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Funded by National Institutes of Health

Funding Years: 2011-2016

This proposal seeks to advance our understanding of the role of psychosocial and environmental health risk factors as well as medical care in understanding the large socioeconomic and racial/ethnic disparities in health and the way health changes with age in our society. It does so by proposing to extend to four waves and 15 years of follow-up an ongoing prospective study (known as Americans' Changing Lives) of a nationally representative sample of 3,617 adults aged 25 and over in the coterminous United States, who were first interviewed in 1986, with reinterviews of about 83 percent of the surviving members of the original sample already completed in 1989 and 1994, along with ongoing mortality ascertainment on the full original 1986 sample. A proposed fourth wave would be collected on about 83 percent of the surviving sample (estimated respondents - 2,300 of about 2,800 survivors) in 2001, primarily by telephone and in person as necessary, with mortality ascertainment continuing indefinitely and the hope and intent of reinterviewing surviving respondents again about 20-22.5 years after the baseline interview. The ongoing ACL study has generated a large body of publications both by staff of the ACL project and users of the public use data sets for the first two waves (with the third wave to be archived for public use by the end of 1999). ACL analyses and publications have illuminated to the role of a broad range of psychosocial factors, ranging from health behaviors through stress and adaptive resources to productive activities, in predicting health, changes in health and mortality, and in mediating or explaining socioeconomic differences in health. It has also played a major role in understanding the nature, causes, and consequences of paid and unpaid productive activities over the lifecourse. The proposed continuation and extension of the ACL project will address a number of aims: (1) continuing and enhancing ongoing analysis by extending prospective follow-up to 15 years, allowing for better analysis of- (a) time- varying covariates, (b) the impact of changes in risk factors on changes in health, and (c) potential reciprocal relationships between and among SES, psychosocial risk factors and health; (2) enhancing and improving the measurement of a number of variables already being considered in ongoing analysis, including SES (e.g., improving assessment of wealth), productive activities, religious beliefs and behaviors, and personality or dispositional factors (e.g., hostility, optimism, hopelessness, and John Henryism); (3) adding new measures to ACL 4 or (via archival data) to all waves of data for both medical care and exposures in physical and social environments; and (4) to undertake more focused analysis of racial/ethnic differences in health and explanations of them.

PI(s): Sarah Burgard

Co-I(s): Wen Ye, Michael Elliott, Philippa Clarke, Kenneth Langa

Funded by National Institutes of Health

Funding Years: 2014-2016

Nearly half of patients undergoing coronary artery bypass grafting (CABG) nationwide are exposed to red blood cell (RBC) products. While large volumes (3+ units) of transfusions may be delivered to a given patient to preserve life in cases of acute blood loss, evidence suggests that even small amounts (1-2 units) of RBCs often transfused to address poor oxygen delivery are associated with a 16% increase in a patient's risk of mortality and a 27% increase in morbidity, even after case mix adjustment. It is vitally important to allocate RBC products appropriately, given both that cardiac surgery utilizes between 20-25% of the total national blood supply, and the Red Cross reports that 32 of their 36 regions had less than a day's supply available to meet hospital needs. In short, it is important to improve our understanding of how and in what context decisions are made regarding 1-2 units of RBCs, given its association with morbidity, mortality and resource utilization. Growing evidence suggests that some transfusions may be discretionary. In the state of Michigan, nearly 40% of CABG patients are exposed to 1-2 units of RBCs, although the absolute rate varies 32% across institutions. Center-specific variation in transfusion practices is likely attributed to thelack of consensus regarding the indications, setting and hematocrit trigger for transfusions. Given this uncertainty, transfusion rates may be the consequence of differences in organizational (e.g. protocols, types of decision-makers, lack of performance feedback regarding transfusion practice) and provider (e.g. knowledge, beliefs concerning the benefit/harm of transfusions, and inclination to transfuse) factors. Interventions to reduce the rate of unnecessary transfusions first require identifying the set of determinants (at the organizational or provider level) that mot fully explain the observed variation in RBC utilization across regional medical centers. We will use the prospective data and infrastructure of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC), a consortium of all 33 cardiac surgical programs in Michigan, to: (1) Develop, pilot, and implement surveys to hospitals and clinical providers within the state of Michigan to describe determinants of 1-2 units of RBC transfusions during cardiac surgery, and (2) Identify the primary organizational and provider characteristics contributing to variability in transfusions. Results from this study will set the sage for a behavioral modification study aimed at reducing the rate of RBC transfusions in the setting of cardiac surgery.

PI(s): Richard Prager, Donald Likosky

Co-I(s): Darin Zahuranec, Min Zhang, Marc Zimmerman, Milo Engoren

Should this patient get a liver transplant? (Nov-08)

There aren't enough donor organs to go around for patients who need aliver transplant. This sometimes forces doctors to make tough choices.If you were the doctor, how would you decide in the following scenario?  There aren't enough donor organs to go around for patients who need a liver transplant. This sometimes forces doctors to make tough choices. If you were the doctor, how would you decide in the following scenario?Suppose there is a person who develops acute liver failure (ALF). While waiting for a liver transplant, this person gets sicker and sicker. When an organ is finally available, the chance that this person will survive WITH a transplant is only 42% at five years after the transplant. Since the average survival for most patients who receive a liver transplant is 75% at five years, the doctor wonders if it would be better to save the liver for someone else. Two possible ethical principles may guide the doctor in making this decision. 

Using the principle of URGENCY, the doctor would give the first available organ to the sickest patient on the transplant waiting list, the ALF patient, because she/he is otherwise likely to die within a few days.

Using the principle of UTILITARIANISM, the doctor would try to maximize the quality and quantity of life of all the people on the transplant list. Let's say there are 25 other patients currently on the waiting list, and transplanting the ALF patient increases their risk of death by 2% each, for a cumulative harm of 50%. Since this harm of 50% is more than the benefit to the ALF patient (42%), the liver should be saved for someone else on the list.

A third possibility is for the doctor to weigh both URGENCY and UTILITARIANISM in making a decision about a transplant.

If you were the ALF patient's doctor, what would you base your decision about a transplant on?
 
  • URGENCY (sickest patient on the list gets preference)
  • UTILITARIANISM (maximize benefit for the entire waiting list)
  • A combination of URGENCY and UTILITARIANISM

How do your answers compare?

There's no absolutely right or wrong answer in this case—the choice depends on which of several competing ethical principles or which combination of principles you follow. In choosing a combination of URGENCY and UTILITARIANISM, you've decided to try to balance the needs of the sickest patient with the needs of all the people on the transplant waiting list.

CBDSM researcher Michael Volk, MD, is the lead author on a recent article that tackles difficult decisions like this one. Volk and his colleagues examined a method to incorporate competing ethical principles in a decision analysis of liver transplantation for a patient with ALF. Currently, liver transplantation in the United States is determined by the principle of “sickest first," with patients at highest risk for death on the waiting list receiving first priority. In other words, the principle of URGENCY is paramount. However, most experts agree that, given the limited supply of organs, there should be a cutoff for posttransplant survival below which transplantation is no longer justified.

Where does society draw this line? And what framework can we use for ethical guidance?

Decision analysis of resource allocation would utilize the principle of UTILITARIANISM, to maximize the broad social benefit. But surveys of the general public have shown that most people prefer to temper utilitarianism with other considerations, such as equal opportunity, racial equity, and personal responsibility. Another factor that might be considered is the principle of fair chances. This is the idea that patients who have not had a chance at a liver transplant should receive priority over those who have already had once chance at a transplant.

Volk constructed a mathematical model (Markov model) to test the use of competing ethical principles. First he compared the benefit of transplantation for a patient with ALF to the harm caused to other patients on the waiting list, to determine the lowest acceptable five-year survival rate for the transplanted ALF patient. He found that giving a liver to the ALF patient resulted in harms to the others on the waiting list that cumulatively outweighed the benefit of transplantation for the ALF patient. That is, using UTILITARIANISM as the sole guiding ethical principle gave a clear threshold for the transplant decision: if the ALF patient did not have a five-year survival rate of at least 48%, she/he should not receive a transplant under this principle.

But UTILITARIANISM is not always the sole guiding ethical principle. When Volk adjusted the model to incorporate UTILITARIANISM, URGENCY, and other ethical principles such as fair chances, he got different thresholds. Depending on the combination of ethical principles used, Volk and his colleagues have shown that the threshold for an acceptable posttransplant survival at five years for the ALF patient would range from 25% to 56%.

The authors of this study conclude:

"Our model is an improvement over clinical judgment for several reasons. First, the complexity of the various competing risks makes clinical decision making challenging without some form of quantitative synthesis such as decision analysis. Second, a systematic approach helps ensure that all patients are treated equally. Most important, this study provides moral guidance for physicians who must simultaneously act as patient advocates and as stewards of scarce societal resources."

Volk ML, Lok ASF, Ubel PA, Vijan S, Beyond utilitarianism: A method for analyzing competing ethical principles in a decision analysis of liver transplantation, Med Decis Making 2008;28, 763-772.

Online: http://mdm.sagepub.com/cgi/content/abstract/28/5/763

More information:

Beyond utilitarianism: A method for analyzing competing ethical principles in a decision analysis of liver transplantation.
Volk M, Lok AS, Ubel PA, Vijan S. Medical Decision Making 2008;28(5):763-772.

 

 The University of Michigan's Center of Excellence in Cancer Communications Research has been renewed for another five years, through August 2013, by the National Institutes of Health. The purpose of the $8.8 million award is to develop an efficient, theory-driven model for generating health behavior interventions that is generalizable across health behaviors and sociodemographic populations. The UM Center for Health Communicaitons Research, under principal investigator Victor Strecher, MPH, PhD, coordinates the core of this Center of Excellence. Former CBSSM Director Peter A. Ubel, MD, and current CBSSM Co-director Angela Fagerlin, PhD, are leading Project 3, in which they will conduct Internet studies to test several movel ways of tailoring a prostate cancer decision aid, with the goal of identifying interventions that increase the perceived salience of patient preferences. After they have determined the best interventions, they will modify the current prostate cancer decision aid and then test it in men with newly diagnosed localized prostate cancer. Co-investigators on Project 3 are John T. Wei, MD, and Brian Zikmund-Fisher, PhD, at the University of Michigan and James Tulsky, MD, and Stewart Alexander, PhD, at Duke University.

Fri, August 16, 2013
1 in 5 women don't believe a tailored breast cancer risk assessment, according to a new study published by CBSSM researchers.

The findings were published in Patient Education and Counseling as part of a larger study where women participated in an online program to learn about medications that can reduce their risk of breast cancer. As part of the program, women who were at above-average risk of developing breast cancer received tailored information about their personal breast cancer risk. The risk assessment tool took into account family history and personal health habits, yet nearly 20 percent of women did not believe their breast cancer risk.

The study has also recently been discussed in CBS “Morning Rounds” (go to 1:45 of video clip) and NPR Shots.

Lead author Laura Scherer completed the research while serving as a CBSSM Post-Doctoral Research Fellow. Senior author Angela Fagerlin is the Co-Director of CBSSM and the Director of the CBSSM Post-Doctoral Fellowship Program.

Dr. Jeff Kullgren and Dr. John Ayanian testified before the Michigan Health Care Cost and Quality Advisory Committee regarding the feasibility of and policy options for creating an All-Payer Claims Database (APCD) in Michigan.

Established by the Healthy Michigan Legislation (PA 107 of 2013), the Committee is composed of cabinet-level leadership from the state's Departments of Community Health and Insurance and Financial Services, as well as leadership from the Michigan House and Senate Health Policy Committees. The Committee is tasked with reviewing existing efforts across the United State to make health care cost and quality more transparent. Dr. Ayanian and Dr. Kullgren shared their research and practical expertise with the Committee by discussing a broad range of issues related to the feasibility of an APCD in Michigan, including governance structure; funding sources; data collection, storage, and security issues; and opportunities for research and innovation. 

[ From IHPI Policy Corner]

Joseph Colbert, BA

Research Associate

Joseph joined CBSSM as a Research Area Specialist in November 2017. As a project manager, he coordinates the daily operations of Dr. Jeffrey Kullgren’s project “Provider, Patient, and Health System Effects of Provider Commitments to Choose Wisely,” a grant funded research project using novel approaches to reduce the overuse of low-value services in healthcare.

Last Name: 
Colbert

Funded by VA Health Services Research and Development Career Development Award

Funding Years: 2015-2019

Heart attack and stroke, which together are called cardiovascular disease, cause over 1/3 of all deaths in VA patients. The current guidelines for the prevention of these conditions focus on lowering patients'blood pressure and cholesterol levels. A new treatment strategy, which I call benefit-based tailored treatment, that instead guides treatment decisions based on the likelihood that a medication would prevent a heart attack or stroke could prevent more cardiovascular disease, with lower medication use, and be more patient centered. The purpose of this Career Development Award is to develop and assess tools and approaches that could enable the implementation of benefit-based tailored treatment of cardiovascular disease, in particular a decision support tool and educational program for clinicians and a performance profiling system. The decision support tool will enable better care by showing clinicians patient-specific estimates of the likelihood that their medication decisions will prevent a cardiovascular disease event. The performance profiling system will encourage better care by assessing the quality of care provided at VA sites and in PACT teams based on how well the medical care provided follows this treatment strategy. The project will have three aims:
Aim 1 : In the first aim, I will seek to understand clinicians' and patients' perceptions of and receptivity to the use of benefit-based tailored treatment for cardiovascular disease. Information gained from qualitative research with clinicians will help assess and improve the usability and effectiveness of the decision support tool and educational program for clinicians, along with the acceptability of the treatment strategies in general. Information gained from focus groups with patients will help learn their priorities in cardiovascular disease prevention, to help identify ways to make the interventions and their assessments more patient-centered.
Aim 2 : In the second aim, the decision support tool and educational program will be assessed in a real-world randomized pilot study involving thirty clinicians. Half of the clinicians will be provided the decision support tool and education intervention for ten patients each, the other half will receive a traditional quality improvement program and treatment reminders. The study will have formative goals of ensuring that clinicians and patients believe the tool is valuable and does not disrupt care processes or workflow for anyone in the PACT team. This will be studied with qualitative and survey assessments. The primary summative outcome will be the influence of the intervention on clinicians'treatment decisions. Secondary outcomes will assess patients'satisfaction with their visits and their clinicians.
Aim 3 : The third aim will develop and evaluate a novel performance measurement system based on benefit- based tailored treatment. First, the performance profiling system will be developed. Then the profiling system's ability to reliably differentiate high quality from low-quality care will be evaluated.

PI: Jeremy Sussman

Funded by: NIH

Funding Years: 2016-2021

 

There is a fundamental gap in understanding how Mild Cognitive Impairment (MCI) influences treatment and Decision Making for serious illnesses, like Cardiovascular disease (CVD), in older patients. Poor understanding of Clinical Decision Making is a critical barrier to the design of interventions to improve the quality and outcomes of CVD care of in older patients with MCI. The long-term goal of this research is to develop, test, and disseminate interventions aimed to improve the quality and outcomes of CVD care and to reduce CVD-related disability in older Americans with MCI. The objective of this application is to determine the extent to which people with MCI are receiving sub-standard care for the two most common CVD events, Acute myocardial infarction (AMI) and acute ischemic stroke, increasing the chance of mortality and morbidity in a population with otherwise good quality of life, and to determine how MCI influences patient preferences and physician recommendations for treatment. AMI and acute ischemic stroke are excellent models of serious, acute illnesses with a wide range of effective therapies for acute management, Rehabilitation, and secondary prevention. Our central hypothesis is that older Adults with MCI are undertreated for CVD because patients and physicians overestimate their risk of dementia and underestimate their risk of CVD. This hypothesis has been formulated on the basis of preliminary data from the applicants' pilot research. The rationale for the proposed research is that understanding how patient preferences and physician recommendations contribute to underuse of CVD treatments in patients with MCI has the potential to translate into targeted interventions aimed to improve the quality and outcomes of care, resulting in new and innovative approaches to the treatment of CVD and other serious, acute illnesses in Adults with MCI. Guided by strong preliminary data, this hypothesis will be tested by pursuing two specific aims: 1) Compare AMI and stroke treatments between MCI patients and cognitively normal patients and explore differences in Clinical outcomes associated with treatment differences; and 2) Determine the influence of MCI on patient and surrogate preferences and physician recommendations for AMI and stroke treatment. Under the first aim, a health services research approach- shown to be feasible in the applicants' hands-will be used to quantify the extent and outcomes of treatment differences for AMI and acute ischemic stroke in older patients with MCI. Under the second aim, a multi-center, mixed-methods approach and a national physician survey, which also has been proven as feasible in the applicants' hands, will be used to determine the influence of MCI on patient preferences and physician recommendations for AMI and stroke treatment. This research proposal is innovative because it represents a new and substantially different way of addressing the important public health problem of enhancing the health of older Adults by determining the extent and causes of underuse of effective CVD treatments in those with MCI. The proposed research is significant because it is expected to vertically advance and expand understanding of how MCI influences treatment and Decision Making for AMI and ischemic stroke in older patients. Ultimately, such knowledge has the potential to inform the development of targeted interventions that will help to improve the quality and outcomes of CVD care and to reduce CVD-related disability in older Americans.

PI: Deborah Levine

CO(s): Darin Zahuranec, Lewis Morgenstern & Ken Langa

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