Monday, October 24, 2011: 1:30 PM
Grand Ballroom EF (Hyatt Regency Chicago)
Category Reference
BECBehavioral Economics ESPApplied Health Economics, Services, and Policy Research
DEC Decision Psychology and Shared Decision Making METQuantitative Methods and Theoretical Developments

  * Candidate for the Lee B. Lusted Student Prize Competition

Session Chairs:
Sophie Desroches, RD, PhD and Marla L. Clayman, PhD, MPH
1:30 PM
Ingrid Nota, MSc1, C.H.C. Drossaert, Dr.1, E. Taal, Dr.1, B.C. Visser, MSc2 and M.A.F.J. Van de Laar, Prof., Dr.1, (1)University of Twente, Enschede, Netherlands, (2)Medisch Spectrum Twente, Enschede, Netherlands

Purpose: This study explores what role patients with rheumatic diseases perceive and prefer to have in decisions about Disease-Modifying Anti-Rheumatic Drugs (DMARD's) and what the concordance between preferred and perceived role in these decisions is.

Methods: Patients (n=519) diagnosed with Rheumatoid Arthritis, Arthritis Psoriatica or Ankylosis Spondylitis from two hospitals in the Netherlands filled out a questionnaire. Questions included perceived and preferred role in medical decision making in general, and in four specific decision-categories: starting to use traditional DMARD's, starting to inject a DMARD, starting to use biological DMARD's and decrease or stop using DMARD's.

Results: Most respondents perceived that, in current practice, treatment decisions in general were made by the doctor (43%) or by the doctor and patient together (55%). However, the perceived roles varied per decision-category: e.g. most patients (72%) felt that the decision to start using a traditional DMARD was made by the doctor, whereas the decision to decrease or stop using DMARD's was more often perceived as being made by the patients themselves (24%) or by doctor and patient together (38%).   The preferred roles were, contrary to the perceived roles, consistent across the decision-categories. Most respondents (59-63%) preferred to share decisions with their doctor. By using a paired sample t-test the concordance between the perceived and preferred role was evaluated. Table 1 shows that there was a significant difference in 4 of 5 decision-categories. Only the decision to decrease or stop using DMARD's had no significant difference between perceived and preferred role.

For a considerable group the perceived and preferred participation for decision making in general matched (61%); about one third (29%) perceived less participation than preferred and a minority perceived more participation than preferred. Again, the concordance varied across the decision-categories. Especially for the decision to start with a traditional DMARD, many respondents had experienced less participation than they preferred (54%).

Conclusions: Although patients seem consistent in their preference for participation in various DMARD-decisions, the amount of perceived participation varied across the different decisions. Patients should especially be more involved in decisions about starting to use a traditional DMARD.  Patient Decision aids might be helpful tools to increase patient participation.

1:45 PM
Jaclyn C. Watkins, M.S.1, Miriam Kuppermann, PhD, MPH2, Jodi Halpern, MD, PhD3 and Maureen Lahiff, PhD3, (1)University of California, San Francisco, Berkeley, CA, (2)University of California, San Francisco, San Francisco, CA, (3)University of California, Berkeley, Berkeley, CA

Purpose: To assess the accuracy of women’s emotional expectations of elective hysterectomy as treatment for noncancerous uterine conditions through the lens of affective forecasting.

Methods: This is a secondary analysis of data collected as part of the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives, a longitudinal study designed to examine the effects of noncancerous uterine conditions on health-related quality of life and to identify predictors of use of and satisfaction with hysterectomy and alternative treatments. Patients who had sought care for bleeding, pain, and/or pressure at one of several Bay Area hospitals were interviewed annually for up to eight years. For this analysis, only women who had a hysterectomy were included (n=159).  The primary predictors and outcomes included agreement scores ranging from 1 to 7 on several 1-item attitude measures phrased as expectations prior to hysterectomy and as outcomes post-hysterectomy. Forecasting ability (tendency to accurately estimate, overestimate, or underestimate affective responses) and an overall hysterectomy expectation score were also outcomes.

Results: Compared to their post-hysterctomy scores, before undergoing hysterectomy, participants reported significantly higher agreement with the following statements: “Having a uterus makes/made me feel complete as a woman” (4.08 v. 3.16; p=<0.001), “My uterus is/was important to my sexual enjoyment” (3.51 v. 2.65; p=<0.001), “Having a hysterectomy would make/made me feel violated” (2.77 v. 2.29; p=0.042), and “Having a hysterectomy would make/made me feel older” (3.36 v. 2.65; p=0.006). They showed significantly less agreement with a statement regarding the benefit of hysterectomy as birth control pre-hysterectomy (4.59 v. 5.20; p=0.008). There was no significant change in response to a statement regarding feeling sad about losing fertility (p=0.955). Multinomial logistic regressions revealed few significant associations between forecasting ability and sociodemographic variables. Notable findings include an association between increased age and accuracy of impact of hysterectomy on sexual enjoyment (relative risk ratio=0.82, CI (0.71, 0.93), p=0.003) and between pre-hysterectomy sexual importance and overestimation of hysterectomy's impact on sexual enjoyment (relative risk ratio=1.93, CI (1.23, 3.02), p=0.004).

Conclusions: Women tend to overestimate the impact of perceived negatives associated with hysterectomy, suggesting the presence of forecasting errors. Further exploration of the specific forecasting errors made in the context of elective hysterectomy would aid in the development of more effective decision tools for women considering hysterectomy.

2:00 PM
Sofia de Achaval, MS1, Liana Fraenkel, MD, MPH2, Vanessa Cox, MS1, Robert J. Volk, PhD1 and Maria E. Suarez-Almazor, MD, PhD1, (1)The University of Texas MD Anderson Cancer Center, Houston, TX, (2)Yale School of Medicine, New Haven, CT

Purpose: To examine the impact of a decision aid coupled with an adaptive conjoint analysis (ACA) program on decisional conflict in decision making for treatment of osteoarthritis (OA).

Method: A total of 209 patients with OA in one or both knees who had not undergone total knee arthroplasty (TKA), but had thought about it or had talked to their doctor about it participated in the study (mean age 63 years; 68% female; 66% White). Participants were randomly allocated into one of three groups: 1) a control arm brochure, 2) a DVD-based decision aid, and 3) the same DVD-based decision aid plus the ACA program. The primary outcome measure [decisional conflict scale (DCS)] was evaluated using pre/post intervention self-administered questionnaires along with demographic characteristics and impact of OA on quality of life (KOOS). Statistical analysis included descriptive statistics and analysis of variance (ANOVA) to estimate the effect of the intervention on decisional conflict.

Result: Overall, the intervention statistically significantly reduced decisional conflict in all groups (p<0.05). The difference between the pre and post mean subscale scores for the DCS measured change in the expected direction: decision uncertainty decreased, informativeness increased, values clarity increased, support increased and effective decision increased. The largest reduction in decision conflict was observed for participants in the DVD decision aid group. Post hoc analyses indicated a statistically significant difference in pre vs. post-intervention DCS total score comparing the DVD group to the control group and comparing the DVD group to the DVD plus ACA group (p<0.001). The changes in decision conflict for the control compared to the DVD decision aid plus ACA group were not significantly different.

Conclusion: In this study, the addition of an ACA program to a DVD decision aid did not lead to greater reductions in decisional conflict. Long-term effectiveness is yet to be determined and should take into account additional patient and provider preferences.

2:15 PM
Michelle McDowell, BPsych(hons)1, Stefano Occhipinti1 and Suzanne Chambers2, (1)Griffith University, Brisbane, Australia, (2)Griffith University, Gold Coast, Australia

Purpose: To understand how men integrate information about prostate cancer risks and screening guidelines to make judgements about prostate cancer and exploring whether having a first-degree family history influences how this information is integrated.

Method: First-degree relatives of men with prostate cancer (n=32) and men without a family history of prostate cancer (n=50) from Queensland, Australia completed a policy-capturing study.  Forty-eight distinct profiles were created based on a full factorial design utilising four cues: family history (none, brother, father, brother and father), age (40’s, 50’s, 60’s), physician discussion (yes, no), and symptoms (presence, absence).  Participants rated each profile according to their perception of the stimulus’s prostate cancer risk and whether the stimulus should consider prostate cancer screening.

Result: Multi-level modelling analyses were employed to predict the use of information cues on perceived risk ratings and on prostate cancer screening recommendations and to explore family history status as a moderator of these ratings.  Family history, older age, and the presence of urinary symptoms in stimulus profiles were associated with greater judgements of prostate cancer risk by all men.  First-degree relatives of men with prostate cancer weighted the family history cue lower in their judgements of risk than did men without a family history.  There was minimal variability in the endorsement of prostate cancer screening across profiles and most men recommended screening for all stimulus men regardless of the values of information cues.

Conclusion: Family history is an important information cue for all men in determining judgements of prostate cancer risk.  However, first-degree relatives weight the family history cue lower than do men without a family history when making judgements about prostate cancer risk where they consider the specific nature of the family history.  First-degree relatives of men with prostate cancer consider the broader context of having a relative with prostate cancer and incorporate this information in determining their judgements which may have implications on the informed decision-making process.

2:30 PM
Hugues Vaillancourt, BSc, France Légaré, MD, PhD, Annie Lapointe, RD, PhD, Sarah-Maude Deschênes, RD and Sophie Desroches, RD, PhD, CHUQ Research Center-Hospital St-François d'Assise, Knowledge Transfer and Health Technology Assessment, Laval University, Québec, QC, Canada

Purpose: Little is known about shared decision making (SDM) in diet-related healthcare and clinical practice. Therefore, our objective was to assess the extent to which dietitians involve patients in decisions about their dietary treatment.

Method: We recruited dietitians working in hospitals in the Province of Quebec (Canada). Participating dietitians were asked to identify one patient to be seen during an upcoming consultation and in which a value-sensitive, nutritional treatment decision was expected to occur. All patients consulting for a diet-related health condition were eligible to participate. We audiotaped dietitians conducting nutritional consultations with their patients and we transcribed the tapes verbatim. Three trained raters independently evaluated the content of the nutritional consultations with a coding frame based on the 12 items of the French-language version of the OPTION scale, a validated and reliable third-observer instrument designed to assess patients’ involvement by examining specific health professional behaviours. Coding was facilitated by the qualitative research software NVivo 8. We assessed internal consistency with Cronbach’s alpha and inter-rater reliability with the intraclass correlation coefficient (ICC).

Result: Of 40 dietitians eligible to participate in the study, 19 took part. All dietitians were women aged between 24 to 60 years old (mean age 39.3±11.0 years).Their mean number of years in dietetic practice was 13.5±9.2. We recruited one patient per participating dietitian. Patients (mean age 40.2±25.2) were consulting for a variety of diet-related health conditions including diabetes, cardiovascular disease, and high risk pregnancy. The overall mean OPTION score was 29±8 (range=0 [no involvement] to 100 [high involvement]). Internal consistency and inter-rater reliability were both good (Cronbach’s alpha=0.938; ICC=0.65). Dietitians demonstrated the highest standard of skill for exploring patient’s expectations about how to manage the problem and the lowest for assessing the patient’s preferred approach to receiving information to assist decision making. Mean duration of consultations was 50±26min. The OPTION score was positively correlated with the duration of consultation (r=0.65,P<0.01).

Conclusion: Results indicate that dietitians’ involvement of patients in decisions about their dietary treatment is suboptimal. Interventions to increase patients’ involvement in decisions about their dietary treatment are needed and should include the training of dietitians. This study was funded by a George Bennett postdoctoral grant from the Foundation for Informed Medical Decision Making awarded to SD (FIMDM 2008-2009, grant #0108-1).

2:45 PM
Evan A. Wilhelms, Priscila G. Brust, Valerie Reyna, PhD, Seth T. Pardo, MA and Wilson Sui, Cornell University, Ithaca, NY

Purpose: To examine relations among intuitive processes (i.e., gist), temporal discounting, sensation seeking (reward sensitivity), and risk-taking in health domains such as alcohol use and food choices, and interactions with gender.

Method: Adults (N=966; 67% female; 37% Minority; mean age 20.2) were surveyed anonymously. Temporal discounting questions were presented for 3 commodities (alcohol, candy bars and money), varying immediate magnitude (1 or 6) and magnitude of the commodity one month later (Which would you choose: 1 candy bar now or 3 candy bars in one month?). Discount rates were calculated for each commodity by magnitude condition. Participants also selected the gist of their decisions from five ordinal options (e.g., Now is always better than later.) and responded to the Brief Sensation Seeking Scale (BSSS). Health behaviors included alcohol use (WHO’s Alcohol Use Disorders Identification Test, AUDIT), risk-taking (Adolescent Risk Questionnaire, ARQ), and spending behavior (Spendthrift Scale).

Result: In a regression using gist, discounting, sensation seeking, and gender as predictors of risky behaviors, discounting and gender were not significant by themselves, but discounting interacted with gender. Moreover, gist explained unique variance beyond other predictors. Specifically, health behaviors (AUDIT and ARQ) correlated with alcohol discount rates among males, whereas these behaviors correlated with candy discount rates among females.  Similarly, alcohol gist correlated with males’ risky behaviors, whereas candy gist correlated with females’ risky behaviors.  Discounting and reward sensitivity also predicted beyond their domains (e.g., alcohol predicted spending).

Conclusion: Consistent with Fuzzy-Trace Theory, unhealthy risk-taking behaviors were predicted by both reward sensitivity (sensation seeking) and information processing based on gist, each accounting for unique variance in health behaviors. In addition, there was a gender-specific effect in which alcohol predicted better for men, but candy bars predicted better for women. These results are consistent with a theoretical mechanism in which the perception of the gist of choices, as well as individual and group differences in reward salience, each account for unique variance in predicting risk taking and unhealthy choices.  Implications for public health messages and medical decision making will be discussed.