Building a Behavioral Research Program in a Medical Setting CHIP - PowerPoint PPT Presentation

Building a Behavioral Research Program in a Medical Setting CHIP Lecture Series University of Connecticut October 12, 2006 Terrance L. Albrecht, PhD Program Leader, Communication & Behavioral Oncology Scientific Director, Behavioral/Field Research Core Professor, Dept. of Family Medicine WSU School of Medicine

“Somewhere in America today, someone will be told they have cancer…” – This will be repeated 3,500 times throughout a standard work day. • the equivalent of more than seven new cancer diagnoses every minute spent at the office.

Factors to Consider in Building a BehavioralResearch Program 1. Context: – Community, Economic Environment – Medical Setting (Primary Care? Specialty Care?) – If cancer institute, what type? Expectations for social and behavioral research? 2. Expectations for Scientific Collaborations: Intra-/Inter- /Programmatic – “transdisciplinary” – “translational” – “community-based participatory research” – “primary/secondary prevention” – “treatment/clinical trials” (phase 1,2,3 testing of therapeutic agents/procedures) – “diagnostic techniques/innovation” (e.g., imaging) – “survivorship”

1. In Our Case: The Urban Context of Detroit Population 911,402 ( see Dying Before Their Time ) African American 81.6% Persons below poverty level (%) 26.1% under age 18 (34.5%) over age 65 (18.6%) Illiteracy rate 47.0% Children born to single mothers 72.0%

Older African Americans in Detroit (compared to Whites): • Colorectal, lung, prostate and breast cancers: – Incidence rates higher than national SEER data – Initial diagnosis at advanced stage – Higher mortality rates • Colorectal, lung and prostate cancers: – Higher incidence rates for tri-county area • Colorectal, breast and lung cancers: – Lower 5-year survival rates for same site/stage at diagnosis

Cancer Sites in which African American Death Rates exceed White Death Rates among U.S. Men (1997-2001) African White Ratio of African Site American American/White • All sites 347.3 245.5 1.4 • Prostate 70.4 28.8 2.4 • Larynx 5.4 2.3 2.3 • Stomach 13.3 5.8 2.3 • Myeloma 9.0 4.4 2.0 • Oral cavity and pharynx 7.5 3.9 1.9 • Esophagus 11.7 7.4 1.6 • Liver and intrahepatic bile duct 9.3 6.1 1.5 • Small intestine 0.7 0.5 1.4 • Colon and rectum 34.3 24.8 1.4 • Lung and bronchus 104.1 76.6 1.4 • Pancreas 16.0 12.0 1.3

Cancer Sites in which African American Death Rates Exceed White Death Rates among U.S. Women (1997-2001) Ratio of African African American Site White American/White • All sites 196.5 165.5 1.2 • Myeloma 6.6 2.9 2.3 • Stomach 6.3 2.8 2.3 • Uterine cervix 5.6 2.6 2.2 • Esophagus 3.2 1.7 1.9 • Larynx 0.9 0.5 1.8 • Uterine corpus 6.9 3.9 1.8 • Pancreas 12.8 8.9 1.4 • Colon and rectum 24.5 17.1 1.4 • Liver and intrahepatic bile duct 3.8 2.7 1.4 • Breast 35.4 26.4 1.3 • Urinary bladder 2.9 2.3 1.3 • Oral cavity and pharynx 2.0 1.6 1.3

2. In Our Case: Collaborations • Intra— – Epidemiology – Genetic Epi (linkage studies of disease) • Inter— – Developmental Therapeutics – Clinical/Disease sites: Breast, Prostate, Lung, Colorectal, Gastrointestinal, Ovarian – Gerontology – Pediatrics – Symptom Control (e.g., pain, fatigue)

Where We Started: Our Selected Research Areas I. Medical Communication and Treatment Decision Making II. Pediatric Cancer Coping and Survivorship III. Cancer Health Disparities: Unequal Burden

Communication and Treatment Decision Making • NIH/NCI 7RO1CA75003 Effects of Physician Communication on Patient Accrual • NIH/NCI 1R21CA113220-01 Biopsychosocial Processes and Treatment Decision Making • Strategic Research Initiative Grant, Karmanos Cancer Institute The Use of Real Time Patient Data to Define “Clinical Benefit” in Phase I Clinical Trials.

Sample Publications • Eggly, et al. (2006). Discussing “bad news” in the outpatient oncology clinic: Rethinking current communication guidelines. Journal of Clinical Oncology. • Eggly, et al. (in press). Information seeking during “bad news” oncology interactions; Question-asking by patients and their companions. Social Science and Medicine .

Physician Communication and Patient Accrual to Cancer Clinical Trials Collaborators: John Ruckdeschel, M.D. Susan Eggly, Ph.D. Louis Penner, Ph.D. Rebecca Cline, Ph.D. Tanina Foster, M. Ed. Felicity Harper, Ph.D. Elizabeth Heath, M.D.

Simplified Structural Model of Patient Decision Making Patient MD-PT Family Experimental Communication Member Treatment Decision Physician Study Protocol

Data Collection • Pre-Test (T 1 ) – Self-reports – Patient/Family Member Sociodemographics • Physician-Patient-Family Member Interaction (T 2 ) – Observational Analysis – Real-Time Video Recording of Clinic Encounter • Post-Test (T 3 ) – Self-reports – Phone Interviews with Patients Regarding Decisionmaking (1-2 Weeks After Clinic Encounter)

Observational Coding • N = 241 video recorded interactions at two comprehensive cancer centers • Coding System – Karmanos Accrual Assessment System (KAAS) • Content checklist (informed consent/informed refusal) • Ratings of: – Quality of Relationship MD-PT; MD-FM (e.g., closeness, trust, rapport) – Physician Actions/Behaviors (e.g., talk overs, dominance, discussion of consent)

(“Front Stage; Back Stage”)

Reliability/Validity Issues Riddle, D.L., Albrecht, T.L., Coovert, M.D., Penner, L.A., Ruckdeschel, J.C.,et al. (2002). Differences in audiotaped versus videotaped physician-patient interactions. Journal of Nonverbal Behavior, 26, 219-240 Albrecht, T. L., Ruckdeschel, J. C., Ray, F.L., et al. (2005) A portable, unobtrusive device for video recording clinical interactions. Behavior Research Methods, 37 (1) 165-169 Penner, L.A., Orom, H., et al. (in press). Camera-related behaviors during video recorded medical interactions. Journal of Nonverbal Behavior.

Different Protocols Same Physician; Offered…

Same Physician, Same Protocol Altruism-Based Decision (for clinical trial) Spousal Role; Distortion; Resistance (against clinical trial)

Clinic Visit Typology ( Karmanos and Moffitt Cancer Centers) Visit Type (Observed) N (%) 100 (43%) CT Not Mentioned 27 (12%) CT Mentioned, MD Reject 0 CT Mentioned, PT Reject 48 (20%) CT Discussed 42 (18%) CT Discussed, Offer Made 17 (7%) Other (e.g., Iressa) 234 (100%) Total

Patient Misperceptions • Thirty-nine percent of patients who only discussed a trial, said they were offered one • Fourteen percent of patients who were offered a trial said they were not offered one

Importance of Decision Factors Accrued vs. Not Accrued (T 3 report) Accrued Did Not Factor Accrue MD IMPACT: 2.84 (0.46) 1.83 (0.75) MD Answered Questions ** 2.78 (0.51) 2.00 (0.82) Trust in MD ** 2.69 (0.63) 1.83 (0.75) MD Supportive * MD Recommendation * 2.48 (0.70) 1.50 (0.55) LIFE/SURVIVAL: 2.74 (0.53) 1.67 (0.52) Extend Life ** Fighting Cancer * 2.69 (0.55) 2.00 (0.82) Quality of Life ** 2.59 (0.69) 1.57 (0.53) ALTRUISM: 2.46 (0.69) 1.57 (0.53) Help Others * FAMILY INFLUENCE: Opinion of FM Present * 2.36 (0.85) 1.40 (0.89) PERCEIVED COSTS: 2.19 (0.85) 1.33 (0.82) Costs Manageable/Insured * *p < .05; **p < .001

Observed Quality of Interaction and Importance of Decision Factors (T 2 � T 3 ) KAAS Relationship Perceived Family Altruism Quality Ratings Costs Influence (Observed) Hierarchical Rapport -.49* Closeness/Connectedness -.54* -.52* -.44 Trust -.63** -.54

Observed Physician Behaviors and Importance of Decision Factors Physician Behaviors Perceived Life Family Costs /Survival Influence MD Directed .64* Toward Consent Amt Info from MD -.61* MD Manner -.55* MD Data-Based -.60* -.40* Info

Observed Quality of Interaction and Reactions to MD/Decision KAAS Relationship Trust/Confidence Comfort Quality Ratings in MD with Decision (Observed) Hierarchical Rapport .44* Trust .41* .54*

Observed Physician Behaviors and Reactions to Decision/MD Obs. Physician Behaviors Trust/Confidence Comfort in MD with Decision MD Code .35* Code Match .36* .40* MD Directed Toward Consent .50* MD Talkovers/Interruptions -.65* -.53 MD Conv. Control/Dominance -.41 MD Data-Based Information .35*

Family Member Obs. Quality Perceived Family Life Altruism Relationship Influence Costs /Survival /MD Behaviors Hierarchical -.76** -.61* Rapport Closeness -.57* /Connectedness Md Responsive to -.52* -.44* Questions/Concerns MD Data Based -.44 -.50* -.45 Information FM Code .64* Code Match -.54* -.63* -.66*

Family Member Obs. Quality PT Trust PT Comfort Relationship with Decision /Confidence /MD Behaviors in MD Hierarchical Rapport .44* MD -.46* -.42* Talkovers/Interruptions MD Provide Hope .39* .53*