Search

BackgroundAll federal agencies are required to support appropriation requests with evidence and evaluation (US Public Law 115-435; the Evidence Act). The StrAtegic PoLicy EvIdence-Based Evaluation CeNTer (SALIENT) is 1 of 6 centers that help the Department of Veterans Affairs (VA) meet this requirement. ObjectiveWorking with the existing VA evaluation structure, SALIENT evaluations will contribute to (1) optimize policies and programs for veteran populations; (2) improve outcomes regarding health, equity, cost, and provider well-being; (3) advance the science of dissemination and knowledge translation; and (4) expand the implementation and dissemination science workforce. MethodsWe leverage the Lean Sprint methodology (iterative, incremental, rule-governed approach to clearly defined, and time-boxed work) and 3 cores to develop our evaluation plans collaboratively with operational partners and key stakeholders including veterans, policy experts, and clinicians. The Operations Core will work with evaluation teams to develop timelines, facilitate work, monitor progress, and guide quality improvement within SALIENT. The Methods Core will work with evaluation teams to identify the most appropriate qualitative, quantitative, and mixed methods approaches to address each evaluation, ensure that the analyses are conducted appropriately, and troubleshoot when problems with data acquisition and analysis arise. The Knowledge Translation (KT) Core will target key partners and decision makers using a needs-based market segmentation approach to ensure that needs are incorporated in the dissemination of knowledge. The KT Core will create communications briefs, playbooks, and other materials targeted at these market segments to facilitate implementation of evidence-based practices and maximize the impact of evaluation results. ResultsThe SALIENT team has developed a center infrastructure to support high-priority evaluations, often to be responsive to shifting operational needs and priorities. Our team has engaged in our core missions and operations to rapidly evaluate a high-priority areas, develop a comprehensive Lean Sprint systems redesign approach to training, and accelerate rapid knowledge translation. ConclusionsWith an array of interdisciplinary expertise, operational partnerships, and integrated resources, SALIENT has an established and evolving infrastructure to rapidly develop and implement high-impact evaluations. Projects are developed with sustained efficiency approaches that can pivot to new priorities as needed and effectively translate knowledge for key stakeholders and policy makers, while creating a learning health system infrastructure to foster the next generation of evaluation and implementation scientists. International Registered Report Identifier (IRRID)PRR1-10.2196/59830

Abstract Background To effectively promote vaccine uptake, it is important to understand which people are most and least inclined to be vaccinated and why. In this study, we examined predictors of COVID-19 vaccine uptake and reasons for non-vaccination. Methods We conducted an online English-language survey study in December-2020, January-2021, and March-2021. A total of 930 US respondents completed all surveys. Multiple logistic regression models were run to test whether the early vaccine eligibility, demographic factors, and psychological factors predict getting at least one dose of a COVID-19 vaccination in January-2021 and in March-2021. Results The proportion of respondents who received ≥ 1-dose of a COVID-19 vaccine increased from 18% (January) to 67% (March). Older age predicted vaccine uptake in January (OR = 2.02[95%CI = 1.14–3.78], p

ABSTRACT Background Individuals with high risk for lung cancer may benefit from lung cancer screening, but there are associated risks as well as benefits. Shared decision‐making (SDM) tools with personalized information may provide key support for patients. Understanding patient perspectives on educational tools to facilitate SDM for lung cancer screening may support tool development. Aim This study aimed to explore patient perspectives related to a SDM tool for lung cancer screening using a qualitative approach. Methods We elicited patient perspectives by showing a provider‐facing SDM tool. Focus group interviews that ranged in duration from 1.5 to 2 h were conducted with 23 individuals with high risk for lung cancer. Data were interpreted inductively using thematic analysis to identify patients' thoughts on and desires for a patient‐facing SDM tool. Results The findings highlight that patients would like to have educational information related to lung cancer screening. We identified several key themes to be considered in the future development of patient‐facing tools: barriers to acceptance, preference against screening and seeking empowerment. One further theme illustrated effects of patient–provider relationship as a limitation to meeting lung cancer screening information needs. Participants also noted several suggestions for the design of technology decision aids. Conclusion These findings suggest that patients desire additional information on lung cancer screening in advance of clinical visits. However, there are several issues that must be considered in the design and development of technology to meet the information needs of patients for lung cancer screening decisions. Patient or Public Contribution Patients, service users, caregivers or members of the public were not involved in the study design, conduct, analysis or interpretation of the data. However, clinical experts in health communication provided detailed feedback on the study protocol, including the focus group approach. The study findings contribute to a better understanding of patient expectations for lung cancer screening decisions and may inform future development of tools for SDM.

Background Considering a patient’s full risk factor profile can promote personalized shared decision making (SDM). One way to accomplish this is through encounter tools that incorporate prediction models, but little is known about clinicians’ perceptions of the feasibility of using these tools in practice. We examined how clinicians react to using one such encounter tool for personalizing SDM about lung cancer screening (LCS). Design We conducted a qualitative study based on field notes from academic detailing visits during a multisite quality improvement program. The detailer engaged one-on-one with 96 primary care clinicians across multiple Veterans Affairs sites (7 medical centers and 6 outlying clinics) to get feedback on 1) the rationale for prediction-based LCS and 2) how to use the DecisionPrecision (DP) encounter tool with eligible patients to personalize LCS discussions. Results Thematic content analysis from detailing visit data identified 6 categories of clinician willingness to use the DP tool to personalize SDM for LCS (adoption potential), varying from “Enthusiastic Potential Adopter” ( n = 18) to “Definite Non-Adopter” ( n = 16). Many clinicians ( n = 52) articulated how they found the concept of prediction-based SDM highly appealing. However, to varying degrees, nearly all clinicians identified challenges to incorporating such an approach in routine practice. Limitations The results are based on the clinician’s initial reactions rather than longitudinal experience. Conclusions While many primary care clinicians saw real value in using prediction to personalize LCS decisions, more support is needed to overcome barriers to using encounter tools in practice. Based on these findings, we propose several strategies that may facilitate the adoption of prediction-based SDM in contexts such as LCS. Highlights Encounter tools that incorporate prediction models promote personalized shared decision making (SDM), but little is known about clinicians’ perceptions of the feasibility of using these tools in practice. We examined how clinicians react to using one such encounter tool for personalizing SDM about lung cancer screening (LCS). While many clinicians found the concept of prediction-based SDM highly appealing, nearly all clinicians identified challenges to incorporating such an approach in routine practice. We propose several strategies to overcome adoption barriers and facilitate the use of prediction-based SDM in contexts such as LCS.

Objectives Patients with chronic conditions enrolled in high-deductible health plans (HDHPs) face cost-related access barriers and high out-of-pocket spending. Our objectives were to develop a novel behavioural intervention to help HDHP enrollees with chronic conditions use cost-conscious strategies and evaluate the intervention’s preliminary effectiveness, acceptability and feasibility.Design Prospective.Setting Online (USA).Participants 36 US adults enrolled in an HDHP through their employer or an exchange with diabetes, hypertension, asthma, coronary artery disease and/or chronic obstructive pulmonary disease. 31/36 participants completed the study.Intervention We developed a 5-week intervention consisting of a website with educational modules on discussing costs with clinicians, saving for future healthcare costs, comparing healthcare prices and quality, preparing for appointments, following up after appointments and planning for future healthcare needs; and emails encouraging participants to access each module.Outcomes We conducted a single-arm proof-of-concept pilot study of the intervention. Baseline and postintervention surveys measured primary outcomes of health insurance literacy and confidence in using cost-conscious strategies. 10 participants completed postintervention interviews.Results 31 (86%) participants completed a baseline and postintervention survey. Mean health insurance literacy scores (20–80 scale) improved from 56.5 to 67.1 (p

OBJECTIVES/GOALS: Serious video games are designed for skill-building and are increasingly being used for healthcare interventions with adolescents and young adults (AYAs). The study goal was to identify AYAs’ preferred game features, by demographic groups, to inform the development of a game to improve AYA’s engagement in their congenital heart disease (CHD) care. METHODS/STUDY POPULATION: Pediatric patients, 12-18 years old, completed surveys at a routine CHD care visit. Participants rated their likelihood of using games to learn CHD management skills (5-point Likert) and preferences for ten game features commonly used, such as: personalization (make your own avatar) and levels (unlock new, advanced stages as you do better). Participants selected one of three response options: 1=would make me less interested in the game, 2=doesn’t matter, 3=would make me more interested in the game. Descriptives and frequencies assessed interest in different game features. Chi-square tests were used to identify potential differences in game feature preferences by gender identity, age group (early/mid-adolescence vs. late adolescence), and race and ethnicity. RESULTS/ANTICIPATED RESULTS: Of 83 participants who completed surveys, the mean age was 15 years old (12-18; SD=1.73), 55% were male, 79% were Non-Hispanic White, and 70% were interested in video games for gaining CHD management skills. The top-rated game features were: levels (78%; unlock advanced stages), conflict (74%; face challenges), personalization (70%; create avatar), and story (70%; journey-based). The three lowest-ranked features were: time (29%; restricted time to complete challenge), competition (47%; score/play against others), strategy (53%; plan to reach goal). No significant differences in game feature preferences were found by demographic characteristics. DISCUSSION/SIGNIFICANCE: Most AYAs with CHD were interested in games, offering a promising avenue for future healthcare interventions. Given no significantly different preferences by demographics, the game may not require tailoring game features for certain groups. However, additional research with diverse participants is needed to fully inform game development.

Abstract Background Previous research has found that individuals may travel outside their home countries in pursuit of alternative cancer therapies (ACT). The goal of this study is to compare individuals in the United States who propose plans for travel abroad for ACT, compared with individuals who seek ACT domestically. Methods Clinical and treatment data were extracted from campaign descriptions of 615 GoFundMe® campaigns fundraising for individuals in the United States seeking ACT between 2011 and 2019. We examined treatment modalities, treatment location, fundraising metrics, and online engagement within campaign profiles. Clinical and demographic differences between those who proposed international travel and those who sought ACT domestically were examined using two‐sided Fisher's exact tests. Differences in financial and social engagement data were examined using two‐sided Mann–Whitney tests. Results Of the total 615 campaigns, 237 (38.5%) mentioned plans to travel internationally for ACT, with the majority (81.9%) pursuing travel to Mexico. Campaigns that proposed international treatment requested more money ($35,000 vs. $22,650, p

Objectives Little research exists on how risk scores are used in counselling. We examined (a) how Breast Cancer Risk Assessment Tool (BCRAT) scores are presented during counselling; (b) how women react and (c) discuss them afterwards.Design Consultations were video-recorded and participants were interviewed after the consultation as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1 (NSABP DMP-1).Setting Two NSABP DMP-1 breast cancer care centres in the USA: one large comprehensive cancer centre serving a high-risk population and an academic safety-net medical centre in an urban setting.Participants Thirty women evaluated for breast cancer risk and their counselling providers were included.Methods Participants who were identified as at increased risk of breast cancer were recruited to participate in qualitative study with a video-recorded consultation and subsequent semi-structured interview that included giving feedback and input after viewing their own consultation. Consultation videos were summarised jointly and inductively as a team.tThe interview material was searched deductively for text segments that contained the inductively derived themes related to risk assessment. Subgroup analysis according to demographic variables such as age and Gail score were conducted, investigating reactions to risk scores and contrasting and comparing them with the pertinent video analysis data. From this, four descriptive categories of reactions to risk scores emerged. The descriptive categories were clearly defined after 19 interviews; all 30 interviews fit principally into one of the four descriptive categories.Results Risk scores were individualised and given meaning by providers through: (a) presenting thresholds, (b) making comparisons and (c) emphasising or minimising the calculated risk. The risk score information elicited little reaction from participants during consultations, though some added to, agreed with or qualified the provider’s information. During interviews, participants reacted to the numbers in four primary ways: (a) engaging easily with numbers; (b) expressing greater anxiety after discussing the risk score; (c) accepting the risk score and (d) not talking about the risk score.Conclusions Our study highlights the necessity that patients’ experiences must be understood and put into relation to risk assessment information to become a meaningful treatment decision-making tool, for instance by categorising patients’ information engagement into types.Trial registration number NCT01399359.

Background. Parents with a fetus diagnosed with a complex congenital heart defect (CHD) are at high risk of negative psychological outcomes. Purpose. To explore whether parents’ psychological and decision-making outcomes differed based on their treatment decision and fetus/neonate survival status. Methods. We prospectively enrolled parents with a fetus diagnosed with a complex, life-threatening CHD from September 2018 to December 2020. We tested whether parents’ psychological and decision-making outcomes 3 months posttreatment differed by treatment choice and survival status. Results. Our sample included 23 parents (average Age [years] : 27 ± 4, range = 21–37). Most were women ( n = 18), non-Hispanic White ( n = 20), and married ( n = 21). Most parents chose surgery ( n = 16), with 11 children surviving to the time of the survey; remaining parents ( n = 7) chose comfort-directed care. Parents who chose comfort-directed care reported higher distress ( x ¯ = 1.51, s = 0.75 v. x ¯ = 0.74, s = 0.55; Mdifference = 0.77, 95% confidence interval [CI], 0.05–1.48) and perinatal grief ( x ¯ = 91.86, s = 22.96 v. x ¯ = 63.38, s = 20.15; Mdifference = 27.18, 95% CI, 6.20–48.16) than parents who chose surgery, regardless of survival status. Parents who chose comfort-directed care reported higher depression ( x ¯ = 1.64, s = 0.95 v. x ¯ = 0.65, s = 0.49; Mdifference = 0.99, 95% CI, 0.10–1.88) than parents whose child survived following surgery. Parents choosing comfort-directed care reported higher regret ( x ¯ = 26.43, s = 8.02 v. x ¯ = 5.00, s = 7.07; Mdifference = 21.43, 95% CI, 11.59–31.27) and decisional conflict ( x ¯ = 20.98, s = 10.00 v. x ¯ = 3.44, s = 4.74; Mdifference = 17.54, 95% CI; 7.75–27.34) than parents whose child had not survived following surgery. Parents whose child survived following surgery reported lower grief (Mdifference = −19.71; 95% CI, −39.41 to −0.01) than parents whose child had not. Conclusions. The results highlight the potential for interventions and care tailored to parents’ treatment decisions and outcomes to support parental coping and well-being. Highlights Question: Do the psychological and decision-making outcomes of parents differ based on their treatment decision and survival outcome following prenatal diagnosis with complex CHD? Findings: In this exploratory study, parents who decided to pursue comfort-directed care after a prenatal diagnosis reported higher levels of psychological distress and grief as well as higher decisional conflict and regret than parents who decided to pursue surgery. Meaning: The findings from this exploratory study highlight potential differences in parents’ psychological and decision-making outcomes following a diagnosis of complex CHD for their fetus, which appear to relate to the treatment approach and the treatment outcome and may require tailoring of psychological and decision support.

BackgroundIn the first year of the COVID-19 pandemic, studies reported delays in health care usage due to safety concerns. Delays in care may result in increased morbidity and mortality from otherwise treatable conditions. Telehealth provides a safe alternative for patients to receive care when other circumstances make in-person care unavailable or unsafe, but information on patient experiences is limited. Understanding which people are more or less likely to use telehealth and their experiences can help tailor outreach efforts to maximize the impact of telehealth. ObjectiveThis study aims to examine the characteristics of telehealth users and nonusers and their reported experiences among veteran and nonveteran respondents. MethodsA nationwide web-based survey of current behaviors and health care experiences was conducted in December 2020-March 2021. The survey consisted of 3 waves, and the first wave is assessed here. Respondents included US adults participating in Qualtrics web-based panels. Primary outcomes were self-reported telehealth use and number of telehealth visits. The analysis used a 2-part regression model examining the association between telehealth use and the number of visits with respondent characteristics. ResultsThere were 2085 participants in the first wave, and 898 (43.1%) reported using telehealth since the pandemic began. Most veterans who used telehealth reported much or somewhat preferring an in-person visit (336/474, 70.9%), while slightly less than half of nonveterans (189/424, 44.6%) reported this preference. While there was no significant difference between veteran and nonveteran likelihood of using telehealth (odds ratio [OR] 1.33, 95% CI 0.97-1.82), veterans were likely to have more visits when they did use it (incidence rate ratio [IRR] 1.49, 95% CI 1.07-2.07). Individuals were less likely to use telehealth and reported fewer visits if they were 55 years and older (OR 0.39, 95% CI 0.25-0.62 for ages 55-64 years; IRR 0.43, 95% CI 0.28-0.66) or lived in a small city (OR 0.63, 95% CI 0.43-0.92; IRR 0.71, 95% CI 0.51-0.99). Receiving health care partly or primarily at the Veterans Health Administration (VA) was associated with telehealth use (primarily VA: OR 3.25, 95% CI 2.20-4.81; equal mix: OR 2.18, 95% CI 1.40-3.39) and more telehealth visits (primarily VA: IRR 1.5, 95% CI 1.10-2.04; equal mix: IRR 1.57, 95% CI 1.11-2.24). ConclusionsTelehealth will likely continue to be an important source of health care for patients, especially following situations like the COVID-19 pandemic. Some groups who may benefit from telehealth are still underserved. Telehealth services and outreach should be improved to provide accessible care for all.

Introduction Chronic kidney disease (CKD) affects 30 million Americans. Early management focused on blood pressure (BP) control decreases cardiovascular morbidity and mortality. Less than 40% of patients with CKD achieve recommended BP targets due to many barriers. These barriers include a lack of understanding of the implications of their diagnosis and how to optimise their health.This cluster randomised control trial hypothesises that the combination of early primary care CKD education, and motivational interviewing (MI)-based health coach support, will improve patient behaviours aligned with BP control by increasing patient knowledge, self-efficacy and motivation. The results will aid in sustainable interventions for future patient-centric education and coaching support to improve quality and outcomes in patients with CKD stages 3–5. Outcomes in patients with CKD stages 3–5 receiving the intervention will be compared with similar patients within a control group. Continuous quality improvement (CQI) and systems methodologies will be used to optimise resource neutrality and leverage existing technology to support implementation and future dissemination. The innovative approach of this research focuses on the importance of a multidisciplinary team, including off-site patient coaching, that can intervene early in the CKD care continuum by supporting patients with education and coaching.Methods and analysis We will test impact of BP control when clinician-delivered education is followed by 12 months of MI-based health coaching. We will compare outcomes in 350 patients with CKD stages 3–5 between intervention and control groups in primary care. CQI and systems methodologies will optimise education and coaching for future implementation and dissemination.Ethics and dissemination This study was approved by the University of Michigan Institutional Review Boards (IRBMED) HUM00136011, HUM00150672 and SITE00000092 and the results of the study will be published on ClinicalTrials.gov, in peer-reviewed journals, as well as conference abstracts, posters and presentations.Trial registration number NCT04087798.

Introduction Decision aids (DAs) are helpful instruments used to support shared decision making (SDM). Patients with atrial fibrillation (AF) face complex decisions regarding stroke prevention strategies. While a few DAs have been made for AF stroke prevention, an encounter DA (EDA) and patient DA (PDA) have not been created to be used in conjunction with each other before. Design Using iterative user-centered design, we developed 2 DAs for anticoagulation choice and stroke prevention in AF. Prototypes were created, and we elicited feedback from patients and experts via observations of encounters, usability testing, and semistructured interviews. Results User testing was done with 33 experts (in AF and SDM) and 51 patients from 6 institutions. The EDA and PDA underwent 1 and 4 major iterations, respectively. Major differences between the DAs included AF pathophysiology and a preparation to meet with the clinician in the PDA as well as different language throughout. Content areas included personalized stroke risk, differences between anticoagulants, and risks of bleeding. Based on user feedback, developers 1) addressed feelings of isolation with AF, 2) improved navigation options, 3) modified content and flow for users new to AF and those experienced with AF, 4) updated stroke risk pictographs, and 5) added structure to the preparation for decision making in the PDA. Limitations These DAs focus only on anticoagulation for stroke prevention and are online, which may limit participation for those less comfortable with technology. Conclusions Designing complementary DAs for use in tandem or separately is a new method to support SDM between patients and clinicians. Extensive user testing is essential to creating high-quality tools that best meet the needs of those using them. Highlights First-time complementary encounter and patient decision aids have been designed to work together or separately. User feedback led to greater structure and different experiences for patients naïve or experienced with anticoagulants in patient decision aids. Online tools allow for easier dissemination, use in telehealth visits, and updating as new evidence comes out.

The American Heart Association's Strategically Focused Children's Research Network started in July 2017 with 4 unique programs at Children's National Hospital in Washington, DC; Duke University in Durham, North Carolina; University of Utah in Salt Lake City, Utah; and Lurie Children's Hospital/Northwestern University in Chicago, Illinois. The overarching goal of the Children's National center was to develop evidence‐based strategies to strengthen the health system response to rheumatic heart disease through synergistic basic, clinical, and population science research. The overall goals of the Duke center were to determine risk factors for obesity and response to treatment including those that might work on a larger scale in communities across the country. The integrating theme of the Utah center focused on leveraging big data‐science approaches to improve the quality of care and outcomes for children with congenital heart defects, within the context of the patient and their family. The overarching hypothesis of the Northwestern center is that the early course of change in cardiovascular health, from birth onward, reflects factors that result in either subsequent development of cardiovascular risk or preservation of lifetime favorable cardiovascular health. All 4 centers exceeded the original goals of research productivity, fellow training, and collaboration. This article describes details of these accomplishments and highlights challenges, especially around the COVID‐19 pandemic.

Rationale & Objective: Multidisciplinary chronic kidney disease (CKD) care has been associated with improved clinical outcomes in comparison to general nephrology care. However, there is little research examining the impact of multidisciplinary care on patient-centered outcomes. We examined if a multidisciplinary approach to CKD care was associated with 4 patient-centered outcomes. Study Design: Cross-sectional study design using previously established surveys to assess patient-centered outcomes in participants with nondialysis CKD. Setting & Participants: Adults with CKD stages 1-5 who had not undergone transplant or were not on dialysis. Exposures: General nephrology care or multidisciplinary care. Patients receiving multidisciplinary care were seen by a pharmacist, social worker, dietitian, and nephrologist, whereas patients receiving general nephrology care only saw a nephrologist. Outcomes: Four patient-centered outcomes: CKD-specific knowledge, disease-related stress, perception of overall health, and perception of health status compared to 1 year ago. Analytical Approach: Differences were examined using a Welch 2-sample t test and linear regression model. Results: Mean age of participants was 60 years with standard deviation of 17 years. 182 (77%) patients were White, and 230 (96%) had formal education greater than or equal to high school. 121 (49%) were women, and 215 (88%) had CKD stage 3-5. 77 (31%) received multidisciplinary care. We did not identify any significant differences in patient knowledge, stress, or perception of health between multidisciplinary and general nephrology care. However, notably, patients in multidisciplinary care were older and had more advanced CKD than those in general nephrology care. Limitations: Cross-sectional study designs only identify associations. Study was conducted at clinics located within 30 miles of each other, limiting generalizability. Conclusions: Our results suggest that a team-based approach to care can better support sicker, more vulnerable patients so that they can achieve similar patient-centered outcomes compared to patients who are younger and with less advanced CKD.

BackgroundA growing number of Americans are enrolled in high-deductible health plans (HDHPs). Enrollees in HDHPs, particularly those with chronic conditions, face high out-of-pocket costs and often delay or forgo needed care owing to cost. These challenges could be mitigated by the use of cost-conscious strategies when seeking health care, such as discussing costs with providers, saving for medical expenses, and using web-based tools to compare prices, but few HDHP enrollees engage in such cost-conscious strategies. A novel behavioral intervention could enable HDHP enrollees with chronic conditions to adopt these strategies, but it is unknown which intervention features would be most valued and used by this patient population. ObjectiveThis study aimed to assess preferences among HDHP enrollees with chronic conditions for a novel behavioral intervention that supports the use of cost-conscious strategies when planning for and seeking health care. MethodsIn an exploratory sequential mixed methods study among HDHP enrollees with chronic conditions, we conducted 20 semistructured telephone interviews and then surveyed 432 participants using a national internet survey panel. Participants were adult HDHP enrollees with diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, or asthma. The interviews and survey assessed participants’ health care experiences when using HDHPs and their preferences for the content, modality, and frequency of use of a novel intervention that would support their use of cost-conscious strategies when seeking health care. ResultsApproximately half (11/20, 55%) of the interview participants reported barriers to using cost-conscious strategies. These included not knowing where to find information and worrying that the use of cost-conscious strategies would be very time consuming. Most (18/20, 90%) interviewees who had discussed costs with providers, saved for medical expenses, or used web-based price comparison tools found these strategies to be helpful for managing their health care costs. Most (17/20, 85%) interviewees expressed interest in an intervention delivered through a website or phone app that would help them compare prices for services at different locations. Survey participants were most interested in learning to compare prices and quality, followed by discussing costs with their providers and putting aside money for care, through a website-based or email-based intervention that they would use a few times a year. ConclusionsRegular use of cost-conscious strategies could mitigate financial barriers faced by HDHP enrollees with chronic conditions. Interventions to encourage the use of cost-conscious strategies should be delivered through a web-based modality and focus on helping these patients in navigating their HDHPs to better manage their out-of-pocket spending.

Objective: To explore themes underlying why anticoagulants are under-prescribed for stroke prevention in atrial fibrillation (AF) patients from the clinician’s perspective and characteristics of those patients. Methods: Clinicians at the University of Utah Health system were recruited for semi-structured 15-minute interviews. An interview guide focused on anticoagulant prescribing practices for patients with AF. Interviews were transcribed verbatim. Two reviewers independently coded passages corresponding with key themes. Results: Eleven practitioners were interviewed from cardiology, internal medicine, and family practice. Five themes were found: the role of compliance in anticoagulation decision making, the role of pharmacists in supporting clinicians, the use of shared decision making and risk communication, risk of bleeding as the main barrier to taking anticoagulants, and the variety of reasons patients have for not starting or discontinuing anticoagulants. Conclusion: Fear of bleeding was the foremost reason underlying anticoagulant underutilization in patients with AF followed by compliance, and patient worries. Communication between patients and clinicians as well as interdisciplinary teamwork are key to understanding and improving anticoagulant prescribing in AF. Innovation: Our study was the first to assess the role pharmacists play in prescribing clinician’s decisions surrounding anticoagulant use in AF. Pharmacists could play an important collaborative role in SDM.

BackgroundAlternative cancer therapy is associated with increased mortality, but little is known about those who pursue it. ObjectiveWe aimed to describe individuals’ motivations for using alternative cancer therapies and determine whether motivations differ based on individuals’ timing of seeking alternative therapies. MethodsWe used data from 649 campaigns posted on the website GoFundMe between 2011 and 2019 for beneficiaries with cancer pursuing alternative therapy. The data were analyzed using a mixed methods approach. Campaigns were categorized by timing of alternative therapy (either before or after experiencing conventional therapy). Qualitative analysis identified motivational themes. Chi-square tests of independence and Fisher tests (all 2-sided) determined significant differences in the presence of motivational themes between groups. ResultsThe expression of concerns about the efficacy of conventional therapy was significantly more likely in campaigns for individuals who used conventional therapy first than in campaigns for individuals who started with alternative therapy (63.3% vs 41.7%; P

Abstract Background While many studies have tested the impact of a decision aid (DA) compared to not receiving any DA, far fewer have tested how different types of DAs affect key outcomes such as treatment choice, patient–provider communication, or decision process/satisfaction. This study tested the impact of a complex medical oriented DA compared to a more simplistic decision aid designed to encourage shared decision making in men with clinically localized prostate cancer. Methods 1028 men at 4 VA hospitals were recruited after a scheduled prostate biopsy. Participants completed baseline measures and were randomized to receive either a simple or complex DA. Participants were men with clinically localized cancer (N = 285) by biopsy and who completed a baseline survey. Survey measures: baseline (biopsy); immediately prior to seeing the physician for biopsy results (pre- encounter); one week following the physician visit (post-encounter). Outcome measures included treatment preference and treatment received, knowledge, preference for shared decision making, decision making process, and patients’ use and satisfaction with the DA. Results Participants who received the simple DA had greater interest in shared decision making after reading the DA (p = 0.03), found the DA more helpful (p’s

Abstract Background Black men are disproportionately affected by prostate cancer, the most common non-cutaneous malignancy among men in the USA. The United States Preventive Services Task Force (USPSTF) encourages prostate-specific antigen (PSA) testing decisions to be based on shared decision-making (SDM) clinician professional judgment, and patient preferences. However, evidence suggests that SDM is underutilized in clinical practice, especially among the most vulnerable patients. The purpose of this study is to evaluate the efficacy of a community health worker (CHW)-led decision-coaching program to facilitate SDM for prostate cancer screening among Black men in the primary care setting, with the ultimate aim of improving/optimizing decision quality. Methods We proposed a CHW-led decision-coaching program to facilitate SDM for prostate cancer screening discussions in Black men at a primary care FQHC. This study enrolled Black men who were patients at the participating clinical site and up to 15 providers who cared for them. We estimated to recruit 228 participants, ages 40–69 to be randomized to either (1) a decision aid along with decision coaching on PSA screening from a CHW or (2) receiving a decision aid along with CHW-led interaction on modifying dietary and lifestyle to serve as an attention control. The independent randomization process was implemented within each provider and we controlled for age by dividing patients into two strata: 40–54 years and 55–69 years. This sample size sufficiently powered the detection differences in the primary study outcomes: knowledge, indicative of decision quality, and differences in PSA screening rates. Primary outcome measures for patients will be decision quality and decision regarding whether to undergo PSA screening. Primary outcome measures for providers will be acceptability and feasibility of the intervention. We will examine how decision coaching about prostate cancer screening impact patient-provider communication. These outcomes will be analyzed quantitatively through objective, validated scales and qualitatively through semi-structured, in-depth interviews, and thematic analysis of clinical encounters. Through a conceptual model combining elements of the Preventative Health Care Model (PHM) and Informed Decision-Making Model, we hypothesize that the prostate cancer screening decision coaching intervention will result in a preference-congruent decision and decisional satisfaction. We also hypothesize that this intervention will improve physician satisfaction with counseling patients about prostate cancer screening. Discussion Decision coaching is an evidence-based approach to improve decision quality in many clinical contexts, but its efficacy is incompletely explored for PSA screening among Black men in primary care. Our proposal to evaluate a CHW-led decision-coaching program for PSA screening has high potential for scalability and public health impact. Our results will determine the efficacy, cost-effectiveness, and sustainability of a CHW intervention in a community clinic setting in order to inform subsequent widespread dissemination, a critical research area highlighted by USPSTF. Trial registration The trial was registered prospectively with the National Institute of Health registry ( www.clinicaltrials.gov ), registration number NCT03726320 , on October 31, 2018.

BackgroundLung cancer risk and life expectancy vary substantially across patients eligible for low-dose computed tomography lung cancer screening (LCS), which has important consequences for optimizing LCS decisions for different patients. To account for this heterogeneity during decision-making, web-based decision support tools are needed to enable quick calculations and streamline the process of obtaining individualized information that more accurately informs patient-clinician LCS discussions. We created DecisionPrecision, a clinician-facing web-based decision support tool, to help tailor the LCS discussion to a patient’s individualized lung cancer risk and estimated net benefit. ObjectiveThe objective of our study is to test two strategies for implementing DecisionPrecision in primary care at eight Veterans Affairs medical centers: a quality improvement (QI) training approach and academic detailing (AD). MethodsPhase 1 comprised a multisite, cluster randomized trial comparing the effectiveness of standard implementation (adding a link to DecisionPrecision in the electronic health record vs standard implementation plus the Learn, Engage, Act, and Process [LEAP] QI training program). The primary outcome measure was the use of DecisionPrecision at each site before versus after LEAP QI training. The second phase of the study examined the potential effectiveness of AD as an implementation strategy for DecisionPrecision at all 8 medical centers. Outcomes were assessed by comparing absolute tool use before and after AD visits and conducting semistructured interviews with a subset of primary care physicians (PCPs) following the AD visits. ResultsPhase 1 findings showed that sites that participated in the LEAP QI training program used DecisionPrecision significantly more often than the standard implementation sites (tool used 190.3, SD 174.8 times on average over 6 months at LEAP sites vs 3.5 SD 3.7 at standard sites; P

Abstract Background Surrogate decision makers of stroke patients are often unprepared to make critical decisions on life-sustaining treatments. We describe the development process and key features for the Understanding Stroke web-based decision support tool. Methods We used multiple strategies to develop a patient-centered, tailored decision aid. We began by forming a Patient and Family Advisory Council to provide continuous input to our multidisciplinary team on the development of the tool. Additionally, focus groups consisting of nurses, therapists, social workers, physicians, stroke survivors, and family members reviewed key elements of the tool, including prognostic information, graphical displays, and values clarification exercise. To design the values clarification exercise, we asked focus groups to provide feedback on a list of important activities of daily living. An ordinal prognostic model was developed for ischemic stroke and intracerebral hemorrhage using data taken from the Virtual International Stroke Trials Archive Plus, and incorporated into the tool. Results Focus group participants recommended making numeric prognostic information optional due to possible emotional distress. Pie charts were generally favored by participants for graphical presentation of prognostic information, though a horizontal stacked bar chart was also added due to its prevalence in stroke literature. Plain language descriptions of the modified Rankin Scale were created to accompany the prognostic information. A values clarification exercise was developed consisting of a list of 13 situations that may make an individual consider comfort measures only. The final version of the web based tool (which can be viewed on tablets) included the following sections: general introduction to stroke, outcomes (prognostic information and recovery), in-hospital and life-sustaining treatments, decision making and values clarification, post-hospital care, tips for talking to the health care team, and a summary report. Preliminary usability testing received generally favorable feedback. Conclusion We developed Understanding Stroke, a tailored decision support tool for surrogate decision makers of stroke patients. The tool was well received and will be formally pilot tested in a group of stroke surrogate decision makers. Trial registration ClinicalTrials.gov ( NCT03427645 ).

Introduction: Individuals with chronic kidney disease (CKD) generally have poor participation in self-care. We hypothesized that greater kidney disease knowledge and health literacy would associate with better self-care. Methods: We enrolled 401 participants with non–dialysis-dependent CKD from one academic center in this cross-sectional study. Validated surveys were used to assess health literacy level (inadequate vs. adequate; Rapid Estimate of Adult Literacy in Medicine), perceived kidney disease knowledge (Perceived Kidney Disease Knowledge Survey [PiKS]), objective kidney disease knowledge (Kidney Disease Knowledge Survey [KiKS]), and a CKD self-care measure was constructed as the sum of self-reported self-care behaviors using the adapted Summary of Diabetes Self-Care Activities Assessment. The association between health literacy level, PiKS scores, KiKS scores, and the CKD self-care measure was assessed with multivariable adjusted linear regression models. Results: Participants had a mean age of 57 years and 17.7% had inadequate health literacy. PiKS scores were positively associated with the CKD self-care measure (β = 1.05, 95% confidence interval [CI] 0.50–1.63), and a positive trend was observed for KiKS scores and the CKD self-care measure (β = 0.30, 95% CI: −0.12 to 0.72). Health literacy was not associated with CKD self-care measure. Conclusion: Objective kidney disease knowledge is likely necessary, but not sufficient for self-care and may depend on the level of health literacy. Perceived kidney knowledge may offer a novel target to assess patients at risk for poor self-care, and be used in targeted educational interventions. Keywords: health literacy, kidney disease knowledge, perceived kidney disease knowledge, self-care, self-efficacy, self-management

Introduction Academic health centers (AHCs) play critical roles in population health by providing health care, conducting population health research, and providing population health training and education. This publication describes an interactive, multipart, case-based session targeted at AHC executives, faculty, and administrators about population health initiatives at AHCs and how the AHC structure can be leveraged to promote population health. Methods This 90-minute virtual session was conducted during the Association of Academic Health Centers’ 2020 annual meeting. The session opened with 5-minute, Ignite-style presentations showcasing population health innovations. Next, in small groups, participants discussed a case introducing a fictional AHC charged with assisting its local government's population health efforts. Participants self-selected into one of four small groups (analytics, education and training, community engagement, and implementation) and were provided additional case content and tailored prompts. In the large group, participants debriefed their discussions. Participants completed a postsession survey. Results Forty-six individuals from 31 AHCs participated. Eighteen participants completed the survey. Sixteen respondents (89%) agreed the session was valuable and provided ideas for implementation at their AHC. Fifteen participants (83%) indicated that they planned to follow up with their colleagues regarding how to leverage the AHC structure to improve population health. Discussion This session provides an interactive forum to discuss population health in the context of an AHC and examine how its structure can facilitate population health. While offered at a conference, the session can also be implemented at a single AHC to foster local understanding of population health and inform future initiatives.

PurposeBeliefs that the risks from a COVID-19 vaccine outweigh the risks from getting COVID-19 and concerns that the vaccine development process was rushed and lacking rigor have been identified as important drivers of hesitancy and refusal to get a COVID-19 vaccine. We tested whether messages designed to address these beliefs and concerns might promote intentions to get a COVID-19 vaccine.MethodWe conducted an online survey fielded between March 8-23, 2021 with US Veteran (n = 688) and non-Veteran (n = 387) respondents. In a between-subjects experiment, respondents were randomly assigned to a control group (with no message) or to read one of two intervention messages: 1. a fact-box styled message comparing the risks of getting COVID-19 compared to the vaccine, and 2. a timeline styled message describing the development process of the COVID-19 mRNA vaccines.ResultsMost respondents (60%) wanted a COVID-19 vaccine. However, 17% expressed hesitancy and 23% did not want to get a COVID-19 vaccine. The fact-box styled message and the timeline message did not significantly improve vaccination intentions, F(2,358) = 0.86, p = .425, [Formula: see text] = .005, or reduce the time respondents wanted to wait before getting vaccinated, F(2,306) = 0.79, p = .453, [Formula: see text] = .005, compared to no messages.DiscussionIn this experimental study, we did not find that providing messages about vaccine risks and the development process had an impact on respondents' vaccine intentions. Further research is needed to identify how to effectively address concerns about the risks associated with COVID-19 vaccines and the development process and to understand additional factors that influence vaccine intentions.

Abstract Background Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, and accounts for 8% of individuals with moderate or severe dizziness. BPPV patients experience substantial inconveniences and disabilities during symptomatic periods. BPPV therapeutic processes – the Dix-Hallpike Test (DHT) and the Canalith Repositioning Maneuver (CRM) – have an evidence base that is at the clinical practice guideline level. The most commonly used CRM is the modified Epley maneuver. The DHT is the gold standard test for BPPV and the CRM is supported by numerous randomized controlled trials and systematic reviews. Despite this, BPPV care processes are underutilized. Methods/design This is a stepped-wedge, randomized clinical trial of a multi-faceted educational and care-process-based intervention designed to improve the guideline-concordant care of patients with BPPV presenting to the emergency department (ED) with dizziness. The unit of randomization and target of intervention is the hospital. After an initial observation period, the six hospitals will undergo the intervention in five waves (two closely integrated hospitals will be paired). The order will be randomized. The primary endpoint is measured at the individual patient level, and is the presence of documentation of either the Dix-Hallpike Test or CRM. The secondary endpoints are referral to a health care provider qualified to treat dizziness for CRM and 90-day stroke rates following an ED dizziness visit. Formative evaluations are also performed to monitor and identify potential and actual influences on the progress and effectiveness of the implementation efforts. Discussion If this study safely increases documentation of the DHT/CRM, this will be an important step in implementing the use of these evidenced-based processes of care. Positive results will support conducting larger-scale follow-up studies that assess patient outcomes. The data collection also enables evaluation of potential and actual influences on the progress and effectiveness of the implementation efforts. Trial registration ClinicalTrials.gov, ID: NCT02809599. The record was first available to the public on 22 June 2016 prior to the enrollment of the first patients in October 2016.

Rationale & Objective: Electronic health record portals are increasingly emphasized in chronic kidney disease (CKD). However, associations of portal use with clinical and patient-centered outcomes remain unknown. Study Design: Cross-sectional survey (April 2015 to March 2018). Setting & Participants: Nondialysis patients with CKD from nephrology clinics within 1 academic medical center. Exposures: Patient demographics (age, sex, race, ethnicity, education, and income), kidney function. Outcomes: Association between portal use as an outcome and exposures. Additionally, associations of portal use and patient demographics with 4 patient–centered outcomes (CKD-specific knowledge, stress, and 2 self-ratings of health). Analytic Approach: Logistic regression to examine associations between patient portal use, demographics, and kidney function. Linear regression to examine associations between portal use and patient-centered outcomes. Results: Of 245 participants, mean age was 60 ± 17 (SD) years, 182 (77%) were White, 121 (49%) were women, 230 (96%) had a high school education or higher, and 96 (45%) had

This study investigated a remote symptom monitoring intervention to examine if older participants with cancer received a similar magnitude of benefit compared with younger adults with cancer. We analyzed a longitudinal symptom monitoring intervention for 358 participants beginning a new course of chemotherapy treatment in community and academic oncology practices. The study design was a randomized control trial; participants were randomized to the intervention or usual care, the intervention was delivered during daily automated coaching. Older adults with moderate and severe symptoms derived similar benefit as those adults younger than 60 years of age, adherence to the study protocol which involved daily calls was high. There was no significant difference between the 2 age categories; on average, older adult participants made 88% of expected daily calls and younger adult participants made 90% of expected daily calls. Our results challenge the perception that older adults are unwilling or unable to use a technological tool such as interactive voice response and suggest that patient utilization may be guided by other factors, such as ease of use and perceived benefit from the intervention.

Purpose. There is no gold-standard health literacy measure. The Single Item Literacy Screener (SILS) and Subjective Literacy Screener (SLS) ask people to self-report ability to understand health information. They were developed in older adults, before common use of electronic health information. This study explored whether the SILS and SLS related to objective literacy, numeracy, and comprehension among young adults, and whether specifying “online” or “paper-based” wording affected these relationships. Methods. Eligible individuals (18–35 years of age, English-speaking, US residents) from an online survey company were randomized to 1) original measures; 2) measures adding “paper-based” to describe health information/forms; or 3) measures adding “online” to describe health information/forms. We examined how each measure related to e-Health Literacy (eHEALS), subjective numeracy (SNS), objective numeracy (ONS), and comprehension of a short passage. Results. A total of 848/1342 respondents correctly answered attention-checks and were analyzed. The validated SILS related to comprehension ( P = 0.003), eHEALS ( P = 0.04), and ONS ( P < 0.001) but not SNS ( P = 0.44). When adding “paper-based,” SILS related to eHEALS ( P < 0.001) and ONS ( P = 0.003) but did not relate to comprehension ( P = 0.25) or SNS ( P = 0.35). When adding “online,” SILS related to comprehension ( P < 0.001), eHEALS ( P < 0.001), ONS ( P = 0.005), and SNS ( P = 0.03). The validated SLS related to comprehension ( P < 0.001), eHEALS ( P < 0.001), ONS ( P < 0.001), and SNS ( P < 0.001). When adding “paper-based,” the SLS only related to eHEALS ( P =

Evidence suggests that older adults with mild cognitive impairment (MCI) might not receive evidence-based treatments. We explored the impact of patient MCI on physician decision-making and recommendations for acute ischemic stroke (AIS) and acute myocardial infarction (AMI) in a pilot concurrent mixed-methods study of physicians recruited from one academic center. The mailed survey included a clinical vignette of AIS or AMI where the patient cognitive status was randomized (normal cognition, MCI, or early-stage dementia). The primary outcome was a composite summary measure of the proportion of guideline-concordant treatments recommended. Linear regression compared the primary outcome across patient cognition groups adjusting for physician characteristics. Semi-structured interviews done with 18 physicians (4 cardiologists, 9 neurologists, 5 internists) using a standard guide. Survey response rate was 72% (82/114) (49/61 neurologists; 33/53 cardiologists). As patient cognition worsened, neurologists recommended less guideline-concordant treatments after AIS (Ptrend

We tested the effect of prior vaccination on response to communication strategies in a hypothetical news article about an influenza pandemic. Vaccinated were more likely than nonvaccinated participants to plan future vaccination, and future vaccination intent was greater with certain communication strategies. Using these findings to target communication may increase vaccination rates.

Abstract Background Prediabetes is an asymptomatic condition in which patients’ blood glucose levels are higher than normal but do not meet diagnostic criteria for type 2 diabetes mellitus (T2DM). A key window of opportunity to increase engagement of patients with prediabetes in strategies to prevent T2DM is when they are screened for T2DM and found to have prediabetes, yet the effects of this screening and brief counseling are unknown. Methods In this parallel-design randomized controlled trial we will recruit 315 non-diabetic patients from the Ann Arbor VA Medical Center (AAVA) who have one or major risk factors for T2DM and an upcoming primary care appointment at the AAVA, but have not had a hemoglobin A1c (HbA1c) test to screen for T2DM in the previous 12 months. After informed consent, participants will complete a baseline survey and be randomly assigned to, at the time of their next primary care appointment, one of two arms: (1) to have a hemoglobin A1c (HbA1c) test to screen for T2DM and receive brief, standardized counseling about these results or (2) to review a brochure about clinical preventive services. Participants will complete surveys 2 weeks, 3 months, and 12 months after their primary care appointment, and a weight measurement 12 months after their primary care appointment. The primary outcome is weight change after 12 months. The secondary outcomes are changes in perception of risk for T2DM; knowledge of T2DM prevention; self-efficacy and motivation to prevent T2DM; use of pharmacotherapy for T2DM prevention; physical activity; participation in weight management programs; and mental health. Quantitative analyses will compare outcomes among participants in the HbA1c test arm found to have prediabetes with participants in the brochure arm. Among participants in the HbA1c test arm found to have prediabetes we will conduct semi-structured interviews about their understanding of and reactions to receiving a prediabetes diagnosis. Discussion This trial will generate foundational data on the effects of a prediabetes diagnosis and brief counseling on patients’ preventive behaviors and mediators of these behaviors that will enable the development of novel strategies to improve patient engagement in T2DM prevention. Trial registration ClinicalTrials.gov, NCT02747108 . Registered on 18 April 2016.

Background. Few Americans obtain all 41 guideline-recommended preventive services for nonpregnant adults. We assessed patient interest in prioritizing their preventive care needs. Methods. We conducted a mixed-methods study, with 4 focus groups ( N = 28) at a single institution and a nationwide survey ( N = 2,103). Participants were middle-aged and older adults with preventive care needs. We obtained reactions to written materials describing the magnitude of benefit from major preventive services, including both absolute and relative benefits. Recommendations were individualized for patient risk factors (“individualized preventive care recommendations”). Focus groups assessed patient interest, how patients would want to discuss individualized recommendations with their providers, and potential for individualized recommendations to influence patient decision making. Survey content was based on focus groups and analyzed with logistic regression. Results. Patients expressed strong interest in individualized recommendations. Among survey respondents, an adjusted 88.2% (95% confidence interval [CI] = 86.7% to 89.7%) found individualized recommendations very easy to understand, 77.2% (95% CI = 75.3% to 79.1%) considered them very useful, and 64.9% (95% CI = 62.8% to 67.0%) highly trustworthy (each ≥6/7 on Likert scale). Three quarters of participants wanted to receive their own individualized recommendations in upcoming primary care visits (adjusted proportion = 77.5%, 95% CI = 75.6% to 79.4%). Both focus group and survey participants supported shared decision making and reported that individualized recommendations would improve motivation to obtain preventive care. Half of survey respondents reported that they would be much more likely to visit their doctor if they knew individualized recommendations would be discussed, compared with 4.2% who would not be more likely to visit their doctor. Survey respondents already prioritized preventive services, stating they were most likely to choose quick/easy preventive services and least likely to choose expensive preventive services (adjusted proportions, 63.8% and 8.5%, respectively). Results were consistent in sensitivity analyses. Conclusions. Individualized preventive care recommendations are likely to be well received in primary care and might motivate patients to improve adherence to evidence-based care.

To investigate determinants of the public’s perceptions of disease threat, in 2015 we conducted a randomized survey experiment in the Netherlands. Adults who read a mock news article describing average +or extreme outcomes from a hypothetical influenza pandemic were more influenced by average than by extreme case information. Presenting both types of information simultaneously appeared counterproductive.

Human papillomavirus (HPV) is the most prevalent sexually transmitted infection worldwide and can lead to the development of genital warts, and cancers throughout the body. Despite the availability of HPV vaccines for over a decade, uptake in the United States among adolescents and young adults remains well below national targets. While most efforts to improve HPV vaccine uptake have rightly focused on adolescents, there is still a tremendous opportunity to improve vaccination among young adults who have not been vaccinated against HPV. To that end, we report an exploratory examination of associations between HPV vaccination status and intentions with psychological traits that may impact HPV vaccine uptake with a national, demographically diverse sample of young adults (N = 1358) who completed an online survey. These psychological traits conceptually mapped onto motivations to: 1) understand health-related information, 2) deliberate, 3) manage uncertainty, and 4) manage threats. We found notable gender differences for the association of these motivations and vaccination status. For women, higher interest in and ability to understand health-related information seemed to distinguish those who reported receiving the HPV vaccine from those who did not. For men, less need to deliberate and greater needs to manage threat and uncertainty seemed to be the distinguishing motives for those who reported receiving the HPV vaccine compared to those who did not. Results for vaccination intentions were less consistent, but there was some evidence to indicate that, regardless of gender, greater health-related information interest and understanding and need to manage uncertainty and threats were associated with increased intention to receive the HPV vaccine, while greater need to deliberate was associated with decreased vaccination intentions. These results suggest that there are psychological differences that are associated with HPV vaccination decisions and that these motivations should be considered in efforts to improve HPV vaccine uptake.

Persons who read information about a hypothetical influenza strain with scientific (H11N3 influenza) or exotic-sounding (Yarraman flu) name reported higher worry and vaccination intentions than did those who read about strains named after an animal reservoir (horse flu). These findings suggest that terms used for influenza in public communications can influence reactions.

When survey respondents rate the quality of life (QoL) associated with a health condition, they must not only evaluate the health condition itself, but must also interpret the meaning of the rating scale in order to assign a specific value. The way that respondents approach this task depends on subjective interpretations, resulting in inconsistent results across populations and tasks. In particular, patients and non-patients often give very different ratings to health conditions, a discrepancy that raises questions about the objectivity of either groups’ evaluations. In this study, we found that the perspective of the raters (i.e., their own current health relative to the health conditions they rated) influences the way they distinguish between different health states that vary in severity. Consistent with prospect theory, a mild and a severe lung disease scenario were rated quite differently by lung disease patients whose own health falls between the two scenarios, whereas healthy non-patients, whose own health was better than both scenarios, rated the two scenarios as much more similar. In addition, we found that the context of the rating task influences the way participants distinguish between mild and severe scenarios. Both patients and non-patients gave less distinct ratings to the two scenarios when each were presented in isolation than when they were presented alongside other scenarios that provided contextual information about the possible range of severity for lung disease. These results raise continuing concerns about the reliability and validity of subjective QoL ratings, as these ratings are highly sensitive to differences between respondent groups and the particulars of the rating task.

Imagine that you have just received a colon cancer diagnosis and need to choose between two different surgical treatments. One surgery, the "complicated surgery," has a lower mortality rate (16% vs. 20%) but compared to the other surgery, the "uncomplicated surgery," also carries an additional 1% risk of each of four serious complications: colostomy, chronic diarrhea, wound infection, or an intermittent bowel obstruction. The complicated surgery dominates the uncomplicated surgery as long as life with complications is preferred over death.