Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF): A Trial Providing Out-of-Pocket Costs for Heart Failure Medications during Clinical Encounters

BACKGROUND

Evidence-based medical therapy for heart failure with reduced ejection fraction (HFrEF) often entails substantial out-of-pocket costs that can vary appreciably between patients. This has raised concerns regarding financial toxicity, equity, and adherence to medical therapy. In spite of these concerns, cost discussions in the HFrEF population appear to be rare, partly because out-of-pocket costs are generally unavailable during clinical encounters. In this trial, out-of-pocket cost information is given to patients and clinicians during outpatient encounters with the aim to assess the impact of providing this information on medication discussions and decisions.

HYPOTHESIS

Cost-informed decision-making will be facilitated by providing access to patient-specific out-of-pocket cost estimates at the time of clinical encounter.

DESIGN

Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF) is a multicenter trial based at Emory Healthcare and University of Colorado Health. Adapting an existing patient activation tool from the EPIC-HF trial, patients and clinicians are presented a checklist with medications approved for treatment of HFrEF with or without patient-specific out-of-pocket costs (obtained from a financial navigation firm). Clinical encounters are audio-recorded, and patients are surveyed about their experience. The trial utilizes a stepped-wedge cluster randomized design, allowing for each site to enroll control and intervention group patients while minimizing contamination of the control arm.

DISCUSSION

This trial will elucidate the potential impact of robust cost disclosure efforts and key information regarding patient and clinician perspectives related to cost and cost communication. It also will reveal important challenges associated with providing out-of-pocket costs for medications during clinical encounters. Acquiring medication costs for this trial requires an involved process and outsourcing of work. In addition, costs may change throughout the year, raising questions regarding what specific information is most valuable. These data will represent an important step towards understanding the role of integrating cost discussions into heart failure care.

CLINICALTRIALS

GOV IDENTIFIER

NCT04793880.

Workplace Harassment, Cyber Incivility, and Climate in Academic Medicine

Importance

The culture of academic medicine may foster mistreatment that disproportionately affects individuals who have been marginalized within a given society (minoritized groups) and compromises workforce vitality. Existing research has been limited by a lack of comprehensive, validated measures, low response rates, and narrow samples as well as comparisons limited to the binary gender categories of male or female assigned at birth (cisgender).

Objective

To evaluate academic medical culture, faculty mental health, and their relationship.

Design, Setting, and Participants

A total of 830 faculty members in the US received National Institutes of Health career development awards from 2006-2009, remained in academia, and responded to a 2021 survey that had a response rate of 64%. Experiences were compared by gender, race and ethnicity (using the categories of Asian, underrepresented in medicine [defined as race and ethnicity other than Asian or non-Hispanic White], and White), and lesbian, gay, bisexual, transgender, queer (LGBTQ+) status. Multivariable models were used to explore associations between experiences of culture (climate, sexual harassment, and cyber incivility) with mental health.

Exposures

Minoritized identity based on gender, race and ethnicity, and LGBTQ+ status.

Main Outcomes and Measures

Three aspects of culture were measured as the primary outcomes: organizational climate, sexual harassment, and cyber incivility using previously developed instruments. The 5-item Mental Health Inventory (scored from 0 to 100 points with higher values indicating better mental health) was used to evaluate the secondary outcome of mental health.

Results

Of the 830 faculty members, there were 422 men, 385 women, 2 in nonbinary gender category, and 21 who did not identify gender; there were 169 Asian respondents, 66 respondents underrepresented in medicine, 572 White respondents, and 23 respondents who did not report their race and ethnicity; and there were 774 respondents who identified as cisgender and heterosexual, 31 as having LGBTQ+ status, and 25 who did not identify status. Women rated general climate (5-point scale) more negatively than men (mean, 3.68 [95% CI, 3.59-3.77] vs 3.96 [95% CI, 3.88-4.04], respectively, P < .001). Diversity climate ratings differed significantly by gender (mean, 3.72 [95% CI, 3.64-3.80] for women vs 4.16 [95% CI, 4.09-4.23] for men, P < .001) and by race and ethnicity (mean, 4.0 [95% CI, 3.88-4.12] for Asian respondents, 3.71 [95% CI, 3.50-3.92] for respondents underrepresented in medicine, and 3.96 [95% CI, 3.90-4.02] for White respondents, P = .04). Women were more likely than men to report experiencing gender harassment (sexist remarks and crude behaviors) (71.9% [95% CI, 67.1%-76.4%] vs 44.9% [95% CI, 40.1%-49.8%], respectively, P < .001). Respondents with LGBTQ+ status were more likely to report experiencing sexual harassment than cisgender and heterosexual respondents when using social media professionally (13.3% [95% CI, 1.7%-40.5%] vs 2.5% [95% CI, 1.2%-4.6%], respectively, P = .01). Each of the 3 aspects of culture and gender were significantly associated with the secondary outcome of mental health in the multivariable analysis.

Conclusions and Relevance

High rates of sexual harassment, cyber incivility, and negative organizational climate exist in academic medicine, disproportionately affecting minoritized groups and affecting mental health. Ongoing efforts to transform culture are necessary.

Modifying an Open Science Online Grocery for parents of youth with anorexia nervosa: A proof-of-concept study

OBJECTIVE

For youth with anorexia nervosa (AN), remission requires high caloric goals to achieve weight restoration, consumption of a wide variety of calorically dense foods, and reintroduction of eliminated foods. Family-based treatment (FBT), the gold-standard treatment for youth with AN, empowers parents to renourish their child and restore them to health; yet, parents often report struggling with shifting meal planning and grocery shopping behaviors to focus on nutritional rehabilitation and weight restoration.

METHODS

This proof-of-concept study aimed to modify a simulated grocery store (Open Science Online Grocery [OSOG]) for parents of youth with AN and explore the acceptability and feasibility of its use as part of standard care. Study staff collaborated with six parent research partners to modify the OSOG prior to piloting it with participants. Participants were 10 parents of youth undergoing a first-time hospitalization for medical stabilization of AN or atypical AN. Parents completed a battery of measures and a semistructured interview assessing the acceptability and feasibility of OSOG.

RESULTS

Parents described the tool as credible and acceptable. Qualitative feedback highlighted common themes of caregiver burden, nutrition education, and acceptability of the tool.

DISCUSSION

Results point to the need for more work in supporting parents in Phase I of FBT.

PUBLIC SIGNIFICANCE

Families are instrumental in supporting youth to recover from anorexia nervosa. During treatment, parents are charged with selecting and serving their adolescent's meals, often requiring them to change grocery shopping and food preparation habits to meet their child's high caloric needs. Parents reported feeling overwhelmed by this task and noted struggling with learning different approaches to nourish their adolescent during an already stressful time. Collaboratively with parents, we modified a tool to support parents in shifting thier shopping habits, which they reported as being a helpful springboard in the early phase of treatment.

Impact of Financial Considerations on Willingness to Take Sacubitril/Valsartan for Heart Failure

Background Sacubitril/valsartan improves health outcomes for heart failure with reduced ejection fraction relative to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, but it carries higher out-of-pocket costs. Neither the impact of cost nor how to integrate cost into medical decisions is well studied. Methods and Results To evaluate the impact of out-of-pocket costs and a novel cost-priming intervention on willingness to take sacubitril/valsartan for heart failure with reduced ejection fraction, participants with self-reported heart disease were surveyed using the online Ipsos Knowledge Panel. Participants were presented with a modified decision aid for sacubitril/valsartan and then, in a 3×2 factorial design, randomly assigned to 1 of 3 cost conditions ($10, $50, or $100/month) and to a control group or cost-priming intervention, defined by being asked questions about their financial situation before learning about the benefits of sacubitril/valsartan. Of the 1013 participants included in the analysis, 85% of respondents were willing to take sacubitril/valsartan at $10, 62% at $50, and 33% at $100 (P<0.0001). In a multivariable logistic regression model, participants were more likely to take sacubitril/valsartan at $10 versus $100 (odds ratio [OR], 14.3 [95% CI, 9.4-21.8]) and $50 compared with $100 (OR, 3.6 [95% CI, 2.5-5.1]). Overall, participants in the cost-primed group were more willing to take sacubitril/valsartan than those not primed to consider their financial situation (63% versus 56%, P=0.04). There was no statistically significant interaction between cost conditions and cost priming. Perceived benefit of sacubitril/valsartan over angiotensin-converting enzyme inhibitors or angiotensin receptor blockers decreased as cost increased but did not vary by cost priming. Conclusions Commonly encountered out-of-pocket costs of sacubitril/valsartan may impact individuals' willingness to take the medication even when recommended by their physicians. Priming individuals to consider personal finances before learning about the drug increased willingness to take sacubitril/valsartan.

Abstract PO-045: Experiences of oncologists treating cancer patients living with HIV: Opportunities to improve care and reduce disparities

Introduction: Prior database studies have demonstrated that cancer patients with comorbid human immunodeficiency virus (HIV) have higher cancer-specific mortality and are less likely to receive cancer treatment. People living with HIV (PLWH) who achieve viral suppression have near normal life expectancy, highlighting the critical importance of reducing cancer treatment disparities. The purpose of this study is to understand how oncologists make treatment decisions for cancer patients living with HIV and to elicit recommendations for improving care in this population. Methods: We conducted in-depth interviews with 25 attending medical, radiation, and surgical oncologists from Duke University, University of Utah, and community practices in Florida, Georgia, Louisiana, Pennsylvania, and Virginia who had recently engaged in a consultation with PLWH and cancer. In semi-structured interviews, we explored three domains: (1) care coordination with other healthcare professionals, (2) knowledge and attitudes regarding patients with comorbid HIV and cancer, and (3) recommendations for improvements in care delivery. Two analysts coded the data using ATLAS.ti. We utilized applied thematic analysis to identify inductive themes across the three domains. Results: Many participants (n=11) reported always communicating with a patient's Infectious Disease (ID) doctor, and others (n=5) said they only communicate with ID if the patient's HIV is not well-controlled. Ten medical oncologists noted they found it helpful to speak to an HIV pharmacist, particularly about drug-drug interactions. Participants also discussed efforts to connect patients with supportive services, such as transportation, payment assistance, and mental health counseling. Many participants described concerns in discussing the patient care plan in the presence of caregivers, given the possibility that patients have not disclosed their HIV status. None of the participants had formal training in management of comorbid cancer and HIV, and most noted that they learned through their own clinical practice. Participants made suggestions for improving treatment decision-making for PLWH, including: more evidence of the risk-benefit ratio of treatment (e.g. treatment goals, life expectancy calculators), greater access to social work and mental health resources, streamlined access to communication with HIV providers, and multidisciplinary HIV cancer rounds. Conclusions: This is the first physician-focused qualitative study interviewing oncologists caring for PLWH. Communication among multiple healthcare providers, particularly oncologist and ID doctor, are noted to be common but not universal in the care of comorbid HIV and cancer. Formal training in cancers in PLWH is lacking in medical training. Future steps to reduce disparities in cancer treatment and outcomes for PLWH may include the establishment of multidisciplinary HIV cancer rounds, facilitating connection and communication between healthcare providers, and enhancing supportive care resources for patients.

Citation Format: Ashley Khouri, Jeanette Young, Patrick Galyean, Brandon Knettel, Emily M. Cherenack, Anthony Ariotti, Noelani Ho, Susan Zickmund, Melissa Watt, Kathryn Pollak, Peter Ubel, Angela Fagerlin, Gita Suneja. Experiences of oncologists treating cancer patients living with HIV: Opportunities to improve care and reduce disparities [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-045.

Preparing Patients with Early Stage Prostate Cancer to Participate in Clinical Appointments Using a Shared Decision Making Training Video

Background

Rates of shared decision making (SDM) are relatively low in early stage prostate cancer decisions, as patients’ values are not well integrated into a preference-sensitive treatment decision. The study objectives were to develop a SDM training video, measure usability and satisfaction, and determine the effect of the intervention on preparing patients to participate in clinical appointments.

Methods

A randomized controlled trial was conducted to compare a plain-language decision aid (DA) to the DA plus a patient SDM training video. Patients with early stage prostate cancer completed survey measures at baseline and after reviewing the intervention materials. Survey items assessed patients’ knowledge, beliefs related to SDM, and perceived readiness/intention to participate in their upcoming clinical appointment.

Results

Of those randomized to the DA + SDM video group, most participants (91%) watched the video and 93% would recommend the video to others. Participants in the DA + SDM video group, compared to the DA-only group, reported an increased desire to participate in the decision (mean = 3.65 v. 3.39, P < 0.001), less decision urgency (mean = 2.82 v. 3.39, P < 0.001), and improved self-efficacy for communicating with physicians (mean = 4.69 v. 4.50, P = 0.05). These participants also reported increased intentions to seek a referral from a radiation oncologist (73% v. 51%, P = 0.004), to take notes (mean = 3.23 v. 2.86, P = 0.004), and to record their upcoming appointments (mean = 1.79 v. 1.43, P = 0.008).

Conclusions

A novel SDM training video was accepted by patients and changed several measures associated with SDM. This may be a scalable, cost-effective way to prepare patients with early stage prostate cancer to participate in their clinical appointments.

Clinical Trial Protocol for a Randomized Trial of Community Health Worker-led Decision Coaching to Promote Shared Decision-making on Prostate Cancer Screening Among Black Male Patients and Their Providers

We propose a randomized controlled trial to evaluate the effectiveness of a community health worker-led decision-coaching program to facilitate shared decision-making for prostate cancer screening decisions by Black men at a primary care federally qualified health center.

Strategies for research participant engagement: A synthetic review and conceptual framework

BACKGROUND

Research participant engagement, which we define as recruitment and retention in clinical trials, is a costly and challenging issue in clinical research. Research teams have leveraged a variety of strategies to increase research participant engagement in clinical trials, although a framework and evidence for effective participant engagement strategies are lacking. We (1) developed a novel conceptual framework for strategies used to recruit and retain participants in clinical trials based on their underlying behavioral principles and (2) categorized empirically tested recruitment and retention strategies in this novel framework.

METHODS

We conducted a synthetic analysis of interventions tested in studies from two Cochrane reviews on clinical trial recruitment and retention, which included studies from 1986 to 2015. We developed a conceptual framework of behavioral strategies for increasing research participant engagement using deductive and inductive approaches with the studies included in the Cochrane reviews. Reviewed interventions were then categorized using this framework. We examined the results of reviewed interventions and categorized the effects on clinical trial recruitment and retention as significantly positive, null, or significantly negative; summary statistics are presented for the frequency and effects of each behavioral strategy type.

RESULTS

We analyzed 141 unique interventions across 96 studies: 91 interventions targeted clinical trial research participant recruitment and 50 targeted retention. Our framework included 14 behavioral strategies to improve research participant engagement grouped into four general approaches: changing attitudes by appealing to social motivators, changing attitudes by targeting individual psychology, reducing barriers and cognitive burdens, and providing incentives. The majority of interventions (54%) aimed to reduce barriers or cognitive burdens, with improving comprehension (27%) as the most common specific strategy identified. For recruitment, the most common behavioral strategies tested were building legitimacy or trust (38%) and framing risks and benefits (32%), while financial or material incentives (32%) and reducing financial, time, and social barriers (32%) were most common for retention interventions. Among interventions tested in randomized controlled trials, 51% had a null effect on research participant engagement, and 30% had a statistically significant positive effect.

DISCUSSION

Clinical researchers have tested a wide range of interventions that leverage distinct behavioral strategies to achieve improved research participant recruitment and retention. Common behavioral strategies include building legitimacy or trust between research teams and participants, as well as improving participant comprehension of trial objectives and procedures. The high frequency of null effects among tested interventions suggests challenges in selecting the optimal interventions for increasing research participant engagement, although the proposed behavioral strategy categories can serve as a conceptual framework for developing and testing future interventions.

Randomized trial of community health worker-led decision coaching to promote shared decision-making for prostate cancer screening among Black male patients and their providers

BACKGROUND

Black men are disproportionately affected by prostate cancer, the most common non-cutaneous malignancy among men in the USA. The United States Preventive Services Task Force (USPSTF) encourages prostate-specific antigen (PSA) testing decisions to be based on shared decision-making (SDM) clinician professional judgment, and patient preferences. However, evidence suggests that SDM is underutilized in clinical practice, especially among the most vulnerable patients. The purpose of this study is to evaluate the efficacy of a community health worker (CHW)-led decision-coaching program to facilitate SDM for prostate cancer screening among Black men in the primary care setting, with the ultimate aim of improving/optimizing decision quality.

METHODS

We proposed a CHW-led decision-coaching program to facilitate SDM for prostate cancer screening discussions in Black men at a primary care FQHC. This study enrolled Black men who were patients at the participating clinical site and up to 15 providers who cared for them. We estimated to recruit 228 participants, ages 40-69 to be randomized to either (1) a decision aid along with decision coaching on PSA screening from a CHW or (2) receiving a decision aid along with CHW-led interaction on modifying dietary and lifestyle to serve as an attention control. The independent randomization process was implemented within each provider and we controlled for age by dividing patients into two strata: 40-54 years and 55-69 years. This sample size sufficiently powered the detection differences in the primary study outcomes: knowledge, indicative of decision quality, and differences in PSA screening rates. Primary outcome measures for patients will be decision quality and decision regarding whether to undergo PSA screening. Primary outcome measures for providers will be acceptability and feasibility of the intervention. We will examine how decision coaching about prostate cancer screening impact patient-provider communication. These outcomes will be analyzed quantitatively through objective, validated scales and qualitatively through semi-structured, in-depth interviews, and thematic analysis of clinical encounters. Through a conceptual model combining elements of the Preventative Health Care Model (PHM) and Informed Decision-Making Model, we hypothesize that the prostate cancer screening decision coaching intervention will result in a preference-congruent decision and decisional satisfaction. We also hypothesize that this intervention will improve physician satisfaction with counseling patients about prostate cancer screening.

DISCUSSION

Decision coaching is an evidence-based approach to improve decision quality in many clinical contexts, but its efficacy is incompletely explored for PSA screening among Black men in primary care. Our proposal to evaluate a CHW-led decision-coaching program for PSA screening has high potential for scalability and public health impact. Our results will determine the efficacy, cost-effectiveness, and sustainability of a CHW intervention in a community clinic setting in order to inform subsequent widespread dissemination, a critical research area highlighted by USPSTF.

TRIAL REGISTRATION

The trial was registered prospectively with the National Institute of Health registry ( www.clinicaltrials.gov ), registration number NCT03726320 , on October 31, 2018.

HIV, cancer, and coping: The cumulative burden of a cancer diagnosis among people living with HIV

OBJECTIVES

People living with HIV (PLWH) have increased risk for cancer and worse cancer-specific survival. We explored the emotional burden of cancer and HIV as a potential driver of cancer mortality.

RESEARCH APPROACH

Semi-structured qualitative interviews with PLWH and cancer.

PARTICIPANTS

27 PLWH who had either completed cancer treatment, were currently undergoing treatment, or experienced challenges in completing treatment.

METHODOLOGICAL APPROACH

An inductive qualitative approach using the constant comparative method.

FINDINGS

Participants drew strong parallels between being diagnosed with HIV and cancer. Many described HIV-related stigma that hindered social support. Cancer treatment side effects were a major challenge, impacting treatment adherence for both cancer and HIV.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

There is a need for convenient, affordable, and visible services to support PLHIV as they navigate cancer care. Services should be tailored to the unique needs of this population by addressing HIV-related stigma, building social support, and fostering resilience.

Patient-oncologist cost communication, financial distress, and medication adherence

BACKGROUND

Little is known about the association between patient-oncologist discussion of cancer treatment out-of-pocket (OOP) cost and medication adherence, a critical component of quality cancer care.

METHODS

We surveyed insured adults receiving anticancer therapy. Patients were asked if they had discussed OOP cost with their oncologist. Medication nonadherence was defined as skipping doses or taking less medication than prescribed to make prescriptions last longer, or not filling prescriptions because of cost. Multivariable analysis assessed the association between nonadherence and cost discussions.

RESULTS

Among 300 respondents (86% response), 16% (n = 49) reported high or overwhelming financial distress. Nineteen percent (n = 56) reported talking to their oncologist about cost. Twenty-seven percent (n = 77) reported medication nonadherence. To make a prescription last longer, 14% (n = 42) skipped medication doses, and 11% (n = 33) took less medication than prescribed; 22% (n = 66) did not fill a prescription because of cost. Five percent (n = 14) reported chemotherapy nonadherence. To make a prescription last longer, 1% (n = 3) skipped chemotherapy doses, and 2% (n = 5) took less chemotherapy; 3% (n = 10) did not fill a chemotherapy prescription because of cost. In adjusted analyses, cost discussion (odds ratio [OR] = 2.58; 95% CI, 1.14 to 5.85; P = .02), financial distress (OR = 1.64, 95% CI, 1.38 to 1.96; P < .001) and higher financial burden than expected (OR = 2.89; 95% CI, 1.41 to 5.89; P < .01) were associated with increased odds of nonadherence.

CONCLUSION

Patient-oncologist cost communication and financial distress were associated with medication nonadherence, suggesting that cost discussions are important for patients forced to make cost-related behavior alterations. Future research should examine the timing, content, and quality of cost-discussions.

Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers

BACKGROUND

Female physician-researchers do not achieve career success at the same rate as men. Differences in nonprofessional responsibilities may partially explain this gap.

OBJECTIVE

To investigate the division of domestic labor by gender in a motivated group of early-career physician-researchers.

DESIGN

Nationwide postal survey between 2010 and 2011.

SETTING

United States.

PARTICIPANTS

Physician recipients of National Institutes of Health K08 or K23 awards between 2006 and 2009 with active academic affiliation at the time of the survey.

MEASUREMENTS

Time spent on parenting and domestic tasks was determined through self-report. Among married or partnered respondents with children, a linear regression model of time spent on domestic activities was constructed considering age, gender, race, specialty, MD or MD/PhD status, age of youngest child, number of children, work hours, K award type, and spousal employment.

RESULTS

A 74% response rate was achieved, and 1049 respondents were academic physicians. Women were more likely than men to have spouses or domestic partners who were employed full-time (85.6% [95% CI, 82.7% to 89.2%] vs. 44.9% [CI, 40.8% to 49.8%]). Among married or partnered respondents with children, after adjustment for work hours, spousal employment, and other factors, women spent 8.5 more hours per week on domestic activities. In the subgroup with spouses or domestic partners who were employed full-time, women were more likely to take time off during disruptions of usual child care arrangements than men (42.6% [CI, 36.6% to 49.0%] vs. 12.4% [CI, 5.4% to 19.5%]).

LIMITATIONS

Analyses relied on self-reported data. The study design did not enable investigation of the relationship between domestic activities and professional success.

CONCLUSION

In this sample of career-oriented professionals, gender differences in domestic activities existed among those with children. Most men's spouses or domestic partners were not employed full-time, which contrasted sharply with the experiences of women.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Does comparative effectiveness research promote rationing of cancer care?

Comparative effectiveness research aims to inform health-care decisions by patients, clinicians, and policy makers. However, questions related to what information is relevant, and how to view the relative attributes of alternative interventions have political, social, and medical considerations. In particular, questions about whether cost is a relevant factor, and whether cost-effectiveness is a desirable or necessary component of such research, have become increasingly controversial as the area has gained prominence. Debate has emerged about whether comparative effectiveness research promotes rationing of cancer care. At the heart of this debate are questions related to the role and limits of patient autonomy, physician discretion in health-care decision making, and the nature of scientific knowledge as an objective good. In this article, we examine the role of comparative effectiveness research in the USA, UK, Canada, and other health-care systems, and the relation between research and policy. As we show, all health systems struggle to balance access to cancer care and control of costs; comparative effectiveness data can clarify choices, but does not itself determine policy or promote rationing of care.

Sex, role models, and specialty choices among graduates of US medical schools in 2006-2008

BACKGROUND

Undergraduate education studies have suggested instructor sex can influence female students to pursue a discipline. We sought to evaluate a similar hypothesis in medical students.

STUDY DESIGN

We obtained Association of American Medical Colleges (AAMC) data about the specialization of 2006-2008 graduates of US medical schools, the sex of their faculty and department chairs, and sex of residents in the residency programs in which they enrolled. We used logistic regression to examine associations between faculty and leadership sex and female students' pursuit of 5 surgical specialties along with 3 nonsurgical specialties for context. We used Wilcoxon rank-sum tests to evaluate whether women entered residency programs with a higher proportion of female residents.

RESULTS

In 2006-2008, US medical school graduates included 23,642 women. Women were substantially under-represented among residents in neurosurgery, orthopaedics, urology, otolaryngology, general surgery, and radiology; women constituted 47.4% of US graduates specializing in internal medicine and 74.9% in pediatrics. We found no significant associations between exposure to a female department chair and selection of that specialty and no consistent associations with the proportion of female full-time faculty. Compared with male students, female students entered residency programs in their chosen specialty that had significantly higher proportions of women residents in the year before their graduation.

CONCLUSIONS

Although we did not detect consistent significant associations between exposure to potential female faculty role models and specialty choice, we observed that female students were more likely than males to enter programs with higher proportions of female residents. Sex differences in students' specialization decisions merit additional investigation.

How bad is depression? Preference score estimates from depressed patients and the general population

OBJECTIVE

To compare depression health state preference scores across four groups: (1) general population, (2) previous history of depression but not currently depressed, (3) less severe current depression, and (4) more severe current depression.

DATA SOURCES

Primary data were collected from 95 general population, 163 primary care, and 83 specialty mental health subjects.

STUDY DESIGN

Stratified sampling frames were used to recruit general population and patient subjects. Subjects completed cross-sectional surveys. Key variables included rating scale and standard gamble scores assigned to depression health state descriptions developed from the Patient Health Questionnaire-9 (PHQ-9) and SF-12.

DATA COLLECTION/EXTRACTION METHODS

Each subject completed an in-person interview. Forty-nine subjects completed test/retest reliability interviews.

PRINCIPAL FINDINGS

Depressed patient preference scores for three of six SF-12 depression health states were significantly lower than the general population using the rating scale and two of six were significantly lower using standard gamble. Depressed patient scores for five of six PHQ-9 depression health states were significantly lower than the general population using the rating scale and two of six were significantly lower using standard gamble.

CONCLUSIONS

Depressed patients report lower preference scores for depression health states than the general population. In effect, they perceived depression to be worse than the general public perceived it to be. Additional research is needed to examine the implications for cost-effectiveness ratios using general population preference scores versus depressed patient preference scores.

The impact of the format of graphical presentation on health-related knowledge and treatment choices

OBJECTIVE

To evaluate the ability of six graph formats to impart knowledge about treatment risks/benefits to low and high numeracy individuals.

METHODS

Participants were randomized to receive numerical information about the risks and benefits of a hypothetical medical treatment in one of six graph formats. Each described the benefits of taking one of two drugs, as well as the risks of experiencing side effects. Main outcome variables were verbatim (specific numerical) and gist (general impression) knowledge. Participants were also asked to rate their perceptions of the graphical format and to choose a treatment.

RESULTS

2412 participants completed the survey. Viewing a pictograph was associated with adequate levels of both types of knowledge, especially for lower numeracy individuals. Viewing tables was associated with a higher likelihood of having adequate verbatim knowledge vs. other formats (p<0.001) but lower likelihood of having adequate gist knowledge (p<0.05). All formats were positively received, but pictograph was trusted by both high and low numeracy respondents. Verbatim and gist knowledge were significantly (p<0.01) associated with making a medically superior treatment choice.

CONCLUSION

Pictographs are the best format for communicating probabilistic information to patients in shared decision making environments, particularly among lower numeracy individuals.

PRACTICE IMPLICATIONS

Providers can consider using pictographs to communicate risk and benefit information to patients of different numeracy levels.

Screening experiments and the use of fractional factorial designs in behavioral intervention research

Health behavior intervention studies have focused primarily on comparing new programs and existing programs via randomized controlled trials. However, numbers of possible components (factors) are increasing dramatically as a result of developments in science and technology (e.g., Web-based surveys). These changes dictate the need for alternative methods that can screen and quickly identify a large set of potentially important treatment components. We have developed and implemented a multiphase experimentation strategy for accomplishing this goal. We describe the screening phase of this strategy and the use of fractional factorial designs (FFDs) in studying several components economically. We then use 2 ongoing behavioral intervention projects to illustrate the usefulness of FFDs. FFDs should be supplemented with follow-up experiments in the refining phase so any critical assumptions about interactions can be verified.

Assessing the economic challenges posed by orphan drugs

Historically, patients with rare diseases have been underserved by commercial drug development. In several jurisdictions, specific legislation has been enacted to encourage the development of drugs for rare diseases (orphan drugs), which would otherwise not be commercially viable. However, because of the small market, these drugs are often very expensive. Under the standard methods of health technology assessment (HTA) incorporating economic evaluation, orphan drugs do not usually prove to be cost-effective and this, coupled with their high cost, means that funding and patient access may be limited. However, these restrictions may not be in line with societal preferences. Therefore, this study discusses whether the standard methods of HTA are adequate for assisting decisions on patient access to and funding of orphan drugs and outlines a research agenda to help understand the societal value of orphan drugs and issues surrounding their development, funding, and use.

Medical study: aspiring parents, genotypes and phenotypes: the unexamined myth of the perfect baby

Although many have argued that assisted reproductive technologies ("ARTs") attract those with a desire to genetically engineer their offspring, this claim has yet to be verified. To address this question, we surveyed three groups: the general public, people enrolling in an in vitro fertilization ("IVF") program, and pregnant couples. We asked subject which traits they would select in their children if it were possible to use a magic wand to do so and to value genetic relatedness. In our sample, the potential parents who were using ARTs were less likely to express a desire to select traits in their offspring than were the general public, and just as likely as the pregnant couples, Those using ARTs , however, place greater importance on having genetically related children than the others. Thus, the widely held view that reproductive technology is utilized by those most likely to favor genetic engineering is falsified by out findings.

RACIAL/ETHNIC DISPARITIES IN THE TREATMENT OF LOCALIZED/REGIONAL PROSTATE CANCER

PURPOSE

Racial/ethnic disparities in the utilization of definitive therapy for prostate cancer are well recognized in the United States. The effect of race on the use of contemporary definitive therapies, including brachytherapy, and the assessment of Hispanic men with regard to racial/ethnic disparity has not been fully characterized.

MATERIALS AND METHODS

We evaluated treatment patterns using Surveillance, Epidemiology and End Results registry data on 142340 localized/regional stage cases between 1992 and 1999 in white, black and Hispanic American men. Definitive therapy was defined as radical prostatectomy, external beam radiation, brachytherapy or combinations thereof. Logistic regression models were constructed to determine the odds of receiving definitive treatment, adjusting for age, marital status, tumor grade, and Surveillance, Epidemiology and End Results site.

RESULTS

Black and Hispanic men were less likely to receive definitive therapy than white men (p <0.001). Higher tumor grade was associated with decreasing odds of definitive therapy for black and Hispanic men (p <0.001) compared to white men. The racial/ethnic disparities in the use of definitive therapy decreased between 1992 and 1999 with the greatest decrease in Hispanic men.

CONCLUSIONS

Hispanic and black men were less likely than white men to receive definitive therapy. The disparity in the use of definitive therapy between 1992 and 1999 decreased significantly in Hispanic men, although a significant disparity in the use of definitive therapy persisted in black men. Our observation of an association between tumor grade and the racial/ethnic disparity in definitive therapy ties together relevant biological and social factors that may contribute to the observed racial/ethnic disparity in mortality.

Incorporating societal concerns for fairness in numerical valuations of health programmes

The paper addresses some limitations of the QALY approach and outlines a valuation procedure that may overcome these limitations. In particular, we focus on the following issues: the distinction between assessing individual utility and assessing societal value of health care; the need to incorporate concerns for severity of illness as an independent factor in a numerical model of societal valuations of health outcomes; similarly, the need to incorporate reluctance to discriminate against patients that happen to have lesser potentials for health than others; and finally, the need to combine measurements of health-related quality of life obtained from actual patients (or former patients) with measurements of distributive preferences in the general population when estimating societal value. We show how equity weights may serve to incorporate concerns for severity and potentials for health in QALY calculations. We also suggest that for chronically ill or disabled people a life year gained should count as one and no less than one as long as the year is considered preferable to being dead by the person concerned. We call our approach 'cost-value analysis'.