The Third Leg: Patient Characteristics, Culture, and Preferences July 5, 2007

The Third Leg Key Question: “What works for whom?” Key Question: “What works for whom?” Involves direct application of best available treatment, in the context of clinical expertise, to the individual patient Involves direct application of best available treatment, in the context of clinical expertise, to the individual patient Involves a prior determination of population or sample relative risk/benefit, and then translating, as best as possible, these data to the patient you are dealing with Involves a prior determination of population or sample relative risk/benefit, and then translating, as best as possible, these data to the patient you are dealing with Bottom line: this is a qualitative decision making process: whether to offer the treatment/assessment or not, in standard or modified form, to the patient Bottom line: this is a qualitative decision making process: whether to offer the treatment/assessment or not, in standard or modified form, to the patient

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

Important Patient Characteristics 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 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 Assessment

te/pubs/pdf/mhlp/qol.pdf

Patient Satisfaction Technical service delivery v. interpersonal care Technical service delivery v. interpersonal care Measurement issues Measurement issues Do patients really have the knowledge to assess quality of care? Do patients really have the knowledge to assess quality of care? Demand characteristics of assessment Demand characteristics of assessment Cultural issues (e.g., Likert scales) Cultural issues (e.g., Likert scales) Satisfaction v. health outcome Satisfaction v. health outcome

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

Multicultural Comptencies (cont’d)

Dominant Culture Racial/Ethnic Family 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 Acceptability Retrospective self-report (reliability limitations) Retrospective self-report (reliability limitations) Concurrent self-report (better) Concurrent self-report (better) Electronic assessment (for medication adherence) Electronic assessment (for medication adherence) Interventions for improving adherence Interventions for improving adherence Factors affecting adherence Factors affecting adherence Cost Cost Lifestyle interruption Lifestyle interruption Cognitive complexity Cognitive complexity Side effects/utility of possible outcomes Side effects/utility of possible outcomes

Expected-values decision making Expected value = utility x probability Expected value = utility x probability Must know potential outcomes of various treatment options as accurately as possible (from systematic reviews or clinical research studies) Must know potential outcomes of various treatment options as accurately as possible (from systematic reviews or clinical research studies) Each potential outcome can then be assigned a “utility” that indicates how desirable it is Each potential outcome can then be assigned a “utility” that indicates how desirable it is

Assessment Techniques Techniques for Utility Measurement: Techniques for Utility Measurement: Time Trade-Off Techniques Time Trade-Off Techniques "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 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. 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 state“ If the person puts the line on 4, the TTO is.4 "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 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. 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 state“ If the person puts the line on 4, the TTO is.4 Patient presented with iterative choices until s/he is indifferent to 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 utility of one-eye blindness is 17/20 =.85 Patient presented with iterative choices until s/he is indifferent to 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 utility of one-eye blindness is 17/20 =.85

Assessment Techniques (cont’d) Standard Gamble Technique Standard Gamble Technique Patient ranks health care states along a continuum, and then is asked to make a choice like the one below; relative size of the “death” region (i.e., risk) is iteratively changed until person is indifferent to choice Patient ranks health care states along a continuum, and then is asked to make a choice like the one below; relative size of the “death” region (i.e., risk) is iteratively changed until person is indifferent to choice

Issues with Utility Measures Not often responsive to change in actual health status – more responsive to changes in preference for health status Not often responsive to change in actual health status – more responsive to changes in preference for health status May be significant differences between TTO and SG methods, thus questioning the true stability of the “utility” concept May be significant differences between TTO and SG methods, thus questioning the true stability of the “utility” concept Cognitively complex; may be difficult to use with impaired populations Cognitively complex; may be difficult to use with impaired populations Patients vs. health care providers as source of ratings Patients vs. health care providers as source of ratings

Concluding Issues Applying best evidence to individual patients is more difficult and complicated than it sounds Applying best evidence to individual patients is more difficult and complicated than it sounds No clear indicator that such application has occurred successfully No clear indicator that such application has occurred successfully No clear indicator which factors are the most important to consider No clear indicator which factors are the most important to consider Lack of extensive research data on many of the key individual difference variables Lack of extensive research data on many of the key individual difference variables