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Angela Fagerlin

Publications and source records attributed to Angela Fagerlin.

30 records · Page 2Linked to original sources
PubMed2004

Lying to insurance companies: the desire to deceive among physicians and the public.

This study examines the public's and physicians' willingness to support deception of insurance companies in order to obtain necessary healthcare services and how this support varies based on perceptions of physicians' time pressures. Based on surveys of 700 prospective jurors and 1617 physicians, the public was more than twice as likely as physicians to sanction deception (26%versus 11%) and half as likely to believe that physicians have adequate time to appeal coverage decisions (22%versus 59%). The odds of public support for deception compared to that of physicians rose from 2.48 to 4.64 after controlling for differences in time perception. These findings highlight the ethical challenge facing physicians and patients in balancing patient advocacy with honesty in the setting of limited societal resources.

Deception↗
PubMed2004

Racial/ethnic disparities in the treatment of localized/regional prostate cancer.

PURPOSE: Racial/ethnic disparities in the utilization of definitive therapy for prostate cancer are well recognized in the United States. The effect of race on the use of contemporary definitive therapies, including brachytherapy, and the assessment of Hispanic men with regard to racial/ethnic disparity has not been fully characterized. MATERIALS AND METHODS: We evaluated treatment patterns using Surveillance, Epidemiology and End Results registry data on 142340 localized/regional stage cases between 1992 and 1999 in white, black and Hispanic American men. Definitive therapy was defined as radical prostatectomy, external beam radiation, brachytherapy or combinations thereof. Logistic regression models were constructed to determine the odds of receiving definitive treatment, adjusting for age, marital status, tumor grade, and Surveillance, Epidemiology and End Results site. RESULTS: Black and Hispanic men were less likely to receive definitive therapy than white men (p <0.001). Higher tumor grade was associated with decreasing odds of definitive therapy for black and Hispanic men (p <0.001) compared to white men. The racial/ethnic disparities in the use of definitive therapy decreased between 1992 and 1999 with the greatest decrease in Hispanic men. CONCLUSIONS: Hispanic and black men were less likely than white men to receive definitive therapy. The disparity in the use of definitive therapy between 1992 and 1999 decreased significantly in Hispanic men, although a significant disparity in the use of definitive therapy persisted in black men. Our observation of an association between tumor grade and the racial/ethnic disparity in definitive therapy ties together relevant biological and social factors that may contribute to the observed racial/ethnic disparity in mortality.

Aged↗
PubMed2003

Support for physician deception of insurance companies among a sample of Philadelphia residents.

BACKGROUND: Some physicians seem to be willing to sanction deception of insurance companies. Little is known about public attitudes regarding this practice. OBJECTIVE: To assess public attitudes regarding physician deception of insurance companies. DESIGN: Cross-sectional survey using clinical vignettes. SETTING: Philadelphia County Courthouse, Philadelphia, Pennsylvania. PARTICIPANTS: Convenience sample of 700 prospective jurors. MEASUREMENTS: Participants were asked whether, in response to restriction of health care, a physician should 1) accept restriction, 2) appeal restriction, or 3) misrepresent a patient's condition to obtain the desired service. The proportion of respondents reporting that the physician should misrepresent a patient's condition was determined. RESULTS: 26% of respondents sanctioned deception, 70% supported appealing, and 4% supported accepting the insurance company decision. Among the 27% of respondents believing physicians have inadequate time to appeal coverage decisions, 50% sanctioned deception. CONCLUSIONS: Sanctioning of deception was substantial in this sample of prospective jurors. Preferences regarding insurance company deception are related to perceptions of physician workload and may further pressure physicians struggling to balance advocacy with honesty.

Adult↗
PubMed2003

Stability of older adults' preferences for life-sustaining medical treatment.

The use of instructional advance directives assumes that preferences for life-sustaining medical treatment remain stable over time and across changes in life condition. A sample of 332 older adults recorded their preferences for 4 life-sustaining treatments in 9 illness scenarios. These preferences were elicited again 1 and 2 years after the original interview. Overall, preferences for life-sustaining treatment were moderately stable over time, but stability varied significantly across judgments. Preferences were most stable for illness scenarios that were most and least serious and for decisions to refuse treatment. Age, gender, education, and prior completion of an advance directive were all related to preference stability, and evidence indicated that declines in physical or psychological functioning resulted in decreased interest in life-sustaining treatment.

Advance Directives↗
PubMed2002

The "Hassle Factor": what motivates physicians to manipulate reimbursement rules?

BACKGROUND: Some physicians are willing to misrepresent clinical information to insurance companies to circumvent appeals processes. Whether characteristics of appeals processes affect the likelihood of misrepresentation is unknown. This study sought to determine the relationship between the likelihood of a successful appeal, appeals process length, and severity of the health condition and physicians' willingness to sanction deception. METHODS: A random sample of 1617 physicians was surveyed by mail to assess their willingness to accept an insurance company restriction, to appeal the restriction, or to misrepresent the facts to an insurance company to obtain coverage for a patient. RESULTS: Most respondents would appeal (77%) rather than accept (12%) or misrepresent (11%) regarding a restriction on medically necessary care. Physicians' decisions were related to the likelihood of a successful appeal (chi(2) = 7.56; P =.02), the appeals process length (chi(2) = 8.53; P =.01), and the severity of the medical condition (chi(2) = 71.10; P<.001). A small but significantly larger number of physicians chose to misrepresent the facts to an insurer as the appeals process became more cumbersome. Among physicians asked about severe angina, their decisions were particularly affected by the hassle associated with appealing, being more likely to choose to misrepresent the facts to the insurer than to appeal as the hassle increased. CONCLUSIONS: Physicians are more willing to sanction deception when the appeals process is longer, the likelihood of a successful appeal is lower, and the health condition is more severe. Changes in the difficulty of appeals processes may ease the tensions physicians face regarding patient advocacy and honesty.

Analysis of Variance↗
PubMedDate not supplied

Effect of assessment method on the discrepancy between judgments of health disorders people have and do not have: a web study.

Three experiments on the World Wide Web asked subjects to rate the severity of common health disorders such as acne or arthritis. People who had a disorder ("Haves") tended to rate it as less severe than people who did not have it ("Not-haves"). Two explanations of this Have versus Not-have discrepancy were rejected. By one account, people change their reference point when they rate a disorder that they have. More precise reference points would, on this account, reduce the discrepancy, but, if anything, the discrepancy was larger. By another account, people who do not have the disorder focus on attributes that are most affected by it, and the discrepancy should decrease when people make ratings on several attributes. Again, if anything, the discrepancy increased when ratings were on separate attributes (combined by a weighted average). The discrepancy varied in size and direction across disorders. Subjects also thought that they would be less affected than others.

Adaptation, Psychological↗
PubMedDate not supplied

"Is 28% good or bad?" Evaluability and preference reversals in health care decisions.

Choices of health care providers can become inconsistent when people lack sufficient context to assess the value of available information. In a series of surveys, general population samples were randomized to read descriptions of either 2 possible health care providers or a single provider. Some information about providers was easy to consider (e.g., travel time), but some was difficult to interpret without additional context (e.g., success rates). Ratings of the described health care providers varied significantly by whether options were evaluated independently or concurrently. For example, one fertility clinic (33% success rate, 15 min away) was rated higher than a 2nd (40% success rate, 45 min away) when each clinic was considered separately (7.1 v. 6.2, P = 0.046), but preferences reversed in joint evaluation (5.9 v. 6.7, P = 0.051). The results suggest that clinicians and developers of patient information materials alike should consider information evaluability when deciding how to present health care options to patients.

Access to Information↗
PubMedDate not supplied

Reducing the influence of anecdotal reasoning on people's health care decisions: is a picture worth a thousand statistics?

BACKGROUND: People's treatment decisions are often influenced by anecdotal rather than statistical information. This can lead to patients making decisions based on others' experiences rather than on evidence-based medicine. OBJECTIVE: . To test whether the use of a quiz or pictograph decreases people's reliance on anecdotal information. DESIGN: . Two cross-sectional survey studies using hypothetical scenarios. Participants read a scenario describing angina and indicated a preference for either bypass surgery or balloon angioplasty. The cure rate of both treatments was presented using prose, a pictograph, a quiz, or a pictograph and quiz combination. Participants read anecdotes from hypothetical patients who described the outcome of their treatment; the number of successful anecdotes was either representative or unrepresentative of the cure rates. Setting and Participants. Prospective jurors at the Philadelphia County Courthouse and travelers at the Detroit-Wayne County Metropolitan Airport. Measurements. Proportion of respondents preferring bypass over balloon angioplasty. RESULTS: . In study 1, when statistical information was presented in prose, treatment choices were influenced by anecdotes, with 41% of participants choosing bypass when the anecdotes were representative and only 20% choosing it when the anecdotes were unrepresentative (x(2) = 14.40, P < 0.001). When statistics were reinforced with the pictograph and quiz, anecdotes had no significant influence on treatment decisions (38% choosing bypass when anecdotes were representative v. 44% when unrepresentative, x(2) = 1.08, P > 0.20). In study 2, the tradeoff quiz did not reduce the impact of the anecdotes (27% v. 28% choosing bypass after receiving or not receiving the quiz, x(2) < 1, P > 0.20). However, the pictograph significantly reduced the impact of anecdotes, with 27% choosing bypass after receiving no pictograph and 40% choosing bypass after receiving a pictograph (x(2) = 6.44, P < 0.001). CONCLUSIONS: . Presenting statistical information using a pictograph can reduce the undue influence of anecdotal reasoning on treatment choices.

Adult↗
PubMedDate not supplied

Cure me even if it kills me: preferences for invasive cancer treatment.

PURPOSE: When making medical decisions, people often care not only about what happens but also about whether the outcome was a result of actions voluntarily taken or a result of inaction. This study assessed the proportion of people choosing nonoptimal treatments (treatments which reduced survival chances) when presented with hypothetical cancer scenarios which varied by outcome cause. METHODS: A randomized survey experiment tested preferences for curing an existent cancer with 2 possible treatments (medication or surgery) and 2 effects of treatment (beneficial or harmful). Participants were 112 prospective jurors in the Philadelphia County Courthouse and 218 visitors to the Detroit-Wayne County Metropolitan Airport. RESULTS: When treatment was beneficial, 27% of participants rejected medication, whereas only 10% rejected surgery with identical outcomes ( 2 = 5.87, P < 0.02). When treatment was harmful, participants offered surgery were significantly more inclined to take action (65% v. 38%, chi(2) = 11.40, P = 0.001), even though doing so reduced overall survival chances. CONCLUSIONS: Faced with hypothetical cancer diagnoses, many people say they would pursue treatment even if doing so would increase their chance of death. This tendency toward active treatment is notably stronger when the treatment offered is surgery instead of medication. Our study suggests that few people can imagine standing by and doing nothing after being diagnosed with cancer, and it should serve to remind clinicians that, for many patients, the best treatment alternative may not only depend on the medical outcomes they can expect to experience but also on whether those outcomes are achieved actively or passively.

Attitude to Health↗
PubMedDate not supplied

Context changes choices: a prospective study of the effects of hospitalization on life-sustaining treatment preferences.

OBJECTIVE: Policy and law encouraging individuals to document their wishes for life-sustaining medical treatment in advance of serious illness assumes that these wishes are unaffected by changes in health condition. To test this assumption, the authors examine the life-sustaining treatment preferences of a sample of elderly adults prior to, soon after, and several months after a hospitalization experience. SUBJECTS AND METHODS: As part of the Advance Directives, Values Assessment, and Communication Enhancement (ADVANCE) project, 401 individuals older than age 65 participated in 3 annual interviews. A subsample of 88 individuals who were hospitalized for greater than 48 hours during the course of the study participated in an additional "recovery" interview conducted soon after their release from the hospital (M = 14 days postdischarge). At each interview, subjects indicated their desire to receive 4 life-sustaining medical treatments in 4 serious illness scenarios. RESULTS: Treatment preferences showed a significant "hospitalization dip," with subjects reporting less desire to receive life-sustaining treatment at the recovery interview than they did at the annual interview conducted prior to hospitalization, but with desire returning to near prehospitalization levels at the annual interview conducted several months after hospitalization. This dip was more pronounced in preferences for cardiopulmonary resuscitation and artificial nutrition and hydration than in preferences for less invasive treatments. CONCLUSIONS: Preferences for life-sustaining treatment are dependent on the context in which they are made, and thus individuals may express different treatment preferences when they are healthy than when they are ill. These results challenge a key psychological assumption underlying the use of instructional advance directives in end-of-life decision making.

Advance Directives↗
PubMedDate not supplied

Enough. The failure of the living will.

In pursuit of the dream that patients' exercise of autonomy could extend beyond their span of competence, living wills have passed from controversy to conventional wisdom, to widely promoted policy. But the policy has not produced results, and should be abandoned.

Bioethics↗