This research represents a paradigm shift in studies of Clinical Decision Making by moving the focus from three earlier generations of work to a new """"""""fourth generation"""""""" study of cognitive (and reasoning) processes. This theoretically based study builds directly (and cost efficiently) on successfully completed studies which used experimental (factorial) designs and demonstrate that patient attributes (gender, age, race and SES), provider characteristics (gender, medical specialty and years of clinical experience) and health care system characteristics independently influence (most p<.001) the diagnosis and management of Coronary Heart Disease (CHD). Clinical decision-making (CDM) with respect to CHD is shaped as much by who the patient is, who the provider is and the setting in which care is provided as it is by what the patient actually presents (the signs/symptoms of CHD). The study will describe how and explain why (and not simply that) different physicians, in different practice settings evidence variations in a broad-range of CHD care with equivalent patients. This project has 4 aims. (1) To estimate the independent effects of two cognitive experimental manipulations: (a) cognitive """"""""priming"""""""" of physicians as to CHD possibility; and (b) systematic substitution of patient attributes purportedly associated with CHD; on the following primary outcomes: probability of a CHD diagnosis, the number and type of diagnostic features recalled, and the timing of CHD diagnosis. The impact of cognitive intervention (a) on intervention (b) will provide estimated effects of analytic vs. non- analytic reasoning (i.e., intentional vs. non-intentional discounting) as measured by the primary outcomes. (2) To understand how patient attributes intrude on physicians' cognitive reasoning processes to produce the observed CHD variations. (3) To explain, using cognitive analysis, how provider characteristics contribute to the documented CHD variability. (4) To understand how organizational influences also intrude on CHD decision-making. Primary care providers (who encounter most CHD) from New York State will be randomly sampled (n=256) and invited to view a clinically authentic videotaped presentation of a """"""""patient"""""""" presenting with signs/symptoms of CHD. Information concerning the primary outcome (probability of CHD diagnosis) and a range of well-justified secondary outcomes will be elicited through structured interviewing. The factorial design permits estimation of independent (unconfounded) main effects and all two-way interactions. Results from the proposed research could reduce or eliminate health care variation in at least two types of interventions: (a) Organizational and reimbursement policies could be developed and evaluated which steer providers away from the patterns of decision-making which produce healthcare variations; (b) Interventions during medical education, when practice styles are not yet firmly established. ? ?

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Type
Research Project (R01)
Project #
1R01HL079174-01A1
Application #
7048016
Study Section
Special Emphasis Panel (ZRG1-HOP-G (90))
Program Officer
Jobe, Jared B
Project Start
2006-03-20
Project End
2009-01-31
Budget Start
2006-03-20
Budget End
2007-01-31
Support Year
1
Fiscal Year
2006
Total Cost
$445,217
Indirect Cost
Name
New England Research Institute
Department
Type
DUNS #
153914080
City
Watertown
State
MA
Country
United States
Zip Code
02472
Lutfey, Karen E; Gerstenberger, Eric; McKinlay, John B (2013) Physician styles of patient management as a potential source of disparities: cluster analysis from a factorial experiment. Health Serv Res 48:1116-34
Welch, Lisa C; Lutfey, Karen E; Gerstenberger, Eric et al. (2012) Gendered uncertainty and variation in physicians' decisions for coronary heart disease: the double-edged sword of ""atypical symptoms"". J Health Soc Behav 53:313-28
Shackelton-Piccolo, Rebecca; McKinlay, John B; Marceau, Lisa D et al. (2011) Differences between internists and family practitioners in the diagnosis and management of the same patient with coronary heart disease. Med Care Res Rev 68:650-66
Siegrist, Johannes; Shackelton, Rebecca; Link, Carol et al. (2010) Work stress of primary care physicians in the US, UK and German health care systems. Soc Sci Med 71:298-304
Lutfey, Karen E; Eva, Kevin W; Gerstenberger, Eric et al. (2010) Physician cognitive processing as a source of diagnostic and treatment disparities in coronary heart disease: results of a factorial priming experiment. J Health Soc Behav 51:16-29
Eva, Kevin W; Link, Carol L; Lutfey, Karen E et al. (2010) Swapping horses midstream: factors related to physicians' changing their minds about a diagnosis. Acad Med 85:1112-7
Ketcham, Jonathan D; Lutfey, Karen E; Gerstenberger, Eric et al. (2009) Physician clinical information technology and health care disparities. Med Care Res Rev 66:658-81
Maserejian, Nancy N; Lutfey, Karen E; McKinlay, John B (2009) Do physicians attend to base rates? Prevalence data and statistical discrimination in the diagnosis of coronary heart disease. Health Serv Res 44:1933-49
Lutfey, Karen E; McKinlay, John B (2009) What happens along the diagnostic pathway to CHD treatment? Qualitative results concerning cognitive processes. Sociol Health Illn 31:1077-92