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The Privileged Choices (Jan-08)

What's the difference between opting in and opting out of an activity? Who decides if people will be put automatically into one category or another? Click this interactive decision to learn how default options work.

Scenario 1

Imagine that you're a US Senator and that you serve on the Senate's Committee on Health, Education, Labor, and Pensions. The Infectious Diseases Society of America has come before your committee because they believe that too many health care workers are getting sick with influenza ("flu") each year and infecting others. As a result, your Senate committee is now considering a new bill that would require that all health care workers get annual influenza vaccinations ("flu shots") unless the worker specifically refuses this vaccination in writing.

Do you think you would support this bill for mandatory flu shots for health care workers?

  • Yes
  • No

Scenario 2

Imagine that you're the human resources director at a mid-sized company that's initiating an employee retirement plan. Management is concerned that many employees are not saving enough for retirement. They're considering a policy that would automatically deduct retirement contributions from all employees' wages unless the employee fills out and submits a form requesting exemption from the automatic deductions.

Do you think a policy of automatic retirement deductions is reasonable for your company to follow?

  • Yes 
  • No

Scenario 3

Organ transplants save many lives each year, but there are always too many deserving patients and too few organs available. To try to improve the number of organs available for donation, the state legislature in your state is considering a new policy that all people who die under certain well-defined circumstances will have their organs donated to others. The system would start in three years, after an information campaign. People who do not want to have their organs donated would be given the opportunity to sign a refusal of organ donation when they renewed their drivers' licenses or state ID cards, which expire every three years. Citizens without either of these cards could also sign the refusal at any drivers' license office in the state. This is a policy similar to ones already in place in some European countries.

Does this seem like an appropriate policy to you?

  • Yes 
  • No

How do your answers compare?

For many decisions in life, people encounter default options-that is, events or conditions that will be set in place if they don't actively choose an alternative. Some default options have clear benefits and are relatively straightforward to implement, such as having drug prescriptions default to "generic" unless the physician checks the "brand necessary" box. Others are more controversial, such as the automatic organ donation issue that you made a decision about.

Default options can strongly influence human behavior. For example, employees are much more likely to participate in a retirement plan if they're automatically enrolled (and must ask to be removed, or opt out) than if they must actively opt in to the plan. Researchers have found a number of reasons for this influence of default options, including people's aversion to change.

But default options can seem coercive also. So, an Institute of Medicine committee recently recommended against making organ donation automatic in the US. One reason was the committee's concern that Americans might not fully understand that they could opt out of donation or exactly how they could do so.

The policy scenarios presented to you here have been excerpted from a 2007 article in the New England Journal of Medicine titled "Harnessing the Power of Default Options to Improve Health Care," by Scott D. Halpern, MD, PhD, Peter A. Ubel, MD, and David A. Asch, MD, MBA. Dr. Ubel is the Director of the Center for Behavioral and Decision Sciences in Medicine.

This article provides guidance for policy-makers in setting default options, specifically in health care. Generally, default options in health care are intended to promote the use of interventions that improve care, reduce the use of interventions that put patients at risk, or serve broader societal agendas, such as cost containment.

In this NEJM article, the researchers argue that default options are often unavoidable-otherwise, how would an emergency-room physician decide on care for an uninsured patient? Many default options already exist but are hidden. Without either returning to an era of paternalism in medicine or adopting a laissez-faire approach, the authors present ways to use default options wisely but actively, based on clear findings in the medical literature.

Some examples of default policies that may improve health care quality:

  • routine HIV testing of all patients unless they opt out.
  • removal of urinary catheters in hospital patients after 72 hours unless a nurse or doctor documents why the catheter should be retained.
  • routine ventilation of all newly intubated patients with lung-protective settings unless or until other settings are ordered.

Drs. Halpern, Ubel, and Asch conclude, "Enacting policy changes by manipulating default options carries no more risk than ignoring such options that were previously set passively, and it offers far greater opportunities for benefit."

Read the article:

Harnessing the power of default options to improve health care.
Halpern SD, Ubel PA, Asch DA. New England Journal of Medicine 2007;357:1340-1344.

A New Drug for the New Year (Jan-04)

Out with the old drugs and in with the new! How is your doctor prescribing for you?

Imagine that you are a physician and your patient is a 55-year-old white male with high blood pressure. He has no other medical problems, is on no medications, and has completed a 1-year program of diet and exercise to control his condition, but his blood pressure remains elevated at 170/105 (140/90 is the definition of high blood pressure).

As his physician, you have to decide on a medication to prescribe him in order to lower his blood pressure. You have the following options to choose from:

Diuretics: Diuretics are medications that lower blood pressure by getting rid of excess fluid in your body, making it easier for your heart to pump. They were first introduced in the 1950s.

Beta-blockers: Beta-blockers are medications that lower blood pressure by helping the heart to relax and pump more effectively, and by also reducing heart rate. They were first introduced in the 1960s.

ACE inhibitors: Angiotensin converting enzyme (ACE) inhibitors are medications that lower blood pressure by widening blood vessels and increasing blood flow. They were first introduced in 1981.

Calcium channel blockers: Calcium channel blockers are medications that lower blood pressure by relaxing blood vessels, reducing the heart's workload, and increasing the amount of blood and oxygen that reach the heart. They were also first introduced in 1981.
 
What type of medication would you prescribe this patient?
 
  • A diuretic
  • A beta-blocker
  • An ACE inhibitor
  • A calcium channel blocker

How do you compare to the physicians surveyed?

Of the physicians surveyed, 18% chose the same medication as you did. 38% chose an ACE inhibitor, 29% chose a beta-blocker, and 11% chose a calcium channel blocker. Most physicians chose an ACE inhibitor, a newer type of medication, rather than beta-blockers or diuretics, which are older types of medication.

Why is this important? When asked how they made their decision, the majority of physicians believed that diuretics were less effective and that beta-blockers were less likely to be tolerated by a patient's body than the other medications. However, a number of important studies have shown that beta-blockers and diuretics are as effective at lowering blood pressure as newer medications like ACE inhibitors and calcium channel blockers. Studies have also shown that beta-blockers and diuretics are equally or even better tolerated than the newer types of medications. Yet, the use of beta-blockers and diuretics has declined steadily in the past 15 years in favor of the newer and more expensive types of medications.

Why do physicians believe these things when the studies say otherwise?

The answer to this question is not fully known. One possibility is that physicians may be prescribing newer medications because these are the medications actively promoted by pharmaceutical companies. By providing free samples of the newer medications for physicians to give to patients, these companies may be influencing which medications physicians actually decide to prescribe. To test this possibility, after physicians had decided between diuretics, beta-blockers, ACE inhibitors, and calcium channel blockers, they were asked if they ever provide their patients with free medication samples from these companies to treat their high blood pressure. It was found that physicians who used free samples were more likely to believe that ACE inhibitors are more effective. This isn't proof that physicians are influenced by pharmaceutical companies when prescribing medication for high blood pressure, but it does urge us to seriously consider if physicians may need to be re-educated about the effectiveness and tolerability of beta-blockers and diuretics.

For more information see:

Ubel, PA, Jepson, C, Asch, DA. Misperceptions about beta-blockers and diuretics. Journal of General Internal Medicine, 18, 977-983. 2003.

 

Are you a numbers person? (Oct-07)

Many types of medical decisions involve making sense of numbers such as test results, risk statistics, or prognosis estimates. But people vary in their ability and confidence with numbers. How would you rate your own "numeracy"?

 

Not good at all

 

 

 

 

 

Extremely good

How good are you at working with fractions?

1

2

3

4

5

6

How good are you at working with percentages?

1

2

3

4

5

6

How good are you at calculating a 15% tip?

1

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6

How good are you at figuring out how much a shirt will cost if it is 25% off?

1

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5

6

 

Not at all helpful

 

 

 

 

Extremely helpful

When reading the newspaper, how helpful do you find tables and graphs that are parts of a story?

1

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5

6

 

Always prefer words

 

 

 

 

Always prefer numbers

When people tell you the chance of something happening, do you prefer that they use words ("it rarely happens") or numbers ("there's a 1% chance")?

1

2

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Always prefer percentages

 

 

 

 

Always prefer words

When you hear a weather forecast, do you prefer predictions using percentages (e.g., "there will be a 20% chance of rain today") or predictions using only words (e.g., "there is a small chance of rain today")

1

2

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6

 

Never

 

 

 

 

Very often

How often do you find numerical information to be useful?

1

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5

6

Why is it important for researchers to know how numerate you are?

When a doctor or health educator is trying to communicate complex statistical information to a patient, it's helpful to know how well the patient understands numbers. This is called numeracy-the ability to process basic probability and numerical concepts. People low in numeracy might want or need different types of explanations than people high in numeracy.

How is numeracy measured?

In the past, researchers have used surveys similar to math tests to evaluate the levels of numeracy of participants in research studies. These objective numeracy tests can be time-consuming to administer and are often seen by the participants as stressful and annoying. As an alternative, a CBDSM research team-including Angela Fagerlin, Brian Zikmund-Fisher, Dylan Smith, Aleksandra Jankovic, and Peter Ubel-recently designed and tested an eight-item self-assessment tool, called the Subjective Numeracy Scale (SNS), to measure numeracy. As you saw when you completed the tool, four of the questions on the SNS measure people's beliefs about their skill in performing various mathematical operations, and four measure people's preferences about the presentation of numerical information. When the CBDSM team tested the SNS, they found that it was moderately correlated with objective numeracy tests. In a variety of risk communication and preference elicitation tasks, the SNS also predicted people's behavior almost as well as an objective numeracy test did. The advantage of the SNS is that it is quick to administer and is less stressful to participants than objective tests. In addition, only the SNS is recommended for phone or Internet administration. The researchers also found that study participants who completed the SNS were much more likely to answer all the numeracy questions and were much more likely to say that they would be willing to participate in an additional research study.

Are their broader implications?

Research has shown that many Americans, including highly educated individuals, have low levels of numeracy. Low numeracy has significant implications for people's health care, especially when it comes to understanding the risks and benefits of treatments. Although we may not easily change people's numeric ability, it may be possible to create health education materials that help patients with low numeracy skills. Several CBDSM researchers are have been pursuing this subject.

Read the articles:

Measuring numeracy without a math test: development of the subjective numeracy scale (SNS).
Fagerlin A, Zikmund-Fisher BJ, Ubel PA, Jankovic A, Derry HA, Smith DM. Medical Decision Making 2007;27(5):672-680.

Validation of the subjective numeracy scale (SNS): Effects of low numeracy on comprehension of risk communications and utility elicitations.
Zikmund-Fisher BJ, Smith DM, Ubel PA, Fagerlin A. Medical Decision Making 2007;27(5):663-671.

Making numbers matter: Present and future research in risk communication.
Fagerlin A, Ubel PA, Smith DM, Zikmund-Fisher BJ. American Journal of Health Behavior 2007;31(Suppl. 1):S47-S56.

 

 

Give or take a few years (Feb-05)

A longer life may result from the amount of social support present in your life, but is the longevity due to giving or receiving that support?

Imagine that in your busy schedule each week, you typically at least have Wednesday and Saturday nights free as time to spend however you want. Recently, however, one of your close friends had her car break down and now she is wondering whether you would be willing to drive her to and from a yoga class on Wednesday nights for the next three weeks while the car is in the shop. She told you that the class is only about a 15 minute drive each way. She said that you shouldn't feel pressured, and she just thought she'd ask if you had the time to help her out.

Would you be willing to drive your friend to and from her yoga class for the next three weeks?
  • Yes, I'd take the time to help her out.
  • No, I'd keep my Wednesday nights free.
Do you think that helping out others could at all affect your health?
  • Yes
  • No

Giving vs. receiving: effects on mortality

A research team of investigators at the U of M Institute for Social Research teamed up with CBDSM investigator, Dylan Smith, to conduct a study investigating whether giving or receiving help affects longevity. The researchers noted that receiving social support is likely to be correlated with other aspects of close relationships, including the extent to which individuals give to one another. Based on this, they hypothesized that some of the benefits of social contact, sometimes attributed to receiving support from others, may instead be due to the act of giving support to others.

Using a sample of 423 married couples from the Detroit area, the investigators conducted face-to-face interviews over an 11-month period. The interviews assessed the amount of instrumental support respondents had given to and received from neighbors, friends, and relatives, as well as the amount of emotional support they had given to and received from their spouse. Instrumental support included things like helping with transportation, errands, and child care, whereas emotional support involved having open discussions with a spouse and feeling emotionally supported. Mortality was monitored over a 5-year period by checking daily obituaries and monthly death record tapes provided by the State of Michigan. To control for the possibility that any beneficial effects of giving support are due to a type of mental or physical robustness that underlies both giving and mortality risk, the investigators also measured a variety of demographic, health, and individual difference variables, including social contact and dependence on the spouse.

The investigators found that those who reported giving support to others had a reduced risk of mortality. This was true for both instrumental supoprt given to neighbors, friends, and relatives, and for emotional support given to a spouse. They also found that the relationship between receiving social support and mortality depended on other factors. Specifically, receiving emotional support appeared to reduce the risk of mortality when dependence on spouse, but not giving emotional support, was controlled. Receiving instrumental support from others actually increased the risk of mortality when giving support, but not dependence on spouse, was controlled.

What can we make of these findings?

It appears from these results that the benefits of social contact are mostly associated with giving rather than receiving. Measures that assess receiving alone may be imprecise, producing different results as a function of dependence and giving support.

Given the correlational nature of this study, it is not possible to determine conclusively that giving support accounts for the social benefit traditionally associated with receiving support. Nevertheless, the results of the present study should be considered a strong argument for the inclusion of measures of giving support in future studies of social support, and perhaps more importantly, researchers should be cautious of assuming that the benefits of social contact reside in receiving support.

It's true that when helping others out, you might have to give up some of your own time, but based on the above findings, it looks like in the long run you may end up ultimately gaining more time.

Read the article:

Providing social support may be more beneficial than receiving it: results from a prospective study of mortality.
Brown S, Nesse RM, Vinokur AD, Smith DM. Psychological Science 2003;14:320-327.

Tue, January 03, 2017

Reshma Jagsi was lead author on a recent study that found many patients with breast cancer unnecessarily choose double mastectomy. This study found that many patients consider contralateral prophylactic mastectomy (CPM), but their knowledge about the procedure is low and discussions with surgeons appear to be incomplete. CPM use is substantial among patients without clinical indications but is lower when patients report that their surgeon recommended against it. The study authors stress that more effective physician-patient communication about CPM is needed to reduce potential overtreatment.

CBSSM faculty, Sarah Hawley, was a co-author on this study.

Wed, February 01, 2017

Sarah Hawley and Reshma Jagsi are co-authors on two studies of the impact of doctor-patient communication on patients' perceptions of their breast cancer recurrence risk. They found that breast cancer patients commonly overestimate their risk of recurrence, which was a negative impact on their quality of life. The two studies were highlighted in a MHealth Lab Report. Brian Zikmund-Fisher was also co-author on one of these studies.

Jacquelyn Miller, MA

Research Associate

Jackie re-joined CBSSM in spring of 2017. She currently works with Drs. Lesly Dossett and Tom Valley on projects related to the worries and concerns of those with loved ones in the ICU, feedback and disclosure of errors that have occurred in other hospital systems, and opioid prescribing after cancer surgery. She has a BS in Environmental Policy and Developing Country Studies (University of Michigan, School of Natural Resources and Environment) and a MA in Sociology, specializing in environmental justice, feminist sociology, and science and technology studies (Michigan State University).

Last Name: 
Miller

Teach-Out Course: Reach Out and RELATE: Communicating and Understanding Scientific Research

Fri, May 05, 2017, 8:00am
Location: 
Online

About this course
Everyone - non-scientists and scientists alike - has some form of expertise, but communicating across a gap in knowledge or experience is challenging. In this Teach-Out, we address this challenge by helping participants to develop core communication skills and more effectively communicate with one another. For more information or to enroll, click here.

What you'll learn

  • Understand why science communication is both important and challenging
  • Develop strategies to effectively bridge communications between public audiences and scientific researchers
  • Understand expert perspectives on different areas of public engagement with science
  • Shape a compelling, message-focused STEM narrative for a specific audience
  • Discuss important issues in science communication with others


Meet the instructors

Elyse L. Aurbach PhD
Co-Founder and Co-Director of RELATE

Brian J. Zikmund-Fisher PhD
Associate Professor of Health Behavior and Health Education

Brandon Patterson MS
Co-Director of RELATE

Katherine E. Prater PhD
Co-Founder and Co-Director of RELATE
 

Mon, April 17, 2017

A new piece by Brian Zikmund-Fisher and former CBSSM post-doc, Laura Scherer is out in the Conversation, "Maximizers vs. minimizers: The personality trait that may guide your medical decisions – and costs." They developed and validated a 10-item questionnaire that assesses a person’s maximizing or minimizing tendencies on a scale, from one (strong minimizing) to seven (strong maximizing). Across four studies, they found this difference predicts health care use across a range of medical interventions and health problems, from cancer screening preferences to vaccination. They hope that identifying variations in maximizing or minimizing tendencies may be useful in trying to address both overuse and underuse in health care.

Research Topics: 
Mon, April 17, 2017

Brian Zikmund-Fisher is quoted in a recent MarketWatch article, "How doctors are getting patients more involved in their own care." Dr. Zikmund-Fisher points out, "Patients are often overwhelmed by massive amounts of data they now have access to. The easier we make it for them to understand, the more likely it is they will use it and the less time the doctor has to spend explaining it.” The article goes on to cite a web-based application developed by Dr. Zikmund-Fisher and colleagues that allows health-care providers and researchers to create graphics that use icons in arrays that show risk information in ways that make it easier for people to grasp information.

A study by former CBSSM Co-Director, Angela Fagerlin, is also cited in the article.

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