientation of research participants raises concerns about the adequacy of consent because such an orientation could cloud understanding of key elements of research. Further, even if participants understand (i.e., intellectually comprehend) elements of research, they may not appreciate them because they fail to apply such facts to themselves.

Study participants frequently made "unrealistic" probability statements, even while providing correct quantitative responses. Analysis showed that this apparent "irrationality" may in fact hide a deeper rationality -- namely, conversational rationality, which is part of the contextual nature of meaning conveyed in everyday language. Ignoring conversational rationality may lead to wrongly labeling research subjects as irrational. Click here for more information.

Susan Goold presented a talk entitled, "Transforming public health: Deliberation, simulation, prioritization" at TEDxUofM, a university-wide initiative to galvanize the community for an event like no other: filled with inspiration, discovery and excitement. TEDxUofM takes place on Thursday, March 29, at the Power Center, 10 am - 5 pm.  Click here for more information.

Borrowing the template of the world-renowned TED conference, TEDxUofM aims to bring a TED-like experience to the University of Michigan. The vision is to showcase the most fascinating thinkers and doers, the "leaders and best" in Michigan terms, for a stimulating day of presentations, discussions, entertainment and art that will spark new ideas and opportunities across all disciplines.

TED is a nonprofit organization devoted to Ideas Worth Spreading. Started as a four-day conference in California 26 years ago, TED has grown to support those world-changing ideas with multiple initiatives. At TED, the world’s leading thinkers and doers are asked to give the talk of their lives in 18 minutes. Talks are then made available, free, at TED.com. TED speakers have included Bill Gates, Jane Goodall, Elizabeth Gilbert, Sir Richard Branson, Benoit Mandelbrot, Philippe Starck, Ngozi Okonjo-Iweala, Isabel Allende and former UK Prime Minister Gordon Brown.

Funded by the Department of Veterans Affairs.

Funding Years: 2012-2013.

Diabetes is a complex, chronic disease encompassing many domains of treatment. VHA and others have created diabetes guidelines to help support providers and patients in making choices about optimal treatment approaches. However, most guidelines are broad in nature, and offer relatively little guidance on how to personalize care in order to maximize treatment benefits, minimize the intensity and negative effects of treatment, and best align with individual treatment preferences. 

We will test the effectiveness of a personalized decision support program. Our long term goals are:

  • To test and implement a decision support program, including decision coaching supported by an interactive, personalized decision support tool, in clinical practice via our Patient-Aligned Care Team (PACT) laboratory.
  • To assess the impact of personalized decision support on patient-centeredness, patient satisfaction, and the effectiveness of risk communication and treatment decision making.

We propose an interventional study to examine the effectiveness of personalized decision support. The intervention will consist of two key components: a decision coach  and a personalized diabetes decision support tool. The decision support tool has mostly been developed via AHRQ and local pilot funding mechanisms, and is informed by personalized estimation of treatment benefits for blood glucose, blood pressure, and lipid treatment based on extensive modeling work done by our investigative team. The personalized benefit information is communicated through graphical risk communication methods (pictographs).  

PI(s): Angela Fagerlin 

Funded by National Institutes of Health; Nationatal Institute on Aging

Funding Years: 2012-2017

A cornerstone of the nation’s social science research infrastructure, the Panel Study of Income Dynamics (PSID) is a longitudinal survey of a nationally representative sample of U.S. families. Begun in 1968, 36 waves of data have now been collected on PSID families and their descendents. Its long-term measures of economic and social well-being have spurred researchers and policy makers to attend to the fundamental dynamism inherent in social and behavioral processes. This project collects, processes, and disseminates three modules in the 2013 and 2015 waves of the PSID:
1.Health module: Including 15 minutes of survey questions on health status, health behaviors, health insurance coverage & health care costs. Linkages to the National Death Index and Medicare will be extended;
2.Wealth module: Including 10 minutes of survey questions on wealth, active savings, and pensions. Linkage to Social Security earnings and benefits records for active sample and decedents will be undertaken for the first time, and a new module to minimize errors in reports of wealth changes will be developed and implemented; and
3.Well-being module with related psychosocial measures: A mixed-mode (web/mail out) questionnaire to collect content from both respondents and spouses about their well-being and related psychosocial measures (e.g., personality, intelligence), with an experiment to identify (and allow researchers to adjust for if necessary) mode effects.

PI(s): Robert Schoeni

Co-I(s): Mick Couper, Vicki Freedman, Katherine McGonagle

Funded by the National Institutes of Health

Funding Years: 2015-2020

Every year, one in 10 older people fall and sustain injury requiring medical care. Fall-related injury is the number one cause of accidental death in older Americans. However, fall injury is rarely considered as a outcome in controlled trials, which have traditionally focused on death and cardiovascular events. Until recently, we lacked methods of capturing fall-related injury in large healthcare databases. We will first use the Health and Retirement Study, a national study of older Americans, to develop a method of classifying severe fall injury in found in Medicare claims data across acute, ambulatory, and long-term care. Next, we will study how a national healthcare system, the Veterans Health Administration (VHA), delivers aggressive hypertension care (AHC) and whether AHC results in net benefit or harm due to cardiovascular events and severe fall-related injury. Hypertension is the single most common chronic condition in older adults. Medication treatment prevents important cardiovascular events (strokes, myocardial infarctions and heart failure), however also contributes to risk of falls. We do not fully understand the net benefits and harms among our oldest patients in clinical practice, especially after age 75 - those most prone to severe fall-injury. Thus, we aim to study the net harms and benefits associated with AHC.

PI(s): Lillian Min

Co-I(s): Timothy Hofer, Kenneth Langa, Neil Burton Alexander, Andrzej Galecki, Eve Kerr, Hyungjin Myra Kim

Funded by National Institutes of Health

Funding Years: 2015-2020

Every day in hospitals across the country, patients with severe stroke and their families are faced with decisions about life-sustaining treatments in the initial hours of admission. These decisions about resuscitation status, invasive treatments, or possible transitions to comfort care are typically made by a surrogate decision- maker due to communication or cognitive deficits in the patient. This surrogate must consider the patient's life goals and values to determine if their loved one would choose on-going intensive treatments where they may survive and yet have long term disabilities, or prioritize comfort and accept the likelihood of an earlier death. Serving as a surrogate decision maker for a patient in the intensive care unit can have long lasting negative consequences. However, almost nothing is known about surrogate decision makers in diverse populations with stroke. Hispanic Americans are now the largest minority group in the US, rapidly growing and aging, with Mexican Americans comprising the largest subgroup. Multiple disparities have been identified in stroke incidence and outcome between Mexican Americans and non-Hispanic Whites, particularly in the use of life- sustaining treatments. Minority populations may be particularly vulnerable to inadequate communication about end-of-life issues due to socioeconomic disadvantage, poor health literacy, and lack of provider empathy and health system strategies to improve communication. However, Mexican American culture includes strong values of family support and religiosity that may have a positive influence on discussions about life-sustaining treatment and adapting to stroke-related disabilities. There is currently a critical gap in understanding the perspectives and outcomes of stroke surrogate decision makers, making it impossible to design interventions to help diverse populations of patients and families through this incredibly trying time.

PI(s): Lewis Morgenstern, Darin Zahuranec

Co-I(s): Lynda Lisabeth, Brisa Sanchez

Funded by National Institutes of Health; National Institute on Aging

Funding Years; 2011-2016

A cornerstone of the nation's social science research infrastructure, the Panel Study of Income Dynamics (PSID) is a longitudinal survey of a nationally representative sample of U.S. families. Begun in 1968, 36 waves of data have now been collected on PSID families and their descendents. Its long-term measures of economic and social wellbeing have spurred researchers and policy makers to attend to the fundamental dynamism inherent in social and behavioral processes. The PSID is increasingly being used to answer innovative social and behavioral research questions in the context of an aging society. This application proposes to collect, process, and disseminate three modules in the 2013 and 2015 waves of the PSID: 1. Health module: Including 15 minutes of survey questions on health status, health behaviors, health insurance coverage & health care costs. Linkages to the National Death Index and Medicare will be extended; 2. Wealth module: Including 10 minutes of survey questions on wealth, active savings, and pensions. Linkage to Social Security earnings and benefits records for active sample and decedents will be undertaken for the first time, and a new module to minimize errors in reports of wealth changes will be developed and implemented; and 3. Wellbeing module with related psychosocial measures: We will design and implement a mixed-mode (web/mail out) questionnaire to collect content from both respondents and spouses about their wellbeing and related psychosocial measures (e.g., personality, intelligence), with an experiment to identify (and allow researchers to adjust for if necessary) mode effects. After collection, the data will be processed and distributed in the PSID Online Data Center, which will allow users to create customized extracts and codebooks using a cross-year variable index.

PI(s): Robert Schoeni

Co-I(s): Charles Brown, James House, Mick Couper

Funded by NIH - Department of Health and Human Services

Funding Years: 2012-2017

Treatments for cancer impose substantial burden and morbidity but net survival benefit of different strategies is often small and virtually always uncertain. Thus, clinicians may do more harm than good if treatment is too aggressive. There are a number of management strategies for breast cancer aimed at reducing unnecessary morbidity and burden on patients with favorable disease. A key barrier to advancing these initiatives is the need for a better understanding of the challenges of individualizing cancer care. The goal of this program is to improve population health by helping clinicians and their patients address the challenges of individualizing treatment of breast cancer for patients with favorable prognosis. Objective 1: To examine the challenges of individualizing treatment for women with breast cancer. Two projects will each undertake an observational study of patients newly diagnosed with breast cancer (including their attending clinicians) who were reported to the SEER registries of Georgia and New Jersey during an 18 month period to examine patient and clinician factors associated with key evaluative tests, treatments, and patient appraisal of decision quality. Project 1 will focus on challenges for surgeons and their patients with regard to locoregional therapy. Project 2 will focus on challenges for medical oncologists and their patients with regard to systemic therapy. Objective 2: To improve treatment decision quality. Project 3 will perform a randomized controlled trial of a practice based online decision tool for patients newly diagnosed with breast cancer in the Detroit and Atlanta SEER regions intended to improve decision quality. Objective 3: To accelerate the dissemination of SEER-based research findings by implementing and evaluating a tailored online portal aimed at all surgeons and medical oncologists who treated the patient samples in P1 and P2 to evaluate whether our research findings can more directly and promptly inform clinicians knowledge and attitudes about individualizing treatment. Objective 4: To advance methods in SEER population translational research focused on quality of cancer care. We propose four shared resource cores that will support program project activities, advance innovative methods in oncology population sciences, and advance team mission and long-term strategic planning.

PI(s): Steven Katz

Co-I(s): Lawrence An, Michael Elliott, Angela Fagerlin, Sarah Hawley, Timothy Hofer, Reshma Jagsi, Nancy Janz, Yun Li, Kenneth Resnicow, Jeremy Taylor, Christopher Friese

Funded by NIH: National Cancer Institute

Funding Years: 2008-2014

Prostate cancer is a leading cause of cancer death among men, and thousands of men must make treatment decisions every year. Decision making for localized prostate cancer is especially challenging as clinical trials have shown that the standard treatment options of active surveillance, surgery and radiation are comparable in terms of survival. Thus, treatment for prostate cancer is a preference-sensitive decision, with the best choice depending in part on patient attitudes towards the risks and benefits of treatment alternatives. Therefore, ideally the treatment decision will be made with full consideration of patient preferences. As such, it is recommended that patients and their physicians discuss any preferences patients have that might be relevant to the treatment decision. This dialogue is complicated by patients’ lack of experience with sharing in these types of decisions. Additionally, physicians often use medical jargon, making it more difficult for patients to understand their diagnosis and treatment options.  Research is needed to determine the best methods for helping patients communicate their preferences to their physicians so that patient values hold considerable weight in treatment decisions.

The goals of this study are two-fold:

  • To demonstrate to patients some of the issues that might arise during their diagnosis visit that may prevent them from communicating preferences to physicians.
  • To provide solutions that would enable greater patient participation in medical decision making.

PI(s): Angela Fagerlin, PhD and Peter A. Ubel, MD

Co-I(s): John T. Wei, MD; Brian Zikmund-Fisher, PhD; Margaret Holmes-Rovner, PhD; James Tulsky, MD; Stewart Alexander, PhD

Parent grantMichigan Center for Health Communication Research II

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