The Third Leg: Patient The Third Leg: Patient Characteristics, Culture, Characteristics, Culture,

and Preferencesand Preferences

July 5, 2007July 5, 2007

The Third LegThe Third Leg Key Question: “What works for whom?”Key Question: “What works for whom?” Involves direct application of best available Involves direct application of best available

treatment, in the context of clinical treatment, in the context of clinical expertise, to the individual patientexpertise, to the individual patient

Involves a prior determination of population Involves a prior determination of population or sample relative risk/benefit, and then or sample relative risk/benefit, and then translating, as best as possible, these data translating, as best as possible, these data to the patient you are dealing withto the patient you are dealing with

Bottom line: this is a qualitative decision Bottom line: this is a qualitative decision making process: whether to offer the making process: whether to offer the treatment/assessment or not, in standard or treatment/assessment or not, in standard or modified form, to the patientmodified form, to the patient

Key Questions (APA EBPP Key Questions (APA EBPP report)report)

Do personality characteristics moderate the effectiveness of interventions?

Do social factors and cultural differences necessitate different forms of treatment according to such factors?

Can interventions widely tested in majority populations be readily adapted for patients with different ethnic or sociocultural backgrounds?

How can widely used interventions adequately attend to developmental considerations, both for children and adolescents?

How does comorbidity and polysymptomatic presentations moderate the impact of interventions?

Bottom line: how best to approach the treatment of patients whose characteristics (e.g., gender, gender identity, ethnicity, race, social class, disability status, sexual orientation) and problems (e.g., comorbidity) may differ from those of samples studied in research

Key concepts: “generalizability: and “transportability” Your ability to make this translation critically depends on your

understanding of research design and of how research can be generalized or qualified in the individual case

General Principles of General Principles of Individual Patient ApplicationIndividual Patient Application

“psychological services are most likely to be effective when responsive to the patient’s specific problems, strengths, personality, sociocultural context, and preferences”

“EBPP involves consideration of patients’ values, religious beliefs, worldviews, goals, and preferences for treatment with the psychologist’s experience and understanding of the available research”

General Principles of General Principles of Individual Patient ApplicationIndividual Patient Application

If the relative beneficial effect of treatment If the relative beneficial effect of treatment is stable across patients at different levels is stable across patients at different levels of risk from their disease, then those at of risk from their disease, then those at greatest risk will have the most to gain greatest risk will have the most to gain from treatment, and those at least risk from treatment, and those at least risk from their disease will have the least to from their disease will have the least to gain. The absolute benefit of treatment gain. The absolute benefit of treatment (how much they have to gain) can be (how much they have to gain) can be calculated by combining the relative effect calculated by combining the relative effect of treatment (from randomised trials and of treatment (from randomised trials and systematic reviews) with the risk of the systematic reviews) with the risk of the outcome without treatment (from cohort outcome without treatment (from cohort studies of prognosis). studies of prognosis).

Important Patient Important Patient CharacteristicsCharacteristics

Variations in presenting problems or disorders, etiology, concurrent symptoms or syndromes, and behavior

Chronological age, developmental status, developmental history, and life stage

Sociocultural and familial factors (e.g., gender, gender identity, ethnicity, race, social class, religion, disability status, family structure, and sexual orientation)

Conurrent environmental context, stressors (e.g., unemployment or recent life event), and social factors (e.g., institutional racism and health care disparities)

Personal preferences and values related to treatment (e.g., goals, beliefs, worldviews, and treatment expectations).

Patient Outcomes AssessmentPatient Outcomes Assessment

Patient Reported Outcomes: Represent domains of assessment that evaluate treatments from the point of view of the patient (impact of disease, benefits of treatment)

Three standards of outcome assessment: Patient, therapist, society; often don’t match

Key domains of interest: Health-related quality of life (HRQoL) Patient satisfaction Medication adherence Primary efficacy endpoints or patient symptoms Work productivity Patient preferences Functional status

Quality of Life Quality of Life AssessmentAssessment

http://www.fmhi.usf.edu/institute/pubs/pdf/mhlp/qol.pdf

Patient SatisfactionPatient Satisfaction

Technical service delivery v. Technical service delivery v. interpersonal careinterpersonal care

Measurement issuesMeasurement issues Do patients really have the knowledge Do patients really have the knowledge

to assess quality of care?to assess quality of care? Demand characteristics of assessmentDemand characteristics of assessment Cultural issues (e.g., Likert scales)Cultural issues (e.g., Likert scales) Satisfaction v. health outcomeSatisfaction v. health outcome

Cultural Issues – Cultural Issues – Multicultural CompetenciesMulticultural Competencies

Hansen, N.D., Pepitone-Arreola-Rockwell, F. & Greene, A.F. (2000). Multicultural competence: Criteria and case examples. Professional Psychology: Research and Practice, 31, 652-660.

Multicultural Comptencies Multicultural Comptencies (cont’d)(cont’d)

Dominant Culture

Racial/EthnicFamily

Gender

Structural factors/barriers

Cultural factors, racial identity, world view

Defining values

Roles/expectations

Biology

Core

Cultural Identity

Societal

Organizational

Professional

Individual

Ethnocentric monoculturalism

Monocultural policies, practices, programs, and structure (e.g., in government or employment setting)

Definition of psychology, standards of practice, ethics (e.g., DSM-IV definition of psychotic d/o)

Attitudes, beliefs, emotions, behaviors, discrimination, misinformation, prejudice

Institutional Factors

Adherence and Adherence and AcceptabilityAcceptability

Retrospective self-report (reliability limitations)Retrospective self-report (reliability limitations) Concurrent self-report (better)Concurrent self-report (better) Electronic assessment (for medication Electronic assessment (for medication

adherence)adherence) Interventions for improving adherenceInterventions for improving adherence Factors affecting adherenceFactors affecting adherence

CostCost Lifestyle interruptionLifestyle interruption Cognitive complexityCognitive complexity Side effects/utility of possible outcomesSide effects/utility of possible outcomes

Expected-values decision Expected-values decision makingmaking

Expected value = utility x probabilityExpected value = utility x probability Must know potential outcomes of Must know potential outcomes of

various treatment options as various treatment options as accurately as possible (from accurately as possible (from systematic reviews or clinical systematic reviews or clinical research studies)research studies)

Each potential outcome can then be Each potential outcome can then be assigned a “utility” that indicates assigned a “utility” that indicates how desirable it ishow desirable it is

Assessment TechniquesAssessment Techniques Techniques for Utility Measurement:Techniques for Utility Measurement:

Time Trade-Off TechniquesTime Trade-Off Techniques "Imagine that you are told that you have 10 years left to live. In "Imagine that you are told that you have 10 years left to live. In

connection with this you are also told that you can choose to live connection with this you are also told that you can choose to live these 10 years in your current health state or that you can choose these 10 years in your current health state or that you can choose to give up some life years to live for a shorter period in full health. to give up some life years to live for a shorter period in full health. Indicate with a cross on the line the number of years in full health Indicate with a cross on the line the number of years in full health that you think is of equal value to 10 years in your current health that you think is of equal value to 10 years in your current health state“ If the person puts the line on 4, the TTO is .4state“ If the person puts the line on 4, the TTO is .4

Patient presented with iterative choices until s/he is indifferent to Patient presented with iterative choices until s/he is indifferent to the choice; e.g., 20 blindness v. 5 perfect health, v. 10 perfect the choice; e.g., 20 blindness v. 5 perfect health, v. 10 perfect health, etc. If the below choice is the indifference point, the health health, etc. If the below choice is the indifference point, the health utility of one-eye blindness is 17/20 = .85utility of one-eye blindness is 17/20 = .85

Assessment Techniques Assessment Techniques (cont’d)(cont’d)

Standard Gamble TechniqueStandard Gamble Technique Patient ranks health care states along a continuum, and then is Patient ranks health care states along a continuum, and then is

asked to make a choice like the one below; relative size of the asked to make a choice like the one below; relative size of the “death” region (i.e., risk) is iteratively changed until person is “death” region (i.e., risk) is iteratively changed until person is indifferent to choiceindifferent to choice

Issues with Utility Issues with Utility MeasuresMeasures

Not often responsive to change in actual Not often responsive to change in actual health status – more responsive to health status – more responsive to changes in preference for health statuschanges in preference for health status

May be significant differences between May be significant differences between TTO and SG methods, thus questioning TTO and SG methods, thus questioning the true stability of the “utility” conceptthe true stability of the “utility” concept

Cognitively complex; may be difficult to Cognitively complex; may be difficult to use with impaired populationsuse with impaired populations

Patients vs. health care providers as Patients vs. health care providers as source of ratingssource of ratings

Concluding IssuesConcluding Issues

Applying best evidence to individual Applying best evidence to individual patients is more difficult and patients is more difficult and complicated than it soundscomplicated than it sounds

No clear indicator that such application No clear indicator that such application has occurred successfullyhas occurred successfully

No clear indicator which factors are the No clear indicator which factors are the most important to considermost important to consider

Lack of extensive research data on many Lack of extensive research data on many of the key individual difference variablesof the key individual difference variables