Michelle van Ryn

The Association between Perceived Discrimination and Underutilization of Needed Medical and Mental Health Care in a Multi-Ethnic Community Sample

This study examines the association between perceived discrimination and underutilization of needed medical and mental health care, in a representative, multi-ethnic community sample. Data were derived from a cross sectional survey of 10,098 White, U.S.-born Black, African-born Black, American Indian, Hispanic, and Southeast Asian adults in Hennepin County, Minnesota. Even after controlling for socio-demographic characteristics, health care access, and physical and mental health, perceived discrimination was associated with underutilization of medical care among Whites, U.S.-born Blacks, and American Indians and was associated with underutilization of mental health care among Whites, U.S.-born Blacks, Southeast Asians, and American Indians. Correlates of different types of discrimination (major, everyday, health care) on underutilization of care varied among ethnic groups. The higher prevalence of discrimination among racial and ethnic minorities may contribute to their underutilization of health care services. Future research is needed to understand the impacts of different types of discrimination on different groups.

Cancer Patients' Roles in Treatment Decisions: Do Characteristics of the Decision Influence Roles?

PURPOSEnPatients with more active roles in decisions are more satisfied and may have better health outcomes. Younger and better educated patients have more active roles in decisions, but whether patients roles in decisions differ by characteristics of the decision itself is unknown.nnnPATIENTS AND METHODSnWe surveyed a large, population-based cohort of patients with recently diagnosed lung or colorectal cancer about their roles in decisions regarding surgery, radiation therapy, and/or chemotherapy. We used multinomial logistic regression to assess whether characteristics of the decision, including evidence about the treatments benefit, whether the decision was likely preference-sensitive (palliative therapy for metastatic cancer), and treatment modality, influenced patients roles in that decision.nnnRESULTSnOf 10,939 decisions made by 5,383 patients, 38.9% were patient controlled, 43.6% were shared, and 17.5% were physician controlled. When there was good evidence to support a treatment, shared control was greatest; when evidence was uncertain, patient control was greatest; and when there was no evidence for or evidence against a treatment, physician control was greatest (overall P < .001). Decisions about treatments for metastatic cancers tended to be more physician controlled than other decisions (P < .001).nnnCONCLUSIONnPatients making decisions about treatments for which no evidence supports benefit and decisions about noncurative treatments reported more physician control, which suggests that patients may not want the responsibility of deciding on treatments that will not cure them. Better strategies for shared decision making may be needed when there is no evidence to support benefit of a treatment or when patients have terminal illnesses that cannot be cured.

Patients' experiences with care for lung cancer and colorectal cancer: findings from the Cancer Care Outcomes Research and Surveillance Consortium.

PURPOSEnTo assess patients experiences with cancer care, ratings of their quality of care, and correlates of these assessments.nnnPATIENTS AND METHODSnFor 4,093 patients with lung cancer and 3,685 patients with colorectal cancer in multiple US regions and health care delivery systems, we conducted telephone surveys of patients or their surrogates in English, Spanish, or Chinese at 4 to 7 months after diagnosis. The surveys assessed ratings of the overall quality of cancer care and experiences with three domains of interpersonal care (physician communication, nursing care, and coordination and responsiveness of care).nnnRESULTSnEnglish-speaking Asian/Pacific Islander patients and Chinese-speaking patients and those in worse health reported significantly worse adjusted experiences with all three domains of interpersonal care, whereas white, black, and Hispanic patients reported generally similar experiences with interpersonal care. The overall quality of cancer care was rated as excellent by 44.4% of patients with lung cancer and 53.0% of patients with colorectal cancer, and these ratings were most strongly correlated with positive experiences with coordination and responsiveness of care (Spearman rank coefficients of 0.49 and 0.42 for lung and colorectal cancer, respectively). After multivariate adjustment, excellent ratings were less common for each cancer among black patients, English-speaking Asian/Pacific Islander patients, Chinese-speaking patients, and patients reporting worse health status (all P ≤ .05).nnnCONCLUSIONnPatients reports and ratings of care differed significantly by race, language, and health status. Efforts to improve patients experiences with cancer care should focus on problems affecting Asian and Pacific Islander patients and those in worse health.

Implicit and explicit weight bias in a national sample of 4,732 medical students: The medical student CHANGES study

To examine the magnitude of explicit and implicit weight biases compared to biases against other groups; and identify student factors predicting bias in a large national sample of medical students.

Implicit and explicit weight bias in a national sample of 4,732 medical students

To examine the magnitude of explicit and implicit weight biases compared to biases against other groups; and identify student factors predicting bias in a large national sample of medical students.

Association of Actual and Preferred Decision Roles With Patient-Reported Quality of Care: Shared Decision Making in Cancer Care.

IMPORTANCEnShared decision making is associated with improved patient-reported outcomes of cancer treatment, but not all patients prefer to participate in medical decisions. Results from studies of the effect of matching between actual and preferred medical decision roles on patients perceptions of care quality have been conflicting.nnnOBJECTIVESnTo determine whether shared decision making was associated with patient ratings of care quality and physician communication and whether patients preferred decision roles modified those associations.nnnDESIGN, SETTING, AND PARTICIPANTSnWe performed a population- and health system-based survey of participants in the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study diagnosed with lung and/or colorectal cancer between 2003 and 2005 (56% with colorectal cancer, 40% with non-small-cell lung cancer, and 5% with small-cell lung cancer). The CanCORS study included 9737 patients (cooperation rate among patients contacted, 59.9%) treated in integrated care delivery systems, academic institutions, private offices, and Veterans Affairs hospitals. The medical records were abstracted between October 11, 2005, and April 30, 2009; all analyses were conducted between 2013 and 2014.nnnINTERVENTIONSnWe surveyed patients specifically about their preferred roles in cancer treatment decisions and their actual roles in decisions about surgery, chemotherapy, and radiation therapy. We analyzed the responses of 5315 patients who completed baseline surveys and reported decision roles for a total of 10u202f817 treatment decisions and assessed associations of patients decision roles with patient-reported quality of care and physician communication.nnnMAIN OUTCOMES AND MEASURESnThe outcomes (identified before data collection) included patient-reported excellent quality of care and top ratings (highest score) on a physician communication scale.nnnRESULTSnAfter adjustment, patients describing physician-controlled (vs shared) decisions were less likely to report excellent quality of care (odds ratio [OR], 0.64; 95% CI, 0.54-0.75; Pu2009<u2009.001). Patients preferred decision roles did not modify this effect (Pu2009=u2009.29 for the interaction). Patients describing either actual or preferred physician-controlled (vs shared) roles were less likely to provide a top rating of physician communication (OR, 0.55; 95% CI, 0.45-0.66; Pu2009<u2009.001, and OR, 0.67; 95% CI, 0.51-0.87; Pu2009=u2009.002, respectively). The preferred role did not modify the effect of the actual role (Pu2009=u2009.76 for interaction).nnnCONCLUSIONS AND RELEVANCEnPhysician-controlled decisions regarding lung or colorectal cancer treatment were associated with lower ratings of care quality and physician communication. These effects were independent of patients preferred decision roles, underscoring the importance of seeking to involve all patients in decision making about their treatment.

Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People among Heterosexual First-Year Medical Students? A Report from the Medical Student CHANGE Study

Purpose A recent Institute of Medicine report concluded that lesbian and gay individuals face discrimination from health care providers and called for research on provider attitudes. Medical school is a critical juncture for improving future providers’ treatment of sexual minorities. This study examined both explicit bias and implicit bias against lesbian women and gay men among first-year medical students, focusing on two predictors of such bias, contact and empathy. Method This study included the 4,441 heterosexual first-year medical students who participated in the baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, which employed a stratified random sample of 49u2009U.S. medical schools in fall 2010. The researchers measured explicit attitudes toward gay and lesbian people using feeling thermometer self-assessments, implicit attitudes using the Implicit Association Test, amount and favorability of contact using self-report items, and empathy using subscales of the Interpersonal Reactivity Index. Results Nearly half (45.79%; 956/2,088) of respondents with complete data on both bias measures expressed at least some explicit bias, and most (81.51%; 1,702/2,088) exhibited at least some implicit bias against gay and lesbian individuals. Both amount and favorability of contact predicted positive implicit and explicit attitudes. Both cognitive and emotional empathy predicted positive explicit attitudes, but not implicit attitudes. Conclusions The prevalence of negative attitudes presents an important challenge for medical education, highlighting the need for more research on possible causes of bias. Findings on contact and empathy point to possible curriculum-based interventions aimed at ensuring high-quality care for sexual minorities.

Racial disparities in VA service connection for posttraumatic stress disorder disability.

Background. “Service connected” veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system. For some veterans, service connection represents the difference between access to VA health care facilities and no access. Objectives. To determine whether there are racial discrepancies in the granting of service connection for posttraumatic stress disorder (PTSD) by the Department of Veterans Affairs and, if so, to determine whether these discrepancies could be attributed to appropriate subject characteristics, such as differences in PTSD symptom severity or functional status. Research Design. Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. Setting and Subjects. The study comprised 2700 men and 2700 women randomly selected from all veterans filing PTSD disability claims between January 1, 1994 and December 31, 1998. Results. A total of 3337 veterans returned useable surveys, of which 17% were black. Only 16% of respondents carried private health insurance, and 44% reported incomes of

Proactive tobacco treatment and population-level cessation a pragmatic randomized clinical trial

20,000 or less. After adjusting for respondents’ sociodemographic characteristics, symptom severity, functional status, and trauma histories, black persons’ rate of service connection for PTSD was 43% compared with 56% for other respondents (P = 0.003). Conclusion. Black persons’ rates of service connection for PTSD were substantially lower than other veterans even after adjusting for differences in PTSD severity and functional status.

The role of families in decisions regarding cancer treatments

IMPORTANCEnCurrent tobacco use treatment approaches require smokers to request treatment or depend on the provider to initiate smoking cessation care and are therefore reactive. Most smokers do not receive evidence-based treatments for tobacco use that include both behavioral counseling and pharmacotherapy.nnnOBJECTIVEnTo assess the effect of a proactive, population-based tobacco cessation care model on use of evidence-based tobacco cessation treatments and on population-level smoking cessation rates (ie, abstinence among all smokers including those who use and do not use treatment) compared with usual care among a diverse population of current smokers.nnnDESIGN, SETTING, AND PARTICIPANTSnThe Veterans Victory Over Tobacco Study, a pragmatic randomized clinical trial involving a population-based registry of current smokers aged 18 to 80 years. A total of 6400 current smokers, identified using the Department of Veterans Affairs (VA) electronic medical record, were randomized prior to contact to evaluate both the reach and effectiveness of the proactive care intervention.nnnINTERVENTIONSnCurrent smokers were randomized to usual care or proactive care. Proactive care combined (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or in-person). Proactive outreach included mailed invitations followed by telephone outreach to motivate smokers to seek treatment with choice of services.nnnMAIN OUTCOMES AND MEASURESnThe primary outcome was 6-month prolonged smoking abstinence at 1 year and was assessed by a follow-up survey among all current smokers regardless of interest in quitting or treatment utilization.nnnRESULTSnA total of 5123 participants were included in the primary analysis. The follow-up survey response rate was 66%. The population-level, 6-month prolonged smoking abstinence rate at 1 year was 13.5% for proactive care compared with 10.9% for usual care (P =u2009.02). Logistic regression mixed model analysis showed a significant effect of the proactive care intervention on 6-month prolonged abstinence (odds ratio [OR], 1.27 [95% CI, 1.03-1.57]). In analyses accounting for nonresponse using likelihood-based not-missing-at-random models, the effect of proactive care on 6-month prolonged abstinence persisted (OR, 1.33 [95% CI, 1.17-1.51]).nnnCONCLUSIONS AND RELEVANCEnProactive, population-based tobacco cessation care using proactive outreach to connect smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term population-level cessation rates.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00608426.