Tuesday, January 7, 2014: 10:30 AM-12:00 PM
Royal Pavilion Ballroom I-III (The Regent Hotel)

Session Chairs:
Ahmed Bayoumi, MD, MSc and Anne M. Stiggelbout, PhD
10:30 AM
Tammy C. Hoffmann, PhD, BOccThy, (Hons)1, Sally Bennett, PhD, BOccThy, (Hons)2, Claire Tomsett, BOccThy, (Hons)2 and Chris Del Mar, MBBChir, MA, MD1, (1)Bond University, Gold Coast, Australia, (2)University of Queensland, Brisbane, Australia
   Purpose: Successful evidence-based practice requires clinicians to practice patient-centred care. Central to this is shared decision making; of which, a key skill is communicating evidence clearly to patients. Many clinicians do this poorly, if at all. One reason is lack of training: evidence-based practice courses and workshops typically do not include these skills. Teaching these skills to student clinicians during evidence-based practice training may be valuable, but methods for doing this have not been evaluated. This study aimed to evaluate, in a multi-site randomised trial, the effectiveness of a brief intervention designed to increase student clinicians’ ability to facilitate shared decision making and evidence communication.   

   Method: Medical, physiotherapy and occupational therapy undergraduate, honours, and postgraduate students (n=107) were randomly allocated to an intervention or control group. Intervention group participants received brief training in shared decision making and evidence communication skills. At baseline and post-intervention, participants performed role-plays which were videorecorded and evaluated by a blinder assessor. The primary outcomes were shared decision making and evidence communication skill, measured using the Observing Patient Involvement (OPTION) scale (range 0-100) and selected items from the Assessing Communication about Evidence and Preferences (ACEPP) Tool (range 0-5).  Secondary outcome measures were confidence in these skills (11-item visual analogue scale) and attitudes towards patient-centred communication (Patient Practitioner Orientation Scale (PPOS), which participants completed as a questionnaire. 

   Result: Post-intervention, intervention group participants scored significantly higher on the OPTION scale (mean between-group difference = 19.2, 95% CI 12.3 to 26.0), ACEPP items (difference = 1.0, 95% CI 0.5 to 1.4), confidence measure (difference = 13.3, 95% CI 7.3 to 19.4), and the Sharing subscale of the PPOS (difference = 0.5, 95% CI 0.2 to 0.7). The between-group difference for the Caring subscale of the PPOS was not significant.

  Conclusion: This brief intervention was effective in improving student clinicians’ ability, attitude toward, and confidence in shared decision making facilitation. Following further testing of the longer-term effects of this intervention, incorporation of this brief intervention into evidence-based practice courses and workshops should be considered so that student clinicians graduate with these important skills, which are typically neglected in clinician training, yet crucial to the uptake of shared decision making.

10:45 AM
Amanda Woolley, BSc and Olga Kostopoulou, PhD, King's College London, London, United Kingdom
Purpose: Unconscious Thought theory states that, in complex tasks that involve working memory load, better decisions can be made after a period of distraction than either immediately or after a period of conscious deliberation (Dijksterhuis & Nordgren, 2006). This is known as the Deliberation Without Attention (DWA) effect (Dijksterhuis et al. 2006). The theory purports to apply to a range of cognitive tasks, including diagnosis. Studies that attempted to replicate the effect in clinical diagnosis produced conflicting results but also changed the conditions of the experimental paradigm (De Vries et al. 2010; Mamede et al. 2010). We sought to replicate the DWA effect with family physicians in the UK.

Method: In a mixed factorial design, we presented participants with 3 patient cases on computer. The cases were based on real patients for whom the diagnosis was known. Each case consisted of a number of cues (items of information) presented sequentially and only for 4 seconds each, to increase working memory load. Participants were allocated randomly to one of 3 thinking modes: Immediate response (limited to 20 seconds), Distracted (participants completed an unrelated memory task before diagnosing each case) or Self-paced (participants took as long as they needed to diagnose). After each case, participants gave their diagnosis and indicated their confidence in the diagnosis.

Result:  Participants were 116 family physicians. Only 27% of responses were correct, i.e. matched the patients’ real diagnoses. Thinking mode was related neither to diagnostic accuracy (p=0.43) nor to confidence (p=0.15). Physicians in the Self-paced condition did not take time to think and tended to diagnose within seconds (median 7 seconds). A significant, inverse relationship was found between diagnostic accuracy and confidence (t=3.03, df=329, p<0.01). 

Conclusion: The study did not replicate the DWA in medical diagnosis, despite maintaining the conditions of the experimental paradigm. It thus resolves the uncertainty surrounding the effect on clinical diagnosis. The quick responses of physicians in the Self-paced condition and the lack of differences in accuracy suggest that all three groups employed similar cognitive processes, constructing their diagnoses "online" rather than at the end. The period of distraction did not improve information processing. The higher confidence associated with inaccurate diagnoses suggests that high confidence in an initial diagnosis may discourage physicians from revising it to account for subsequent, inconsistent information.

11:00 AM
Chetna Malhotra, MD, MPH1, Eric A. Finkelstein, PhD, MHA2, Ravindran Kanesvaran, MD3 and Assad Farooqui, BA1, (1)Duke-NUS Graduate Medical School, Singapore, Singapore, (2)Duke-NUS Graduate Medical School Singapore, Singapore, Singapore, (3)National Cancer Centre, Singapore, Singapore
Purpose: To assess preferences for end-of-life (EOL) care among advanced cancer patients and their caregivers and the extent of concordance in preferences within patient-caregiver dyads

Method: A discrete choice experiment was administered to 138 patients with advanced cancers and their caregivers in which they were asked to choose between two EOL care scenarios. Each scenario was described through 7 attributes with between 2 and 4 levels for each: severity of pain, amount of care required from family-members or friends, expected length of survival, quality of health care experience, expected cost of treatment from diagnosis to death, source of payment, and place of death.  Ten scenarios were presented to each respondent. Annual willingness to pay (WTP) for specific EOL improvements was estimated for patients and their caregivers. Attribute importance was assessed for each respondent and proportion of dyads in which patients and caregivers matched on their top and bottom ranked attributes was calculated.

 Result: Caregivers had a greater WTP for specific EOL improvements compared to patients. Only 28% of the patient-caregiver dyads matched on their topmost EOL attribute, which was most commonly place of death. Similarly, 27% of the dyads matched on their bottom ranked attribute, which was most commonly care required from family-members or friends.

Conclusion: Patient’s priorities for EOL treatments systematically differ from those of their caregivers. As a result, caregivers are likely to make decisions that are not consistent with the patient’s wishes. To the extent possible, physicians should work to ensure that patient’s preferences are elicited as opposed to relying on the recommendations of caregivers when it comes to EOL treatment.

11:15 AM
Marilyn Schapira, MD, MPH, University of Pennsylvania, Philadelphia, PA, Masako Okamoto, Ph.D., Obihiro University of Agriculture and Veterinary Medicine, Obihiro Hokkaido, Japan, Yasuchi Kyutoku, Ph.D., Chuo University, Tokyo, Japan, Yurie Sugimoto, Kyushu Institute of Technology, Tokyo, Japan, Lester Clowney, Jichi Medical University, -, Japan, Ippeita Dan, Ph.D., Chuo University, -, Japan, Tamara Miller, PT, MS, University of Wisconsin-Milwaukee, Milwaukee, WI and Cynthia M. Walker, Ph.D., University of Wisconsin, Milwaukee, WI

Although understanding numerical information is a crucial factor when people make medical decisions, health numeracy has been understudied in Japan due to the absence of adequate assessment tools. In the United States, one such tool is Numeracy Understanding in Medicine Instrument (NUMi; Schapira et al., 2012), which was developed based on empirically derived health numeracy framework. In the current study, we aimed to examine validity of NUMi for the Japanese public, and to compare the Japanese (NUMi-J) and original versions.


NUMi-J was prepared using a forward and backward translation, with context and wordings being modified based on feedback from experts in clinical medicine and statistics and pilot respondents (N=1054). In the main survey, responses from a quota sample (N=2000) approximating the composition of the Japanese population was collected. As in the original study, both classical test theory (CTT) and item response theory (IRT) were used to examine the psychometrical nature of NUMi-J. Validity was assessed by examining the association of NUMi-J scores with other measures of numeracy, literacy, psychographics and levels of understanding of medical information.


The performance of Japanese sample was better than in the original study (mean scores of 14.5 vs. 13.2, respectively). Consequently, the IRT parameter for difficulty was lower with the 20 items ranging respectively from -2.70 to 0.96 in the current, and –1.70 to 1.45 in the original study). Except for difficulty parameter, the results from NUMi-J were comparable with the original ones, with sufficient reliability (Cronbach α=0.83) and discriminability (range of IRT parameter 0.33 to 2.48). As expected, performance on NUMi-J was more strongly correlated with numeracy scores (11-item objective scale, r=0.52; Berlin Numeracy test, r=0.47) than literacy scores (Health knowledge test, r=0.35; Science literacy test, r=0.40), or psychographic scores (Rational-Experiential Index-ability, r=0.19; Self-efficacy, r=0.05). Finally, logistic regression analysis indicated that the predictive ability of NUMi-J on the understanding of quantitative medical information to be the best among all the other parameters (numeracy, literacy and psychographic; All the independent variables were standardized; odds ratio of NUMi-J, 2.3).


In its translated form, NUMi worked well in this culturally different population, and will be a useful tool for assessing patients’ health numeracy in Japan, especially for those with relatively lower numeracy levels.

11:30 AM
Sorapop Kiatpongsan, MD, Harvard Interfaculty Initiative in Health Policy, Cambridge, MA, Anjali Kaimal, MD, MAS, Massachusetts General Hospital, Harvard Medical School, Boston, MA, Michael I. Norton, PhD, Harvard Business School, Boston, MA and Milton C. Weinstein, PhD, Harvard School of Public Health, Boston, MA


To compare patients' and physicians' perceptions of the value of a medical service, such as cord-blood stem cell banking, whose future benefits are ambiguous, and to investigate if the differences in perceptions derive from discrepant assessments of the probability of realizing benefits, of the magnitude of benefits, or both. Also, to investigate if the differences in perceptions depend on whether the service offers unambiguous benefits in addition to ambiguous benefits.


Four hundred thirty-nine 18-45 years old U.S. women  (“patients”) and 59 U.S. obstetric providers (“physicians”) were asked to predict benefits (probability and magnitude) of cord-blood stem cell banking within the next 5, 10, 20 and 40 years. Patients were then randomly assigned to 1 of 3 scenarios representing varying degrees of ambiguity about the benefits – (A) only unambiguous benefits, (B) both unambiguous and ambiguous benefits, or (C) only ambiguous benefits – and reported their family's willingness to pay for the service. Physicians were also asked to predict a typical family's willingness to pay in each scenario.


Patients' predictions of the probability of realizing benefits are significantly more favorable than physicians' (16%, 26%, 39% and 52% versus 2%, 4%, 7% and 12% at 5, 10, 20 and 40 years respectively; p < 0.001 for all). See Figure 1. Predictions of magnitude of benefits, in contrast, were not significantly different at 5, 10 and 20 years, but were significantly more favorable among patients at 40 years (p < 0.01).

Physicians underestimated families' willingness to pay in all scenarios for families with income < $50K (p < 0.05) but not for families with income $50-100K. Interestingly, a service offering both unambiguous and ambiguous benefits has significantly lower value than a service with only unambiguous benefits to families with income $50-100K (p < 0.05), but not to physicians or to families with income < $50K.


Patients and physicians have different perceptions of the value of a medical service with ambiguous future benefits, owing primarily to different perceptions of the probability of realizing the benefits. Physicians underestimated willingness to pay for a service in low-income families. These differences suggest the value of improved communication between physicians and patients when the benefits of a medical service are ambiguous.