Health decisions and decision support for women.

Women are more likely to live longer with chronic illness and have a long-term relationship with their health care provider; this requires a situation in which patients and providers have a role in managing illness. In this chapter, the authors provide a conceptual overview of decision making along with key issues: historical concepts related to patients and providers, consumerism, informed choice/consent, patient rights, shared decision making, patient involvement, as well as an overview of models of patient/provider partnerships. This review builds on the work of O'Connor et al. (1999), which resulted in a Cochrane review of decision aids and focuses the examination of patient decision aids that support women's decisions regarding health treatment or screening. The authors conclude with a look to the future and recommendations for research in the area of shared decision making and health care decision aids.

An educational intervention as decision support for menopausal women.

The purpose of this study was to develop and test a decision support intervention (DSI) to assist women to make and act on informed decisions that are consistent with their values in the area of menopause and hormone replacement therapy (HRT). Mode and intensity of intervention were tested in midlife women (N = 248), randomly assigned to one of three intervention formats: written information only, guided discussion, or personalized decision exercise. Data were collected over 12 months. Knowledge, decisional conflict, satisfaction with health care provider, and self-efficacy improved following intervention and were maintained for 12 months for all groups. Women's adherence to their own plans over 12 months was 59% (exercise), 76% (calcium intake), and 89% (HRT). Carefully written information is effective in promoting knowledge, adherence, and satisfaction among well-educated, interested women. It was concluded that women can understand complex information, including tradeoffs regarding treatment options. Women will adhere to their own plans, suggesting that consumer rather than provider plans may be the more appropriate gold standard for measuring adherence.

Patient satisfaction with health care decisions: the satisfaction with decision scale.

Patient satisfaction measures have previously addressed satisfaction with medical care, satisfaction with providers, and satisfaction with outcomes, but not satisfaction with the health care decision itself. As patients become more involved in health care decisions, it is important to understand specific dynamics of the decision itself. The Satisfaction with Decision (SWD) scale measures satisfaction with health care decisions. It was developed in the context of postmenopausal hormone-replacement therapy decisions. The six-item scale has excellent reliability (Cronbach's alpha = 0.86). Discriminant validity, tested by performing principal-components analysis of items pooled from the SWD scale and two conceptually related measures, was good. Correlation of the SWD scale with measures of satisfaction with other aspects of the decision-making process showed the SWD scale was correlated most highly (0.64) with "decisional confidence," and least with "desire to participate in health care decisions" and "satisfaction with provider." The SWD scale predicts decision certainty in this study. Use in an independent study showed that the SWD scale was correlated with the likelihood of patients' intentions to get a flu shot. Further investigation in relation to other health decisions will establish the utility of the SWD scale as an outcome measure.

Methods of analyzing physician practice patterns in hypertension.

A principal method of studying physician practice patterns has been to examine physicians' responses to brief written cases. We have compared this method with practice patterns of the same physicians derived from chart audit. Subjects were 98 family practice residents for whom data were available in actual patient encounters for the workup of asymptomatic hypertension. Short, carefully structured case reports using four cues were designed and a checklist similar to the one used for test ordering in practice was employed. Chart reviews and billing encounter forms were used for comparison. Results indicated residents ordered fewer tests in clinical practice, due, in part, to practice constraints not represented in the written cases. Physicians tend to make the diagnosis of hypertension incrementally in practice, with no one visit adequately representing the point of diagnosis. Studies based on data bases using a patient encounter as the unit of analysis in chronic disease such as hypertension may spuriously underestimate the actual number of tests ordered for the workup. Judgment cases may better reflect the patterns of use of information in a well-defined problem. Prediction of number of tests ordered in the clinical setting has not been established in this case.

Women's and physicians' utilities for health outcomes in estrogen replacement therapy.

Estrogen replacement therapy (ERT) prevents fractures and relieves vasomotor symptoms, but it increases the risk of endometrial cancer. Previous studies and national prescribing patterns show that physicians are conservative in their approach to this therapy. The authors interviewed physicians and perimenopausal women to assess their utilities for the various health outcomes of estrogen replacement therapy. On all outcomes, physicians rated illness episodes followed by recovery as being closer to perfect health than did perimenopausal women. Physicians, in judging which outcomes were most important to women, estimated relief of symptoms above fracture prevention, whereas women rated fracture prevention above symptom relief. These results emphasize the need to assess patients' utilities directly, particularly when utilities for the outcome of a particular therapy may influence the choice of a therapeutic regimen.

Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model.

Decisions regarding estrogen replacement therapy were obtained from 50 physicians for 12 cases representing menopausal women with systematically varying levels of cancer risk, fracture risk, and symptom severity. Their decisions were compared with a decision analytic model for which each physician provided needed quantities--subjective probabilities, utilities of various outcomes, and weightings of the importance of the outcome categories. The majority of observed decisions were not to treat. By contrast, the decision analysis based on physician-provided estimates indicated that the optimal strategy was either to treat or a toss-up. Sensitivity analysis showed that these conclusions would hold over all possible utilities, over all plausible probabilities of cancer, and so long as symptom relief and fracture prevention were also considered as treatment objectives. The increased probability of early detection of cancer by regular follow-up was systematically incorporated into the decision analysis but apparently neglected in unaided clinical judgment, which follows the principle of minimizing the most important risk, regardless of its probability.

Rationale for physicians' decisions to refer obese patients.

Health care costs are an increasing burden upon American society. Referral of patients to a specialist generates additional cost. We studied the reasons behind decisions to refer patients with uncomplicated obesity to endocrinologists. Obesity may be viewed as a paradigm of diseases with relatively well-known etiology, low morbidity and mortality, chronicity, and poor outcome from standard therapy. In addition, it is a disease that is rarely curable by medical intervention, requiring behavioral change. Physicians have little direct experience in the differential diagnosis of endocrine disease, because of its low prevalence. We studied the referral decisions of 45 physicians in three medical specialties. Clinical decision making was studied using a standard set of 24 carefully structured case reports of obese women, all without obvious endocrine disease cues on history or physical. In these cases the patients' desire to be seen by endocrinologists was the major factor in the decision to refer. Referrals were not made primarily to rule out suspected endocrine disorder or because of concern for increased risk of morbidity.

Physicians' judgments about estrogen replacement therapy for menopausal women.

A study was undertaken to determine how physicians decide when to prescribe estrogen. Twenty-five gynecologists and 25 family physicians responded to case histories and a questionnaire regarding estrogen administration. There was no difference in mean probability of prescribing, 0.42 for gynecologists and 0.40 for family physicians. Endometrial cancer risk and vasomotor symptom severity were significant factors in prescribing judgments; osteoporosis risk and current treatment status were not. In linear regression analysis the constant, not factor weights, were significantly related to each physician's overall likelihood of prescribing and to the individual's self-characterization as prescriber or nonprescriber. Most physicians indicated that estrogen reduces fracture risk, and that progestin reduces cancer risk. Physicians' responses to cases were not consistent with these stated beliefs about estrogen effects.

Differences in medical referral decisions for obesity among family practitioners, general internists, and gynecologists.

This study explored variation in the decisions of primary care physicians to refer or not to refer obese patients to an endocrinologist and the principles underlying their decisions. Forty-five physicians--family practitioners, obstetricians, and general internists--made referral judgments on 24 cases and completed a questionnaire. Data indicated a difference among specialties in the number of cases referred (P less than or equal to 0.01) that was not accounted for by physician characteristics. The number of cases referred ranged from 0 to 19, with a mean of 8. The patient's desire for treatment by an endocrinologist was overwhelmingly the major factor in decisions to refer. Gynecologists differed from other physicians by referring for management and not expecting the patient to return to their care. Referrals were not made primarily to rule out suspected endocrine disease or out of concern for morbidity due to obesity. These referrals are thus not perceived as medically beneficial, but are responses to patient pressure or physicians' desire to transfer management.

Diagnostic cues in gastroenterology.

Twenty seven gastroenterologists (15 physicians and 12 surgeons) were studied to capture their policy in the usage and weighting of cues in making a diagnosis. This was a relatively small sample and on account of possible sampling bias only tentative generalisations will be made. Five case vignettes, each consisting of four to eight cues, were used. Subjects were asked to give their percentage likelihood estimates of various diagnostic possibilities after each cue. This gave an indication of their perception of the significance of various cues in relationship to each diagnosis. There were marked variations in cue weighting by these experts, and in particular, most individuals were far off the mean regarding the weighting of certain clinical features, thus displaying idiosyncratic behaviour in these instances. As may be expected, there were differences in disease prevalence estimates between physicians and surgeons. Early information had an overwhelming effect on the final diagnosis. In most cases the expert relied on a few critical cues rather than on a pattern to make a diagnosis. In view of the strong influences of early diagnostic formulations, these findings confirm the need for doctors to learn to use and collect accurate factual information on prevalence rates and on the most significant critical cues for various disease processes. The study highlights some of the problems faced by novices in learning from experts who may teach them contradictory information about what are the most significant factors in coming to a diagnosis.

A chart audit study of the referral of obese patients to endocrinologists.

The aim of this study was to identify factors in primary care physicians' decisions to refer obese patients to an endocrine clinic. Charts of 83 referred obese patients were compared with randomly selected charts of 300 obese adults in the general ambulatory clinic files. The referral rate is estimated at 1% of obese patients in the clinical center and 0.25% of obese persons in the Lansing area. Referral of obese patients appears to depend primarily on degree of obesity and secondarily on suspicion of endocrine disease. Considerations limiting the usefulness of patient charts for studies of physicians' decision making are discussed.

Physicians' and patients' judgments of compliance with a hypertensive regimen.

This study examines an early decision point in the process of compliance. Thirty primary care physicians and thirty outpatients responded to a series of written scenarios. These scenarios systematically incorporated four factors thought to affect adherence to a hypertensive regimen--convenience, cost, severity, and support. Data were analyzed using multiple regression and multivariate analysis of variance. A mean R2 was obtained of 0.70 for physicians and 0.58 for patients. In making these judgments, physicians and patients placed similar emphasis on cost, convenience, and severity, but physicians placed greater emphasis on support. There was a significant difference between the judgments of physicians and patients (p less than 0.0001). Patients tended to be more optimistic than physicians regarding adherence and put more importance on severity of illness than on support. These findings are useful to the clinician concerned with compliance and demonstrate the potential of this paradigm for research in clinical reasoning.

A preclinical course in decision making.

An existing multidisciplinary sequence in the preclinical curriculum of the College of Human Medicine at Michigan State University has been revised to include emphasis on psychological principles of clinical reasoning, decision analysis, ethical issues, and health economics. The course is a four-term sequence taught in the first and second years. In each term, the course consists of a one-hour lecture and two hours of group discussion weekly. The focus of the discussions is a series of carefully constructed paper-and-pencil cases that are graded in difficulty and coordinated with concurrent or previous biological science courses. Examinations have been developed based on written cases and using multiple choice, true-false, and short essay questions. The course is aimed at bringing about fundamental change in the new physicians' conceptions of value and benefit, the way uncertainty is managed, and the traditional belief that data and information are identical.