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Mon, June 11, 2018

A new study shows how to personalize the lung cancer screening decision for every patient. The results could help doctors fine-tune their advice to patients, so that it’s based not just on a patient’s individual lung cancer risk and the potential benefits and harms of screening, but also a likely range of patient attitudes about looking for problems and dealing with the consequences.

Published in the Annals of Internal Medicine, the study forms the backbone for new free online decision tools aimed at physicians and their teams, and at members of the public.

The tool for clinicians, called Lung Decision Precision, was designed by a University of Michigan and Veterans Affairs team to help clinicians talk with patients and their loved ones about whether to a lung CT scan might be a good idea for them.

The same team has also launched a website for patients and their loved ones, U.S. News & World Report: Should You Get Screened for Lung Cancer?, that gives easy-to-understand information about the positives and potential negatives of lung cancer screening, and allows individuals to calculate their personal risk of lung cancer.

Tanner Caverly, M.D., M.P.H., led the team that did the new computer-based simulation analysis using data from major studies of lung cancer screening, and national data on the potential screening population under the current guidelines.

Tanner Caverly was also recently interviewed for U.S. News & World Report on the risks and benefits of lung cancer screening. According to Dr. Caverly, it important to tailor the conversation about screening because the benefit-versus-risk calculation differs for each patient.

Funded by Society of Family Planning.

Funding Years: 2013-2015.

Reproductive autonomy (RA) means having control over one’s own fertility desires. Identification in a religious community may affect women’s decision-making abilities surrounding family planning. Upadhyay et al. developed a scale consisting of three domains that measure RA as it applies to a woman and her partner: freedom from coercion, communication and decision making. However, little is known about how religious norms influence RA. We aimed to expand the current RA scale to capture religious influences and assess the relationship between RA and unprotected sex among religious women.

 

Fri, March 02, 2018

Jeffrey Kullgren was recently interviewed for the US News & World Report article, "Why You Should Talk to Your Doctor About Drug Pricing." According to Dr. Kullgren, "It's important then, especially if a patient's health changes as they age, to periodically be reviewing those medications with their health care team to ensure that they are able to get the medications that are going to be the most beneficial to them, while we avoid prescribing medications to patients who are unlikely to benefit from them and for who those unneeded prescriptions can lead to cost burdens."

The full article can be found below.

The Importance of First Impressions (Jun-05)

How do your risk estimate and your actual level of risk impact your anxiety? Please answer the following question to the best of your ability:

What is the chance that the average woman will develop breast cancer in her lifetime?

The average lifetime chance of developing breast cancer is actually 13%.

How does this risk of breast cancer (13% or 13 out of 100 women) strike you?
 
As an extremely low risk 1       2       3       4       5        6        7        8       9       10 As an extremely high risk
 

How do your answers compare?

Making a risk estimate can change the feel of the actual risk

CBDSM investigators Angela Fagerlin, Brian Zikmund-Fisher, and Peter Ubel designed a study to test whether people react differently to risk information after they have been asked to estimate the risks. In this study, half the sample first estimated the average woman's risk of breast cancer (just as you did previously), while the other half made no such estimate. All subjects were then shown the actual risk information and indicated how the risk made them feel and gave their impression of the size of the risk. The graph below shows what they found:

 

As shown in the graph above, subjects who first made an estimated risk reported significantly more relief than those in the no estimate group. In contrast, subjects in the no estimate group showed significantly greater anxiety. Also, women in the estimate group tended to view the risk as low, whereas those in the no estimate group tended to view the risk as high.

So what's responsible for these findings? On average, those in the estimate group guessed that 46% of women will develop breast cancer at some point in their lives, which is a fairly large overestimate of the actual risk. It appears, then, that this overestimate makes the 13% figure feel relatively low, leading to a sense of relief when subjects find the risk isn't as bad as they had previously thought.

Why this finding is important

Clinical practice implications - The current research suggests that clinicians need to be very deliberate but very cautious in how they communicate risk information to their patients. These results argue that a physician should consider whether a person is likely to over-estimate their risk and whether they have an unreasonably high fear of cancer before having them make a risk estimation. For the average patient who would overestimate their risk, making a risk estimation may be harmful, leading them to be too relieved by the actual risk figure to take appropriate actions. On the other hand, if a patient has an unreasonably high fear of cancer, having them make such an estimate may actually be instrumental in decreasing their anxiety. Physicians may want to subtly inquire whether their patient is worried about her cancer risk or if she has any family history of cancer to address the latter type of patient.

Research implications - Many studies in cancer risk communication literature have asked participants at baseline about their perceived risk of developing specific cancers. Researchers then implement an intervention to "correct" baseline risk estimates. The current results suggest that measuring risk perceptions pre-intervention will influence people's subsequent reactions, making it difficult to discern whether it was the intervention that changed their attitudes or the pre-intervention risk estimate. Researchers testing out such interventions need to proceed with caution, and may need to add research arms of people who do not receive such pre-tests.

For more details: Fagerlin A, Zikmund-Fisher BJ, Ubel PA. How making a risk estimate can change the feel of that risk: shifting attitudes toward breast cancer risk in a general public survey. Patient Educ Couns. 2005 Jun;57(3):294-9.

 

 

Fri, October 04, 2013

The US News & World Report quoted Sarah Hawley and cited her research in a story about the tendency of young women with breast cancer to overestimate their risk of getting cancer in the opposite, healthy breast. 

An excerpt from the article, "Unfounded Fear Prompts Some Preventive Mastectomies: Study":

The findings echo some previous research, according to Sarah Hawley, an associate professor of internal medicine at the University of Michigan Health System, in Ann Arbor. In her study, presented last year at a medical meeting, Hawley found that nearly 70 percent of women choosing the contralateral prophylactic mastectomy actually had a low risk of developing cancer in the healthy breast.

"Their findings are consistent with ours, in that desire to prevent cancer in the non-affected breast is a big reason patients reported for getting [contralateral prophylactic mastectomy]," Hawley said.

Better communication is needed to be sure women know the risks and benefits, and lack of benefit of getting the preventive surgery, Hawley pointed out. Better strategies to help patients manage anxiety and worry would help, too, she added.

 

Research Topics: 

Funded by NIH Department of Health and Human Services

Funding Years: 2015-2020

Colorectal rectal cancer (CRC) is the third most common cancer in the US with over 50,000 individuals dying annually from the disease. Despite multiple effective screening tests, CRC screening remains underutilized relative to other cancer screening. A driving factor behind this underutilization among insured populations is the gap that exists between a physician recommendation for care and the patient's receipt of screening. How best to support patients in CRC screening once they have a physician recommendation for care remains unknown. The proposed project will test the effectiveness and impact of a post-visit, patient portal tool, e-Assist, for engaging and supporting primary care patients in their decision making regarding, and ultimately in their obtaining, CRC screening. The tool purposely leverages the cue to action provided by a physician recommendation for care as well as the secure patient portal platform now commonly found within primary care practices. It seamlessly combines important patient-physician decision making content with assistance in removing personal and structural barriers to screening. Our research will answer four overarching questions: (1) Can a post-visit, patient portal tool, e-Assist, increase adherence to physician-recommended CRC screening? (2) How does e-Assist engage primary care patients in the CRC screening decision making process? (3) Are there subgroups of the primary care population for whom e-Assist is more engaging and effective? and (4) What adaptations are needed to e-Assist to improve its reach, and ensure its adoption, implementation, and ultimately its impact on evidence-based CRC screening use among diverse primary care patients and clinics? These questions will be addressed using a two-arm, practical randomized trial supplemented with findings from focus groups and in-depth interviews with patients, clinicians and other clinic staff to ensure a comprehensive understanding of not only program effectiveness and implementation, but the factors driving overall program impact. Results will illustrate how e-tools can be used following an office visit to support both patient decision making, and the dissemination and implementation of evidence-based cancer screening services in primary care.

PI(s): Jennifer Lafata

Co-I(s): Sarah Hawley, Kenneth Resnicow

Funded by the NIH

The overarching goal of our research is to improve opioid analgesic safety and efficacy by optimizing opioid risk recognition, informed analgesic decision-making, and drug storage/disposal behaviors among parents of youth who are prescribed these agents for home use. With this proposal, we aim to demonstrate that our Scenario-Tailored Opioid Messaging Program (STOMP?) will: 1) Improve parents' opioid risk understanding and their analgesic decision-making; 2) Enhance parents' analgesic self-efficacy, analgesic use, storage behaviors and their children's pain outcomes, and 3) To demonstrate that the STOMP? plus provision of a method to get rid of left-over medications will effectively nudge parents to safely dispose of left-over opioid analgesics. For more info: http://grantome.com/grant/NIH/R01-DA044245-01A1

PI: Terri Lewis-Voepel

CBSSM Co-Is: Brian Zikmund-Fisher & Alan Tait

Brian Zikmund-Fisher, PhD, a CBSSM investigator and Director of the CBSSM Internet Survey lab, is the principal investigator on an Investigator Initiated Research award from the Foundation for Informed Medical Decision Making that began in October 2008.  The grant, entitled "Learning by Doing: Improving Risk Communication Through Active Processing of Interactive Pictographs," will fund the development and testing of of Flash-based interactive risk graphics that research participants or patients can use to visually demonstrate how likely they believe some event is to occur. Dr. Zikmund-Fisher hopes that people who create risk graphics themselves will have a better intuitive understanding of risk than people who just view static images. Co-investigators on the award include Angela Fagerlin, Peter A. Ubel, and Amanda Dillard.

Brian Zikmund-Fisher, PhD, is the featured guest editor for a special supplement to Medical Decision Making's September/October 2010 issue, highlighting the DECISIONS study, a nationwide survey of adults in the US regarding common medical decisions.  Lead author on the main paper of the supplement, Zikmund-Fisher and co-authors (including CBSSM faculty Angela Fagerlin, PhD and Mick Couper, PhD) describe the DECISIONS study, a telephone interview of a nationally representative sample of 3010 adults age 40 and over faced with making a medical decision in the past two years.  Researchers defined medical decisions as the patient having initiated medications, been screened, or had surgery within the past 2 years or having discussed these actions with a health care provider during the same interval.  Key findings from the study:

Although patients frequently receive information about the benefits of a procedure or medication, they don't always learn about the disadvantages.

Healthcare providers don't always ask patients what they want to do.

Most patients don't use the Internet to help them make common medical decisions; healthcare professionals remain the most important source of information.

Patients often don't know as much as they think they do.  Many patients feel well informed even when they don't know key facts that would help them make a better decision.

African-Americans and Hispanics were less knowledgeable than other patients about medications to treat high cholesterol.  In addition, they were more likely to say their doctor made decisions about cholesterol medications for them.

Most patients think they are more likely to get cancer than they really are, and tend to view cancer screenings as more accurate than they are.

Men and women think about cancer risks differently.  Women are more active participants in cancer screening decisions regardless of their perception of risk, whereas men tended to get involved only if they felt at higher risk.

Funded by Veterans Affairs Health Services Research & Development CDA-2

Funding Years: 2014-2015


Despite the availability of evidence-based strategies to prevent type 2 diabetes mellitus (T2DM), engagement in these strategies is low among at-risk Veterans. A key opportunity to engage at-risk Veterans in interventions to prevent T2DM is when they are informed they have prediabetes. It remains unclear how VHA communications to patients diagnosed with prediabetes could be optimized to improve their engagement in evidence-based preventive strategies.

  • Aim 1: To describe at-risk Veterans' current engagement in behaviors to prevent T2DM and the mediators of this engagement.
  • Aim 2: To examine the effects of receipt of a prediabetes diagnosis on at-risk Veterans' weight and engagement in behaviors to prevent T2DM.
  • Aim 3: To identify the effects of 4 strategies from behavioral economics and health psychology on weight, HbA1c, and engagement in behaviors to prevent T2DM among Veterans with prediabetes.

To accomplish Aim 1, we will survey 189 non-diabetic Veterans with risk factors for T2DM about their engagement in behaviors to prevent T2DM and mediators of this engagement such as risk perception, motivation, and awareness of and preferences for preventive strategies. To accomplish Aim 2, we will conduct a pilot randomized trial among the same 189 non-diabetic Veterans from Project 1 in which we will randomly assign 126 of these Veterans to undergo screening for T2DM using a hemoglobin A1c (HbA1c) test. The 63 Veterans who we project will have HbA1c values in the prediabetes range will receive that diagnosis and preventive recommendations from their PACT provider via brief standardized counseling. All 189 Veterans will have their weight tracked over the next year and will be surveyed immediately after the screening and brief counseling process, at 3 months, and at 1 year. Then we will compare changes in weight, engagement in behaviors to prevent T2DM, and mediators of this engagement between the 63 Veterans who we project will have prediabetes and the 63 Veterans who were not screened. Among the 63 Veterans with prediabetes, we will conduct 20 semi-structured interviews to gain insights into the effects of this diagnosis and brief counseling. To accomplish Aim 3, we will conduct a fractional factorial design experiment to evaluate the effectiveness of 4 innovative strategies from behavioral economics and health psychology in promoting weight loss, decreasing HbA1c, and increasing engagement in behaviors to prevent T2DM among 144 Veterans who are identified as having prediabetes through an HbA1c test. We will conduct qualitative evaluations of the acceptability of these strategies to patients.

PI(s): Jeffrey Kullgren

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