Tuesday, October 22, 2013: 1:30 PM - 3:00 PM
Key Ballroom 8,11,12 (Hilton Baltimore)
Category Reference for Presentations
AHEApplied Health Economics DECDecision Psychology and Shared Decision Making
HSPHealth Services, and Policy Research METQuantitative Methods and Theoretical Developments

* Candidate for the Lee B. Lusted Student Prize Competition

Session Chairs:
Jane J. Kim, PhD and Lawrence J. Cheskin, MD
1:30 PM
Brownsyne Tucker Edmonds, MD, MPH, MS1, Fatima McKenzie, MS1, Amber E. Barnato, MD, MPH, MS2 and Richard M. Frankel, PhD1, (1)Indiana University School of Medicine, Indianapolis, IN, (2)University of Pittsburgh School of Medicine, Pittsburgh, PA
Purpose: To qualitatively assess and compare obstetricians’ and neonatologists’ responses to patients asking: “What would you do?” when discussing treatment options and prognosis for potential delivery at 23 weeks gestation.

Method: We conducted an exploratory single-center simulation study.  Fifteen obstetricians and 15 neonatologists counseled simulated patients (SPs) portraying a pregnant woman presenting with ruptured membranes at 23 weeks gestation. The SPs were instructed to ask, “What would you do?” if the physician presented more than one treatment option (e.g. comfort measures versus attempted neonatal resuscitation).  We audio and video-recorded the simulations.  Two investigators (BTE, FM) independently reviewed the video segments and iteratively developed codes to classify physician response categories.

Result: All but one encounter (29/30) included the SP’s prompt.  All 15 of the neonatologists and 6/14 (43%) obstetricians deflected the question, saying, “I don’t know,” either because: “I’ve never faced this decision before;”  “I don’t know what your values are;” or “It doesn’t matter what I would do.”  One obstetrician ignored the question and 2 explicitly declined to answer it.  After deflecting the question, physicians often restated the morbidity and mortality statistics; repeated the management options; or offered to provide the patient with additional information to help them make their own decision.   Five of 14 (38%) obstetricians provided a personal preference, opinion, or recommendation; no neonatologists did.  Several physicians discussed values indirectly by describing the decisions of other parents; emphasizing that “good parents” who make “loving decisions” have chosen either option. Only one of the physicians directly explored the patient’s values. However, the majority of physicians (17/29, 58%) stated that it was a “personal decision” for which there were “no right answers.” Many redirected patients to seek guidance from family, friends, and religious leaders, rather than the physician, to aid them in decision-making.              

Conclusion: Obstetricians and neonatologists responsible for counseling women about “preference sensitive” treatment options in the face of periviable delivery typically avoided disclosing personal opinions or recommendations regarding resuscitation.  Their efforts to respect autonomy and avoid biasing parental decision-making may have the unintended consequence of implicitly or explicitly communicating messages that could leave patients feeling abandoned or disregarded.  “What would you do?” inquiries represented a missed opportunity for providers to facilitate values elicitation which could guide decision-making, with or without disclosing personal opinions.

1:45 PM
Nilanjana Dwibedi, MBA, PhD, West Virginia University, School of Pharmacy, Morgantown, WV and Sujit S. Sansgiry, PhD, College of Pharmacy, University of Houston, Houston, TX
Purpose: Physician’s perception regarding parents’ expectation to receive antibiotic prescription for their children is a significant predictor of overprescribing antibiotics for young children. The purpose of this study was to evaluate whether parents’ level of expectation would change after manipulating their ‘perceived barriers to visit doctors without any expectation of antibiotic prescription’ and their ‘perceived benefits of using antibiotics’.

Method: A prospective experimental study was conducted using a structured data-collection instrument to manipulate perceived barriers and perceived benefits using four scenarios and keep other factors of Health Belief Model constant. Scenarios were developed with the help of pediatricians and by conducting elicitation survey among parents of young children. Each subject viewed four scenarios. Parents’ expectation to receive antibiotic prescription associated with each scenario was measured on a scale of 0 (‘No Expectation’) to 100 (‘High Expectation’); a 100mm visual-analog-scale was used. Data were collected at public places (Houston, TX) from subjects who had at least one child (age≤5 years) during the study and who could speak, read and write English. Psychometric properties of the instrument were tested; descriptive and repeated measures mixed method covariance adjusted analyses were performed using SAS®9.3 with a 0.05 significance level.

Result: A total of 300 completed surveys were analyzed. Mean age of the sample was 30.3±7 years. The mean general expectation score (before reading any scenario) to receive antibiotic prescription for children was 53.6±25.7. The repeated measure mixed methods analyses indicated that there was 12-point reduction (p<0.0001) in expectation score after removing perceived barriers from the situational scenarios; 16-point decrease (p<0.0001) in expectation score was observed after removing perceived benefits and 18-point decrease (p<0.0001) in expectation score after removing both perceived barriers and perceived benefits. Some covariates (general expectation toward an antibiotic prescription, training in the healthcare field and parents’ preference for communication) had significant effect on parents’ expectation.

Conclusion: There was significant effect of perceived barriers and perceived benefits on expectation scores. When both perceived barriers and perceived benefits were removed from the scenarios there was the highest decrease in the expectation score indicating the successful manipulation of both variables. Policy makers and intervention programs should consider these factors to enhance successful reduction of antibiotic expectations.

2:00 PM
Kristin S. Hendrix, PhD, S. Maria E. Finnell, MD, MS, Gregory D. Zimet, PhD, Lynne A. Sturm, PhD and Stephen M. Downs, MD, MS, Indiana University School of Medicine, Indianapolis, IN
Purpose: Determine whether emphasizing benefits of the measles, mumps, and rubella (MMR) vaccine to the child recipient or to others in society beyond the child recipient (i.e., the concept of herd immunity) differentially impacts parents' intentions to vaccinate their infants for MMR.

Method: Parents (N=802) of infants less than 1 year of age responded to an online survey in the United States. Participants were randomized to receive 1 of 4 messages about the MMR vaccine: 1) the Centers for Disease Control and Prevention’s Vaccine Information Statement (CDC VIS); 2) CDC VIS and information emphasizing the MMR vaccine's benefits to the child; 3) CDC VIS and information emphasizing the MMR vaccine's benefits to society; 4) CDC VIS and information emphasizing the MMR vaccine's benefits both to the child and to society. Parents then rated the likelihood of vaccinating their infants on an 11-point response scale ranging from 0 (extremely unlikely) to 100 (extremely likely) in 10-point increments. We also assessed medical trust, as well as attitudes and worries about immunization. We analyzed the data using linear regression models.

Result: Compared to receiving only the CDC VIS, respondents who received additional information emphasizing either 1) the vaccine's benefit to the child or 2) the vaccine's benefits both to the child and to society indicated higher levels of intention to vaccinate their infant for MMR (p=0.01 and p=0.03, respectively). Additional information emphasizing the MMR vaccine's benefits to society did not increase parents’ intentions to vaccinate compared to the CDC VIS alone (p=0.97, ns). Additionally, parents with positive attitudes towards vaccination, high levels of medical trust, or low levels of worry that autism is caused by the MMR vaccine indicated greater vaccine intentions (p<0.01).

Conclusion: Unlike in previous research on adult intentions to be vaccinated, emphasizing additional information about a vaccine's benefits to society (i.e., herd immunity) did not increase parents’ MMR vaccination intentions for their infants. Results suggest that health care providers who want to increase MMR vaccination rates should emphasize the direct benefits of vaccination to the child. Mention of the vaccine’s benefits to society appears to have no added value but also does not interfere with message concerning benefits to the child.

2:15 PM
Holly O. Witteman, PhD1, Laura D. Scherer, PhD2, Teresa Gavaruzzi, PhD3, Arwen H. Pieterse, PhD4, Andrea Fuhrel-Forbis5, Nicole Exe, MPH5, Valerie C. Kahn, MPH5, Deb Feldman-Stewart, PhD6, Nananda F. Col, MD, MPH, MPP, FACP7 and Angela Fagerlin, PhD8, (1)Université Laval, Quebec City, QC, Canada, (2)University of Missouri, Columbia, MO, (3)University of Leeds, Leeds, United Kingdom, (4)Leiden University Medical Center, Leiden, Netherlands, (5)University of Michigan, Ann Arbor, MI, (6)Division of Cancer Care and Epidemiology, Kingston, ON, Canada, (7)University of New England, Georgetown, ME, (8)VA Ann Arbor Healthcare System & University of Michigan, Ann Arbor, MI
Purpose: Values clarification is a key component of informed decision making and a core aspect of shared decision making, but there is little synthesis or consensus in this area, making it difficult for researchers who are developing values clarification exercises to look to established norms or best practices for guidance.

Methods: We conducted a systematic review of values clarification exercises, consulting electronic databases, reference lists, and expert contacts to identify articles describing the development, design and/or evaluation of exercises. We extracted data from included articles about decisions addressed, use of theory and guidelines, and development processes. We then developed a taxonomy of design features linked to relevant theories, used the taxonomy to catalogue exercises, and explored relationships between features. Finally, from articles reporting evaluations of exercises, we extracted data about heterogeneous outcomes, created a crude aggregate measure of overall effect, and explored associations between design features of exercises and overall effect.

Results: Out of 2145 articles eligible for screening, we identified 93 articles describing 81 values clarification exercises, of which 15 had been evaluated. Forty-one of 81 exercises (51%) addressed a decision between just two options. Most exercises (60%) were guided by neither theory nor guidelines. Development processes were described unevenly, with relatively little consultation with patients and infrequent reporting of methods that help make exercises easier for patients to use. The designs of exercises were extremely diverse. Only 56% of exercises were designed to be used independently by a patient. Most exercises (63%) were closed-ended, meaning that users could not add concerns that were not pre-specified in the exercise. Few exercises (11%) encouraged users to explore their values in an iterative discovery process. Users were presented with the implications of their stated values in 33% of exercises. Exploratory analyses suggested that exercises that showed users the implications of their expressed values were associated with positive overall effect (p = .006). Exercises based on relevant theory showed a trend toward overall positive effect (p = .06).

Conclusions: Values clarification exercises differ greatly in design. Many do not employ theories or guidelines. Many articles do not report development processes in detail. More research is needed to investigate the use of values clarification methods across decision contexts and to study the effects of different design features.

2:30 PM
Teresa Gavaruzzi, PhD1, Michela Sarlo, PhD2, Francesca Giandomenico, MA2, Francesca Polato, MD3, Franca De Lazzari, MD3, Rino Rumiati, MA2 and Lorella Lotto, PhD2, (1)University of Leeds, Leeds, United Kingdom, (2)University of Padova, Padova, Italy, (3)S. Antonio Hospital, Padova, Italy

   Patient narratives or personal stories are often used in resources for patients, but there is a paucity of research on what their active ingredients are (Bekker et al., 2012; Shaffer & Zickmund-Fisher, 2013). This study investigated the emotions elicited, at both subjective and physiological level, while reading narratives about colorectal cancer screening.


   A mixed design was used, with a between-participants factor (group: emotion vs. no emotion) and a within-participants factor (type of narrative). Participants read an informative leaflet about fecal occult blood testing and three narratives. In the emotion condition the three characters explicitly reported their emotions at the end of their story, whereas in the no emotion condition they did not refer to their emotions. All narratives described the experience of a character who underwent testing and: a) was still waiting for the result (control narrative), b) had a negative result (reassuring narrative) and c) had a positive result and was successfully treated for early-stage cancer (anticipated regret narrative).

Participants (N=39; 50% females; aged 45-50, M=48) read all the three narratives (in random order) on a computer screen while physiological measures (skin conductance and corrugator muscle activity) were recorded; then they evaluated the intensity of emotions evoked by each narrative. 


   Relative to the control condition, the regret and the reassurance narratives elicited stronger and weaker negative emotions, respectively, regardless of the group manipulation. Fear and anxiety were the most intense negative emotions reported for all narratives. However, peace of mind was the most intense emotion overall.

The group manipulation (emotion vs. no emotion) significantly affected the physiological responses while reading the narratives. Skin conductance, an index of physiological arousal, was significantly lower in the emotion condition than in the no emotion condition. EMG corrugator activity, which typically increases in response to unpleasant stimuli, comparably increased from baseline in both groups at the beginning of the narratives. However, in the second half, in the no emotion group EMG remained steady, while in the emotion group it decreased.


   The regret narrative was the one eliciting the strongest self-reported negative emotions. Making explicit the emotions experienced by the character reduced the negative emotions unveiled by the physiological activation. These findings contribute to shed light on what makes narratives powerful and under which circumstances.

2:45 PM
Laura Scherer, PhD, VA HSR&D and University of Michigan, Ann Arbor, MI, Marieke de Vries, PhD, Tilburg University, Tilburg, Netherlands, Brian J. Zikmund-Fisher, PhD, University of Michigan, Ann Arbor, MI, Holly O. Witteman, PhD, Université Laval, Quebec City, QC, Canada and Angela Fagerlin, PhD, VA Ann Arbor Healthcare System & University of Michigan, Ann Arbor, MI
Purpose:  It is often assumed that deliberative decisions are better than intuitive ones, and this assumption has guided the development of patient decision aids. However, the psychological literature suggests that deliberation is not always superior to intuition. Hence, it is unclear how to best support patient decisions, and the topic has generated considerable debate. The purpose of the present research is to clarify the impact of these decision strategies in the context of patient decision-making. 

Method: In Study 1, 1470 participants were recruited online and made one of two hypothetical cancer treatment choices. The choice involved either a trade-off between the quantity and quality of their lives, or a choice between watchful waiting with a 5% chance of death, and surgery with a 10% chance of death. Participants were randomly assigned to make their decision (a) intuitively, (b) deliberatively, by writing about which decision is objectively best, (c) deliberatively, by writing about one’s feelings, or (d) without instructions. In Study 2, 326 men (40-87 years) were recruited from the University of Michigan and Ann Arbor VA hospitals. They read an abbreviated prostate cancer decision aid, and were randomly assigned to make a hypothetical treatment decision (a) intuitively, (b) deliberatively, by writing about pros and cons, or (c) deliberatively, using a checklist exercise. Outcomes included choice, satisfaction, decision conflict, and attitudes toward the decision strategy. In Study 2, knowledge was also measured.

Result: In both studies, the decision strategies had no impact on treatment choice, however deliberators liked their decision strategy significantly more than intuitors, both p<.01.  In Study 1, deliberators reported greater satisfaction (F(3,1463)=26.30, p<.001) and less conflict (F(3,1466)=21.51, p<.001) than intuitors. In Study 2 there were no effects involving satisfaction and conflict, and the deliberative writing condition reduced knowledge (M=5.36) compared to the intuition and checklist conditions (Ms=6.00 and 6.02), F(2,289)=5.05, p<.01.

Conclusion: Regardless of the specific decision or how deliberation was evoked, participants liked using deliberation better than intuition. However, there was no evidence that deliberation changed participants’ decisions, and only partial evidence that it improved satisfaction and conflict. There was also some evidence that deliberation can reduce knowledge. These results indicate that deliberation may help people to feel better about their decision process, even if it does not change or improve decisions.