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Waidyaratne G, Steinbrook E, Roy S, Opoku A, Jaffe K, Goold SD. Trust and distrust in low-income Michigan residents during the early COVID-19 pandemic: A qualitative study. Health Expect 2023; 26:2245-2251. [PMID: 37452517 PMCID: PMC10632642 DOI: 10.1111/hex.13826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/07/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Trust and distrust have shaped health behaviour during the COVID-19 pandemic. Since the start of the pandemic, misinformation and polarization eroded trust across the United States. In states like Michigan, pandemic restrictions led to significant unrest. Michiganders also faced disproportionate morbidity and mortality from COVID-19 during this period. OBJECTIVE The objective of this qualitative study was to understand the individual experiences of trust in low-income Michiganders during the early COVID-19 pandemic. PARTICIPANTS Twenty-four participants at or below 200% of the federal poverty line who resided in Michigan were recruited for this study. APPROACH Interviews were conducted during the winter of 2020 using a formal interview guide that addressed sources of information, perceptions of risk and exposure, protective behaviours and impacts of the pandemic at home, work and in receiving healthcare. RESULTS Thematic analysis showed that themes of trust and distrust emerged in multiple facets of our participants' experiences, including in the context of information sources, the behaviours of others, health, financial security, employment and overall safety. Trust and distrust in low-income communities often stemmed from significant financial and economic vulnerabilities and instability in access to healthcare that was exacerbated in the pandemic. Furthermore, participant trust was shaped by internal (e.g., relationships with others) and external (e.g., source of information, social inequity) factors that influenced their perceptions and experiences during the pandemic. CONCLUSION Trust has played an important role in many aspects of the experiences of low-income communities during the COVID-19 pandemic. This is important for clinicians to consider as COVID-19 becomes endemic, and trust continues to impact patients' approaches to vaccines, testing and treatment options. PATIENT OR PUBLIC CONTRIBUTION This study was designed and conducted with the assistance and input of the members of the DECIDERS Steering Committee, a diverse statewide network of community members in Michigan. The DECIDERS team allows community members to have a voice in the design and conduct of health research, and collaborates with researchers to improve health across the state of Michigan.
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Affiliation(s)
- Gavisha Waidyaratne
- Department of Internal MedicineOhio State University Wexner Medical CenterColumbusOhioUSA
| | | | - Shalini Roy
- University of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Annabella Opoku
- Department of Community Medicine and Population Health, College of Community Health SciencesUniversity of AlabamaTuscaloosaAlabamaUSA
| | - Kaitlyn Jaffe
- Center for Bioethics and Social Sciences in MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Susan Dorr Goold
- Center for Bioethics and Social Sciences in Medicine and Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of Health Management and Policy, School of Public HealthUniversity of MichiganAnn ArborMichiganUSA
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Platt J, Goold SD. Betraying, Earning, or Justifying Trust in Health Organizations. Hastings Cent Rep 2023; 53 Suppl 2:S53-S59. [PMID: 37963048 DOI: 10.1002/hast.1524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Health care and public health programs increasingly rely on, and often even require, organizational action, which is facilitated, if not dependent on, trust. Case examples in this essay highlight trust, trustworthiness, and distrust in public and private organizations, providing insights into how trust in health-related organizations can be betrayed, earned, and justified and into the consequences of organizational trust and trustworthiness for the health of individuals and communities. These examples demonstrate the need for holistic assessments of trust in clinicians and trust in organizations and for organizations, public health, and the medical profession to address questions concerning their own trustworthiness. Normative and empirical assessments of trust and trustworthiness that capture the experiences of those treated within the walls of a health care organization, as well as the care of those outside, will contribute to more trustworthy systems of care.
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Perumalswami CR, Chen E, Martin C, Goold SD, De Vries RG, Griggs JJ, Jagsi R. ‘I’m being forced to make decisions I have never had to make before’: Oncologists and the conundrums created by COVID-19. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.12001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12001 Background: The COVID-19 pandemic has created conundrums for physicians. This study examines the experiences of oncologists who engage in complex decision-making regarding the use of chemotherapy in seriously ill persons in the context of the COVID-19 pandemic. Methods: Between January 2020 and August 2020, the authors conducted semi-structured, in-depth individual interviews with 22 purposefully sampled oncologists from practices enrolled in the Michigan Oncology Quality Consortium. Transcripts were double-coded and reconciled by consensus using qualitative data analysis software for thematic analysis. Results: Among the thematic clusters we identified, one was related to conundrums created by the COVID-19 pandemic. In this presentation, we report the results pertaining to three themes within this cluster: (1) the ethical dilemmas faced by oncologists due to the COVID-19 pandemic, (2) the need for both patients and oncologists to manage uncertainty and emotions, and (3) the importance and complexity of integrating technology and communication for seriously ill persons. Oncologists grappled with several conundrums including resource scarcity, resource allocation, delays in care, a duty to promote equity and non-abandonment, high levels of uncertainty and fear, and the importance of advanced care directives and end-of-life care planning. Non-abandonment featured as a coping mechanism for increased stress, and integration of communication with telemedicine was frequent and necessary. Conclusions: This study offers an in-depth exploration of the conundrums faced by oncologists due to the COVID-19 pandemic and how they navigated them. Optimal decision-making for seriously ill persons with cancer during the COVID-19 pandemic must include open acknowledgement of the ethical dilemmas faced, the heightened emotions experienced by both patients and their oncologists, and the urgent need for integrating technology with compassionate communication in determining patient preferences.
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Warsame R, Riordan L, Jenkins S, Lackore K, Pacyna J, Antiel R, Beebe T, Liebow M, Thorsteinsdottir B, Grover M, Wynia M, Goold SD, DeCamp M, Danis M, Tilburt J. Responsibilities, Strategies, and Practice Factors in Clinical Cost Conversations: a US Physician Survey. J Gen Intern Med 2020; 35:1971-1978. [PMID: 32399911 PMCID: PMC7351917 DOI: 10.1007/s11606-020-05807-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Physicians play a key role in mitigating and managing costs in healthcare which are rising. OBJECTIVE Conduct a cross-sectional survey in 2017, comparing results to a 2012 survey to understand US physicians' evolving attitudes and strategies concerning healthcare costs. PARTICIPANTS Random sample of 1200 US physicians from the AMA Masterfile. MEASURES Physician views on responsibility for costs of care, enthusiasm for cost-saving strategies, cost-consciousness scale, and practice strategies on addressing cost. KEY RESULTS Among 1200 physicians surveyed in 2017, 489 responded (41%). In 2017, slightly more physicians reported that physicians have a major responsibility for addressing healthcare costs (32% vs. 27%, p = 0.03). In 2017, more physicians attributed "major responsibility" for addressing healthcare costs to pharmaceutical companies (68% vs. 56%, p < 0.001) and hospital and health systems (63% vs. 56%%, p = 0.008) in contrast to 2012. Fewer respondents in 2017 attributed major responsibility for addressing costs to trial lawyers (53% vs. 59%, p = 0.007) and patients (42% vs. 52%, p < 0.0001) as compared to 2012. Physician enthusiasm for patient-focused cost-containment strategies like high deductible health plans and higher co-pays (62% vs. 42%, p < 0.0001 and 62% vs. 39%, p < 0.0001, not enthusiastic, respectively) declined. Physicians reported that when they discussed cost, it resulted in a change in disease management 56% of the time. Cost-consciousness within surveyed physicians had not changed meaningfully in 2017 since 2012 (31.7 vs. 31.2). Most physicians continued to agree that decision support tools showing costs would be helpful in their practice (> 70%). After adjusting for specialty, political affiliation, practice setting, age, and gender, only democratic/independent affiliation remained a significant predictor of cost-consciousness. CONCLUSIONS AND RELEVANCE US physicians increasingly attribute responsibility for rising healthcare costs to organizations and express less enthusiasm for strategies that increase patient out-of-pocket cost. Interventions that focus on physician knowledge and communication strategies regarding cost of care may be helpful.
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Affiliation(s)
- Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, USA. .,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | | | - Sarah Jenkins
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Kandace Lackore
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Joel Pacyna
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA
| | - Ryan Antiel
- Division of Pediatric Surgery, St. Louis Children's Hospital and Washington University School of Medicine, St. Louis, MO, USA
| | - Timothy Beebe
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Mark Liebow
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bjorg Thorsteinsdottir
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA.,Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael Grover
- Department of Family Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Matthew Wynia
- Center for Bioethics and Humanities, University of Colorado, Aurora, CO, USA.,Division of General Internal Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Susan Dorr Goold
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Matthew DeCamp
- Center for Bioethics and Humanities, University of Colorado, Aurora, CO, USA.,Division of General Internal Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
| | - Jon Tilburt
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Affiliation(s)
- Susan Dorr Goold
- Center for Bioethics and Social Science in Medicine, Institute for Healthcare Policy and Innovation
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Myers CD, Gordon HG, Kim HM, Rowe Z, Goold SD. Does Group Deliberation Mobilize? The Effect of Public Deliberation on Willingness to Participate in Politics. Polit Behav 2020; 42:557-580. [PMID: 32367900 PMCID: PMC7197766 DOI: 10.1007/s11109-018-9507-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Proponents of public deliberation suggest that engaging in deliberation increases deliberators' subsequent participation in other forms of politics. We evaluate this "deliberative participation hypothesis" using data drawn from a deliberative field experiment in which members of medically underserved communities in Michigan deliberated in small groups about the design of that state's Medicaid program. Participants were randomly assigned to deliberate about the program in a group or to think about the decision individually, and then completed a post-survey that included measures of willingness to engage in a variety of political acts. We measured willingness to engage in common forms of political participation, as well as willingness to participate in particularistic resistance to adverse decisions by insurance bureaucracies. Contrary to the claims of much of the existing literature, we find no impact of deliberation on willingness to engage in political participation. These results suggest that the ability of public deliberation to increase broader political engagement may be limited or may only occur in particularly intensive, directly empowered forms of public deliberation.
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Affiliation(s)
- C Daniel Myers
- Department of Political Science, University of Minnesota
| | | | - Hyungjin Myra Kim
- Center for Statistical Consulting & Research, University of Michigan
| | | | - Susan Dorr Goold
- Center for Bioethics and Social Sciences in Medicine, University of Michigan
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Myers CD, Kieffer EC, Fendrick AM, Kim HM, Calhoun K, Szymecko L, LaHahnn L, Ledón C, Danis M, Rowe Z, Goold SD. How Would Low-Income Communities Prioritize Medicaid Spending? J Health Polit Policy Law 2020; 45:373-418. [PMID: 32084263 PMCID: PMC9450686 DOI: 10.1215/03616878-8161024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CONTEXT Medicaid plays a critical role in low-income, minority, and medically underserved communities, particularly in states that have expanded Medicaid under the Affordable Care Act. Yet, the voices of underresourced communities are often unheard in decisions about how to allocate Medicaid's scarce resources, and traditional methods of public engagement are poorly suited to gathering such input. We argue that deliberative public engagement can be a useful tool for involving communities in setting Medicaid priorities. METHOD We engaged 209 residents of low-income, medically underserved Michigan communities in discussions about Medicaid spending priorities using an exercise in informed deliberation: CHAT (CHoosing All Together). Participants learned about Medicaid, deliberated in small groups, and set priorities both individually and collectively. FINDINGS Participants prioritized broad eligibility consistent with the ACA expansion, accepted some cost sharing, and prioritized spending in areas-including mental health-that are historically underfunded. Participants allocated less funding beyond benefit coverage, such as spending on healthy communities. Participants perceived the deliberative process as fair and informative, and they supported using it in the policy-making process. CONCLUSION The choices of participants from low-income, medically underserved communities reflect a unique set of priorities and suggest that engaging low-income communities more deeply in Medicaid policy making might result in different prioritization decisions.
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Goold SD, Tipirneni R, Chang T, Kirch MA, Bryant C, Rowe Z, Beathard E, Solway E, Lee S, Clark SJ, Skillicorn J, Ayanian JZ, Kullgren JT. Primary Care, Health Promotion, and Disease Prevention with Michigan Medicaid Expansion. J Gen Intern Med 2020; 35:800-807. [PMID: 31792868 PMCID: PMC7080942 DOI: 10.1007/s11606-019-05370-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/12/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Medicaid expansion in Michigan, known as the Healthy Michigan Plan (HMP), emphasizes primary care and preventive services. OBJECTIVE Evaluate the impact of enrollment in HMP on access to and receipt of care, particularly primary care and preventive services. DESIGN Telephone survey conducted during January-November 2016 with stratified random sampling by income and geographic region (response rate = 53.7%). Logistic regression analyses accounted for sampling and nonresponse adjustment. PARTICIPANTS 4090 HMP enrollees aged 19-64 with ≥ 12 months of HMP coverage MAIN MEASURES: Surveys assessed demographic factors, health, access to and use of health care before and after HMP enrollment, health behaviors, receipt of counseling for health risks, and knowledge of preventive services' copayments. Utilization of preventive services was assessed using Medicaid claims. KEY RESULTS In the 12 months prior to HMP enrollment, 33.0% of enrollees reported not getting health care they needed. Three quarters (73.8%) of enrollees reported having a regular source of care (RSOC) before enrollment; 65.1% of those reported a doctor's office/clinic, while 16.2% reported the emergency room. After HMP enrollment, 92.2% of enrollees reported having a RSOC; 91.7% had a doctor's office/clinic and 1.7% the emergency room. One fifth (20.6%) of enrollees reported that, before HMP enrollment, it had been over 5 years since their last primary care visit. Enrollees who reported a visit with their primary care provider after HMP enrollment (79.3%) were significantly more likely than those who did not report a visit to receive counseling about health behaviors, improved access to cancer screening, new diagnoses of chronic conditions, and nearly all preventive services. Enrollee knowledge that some services have no copayments was also associated with greater utilization of most preventive services. CONCLUSIONS After enrolling in Michigan's Medicaid expansion program, beneficiaries reported less forgone care and improved access to primary care and preventive services.
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Affiliation(s)
- Susan Dorr Goold
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA. .,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Renuka Tipirneni
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Tammy Chang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Matthias A Kirch
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Corey Bryant
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | | | - Erin Beathard
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Erica Solway
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Sunghee Lee
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Sarah J Clark
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer Skillicorn
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John Z Ayanian
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey T Kullgren
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Riordan L, Warsame R, Jenkins S, Lackore K, Pacyna JE, Antiel RM, Beebe T, Liebow M, Thorsteinsdottir B, Wynia M, Goold SD, DeCamp M, Danis M, Tilburt J. US Physicians' Reactions To ACA Implementation, 2012-17. Health Aff (Millwood) 2019; 38:1530-1536. [PMID: 31479366 DOI: 10.1377/hlthaff.2019.00224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Physicians play a key role in implementing health policy, and US physicians were split in their opinions about the Affordable Care Act (ACA) soon after its implementation began. We readministered elements of a prior survey of US physicians to a similar sample to understand how US physicians' opinions of the ACA may have changed over a crucial five-year implementation period (2012-17), and we compared responses across both surveys. Of the 1,200 physicians to whom we sent a survey in the summer of 2017, 489 responded (a response rate of 41 percent). A majority of respondents (60 percent) believed that the ACA had improved access to care and insurance, yet many (43 percent) felt that it had reduced the affordability of coverage. More physicians agreed in 2017 than in 2012 that the ACA "would turn United States health care in the right direction" (53 percent versus 42 percent), despite reporting perceived worsening in several practice conditions over the same time period. After we adjusted for specialty, political party affiliation, practice setting type, perceived social responsibility, age, and sex, we found that only political party affiliation was a significant predictor of support for the ACA in the 2017 results.
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Affiliation(s)
- Lindsay Riordan
- Lindsay Riordan is a medical student in the Mayo Clinic Alix School of Medicine, in Rochester, Minnesota
| | - Rahma Warsame
- Rahma Warsame is a consultant in the Division of Hematology, Mayo Clinic Minnesota, in Rochester
| | - Sarah Jenkins
- Sarah Jenkins is a statistician in the Division of Biomedical Statistics and Informatics, Mayo Clinic Minnesota
| | - Kandace Lackore
- Kandace Lackore is a statistician in the Division of Biomedical Statistics and Informatics, Mayo Clinic Minnesota
| | - Joel E Pacyna
- Joel E. Pacyna is a analyst in the Biomedical Ethics Research Program, Mayo Clinic Minnesota
| | - Ryan M Antiel
- Ryan M. Antiel is a fellow in the Division of General Surgery, Mayo Clinic Minnesota
| | - Timothy Beebe
- Timothy Beebe is a professor of health policy and management at the University of Minnesota, in Minneapolis
| | - Mark Liebow
- Mark Liebow is a consultant in the Division of General Internal Medicine, Mayo Clinic Minnesota
| | - Bjorg Thorsteinsdottir
- Bjorg Thorsteinsdottir is a consultant in the Division of Community Internal Medicine, Mayo Clinic Minnesota
| | - Matthew Wynia
- Matthew Wynia is director of the Center for Bioethics and Humanities, Anschutz Medical Campus, University of Colorado, in Aurora
| | - Susan Dorr Goold
- Susan Dorr Goold is a professor of internal medicine and a professor of health management and policy at the University of Michigan, in Ann Arbor
| | - Matthew DeCamp
- Matthew DeCamp is an associate professor in the Center for Bioethics and Humanities and Division of General Internal Medicine, Anschutz Medical Campus, University of Colorado
| | - Marion Danis
- Marion Danis is head of the Section on Ethics and Health Policy, Department of Bioethics, Clinical Center, National Institutes of Health, in Bethesda, Maryland
| | - Jon Tilburt
- Jon Tilburt ( ) is a consultant in the Division of General Internal Medicine and the Division of Health Care Policy and Research, Mayo Clinic Minnesota
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Goold SD, Danis M, Abelson J, Gornick M, Szymecko L, Myers CD, Rowe Z, Kim HM, Salman C. Evaluating community deliberations about health research priorities. Health Expect 2019; 22:772-784. [PMID: 31251446 PMCID: PMC6737773 DOI: 10.1111/hex.12931] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/05/2019] [Accepted: 05/21/2019] [Indexed: 11/28/2022] Open
Abstract
CONTEXT Engaging underrepresented communities in health research priority setting could make the scientific agenda more equitable and more responsive to their needs. OBJECTIVE Evaluate democratic deliberations engaging minority and underserved communities in setting health research priorities. METHODS Participants from underrepresented communities throughout Michigan (47 groups, n = 519) engaged in structured deliberations about health research priorities in professionally facilitated groups. We evaluated some aspects of the structure, process, and outcomes of deliberations, including representation, equality of participation, participants' views of deliberations, and the impact of group deliberations on individual participants' knowledge, attitudes, and points of view. Follow-up interviews elicited richer descriptions of these and also explored later effects on deliberators. RESULTS Deliberators (age 18-88 years) overrepresented minority groups. Participation in discussions was well distributed. Deliberators improved their knowledge about disparities, but not about health research. Participants, on average, supported using their group's decision to inform decision makers and would trust a process like this to inform funding decisions. Views of deliberations were the strongest predictor of these outcomes. Follow-up interviews revealed deliberators were particularly struck by their experience hearing and understanding other points of view, sometimes surprised at the group's ability to reach agreement, and occasionally activated to volunteer or advocate. CONCLUSIONS Deliberations using a structured group exercise to engage minority and underserved community members in setting health research priorities met some important criteria for a fair, credible process that could inform policy. Deliberations appeared to change some opinions, improved some knowledge, and were judged by participants worth using to inform policymakers.
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Affiliation(s)
- Susan Dorr Goold
- Department of Internal Medicine, Division of General Medicine, Institute for Healthcare Policy and InnovationCenter for Bioethics and Social Sciences in MedicineAnn ArborMichigan
| | - Marion Danis
- Warren Magnuson Clinical CenterNational Institutes of HealthBethesdaMaryland
| | - Julia Abelson
- Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonOntarioCanada
| | - Michelle Gornick
- Center for Bioethics and Social Sciences in MedicineUniversity of MichiganAnn ArborMichigan
| | - Lisa Szymecko
- Center for Bioethics and Social Sciences in MedicineUniversity of MichiganAnn ArborMichigan
| | - C. Daniel Myers
- Department of Political ScienceUniversity of MinnesotaMinneapolisMinnesota
| | | | - Hyungjin Myra Kim
- Center for Statistical Computation and ResearchUniversity of MichiganAnn ArborMichigan
| | - Cengiz Salman
- Center for Bioethics and Social Sciences in MedicineUniversity of MichiganAnn ArborMichigan
- Present address:
Department of American Culture, College of Literature, Science and the ArtsUniversity of MichiganAnn ArborMichigan
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11
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Goold SD, Myers CD, Danis M, Abelson J, Barnett S, Calhoun K, Campbell EG, LaHAHNN L, Hammad A, Rosenbaum RP, Kim HM, Salman C, Szymecko L, Rowe ZE. Members of Minority and Underserved Communities Set Priorities for Health Research. Milbank Q 2019; 96:675-705. [PMID: 30537366 DOI: 10.1111/1468-0009.12354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Policy Points Engaging and involving underrepresented communities when setting research priorities could make the scientific research agenda more equitable, more just, and more responsive to their needs and values. Groups and individuals from minority and underserved communities strongly prioritized child health and mental health research, often choosing to invest at the highest possible level. Groups consisting of predominantly Native American or Arab American participants invested in culture and beliefs research at the highest level, while many groups did not select it at all. The priority given to culture and beliefs research by these groups illustrates the importance of paying special attention to unique preferences, and not just commonly held views, when getting public input on spending priorities for research. CONTEXT A major contributor to health disparities is the relative lack of resources-including resources for science-allocated to address the health problems of those with disproportionately greater needs. Engaging and involving underrepresented communities in setting research priorities could make the scientific research agenda more equitable, more just, and more responsive to their needs and values. We engaged minority and underserved communities in informed deliberations and report here their priorities for health research. METHODS Academic-community partnerships adapted the simulation exercise CHAT for setting health research priorities. We had participants from minority and medically underserved communities (47 groups, n = 519) throughout Michigan deliberate about health research priorities, and we used surveys and CHAT software to collect the demographic characteristics and priorities selected by individuals and groups. FINDINGS The participants ranged in age (18 to 88), included more women than men, and were overrepresented by minority groups. Nearly all the deliberating groups selected child health and mental health research (93.6% and 95.7%), and most invested at the highest level. Aging, access, promote health, healthy environment, and what causes disease were also prioritized by groups. Research on mental health and child health were high priorities for individuals both before and after group deliberations. Access was the only category more likely to be selected by individuals after group deliberation (77.0 vs 84.0%, OR = 1.63, p = .005), while improve research, health policy, and culture and beliefs were less likely to be selected after group deliberations (all, p < .001). However, the level of investment in many categories changed after the group deliberations. Participants identifying as Black/African American were less likely to prioritize mental health research, and those of Other race were more likely to prioritize culture and beliefs research. CONCLUSIONS Minority and medically underserved communities overwhelmingly prioritized mental health and child health research in informed deliberations about spending priorities.
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Affiliation(s)
- Susan Dorr Goold
- Center for Bioethics and Social Sciences in Medicine, University of Michigan
| | | | | | | | | | - Karen Calhoun
- Michigan Institute for Clinical & Health Research, University of Michigan
| | - Eric G Campbell
- Harvard Medical School and Mongan Institute for Health Policy Center, Massachusetts General Hospital
| | | | | | | | - Hyungjin Myra Kim
- Center for Statistical Consulting & Research, University of Michigan
| | - Cengiz Salman
- Center for Bioethics and Social Sciences in Medicine, University of Michigan
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Goold SD, Tipirneni R, Kieffer E, Haggins A, Salman C, Solway E, Szymecko L, Chang T, Rowe Z, Clark S, Lee S, Campbell EG, Ayanian JZ. Primary Care Clinicians' Views About the Impact of Medicaid Expansion in Michigan: A Mixed Methods Study. J Gen Intern Med 2018; 33:1307-1316. [PMID: 29948813 PMCID: PMC6082204 DOI: 10.1007/s11606-018-4487-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 02/21/2018] [Accepted: 05/04/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Michigan's approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs). OBJECTIVE Assess PCPs' perspectives about the impact of HMP on their patients and practices. DESIGN In 2014-2015, we conducted semi-structured interviews then a statewide survey of PCPs. SETTING Interviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail. PARTICIPANTS Interviewees were physician (n = 16) and non-physician practitioners (n = 3). All Michigan PCPs caring for ≥ 12 HMP enrollees were surveyed (response rate 55.5%, N = 2104). MEASUREMENTS PCPs' experiences with HMP patients and recent changes in their practices. RESULTS Interviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients' access to urgent appointments worsened. LIMITATIONS PCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ≥ 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias. CONCLUSIONS PCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients' access did not diminish, perhaps due to reported practice changes.
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Affiliation(s)
- Susan Dorr Goold
- Department of Internal Medicine, Medical School, University of Michigan, 2800 Plymouth Road, 425W, Ann Arbor, MI, 48109, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Renuka Tipirneni
- Department of Internal Medicine, Medical School, University of Michigan, 2800 Plymouth Road, 425W, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Edith Kieffer
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- School of Social Work and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Adrianne Haggins
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Emergency Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Cengiz Salman
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Erica Solway
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Lisa Szymecko
- Department of Community Psychology, Michigan State University, East Lansing, MI, USA
| | - Tammy Chang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Sarah Clark
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sunghee Lee
- The Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Eric G Campbell
- CU Center for Bioethics and Humanities, University of Colorado, Denver, CO, USA
| | - John Z Ayanian
- Department of Internal Medicine, Medical School, University of Michigan, 2800 Plymouth Road, 425W, Ann Arbor, MI, 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI, USA
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Goold SD. Market Language, Moral Language. Hastings Cent Rep 2018; 48:inside back cover. [DOI: 10.1002/hast.815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Cargill SS, Baker LL, Goold SD. Show me the money! An analysis of underserved stakeholders' funding priorities in Patient Centered Outcomes Research domains. J Comp Eff Res 2017; 6:449-459. [PMID: 28686060 DOI: 10.2217/cer-2017-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Develop an accessible exercise to engage underserved populations about research funding priorities; analyze the criteria they use to prioritize research; contrast these criteria to those currently used by Patient Centered Outcomes Research Institute (PCORI). MATERIALS & METHODS Academic and community partners collaborated to develop an Ipad exercise to facilitate group deliberation about PCOR funding priorities. 16 groups (n = 183) of underserved individuals in both urban and rural areas participated. Recordings were qualitatively analyzed for prioritization criteria. RESULTS Analysis yielded ten codes, many of which were similar to PCORI criteria, but all of which challenged or illuminated these criteria. CONCLUSION Directly involving underserved populations in determining funding criteria is both feasible and important, and can better fulfill PCORI's goal of incorporating patient priorities.
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Affiliation(s)
- Stephanie Solomon Cargill
- Albert Gnaegi Center for Healthcare Ethics, Saint Louis University, 3545 Lafayette Ave, Salus Center Suite 505, Saint Louis, MO 63104, USA
| | - Lauren Lyn Baker
- Albert Gnaegi Center for Healthcare Ethics, Saint Louis University, 3545 Lafayette Ave, Salus Center Suite 505, Saint Louis, MO 63104, USA
| | - Susan Dorr Goold
- Center for Bioethics & Social Sciences in Medicine, University of Michigan, 2800 Plymouth road, Building 16, Ann Arbor, MI 48109, USA
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Sheeler RD, Mundell T, Hurst SA, Goold SD, Thorsteinsdottir B, Tilburt JC, Danis M. Self-Reported Rationing Behavior Among US Physicians: A National Survey. J Gen Intern Med 2016; 31:1444-1451. [PMID: 27435251 PMCID: PMC5130942 DOI: 10.1007/s11606-016-3756-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 01/25/2016] [Accepted: 05/20/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Rationing is a controversial topic among US physicians. Understanding their attitudes and behaviors around rationing may be essential to a more open and sensible professional discourse on this important but controversial topic. OBJECTIVE To describe rationing behavior and associated factors among US physicians. DESIGN Survey mailed to US physicians in 2012 to evaluate self-reported rationing behavior and variables related to this behavior. SETTING US physicians across a full spectrum of practice settings. PARTICIPANTS A total of 2541 respondents, representing 65.6 % of the original mailing list of 3872 US addresses. INTERVENTIONS The study was a cross-sectional analysis of physician attitudes and self-reported behaviors, with neutral language representations of the behaviors as well as an embedded experiment to test the influence of the word "ration" on perceived responsibility. MAIN OUTCOME MEASURES Overall percentage of respondents reporting rationing behavior in various contexts and assessment of attitudes toward rationing. KEY RESULTS In total, 1348 respondents (53.1 %) reported having personally refrained within the past 6 months from using specific clinical services that would have provided the best patient care, because of health system cost. Prescription drugs (n = 1073 [48.3 %]) and magnetic resonance imaging (n = 922 [44.5 %]) were most frequently rationed. Surgical and procedural specialists were less likely to report rationing behavior (adjusted odds ratio [OR] [95 % CI], 0.8 [0.9-0.9] and 0.5 [0.4-0.6], respectively) compared to primary care. Compared with small or solo practices, those in medical school settings reported less rationing (adjusted OR [95 % CI], 0.4 [0.2-0.7]). Physicians who self-identified as very or somewhat liberal were significantly less likely to report rationing (adjusted OR [95 % CI], 0.7 [0.6-0.9]) than those self-reporting being very or somewhat conservative. A more positive opinion about rationing tended to align with greater odds of rationing. CONCLUSIONS More than one-half of respondents engaged in behavior consistent with rationing. Practicing physicians in specific subgroups were more likely to report rationing behavior.
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Affiliation(s)
| | | | - Samia A Hurst
- Institute for Ethics, History, and Humanities, University of Geneva, Geneva, Switzerland
| | - Susan Dorr Goold
- Division of General Internal Medicine, Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Bjorg Thorsteinsdottir
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon C Tilburt
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
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Goold SD, Myers CD, Szymecko L, Cunningham Collins C, Martinez S, Ledón C, Campbell TR, Danis M, Cargill SS, Kim HM, Rowe Z. Priorities for Patient-Centered Outcomes Research: The Views of Minority and Underserved Communities. Health Serv Res 2016; 52:599-615. [PMID: 27206519 DOI: 10.1111/1475-6773.12505] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To learn how minority and underserved communities would set priorities for patient-centered outcomes research (PCOR). DATA SOURCES Sixteen groups (n = 183) from minority and underserved communities in two states deliberated about PCOR priorities using the simulation exercise CHoosing All Together (CHAT). Most participants were minority, one-third reported income <$10,000, and one-fourth reported fair/poor health. DESIGN Academic-community partnerships adapted CHAT for PCOR priority setting using existing research agendas and interviews with community leaders, clinicians, and key informants. DATA COLLECTION Tablet-based CHAT collected demographic information, individual priorities before and after group deliberation, and groups' priorities. PRINCIPAL FINDINGS Individuals and groups prioritized research on Quality of Life, Patient-Doctor, Access, Special Needs, and (by total resources spent) Compare Approaches. Those with less than a high school education were less likely to prioritize New Approaches, Patient-Doctor, Quality of Life, and Families/Caregivers. Blacks were less likely to prioritize research on Causes of Disease, New Approaches, and Compare Approaches than whites. Compare Approaches, Special Needs, Access, and Families/Caregivers were significantly more likely to be selected by individuals after compared to before deliberation. CONCLUSIONS Members of underserved communities, in informed deliberations, prioritized research on Quality of Life, Patient-Doctor, Special Needs, Access, and Compare Approaches.
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Affiliation(s)
- Susan Dorr Goold
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | - C Daniel Myers
- Department of Political Science, University of Minnesota, Minneapolis, MN
| | - Lisa Szymecko
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | | | - Sal Martinez
- Community Renewal and Development, Inc., St. Louis, MO
| | | | - Terrance R Campbell
- Wayne State University College of Education VAC Program, YOUR Center, Flint, MI
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD
| | - Stephanie Solomon Cargill
- Department of Health Care Ethics, Albert Gnaegi Center for Health Care Ethics, Saint Louis University, St. Louis, MO
| | - Hyungjin Myra Kim
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI
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Tilburt JC, Wynia MK, Montori VM, Thorsteinsdottir B, Egginton JS, Sheeler RD, Liebow M, Humeniuk KM, Goold SD. Shared decision-making as a cost-containment strategy: US physician reactions from a cross-sectional survey. BMJ Open 2014; 4:e004027. [PMID: 24430879 PMCID: PMC3902508 DOI: 10.1136/bmjopen-2013-004027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To assess US physicians' attitudes towards using shared decision-making (SDM) to achieve cost containment. DESIGN Cross-sectional mailed survey. SETTING US medical practice. PARTICIPANTS 3897 physicians were randomly selected from the AMA Physician Masterfile. Of these, 2556 completed the survey. MAIN OUTCOME MEASURES Level of enthusiasm for "Promoting better conversations with patients as a means of lowering healthcare costs"; degree of agreement with "Decision support tools that show costs would be helpful in my practice" and agreement with "should promoting SDM be legislated to control overall healthcare costs". RESULTS Of 2556 respondents (response rate (RR) 65%), two-thirds (67%) were 'very enthusiastic' about promoting SDM as a means of reducing healthcare costs. Most (70%) agreed decision support tools that show costs would be helpful in their practice, but only 24% agreed with legislating SDM to control costs. Compared with physicians with billing-only compensation, respondents with salary compensation were more likely to strongly agree that decision support tools showing costs would be helpful (OR 1.4; 95% CI 1.1 to 1.7). Primary care physicians (vs surgeons, OR 1.4; 95% CI 1.0 to 1.6) expressed more enthusiasm for SDM being legislated as a means to address healthcare costs. CONCLUSIONS Most US physicians express enthusiasm about using SDM to help contain costs. They believe decision support tools that show costs would be useful. Few agree that SDM should be legislated as a means to control healthcare costs.
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Affiliation(s)
- Jon C Tilburt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew K Wynia
- Institute for Ethics, American Medical Association, Chicago, Illinois, USA
| | - Victor M Montori
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jason S Egginton
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert D Sheeler
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Liebow
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Susan Dorr Goold
- Department of General Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
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Sommers R, Goold SD, McGlynn EA, Pearson SD, Danis M. Focus groups highlight that many patients object to clinicians' focusing on costs. Health Aff (Millwood) 2013; 32:338-46. [PMID: 23381527 DOI: 10.1377/hlthaff.2012.0686] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Having patients weigh costs when making medical decisions has been proposed as a way to rein in health care spending. We convened twenty-two focus groups of people with insurance to examine their willingness to discuss health care costs with clinicians and consider costs when deciding among nearly comparable clinical options. We identified the following four barriers to patients' taking cost into account: a preference for what they perceive as the best care, regardless of expense; inexperience with making trade-offs between health and money; a lack of interest in costs borne by insurers and society as a whole; and noncooperative behavior characteristic of a "commons dilemma," in which people act in their own self-interest although they recognize that by doing so, they are depleting limited resources. Surmounting these barriers will require new research in patient education, comprehensive efforts to shift public attitudes about health care costs, and training to prepare clinicians to discuss costs with their patients.
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Affiliation(s)
- Jon C Tilburt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Goold SD. The faces of injustice : comment on "moral distress in uninsured health care" by Anita Nivens and Janet Buelow. J Bioeth Inq 2013; 10:427-428. [PMID: 23979799 DOI: 10.1007/s11673-013-9453-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 03/23/2013] [Indexed: 06/02/2023]
Affiliation(s)
- Susan Dorr Goold
- Internal Medicine and Health, Management and Policy, Center for Bioethics and Social Sciences in Medicine, University of Michigan, North Campus Research Complex 2800 Plymouth Road Building 16, Rm 425W, Ann Arbor, MI, 48109, USA,
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Abstract
IMPORTANCE Physicians' views about health care costs are germane to pending policy reforms. OBJECTIVE To assess physicians' attitudes toward and perceived role in addressing health care costs. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional survey mailed in 2012 to 3897 US physicians randomly selected from the AMA Masterfile. MAIN OUTCOMES AND MEASURES Enthusiasm for 17 cost-containment strategies and agreement with an 11-measure cost-consciousness scale. RESULTS A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a "major responsibility" for reducing health care costs, whereas only 36% reported that practicing physicians have "major responsibility." Most were "very enthusiastic" for "promoting continuity of care" (75%), "expanding access to quality and safety data" (51%), and "limiting access to expensive treatments with little net benefit" (51%) as a means of reducing health care costs. Few expressed enthusiasm for "eliminating fee-for-service payment models" (7%). Most physicians reported being "aware of the costs of the tests/treatments [they] recommend" (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they "should be solely devoted to individual patients' best interests, even if that is expensive" (78%) and that "doctors need to take a more prominent role in limiting use of unnecessary tests" (89%). Most (85%) disagreed that they "should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more." In multivariable logistic regression models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for "eliminating fee for service" (salary plus bonus: odds ratio [OR], 3.3, 99% CI, 1.8-6.1; salary only: OR, 4.3, 99% CI, 2.2-8.5). In multivariable linear regression models, group or government practice setting (β = 0.87, 95% CI, 0.29 to 1.45, P = .004; and β = 0.99, 95% CI, 0.20 to 1.79, P = .01, respectively) and having a salary plus bonus compensation type (β = 0.82; 95% CI, 0.32 to 1.33; P = .002) were positively associated with cost-consciousness. Finding the "uncertainty involved in patient care disconcerting" was negatively associated with cost-consciousness (β = -1.95; 95% CI, -2.71 to -1.18; P < .001). CONCLUSION AND RELEVANCE In this survey about health care cost containment, US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models.
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Affiliation(s)
- Jon C Tilburt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Antiel RM, James KM, Egginton JS, Sheeler RD, Liebow M, Goold SD, Tilburt JC. Specialty, Political Affiliation, and Perceived Social Responsibility Are Associated with U.S. Physician Reactions to Health Care Reform Legislation. J Gen Intern Med 2013; 29:399-403. [PMID: 23797921 DOI: 10.1007/s11606-013-2523-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/21/2013] [Accepted: 05/23/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little is known about how U.S. physicians' political affiliations, specialties, or sense of social responsibility relate to their reactions to health care reform legislation. OBJECTIVE To assess U.S. physicians' impressions about the direction of U.S. health care under the Affordable Care Act (ACA), whether that legislation will make reimbursement more or less fair, and examine how those judgments relate to political affiliation and perceived social responsibility. DESIGN A cross-sectional, mailed, self-reported survey. PARTICIPANTS Simple random sample of 3,897 U.S. physicians. MAIN MEASURES Views on the ACA in general, reimbursement under the ACA in particular, and perceived social responsibility. KEY RESULTS Among 2,556 physicians who responded (RR2: 65 %), approximately two out of five (41 %) believed that the ACA will turn U.S. health care in the right direction and make physician reimbursement less fair (44 %). Seventy-two percent of physicians endorsed a general professional obligation to address societal health policy issues, 65 % agreed that every physician is professionally obligated to care for the uninsured or underinsured, and half (55 %) were willing to accept limits on coverage for expensive drugs and procedures for the sake of expanding access to basic health care. In multivariable analyses, liberals and independents were both substantially more likely to endorse the ACA (OR 33.0 [95 % CI, 23.6-46.2]; OR 5.0 [95 % CI, 3.7-6.8], respectively), as were physicians reporting a salary (OR 1.7 [95 % CI, 1.2-2.5]) or salary plus bonus (OR 1.4 [95 % CI, 1.1-1.9) compensation type. In the same multivariate models, those who agreed that addressing societal health policy issues are within the scope of their professional obligations (OR 1.5 [95 % CI, 1.0-2.0]), who believe physicians are professionally obligated to care for the uninsured / under-insured (OR 1.7 [95 % CI, 1.3-2.4]), and who agreed with limiting coverage for expensive drugs and procedures to expand insurance coverage (OR 2.3 [95 % CI, 1.8-3.0]), were all significantly more likely to endorse the ACA. Surgeons and procedural specialists were less likely to endorse it (OR 0.5 [95 % CI, 0.4-0.7], OR 0.6 [95 % CI, 0.5-0.9], respectively). CONCLUSIONS Significant subsets of U.S. physicians express concerns about the direction of U.S. health care under recent health care reform legislation. Those opinions appear intertwined with political affiliation, type of medical specialty, as well as perceived social responsibility.
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Affiliation(s)
- Ryan M Antiel
- Department of General Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
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Goold SD. Is the standard of care always worth the cost? Virtual Mentor 2013; 15:104-106. [PMID: 23398793 DOI: 10.1001/virtualmentor.2013.15.2.ecas1-1302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Susan Dorr Goold
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
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Walter J, Goold SD. Reason giving: when public leaders ignore evidence. Am J Bioeth 2011; 11:13-16. [PMID: 22146023 DOI: 10.1080/15265161.2011.626995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Goold SD. Letter to the editors. Am J Bioeth 2011; 11:62-63. [PMID: 21806448 DOI: 10.1080/15265161.2011.602268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Cinti SK, Barnosky AR, Gay SE, Goold SD, Lozon MM, Kim K, Rodgers PE, Baum NM, Cadwallender BA, Collins CD, Wright CM, Winfield RA. Bacterial pneumonias during an influenza pandemic: how will we allocate antibiotics? Biosecur Bioterror 2010; 7:311-6. [PMID: 19821750 DOI: 10.1089/bsp.2009.0019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We are currently in the midst of the 2009 H1N1 pandemic, and a second wave of flu in the fall and winter could lead to more hospitalizations for pneumonia. Recent pathologic and historic data from the 1918 influenza pandemic confirms that many, if not most, of the deaths in that pandemic were a result of secondary bacterial pneumonias. This means that a second wave of 2009 H1N1 pandemic influenza could result in a widespread shortage of antibiotics, making these medications a scarce resource. Recently, our University of Michigan Health System (UMHS) Scarce Resource Allocation Committee (SRAC) added antibiotics to a list of resources (including ventilators, antivirals, vaccines) that might become scarce during an influenza pandemic. In this article, we summarize the data on bacterial pneumonias during the 1918 influenza pandemic, discuss the possible impact of a pandemic on the University of Michigan Health System, and summarize our committee's guiding principles for allocating antibiotics during a pandemic.
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Affiliation(s)
- Sandro K Cinti
- Infectious Diseases, University of Michigan Hospitals/VA Ann Arbor Health Systems, Ann Arbor, Michigan 48105, USA.
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Affiliation(s)
- Kavita R Shah
- American Medical Association's Council on Ethical and Judicial Affairs, USA.
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Affiliation(s)
- Carla C Keirns
- Robert Wood Johnson Clinical Scholars Program, University of Michigan School of Medicine, Ann Arbor, USA.
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Keirns CC, Goold SD. Case study. Dirty blood. Commentary. Hastings Cent Rep 2009; 39:13-14. [PMID: 19810225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Carla C Keirns
- Center for Medical Humanities, Compassionate Care, and Bioethics, Stony Brook University, USA
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Sofaer N, Thiessen C, Goold SD, Ballou J, Getz KA, Koski G, Krueger RA, Weissman JS. Subjects' views of obligations to ensure post-trial access to drugs, care and information: qualitative results from the Experiences of Participants in Clinical Trials (EPIC) study. J Med Ethics 2009; 35:183-8. [PMID: 19251971 PMCID: PMC3044680 DOI: 10.1136/jme.2008.024711] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVES To report the attitudes and opinions of subjects in US clinical trials about whether or not, and why, they should receive post-trial access (PTA) to the trial drug, care and information. DESIGN Focus groups, short self-administered questionnaires. SETTING Boston, Dallas, Detroit, Oklahoma City. PARTICIPANTS Current and recent subjects in clinical trials, primarily for chronic diseases. RESULTS 93 individuals participated in 10 focus groups. Many thought researchers, sponsors, health insurers and others share obligations to facilitate PTA to the trial drug, if it benefited the subject, or to a therapeutic equivalent. Some thought PTA obligations include providing transition care (referrals to non-trial physicians or other trials, limited follow-up, short-term drug supply) or care for long-term adverse events. Others held, in contrast, that there are no PTA obligations regarding drugs or care. However, there was agreement that former subjects should receive information (drug name, dosage received, market approval date, long-term adverse effects, trial results). Participants frequently appealed to health need, cost, relationships, reciprocity, free choice and sponsor self-interest to support their views. Many of their reasons overlapped with those commonly discussed by bioethicists. CONCLUSION Many participants in US trials for chronic conditions thought there are obligations to facilitate PTA to the trial drug at a "fair" price; these views were less demanding than those of non-US subjects in other studies. However, our participants' views about informational obligations were broader than those of other subjects and many bioethicists. Our results suggest that the PTA debate should expand beyond the trial drug and aggregate results.
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Affiliation(s)
- N Sofaer
- Harvard University, Boston, Massachusetts, USA
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Goold SD, Campbell EG. Industry support of continuing medical education: evidence and arguments. Hastings Cent Rep 2009; 38:34-7. [PMID: 19192715 DOI: 10.1353/hcr.0.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tilburt JC, Mangrulkar RS, Goold SD, Siddiqui NY, Carrese JA. Do we practice what we preach? A qualitative assessment of resident-preceptor interactions for adherence to evidence-based practice. J Eval Clin Pract 2008; 14:780-4. [PMID: 19018911 DOI: 10.1111/j.1365-2753.2008.00966.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence-based medicine (EBM) is important in training doctors for high-quality care. Yet little is known about whether ambulatory precepting incorporates the concepts and principles of EBM. METHODS The authors observed and audiotaped 95 internal medicine residency precepting interactions and rated interactions using a qualitative analytic template consisting of three criteria: (1) presence of clinical questions; (2) presence of an evidence-based process; and (3) resident ability to articulate a clinical question. RESULTS Sixty-seven of 95 audio tapes (71%) were of acceptable quality to allow template analysis. Thirty (45%) contained explicit clinical questions; 11 (16%) included an evidence-based process. Resident ability to articulate a clinical question when prompted was rated as at least 'fair' in 59 of 67 interactions (88%). CONCLUSIONS EBM was not optimally implemented in these clinics. Future research could explore more systematically what factors facilitate or impair the use of EBM in the real-time ambulatory training context.
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Affiliation(s)
- Jon C Tilburt
- Division of General Internal Medicine and the Program in Professionalism and Bioethics, Mayo Clinic, Rochester, MN, USA.
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Douglas S, Goold SD. When Prisoners Are Patients. The Journal of Clinical Ethics 2008. [DOI: 10.1086/jce200819306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Goold SD. The faces of injustice. Mich Med 2008; 107:5-6. [PMID: 18472671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Abstract
CONTEXT Institutional financial conflicts of interest may affect research results. No national data exist on the extent to which US medical schools have formally responded to challenges associated with institutional conflicts of interest (ICOI). OBJECTIVE To assess the current state of ICOI policies and practices in US medical schools using the recommendations issued by 2 national higher education and research organizations as the standard. DESIGN, SETTING, AND PARTICIPANTS National survey of deans of all 125 accredited allopathic medical schools in the United States, administered between February 2006 and December 2006. MAIN OUTCOME MEASURES The extent to which medical schools have adopted ICOI policies applicable to their institution and to their institutional officials; the scope of these policies in terms of those covered entities, offices, and financial relationships; the existence of recommended organizational structures as means to address ICOI; and the institutions' linkages between ICOI and their institutional review boards (IRBs). RESULTS Responses were received from a total of 86 (69%) of 125 US medical schools. Although only 30 (38%) respondents (not all overall respondents answered all questions) have adopted an ICOI policy applicable to financial interests held by the institutions, a much higher number have adopted ICOI policies applicable to the financial interests of the officials: 55 (71%) for senior officials, 55 (69%) for midlevel officials, 62 (81%) for IRB members, and 51 (66%) for governing board members. Most institutions treat as potential ICOI the financial interests held by an institutional research official for a research sponsor (43 [78%]) or for a product that is the subject of research (43 [78%]). The majority of institutions have adopted organizational structures that separate research responsibility from investment management and from technology transfer responsibility. Gaps exist in institutions informing their IRBs of potential ICOI in research projects under review. CONCLUSIONS This study provides the first national data on the existence and nature of policies and practices of US medical schools for addressing potential ICOI. The gaps identified suggest the need for continuing attention by the academic medical community to address the challenges presented by ICOI more consistently and comprehensively.
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Douglas S, Goold SD. When prisoners are patients. J Clin Ethics 2008; 19:249-273. [PMID: 19004434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Abstract
CONTEXT Institutional academic-industry relationships have the potential of creating institutional conflicts of interest. To date there are no empirical data to support the establishment and evaluation of institutional policies and practices related to managing these relationships. OBJECTIVE To conduct a national survey of department chairs about the nature, extent, and consequences of institutional-academic industry relationships for medical schools and teaching hospitals. DESIGN, SETTING, AND PARTICIPANTS National survey of department chairs in the 125 accredited allopathic medical schools and the 15 largest independent teaching hospitals in the United States, administered between February 2006 and October 2006. MAIN OUTCOME MEASURE Types of relationships with industry. RESULTS A total of 459 of 688 eligible department chairs completed the survey, yielding an overall response rate of 67%. Almost two-thirds (60%) of department chairs had some form of personal relationship with industry, including serving as a consultant (27%), a member of a scientific advisory board (27%), a paid speaker (14%), an officer (7%), a founder (9%), or a member of the board of directors (11%). Two-thirds (67%) of departments as administrative units had relationships with industry. Clinical departments were more likely than nonclinical departments to receive research equipment (17% vs 10%, P = .04), unrestricted funds (19% vs 3%, P < .001), residency or fellowship training support (37% vs 2%, P < .001), and continuing medial education support (65% vs 3%, P < .001). However, nonclinical departments were more likely to receive funding from intellectual property licensing (27% vs 16%, P = .01). More than two-thirds of chairs perceived that having a relationship with industry had no effect on their professional activities, 72% viewed a chair's engaging in more than 1 industry-related activity (substantial role in a start-up company, consulting, or serving on a company's board) as having a negative impact on a department's ability to conduct independent unbiased research. CONCLUSION Overall, institutional academic-industry relationships are highly prevalent and underscore the need for their active disclosure and management.
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Abstract
OBJECTIVE To demonstrate that employees can gain understanding of the financial constraints involved in designing health insurance benefits. BACKGROUND While employees who receive their health insurance through the workplace have much at stake as the cost of health insurance rises, they are not necessarily prepared to constructively participate in prioritizing their health insurance benefits in order to limit cost. DESIGN Structured group exercises. SETTING AND PARTICIPANTS Employees of 41 public and private organizations in Northern California. INTERVENTION Administration of the CHAT (Choosing Healthplans All Together) exercise in which participants engage in deliberation to design health insurance benefits under financial constraints. MAIN OUTCOME MEASURES Change in priorities and attitudes about the need to exercise insurance cost constraints. RESULTS Participants (N = 744) became significantly more cognizant of the need to limit insurance benefits for the sake of affordability and capable of prioritizing benefit options. Those agreeing that it is reasonable to limit health insurance coverage given the cost increased from 47% to 72%. CONCLUSION It is both possible and valuable to involve employees in priority setting regarding health insurance benefits through the use of structured decision tools.
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Affiliation(s)
- Marion Danis
- Section on Ethics and Health Policy, National Institutes of Health, Bethesda, MD 20892-1156, USA.
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Abstract
Many initiatives for covering the uninsured call for "basic" health care coverage, yet few define that term. The Just Coverage project used a computer-based simulation exercise to learn how nearly 800 community members in northern California identified the inclusions and exclusions that would constitute basic coverage. Working with a limited budget, participants distinguished essential from nonessential health care needs, resisted high patient cost sharing, and tolerated tight restrictions on provider choice. They also supported practice guidelines and standards of effectiveness, and they excluded high-cost, low-value interventions. These results reinforce the importance of community input to policymakers.
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Abstract
Medi-Cal, like other Medicaid programs around the U.S., has been pressed to cut its budget. We report the results of a project using the CHAT (Choosing Healthplans All Together) exercise, designed to ascertain the priorities of disabled adult Medi-Cal beneficiaries to inform any decisions regarding Medi-Cal benefits. Participants voiced greatest interest in maintaining a wide spectrum of benefits and access to a large pool of providers and were most willing to restrict pharmacy benefits. The resulting findings may be of value to legislators drafting Medicaid proposals that revise benefits for this vulnerable population.
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Affiliation(s)
- Marion Danis
- Section on Ethics and Health Policy, Department of Clinical Bioethics, National Institutes of Health, Bethesda, MD, USA.
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Dorr Goold S, Baum NM. Define "affordable". Hastings Cent Rep 2006; 36:22-4. [PMID: 17091695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Abstract
Training in ethics and professionalism is a fundamental component of residency education, yet there is little empirical information to guide curricula. The objective of this study is to describe empirically derived ethics objectives for ethics and professionalism training for multiple specialties. Study design is a thematic analysis of documents, semi-structured interviews, and focus groups conducted in a setting of an academic medical center, Veterans Administration, and community hospital training more than 1000 residents. Participants were 84 informants in 13 specialties including residents, program directors, faculty, practicing physicians, and ethics committees. Thematic analysis identified commonalities across informants and specialties. Resident and nonresident informants identified consent, interprofessional relationships, family interactions, communication skills, and end-of-life care as essential components of training. Nonresidents also emphasized formal ethics instruction, resource allocation, and self-monitoring, whereas residents emphasized the learning environment and resident-attending interactions. Conclusions are that empirically derived learning needs for ethics and professionalism included many topics, such as informed consent and resource allocation, relevant for most specialties, providing opportunities for shared curricula and resources.
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Abstract
BACKGROUND Patient-centered assessments are increasingly important. Patients repeatedly emphasize the importance of trust in health care institutions and personnel. OBJECTIVES (1) Develop a conceptual framework for trust in health care organizations and a comprehensive, reliable measure of trust in health insurers. (2) Examine predictors and correlates of trust in insurers. STUDY DESIGN A conceptual framework for trust in health organizations based on theory and empirical studies was used to develop items for a structured telephone survey, which also included measures of health and utilization, doctor-patient trust, and satisfaction with care. Principal components factor analyses identified hypothesized domains of trust in health insurers and identified items for scales. Internal consistency assessment used Cronbach's alpha. Univariate analyses used Pearson's r or Student's t-tests. SAMPLE Insured residents of Southeastern Michigan (n=400). RESULTS Respondents were diverse in age, gender, ethnicity, health, and socioeconomic status. One dominant factor (eigenvalue>10) included hypothesized domains: administrative competence, clinical competence, advocacy and beneficence, fairness, honesty and openness, and one global item. Multidimensional scales were reliable (long version 13 items, alpha=0.95, short: 9 items, alpha=0.91). Insurer trust correlated strongly with trust in doctors (r=0.49 and 0.46) and satisfaction with care (r=0.70 and 0.66), and with an item assessing overall worry about health insurance (r=-0.37 and -0.35). Those with less trust in their insurer were more likely to say that they would change insurance plans (p<.001). CONCLUSIONS This well-grounded, reliable measure of enrollee trust in insurers can be a useful patient-centered assessment tool.
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Affiliation(s)
- Susan Dorr Goold
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI 48109-0429, USA
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Goold SD, Biddle AK, Klipp G, Hall CN, Danis M. Choosing Healthplans All Together: a deliberative exercise for allocating limited health care resources. J Health Polit Policy Law 2005; 30:563-601. [PMID: 16318163 DOI: 10.1215/03616878-30-4-563] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
CHAT (Choosing Healthplans All Together) is an exercise in participatory decision making designed to engage the public in health care priority setting. Participants work individually and then in groups to distribute a limited number of pegs on a board as they select from a wide range of insurance options. Randomly distributed health events illustrate the consequences of insurance choices. In 1999-2000, the authors conducted fifty sessions of CHAT involving 592 residents of North Carolina. The exercise was rated highly regarding ease of use, informativeness, and enjoyment. Participants found the information believable and complete, thought the group decision-making process was fair, and were willing to abide by group decisions. CHAT holds promise as a tool to foster group deliberation, generate collective choices, and incorporate the preferences and values of consumers into allocation decisions. It can serve to inform and stimulate public dialogue about limited health care resources.
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Abstract
Must health care professionals provide treatments or interventions that they consider futile? Although much of the past and current debate about futility has centered on how to best define futility, it is the application of the concept in clinical decision making that is of central concern. Most physicians feel confident that they know futile treatment when they see it, but despite years of debate in scholarly journals, professional meetings, and popular media, consensus on a precise definition eludes us still. This article reviews numerous definitions of futility to illustrate the general lack of consensus over this concept. It also provides a flexible definition of futility that is patient centered and reliant on goals of care as the morally preferable definition. In short, the concept of futility as a means to resolve disputes over treatment decisions may, itself, be futile.
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Affiliation(s)
- Kathryn L Moseley
- Bioethics Program, University of Michigan Medical School, 300 North Ingalls Street, 7D20, Ann Arbor, MI 48109-0429, USA
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Peck BM, Ubel PA, Roter DL, Goold SD, Asch DA, Jeffreys AS, Grambow SC, Tulsky JA. Do unmet expectations for specific tests, referrals, and new medications reduce patients' satisfaction? J Gen Intern Med 2004; 19:1080-7. [PMID: 15566436 PMCID: PMC1494793 DOI: 10.1111/j.1525-1497.2004.30436.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient-centered care requires clinicians to recognize and act on patients' expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit. OBJECTIVE To describe the nature and prevalence of patients' specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction. DESIGN Prospective cohort study. SETTING VA general medicine clinic. PATIENTS/PARTICIPANTS Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit. MEASUREMENTS AND MAIN RESULTS Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing "excellent"). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction. CONCLUSIONS Patients' expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations.
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Affiliation(s)
- B Mitchell Peck
- College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
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