Peter A Ubel

Duke University Medical Center, Durham, North Carolina, United States

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Publications (346)

  • Article · Nov 2016 · Pediatrics
  • J. S. Blumenthal-Barby · Peter A. Ubel
    Article · Nov 2016 · The American Journal of Bioethics
  • Amanda J. Dillard · Laura D. Scherer · Peter A. Ubel · [...] · Angela Fagerlin
    [Show abstract] [Hide abstract] ABSTRACT: Research suggests that anxiety may be a common response to a cancer diagnosis, but research is needed to examine anxiety before diagnosis. Anxiety before diagnosis may relate to the comprehension of relevant health information or openness to potential treatments. This study examined anxiety and these outcomes in men who were waiting to learn of a prostate cancer diagnosis. One goal of this study was to determine whether anxiety would increase as men came closer to learning the results of their prostate cancer biopsy. Another goal was to test whether anxiety was associated with knowledge about prostate cancer or openness to different treatments. Men (N = 265) who were facing a prostate cancer diagnosis were surveyed at two time points. Time 1 occurred at the time of biopsy, and Time 2 occurred immediately before men received their biopsy result. At each time point, men reported their anxiety about prostate cancer and their biopsy result. At Time 2, they completed a knowledge test of information about prostate cancer and reported their openness to different potential treatments. Anxiety symptoms increased as men came closer to learning their diagnosis. Also, higher anxiety was associated with lower knowledge and greater openness to particular treatments like surgery. Interactions showed that when anxiety increased from Time 1 to Time 2, having high or low knowledge mattered less to treatment openness. Waiting for a cancer diagnosis is an important time period in which anxiety may increase and relate to information processing and openness to treatments. Statement of contribution What is already known on this subject? Men undergoing prostate cancer screening have been found to experience high and low levels of anxiety. Research has shown that negative emotions like anxiety are common following a cancer diagnosis, but little research has examined emotions right before diagnosis. Anxiety has been associated with information processing and motivation to engage in preventive behaviours. What does this study add? Applies and tests a theoretical idea related to how anxiety may change as one approaches personally relevant threatening health feedback. Shows relationships between changes in anxiety and knowledge in the context of waiting for actual health feedback. Associates increased anxiety in the prostate cancer context with knowledge and openness to different treatments. What is already known on this subject? Men undergoing prostate cancer screening have been found to experience high and low levels of anxiety. Research has shown that negative emotions like anxiety are common following a cancer diagnosis, but little research has examined emotions right before diagnosis. Anxiety has been associated with information processing and motivation to engage in preventive behaviours. What does this study add? Applies and tests a theoretical idea related to how anxiety may change as one approaches personally relevant threatening health feedback. Shows relationships between changes in anxiety and knowledge in the context of waiting for actual health feedback. Associates increased anxiety in the prostate cancer context with knowledge and openness to different treatments.
    Article · Nov 2016 · British Journal of Health Psychology
  • Peter A Ubel · Peter B Bach
    Article · Oct 2016 · Annals of internal medicine
  • Article · Sep 2016 · The American Journal of Managed Care
  • Karen A Scherr · Angela Fagerlin · Timothy Hofer · [...] · Peter A Ubel
    [Show abstract] [Hide abstract] ABSTRACT: Objective: To assess the influence of patient preferences and urologist recommendations in treatment decisions for clinically localized prostate cancer. Methods: We enrolled 257 men with clinically localized prostate cancer (prostate-specific antigen <20; Gleason score 6 or 7) seen by urologists (primarily residents and fellows) in 4 Veterans Affairs medical centers. We measured patients' baseline preferences prior to their urology appointments, including initial treatment preference, cancer-related anxiety, and interest in sex. In longitudinal follow-up, we determined which treatment patients received. We used hierarchical logistic regression to determine the factors that predicted treatment received (active treatment v. active surveillance) and urologist recommendations. We also conducted a directed content analysis of recorded clinical encounters to determine if urologists discussed patients' interest in sex. Results: Patients' initial treatment preferences did not predict receipt of active treatment versus surveillance, Δχ(2)(4) = 3.67, P = 0.45. Instead, receipt of active treatment was predicted primarily by urologists' recommendations, Δχ(2)(2) = 32.81, P < 0.001. Urologists' recommendations, in turn, were influenced heavily by medical factors (age and Gleason score) but were unrelated to patient preferences, Δχ(2)(6) = 0, P = 1. Urologists rarely discussed patients' interest in sex (<15% of appointments). Conclusions: Patients' treatment decisions were based largely on urologists' recommendations, which, in turn, were based on medical factors (age and Gleason score) and not on patients' personal views of the relative pros and cons of treatment alternatives.
    Article · Aug 2016 · Medical Decision Making
  • Karen A Scherr · Angela Fagerlin · Lillie D Williamson · [...] · Peter A Ubel
    [Show abstract] [Hide abstract] ABSTRACT: Background. Physicians’ recommendations affect patients’ treatment choices. However, most research relies on physicians’ or patients’ retrospective reports of recommendations, which offer a limited perspective and have limitations such as recall bias. Objective. To develop a reliable and valid method to measure the strength of physician recommendations using direct observation of clinical encounters. Methods. Clinical encounters (n = 257) were recorded as part of a larger study of prostate cancer decision making. We used an iterative process to create the 5-point Physician Recommendation Coding System (PhyReCS). To determine reliability, research assistants double-coded 50 transcripts. To establish content validity, we used 1-way analyses of variance to determine whether relative treatment recommendation scores differed as a function of which treatment patients received. To establish concurrent validity, we examined whether patients’ perceived treatment recommendations matched our coded recommendations. Results. The PhyReCS was highly reliable (Krippendorf’s alpha = 0.89, 95% CI [0.86, 0.91]). The average relative treatment recommendation score for each treatment was higher for individuals who received that particular treatment. For example, the average relative surgery recommendation score was higher for individuals who received surgery versus radiation (mean difference = 0.98, SE = 0.18, P < 0.001) or active surveillance (mean difference = 1.10, SE = 0.14, P < 0.001). Patients’ perceived recommendations matched coded recommendations 81% of the time. Conclusion. The PhyReCS is a reliable and valid way to capture the strength of physician recommendations. We believe that the PhyReCS would be helpful for other researchers who wish to study physician recommendations, an important part of patient decision making.
    Article · Jun 2016 · Medical Decision Making
  • Source
    Sunita Sah · Angela Fagerlin · Peter Ubel
    [Show abstract] [Hide abstract] ABSTRACT: This paper explores the impact of disclosures of bias on advisees. Disclosure-informing advisees of a potential bias-is a popular solution for managing conflicts of interest. Prior research has focused almost exclusively on disclosures of financial conflicts of interest but little is known about how disclosures of other types of biases could impact advisees. In medicine, for example, physicians often recommend the treatment they specialize in; e.g., surgeons are more likely to recommend surgery than nonsurgeons. In recognition of this bias, some physicians inform patients about their specialty bias when other similarly effective treatment options exist. Using field data (recorded transcripts of surgeon-patient consultations) from Veteran Affairs hospitals and a randomized controlled laboratory experiment, we examine and find that disclosures of specialty bias increase patients' trust and their likelihood of choosing a treatment in accordance with the physicians' specialty. Physicians in the field also increased the strength of their recommendation to have the specialty treatment when they disclosed their bias or discussed the opportunity for the patient to seek a consultation with a physician from another specialty. These findings have important implications for handling advisor bias, shared advisor-advisee decision-making, and disclosure policies.
    Full-text available · Article · Jun 2016 · Proceedings of the National Academy of Sciences
  • Rochelle DeCastro Jones · Kent A Griffith · Peter A Ubel · [...] · Reshma Jagsi
    [Show abstract] [Hide abstract] ABSTRACT: Purpose: Understanding the goals and aspirations of the physician-scientist workforce can inform policies to promote retention. The authors explored gender differences therein, given women's increasing representation. Method: In 2010-2011, the authors qualitatively analyzed interviews with 100 former recipients of National Institutes of Health career development awards and 28 of their mentors. They also compared survey responses of 1,267 clinician-investigators who received these awards from 2006 to 2009, using logistic regression to evaluate gender differences after adjusting for other characteristics. Results: Interview participants described relatively consistent career goals, including scientific contribution and desire to positively affect lives through research, clinical care, and teaching. For many, the specific ways they sought to achieve and measure goal attainment evolved over time. Survey respondents endorsed a goal of publishing high-quality research with highest frequency (97.3%, no significant gender difference). Women were more likely to endorse the importance of balancing work and other activities (95.5% vs. 90.5%, P < .001). There were no significant gender differences in the importance of patient care (86.6%), teaching (71.6%), or publishing prolifically (64.9%). Men were more likely than women to consider salary (49.4% vs. 41.8%, P < .001), reputation (84.2% vs. 77.6%, P = .004), and leadership positions (38.9% vs. 34.3%, P = .03) important. Conclusions: In an elite research-oriented sample, gender differences in initial aspirations were generally limited. Gender differences in career outcomes in such groups are unlikely to exclusively result from different baseline aspirations. Goals appear to evolve in response to challenges experienced.
    Article · May 2016 · Academic medicine: journal of the Association of American Medical Colleges
  • [Show abstract] [Hide abstract] ABSTRACT: This survey study of recent National Institutes of Health career development (K) award recipients assessed the proportion who reported gender bias and advantage and sexual harrassment in their professional careers.Recent high-profile cases of sexual harassment illustrate that such experiences still occur in academic medicine.1 Less is known about how many women have directly experienced such behavior. Most studies have focused on trainees, single specialties, and non-US settings or lack currency.2 In a 1995 cross-sectional survey,3 52% of US academic medical faculty women reported harassment in their careers compared with 5% of men. These women had begun their careers when women constituted a minority of the medical school class; less is known about the prevalence of such experiences among more recent faculty cohorts.
    Article · May 2016 · JAMA The Journal of the American Medical Association
  • Karen A Scherr · Angela Fagerlin · John T Wei · [...] · Peter A Ubel
    [Show abstract] [Hide abstract] ABSTRACT: In order to empower patients as decision makers, physicians must educate them about their treatment options in a factual, nonbiased manner. We propose that site-specific availability of treatment options may be a novel source of bias, whereby physicians describe treatments more positively when they are available. We performed a content analysis of physicians' descriptions of robotic prostatectomy within 252 appointments at four Veterans Affairs medical centers where robotic surgery was either available or unavailable. We coded how physicians portrayed robotic versus open prostatectomy across specific clinical categories and in the appointment overall. We found that physicians were more likely to describe robotic prostatectomy as superior when it was available [F(1, 42) = 8.65, p = .005]. We also provide initial qualitative evidence that physicians may be shaping their descriptions of robotic prostatectomy in an effort to manage patients' emotions and demand for the robotic technology. To our knowledge, this is the first study to provide empirical evidence that treatment availability influences how physicians describe the advantages and disadvantages of treatment alternatives to patients during clinical encounters, which has important practical implications for patient empowerment and patient satisfaction.
    Article · May 2016 · Health Communication
  • PA Ubel · C. J. Zhang · A. Hesson · [...] · W. G. Hunter
    [Show abstract] [Hide abstract] ABSTRACT: Some experts contend that requiring patients to pay out of pocket for a portion of their care will bring consumer discipline to health care markets. But are physicians prepared to help patients factor out-ofpocket expenses into medical decisions? In this qualitative study of audiorecorded clinical encounters, we identified physician behaviors that stand in the way of helping patients navigate out-of-pocket spending. Some behaviors reflected a failure to fully engage with patients' financial concerns, from never acknowledging such concerns to dismissing them too quickly. Other behaviors reflected a failure to resolve uncertainty about out-of-pocket expenses or reliance on temporary solutions without making long-term plans to reduce spending. Many of these failures resulted from systemic barriers to health care spending conversations, such as a lack of price transparency. For consumer health care markets to work as intended, physicians need to be prepared to help patients navigate out-of-pocket expenses when financial concerns arise during clinical encounters. © 2016 Project HOPE- The People-to-People Health Foundation, Inc.
    Article · Apr 2016 · Health Affairs
  • Wynn G Hunter · Cecilia Z Zhang · Ashley Hesson · [...] · Peter A Ubel
    [Show abstract] [Hide abstract] ABSTRACT: Background: More than 1 in 4 Americans report difficulty paying medical bills. Cost-reducing strategies discussed during outpatient physician visits remain poorly characterized. Objective: We sought to determine how often patients and physicians discuss health care costs during outpatient visits and what strategies, if any, they discussed to lower patient out-of-pocket costs. Design: Retrospective analysis of dialogue from 1755 outpatient visits in community-based practices nationwide from 2010 to 2014. The study population included 677 patients with breast cancer, 422 with depression, and 656 with rheumatoid arthritis visiting 56 oncologists, 36 psychiatrists, and 26 rheumatologists, respectively. Results: Thirty percent of visits contained cost conversations (95% confidence interval [CI], 28 to 32). Forty-four percent of cost conversations involved discussion of cost-saving strategies (95% CI, 40 to 48; median duration, 68 s). We identified 4 strategies to lower costs without changing the care plan. They were, in order of overall frequency: 1) changing logistics of care, 2) facilitating co-pay assistance, 3) providing free samples, and 4) changing/adding insurance plans. We also identified 4 strategies to reduce costs by changing the care plan: 1) switching to lower-cost alternative therapy/diagnostic, 2) switching from brand name to generic, 3) changing dosage/frequency, and 4) stopping/withholding interventions. Strategies were relatively consistent across health conditions, except for switching to a lower-cost alternative (more common in breast oncology) and providing free samples (more common in depression). Limitation: Focus on 3 conditions with potentially high out-of-pocket costs. Conclusions: Despite price opacity, physicians and patients discuss a variety of out-of-pocket cost reduction strategies during clinic visits. Almost half of cost discussions mention 1 or more cost-saving strategies, with more frequent mention of those not requiring care-plan changes.
    Article · Jan 2016 · Medical Decision Making
  • Peter A Ubel
    [Show abstract] [Hide abstract] ABSTRACT: This Viewpoint argues that if value-based insurance designs are to reduce expenditures, they must offer disincentives to purchasing low-value care in addition to providing incentives for purchasing high-value care.Health care systems around the world are under pressure to restrain health care expenditures. In response, many health care leaders have embraced the idea of promoting health care value, with value defined “as the healthcare outcomes achieved per dollar spent.”1 For instance, some experts have urged third-party payers to adopt value-based insurance designs, whereby the amount patients pay out-of-pocket for health care services varies not as a function of the cost of those services but, instead, as a function of their value.2
    Article · Dec 2015 · JAMA The Journal of the American Medical Association
  • Source
    Wynn G. Hunter · Ashley Hesson · J. Kelly Davis · [...] · Peter A. Ubel
    [Show abstract] [Hide abstract] ABSTRACT: Background: Nearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings. Methods: Retrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010-2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson's Chi-Square Tests. Results: Three cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost -- discussion of the patient's OoP costs for a healthcare service; (b) Cost/Coverage -- discussion of the patient's OoP costs or insurance coverage; (c) Cost of Illness-- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24 % of clinic visits contained cost conversation (OOP Cost, Cost/Coverage, Cost of Illness, respectively; P < 0.001); depression: 30, 38, 43 %, (P < 0.001); and rheumatoid arthritis, 26, 33, 35 %, (P < 0.001). Conclusions: The estimated incidence of physician-patient cost conversation varied significantly depending on the definition used. Our findings and proposed definitions may assist in retrospective interpretation and prospective design of investigations on this topic.
    Full-text available · Article · Dec 2015 · BMC Health Services Research
  • Ezekiel J. Emanuel · Peter A. Ubel · Judd B. Kessler · [...] · Kevin G. Volpp
    [Show abstract] [Hide abstract] ABSTRACT: Behavioral economics provides insights about the development of effective incentives for physicians to deliver high-value care. It suggests that the structure and delivery of incentives can shape behavior, as can thoughtful design of the decision-making environment. This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided, even as the authors recognize that its application to the design of physician incentives is largely untested, and many outstanding questions exist. Application and rigorous evaluation of infrastructure changes and incentives are needed to design payment systems that incentivize high-quality, cost-conscious care.
    Article · Nov 2015 · Annals of internal medicine
  • S Yousuf Zafar · Fumiko Chino · Peter A Ubel · [...] · Jeffery M Peppercorn
    [Show abstract] [Hide abstract] ABSTRACT: Objectives: Patients with cancer can experience substantial financial burden. Little is known about patients' preferences for incorporating cost discussions into treatment decision making or about the ramifications of those discussions. The objective of this study was to determine patient preferences for and benefits of discussing costs with doctors. Study Design: Cross-sectional, survey study. Methods: We enrolled insured adults with solid tumors on anticancer therapy who were treated at a referral cancer center or an affiliated rural cancer clinic. Patients were surveyed at enrollment and again 3 months later about cost discussions with doctors, decision making, and financial burden. Medical records were abstracted for disease and treatment data. Logistic regression investigated characteristics associated with greater desire to discuss costs. Results: Of 300 patients (86% response rate), 52% expressed some desire to discuss treatment-related out-of-pocket costs with doctors and 51% wanted their doctor to take costs into account to some degree when making treatment decisions. However, only 19% had talked to their doctor about costs. Of those, 57% reported lower out-of-pocket costs as a result of cost discussions. In multivariable logistic regression, higher subjective financial distress was associated with greater likelihood to desire cost discussions (odds ratio [OR], 1.22; 95% CI, 1.10-1.36). Nonwhite race was associated with lower likelihood to desire cost discussions (OR, 0.53; 95% CI, 0.30-0.95). Conclusions: Patients with cancer varied in their desire to discuss costs with doctors, but most who discussed costs believed the conversations helped reduce their expenses. Patient-physician cost communication might reduce out-of-pocket costs even in oncology where treatment options are limited.
    Article · Sep 2015 · The American Journal of Managed Care
  • [Show abstract] [Hide abstract] ABSTRACT: Little is known about how physicians present diagnosis and treatment planning in routine practice in preference-sensitive treatment decisions. We evaluated completeness and quality of informed decision making in localized prostate cancer post biopsy encounters. We analyzed audio-recorded office visits of 252 men with presumed localized prostate cancer (Gleason 6 and Gleason 7 scores) who were seeing 45 physicians at 4 Veterans Affairs Medical Centers. Data were collected between September 2008 and May 2012 in a trial of 2 decision aids (DAs). Braddock's previously validated Informed Decision Making (IDM) system was used to measure quality. Latent variable models for ordinal data examined the relationship of IDM score to treatment received. Mean IDM score showed modest quality (7.61±2.45 out of 18) and high variability. Treatment choice and risks and benefits were discussed in approximately 95% of encounters. However, in more than one-third of encounters, physicians provided a partial set of treatment options and omitted surveillance as a choice. Informing quality was greater in patients treated with surveillance (β = 1.1, p = .04). Gleason score (7 vs 6) and lower age were often cited as reasons to exclude surveillance. Patient preferences were elicited in the majority of cases, but not used to guide treatment planning. Encounter time was modestly correlated with IDM score (r = 0.237, p = .01). DA type was not associated with IDM score. Physicians informed patients of options and risks and benefits, but infrequently engaged patients in core shared decision-making processes. Despite patients having received DAs, physicians rarely provided an opportunity for preference-driven decision making. More attention to the underused patient decision-making and engagement elements could result in improved shared decision making. © The Author(s) 2015.
    Article · Aug 2015 · Medical Decision Making
  • Steven K Dallas · Peggy J Liu · Peter A Ubel
    [Show abstract] [Hide abstract] ABSTRACT: The United States Food and Drug Administration recently announced that the serving sizes on the Nutrition Facts labels for many products will be increased, but the effect of these increases remains unclear. The present research examined consumers' interpretation of the meaning of serving size information (study 1) and tested whether exposing consumers to the increased serving sizes of the proposed Nutrition Facts label leads consumers to serve and purchase more food for themselves and others (studies 2-4). Study 1 (N = 101; 44.7% female) tested what consumers believe the serving sizes on Nutrition Facts labels refer to, and the majority of participants (over 78%) incorrectly believed that the serving sizes refer to how much food can or should be consumed in one sitting as part of a healthy diet. Study 2 (N = 51; 41.2% female) tested how exposure to the current versus proposed Nutrition Facts label influences the amount of food that consumers serve themselves, and studies 3 (N = 60; 46.7% female) and 4 (N = 61; 48.2% female) assessed how exposure to the current versus proposed label influences the amount of food that people serve and purchase for others. In studies 2-4, the proposed label (vs. the current label) led consumers to serve themselves 41% more cookies (study 2); serve 27% more cheese crackers to another person (study 3); and buy 43% more lasagnas for others and divide a lasagna into 22% larger slices (study 4). The results suggest that the proposed Nutrition Facts label's increased serving sizes may lead people who use this information as a reference to serve more food to themselves and others. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Article · Aug 2015 · Appetite
  • Peter A Ubel
    Article · Jun 2015 · New England Journal of Medicine

Publication Stats

11k Citations


  • 2014
    • Duke University Medical Center
      Durham, North Carolina, United States
  • 2008
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
  • 2007
    • University of Michigan
      • Department of Psychology
      Ann Arbor, Michigan, United States
    • National Institutes of Health
      • Division of Cancer Control and Population Sciences
      Bethesda, MD, United States
    • Northwestern University
      Evanston, Illinois, United States
  • 2006
    • Icahn School of Medicine at Mount Sinai
      Borough of Manhattan, New York, United States
  • 2000-2006
    • Carnegie Mellon University
      • • Department of Social and Decision Sciences
      • • Department of Psychology
      • • Department of Engineering and Public Policy
      Pittsburgh, Pennsylvania, United States
  • 2004
    • University of Toledo
      • Department of Psychology
      Toledo, Ohio, United States
    • Duke University
      Durham, North Carolina, United States
  • 1998-2003
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 1998-2002
    • University of Pennsylvania
      • • Center for Clinical Epidemiology and Biostatistics
      • • Department of Medicine
      Philadelphia, PA, United States
  • 1998-2001
    • William Penn University
      Filadelfia, Pennsylvania, United States
  • 1999
    • University Pompeu Fabra
      Barcino, Catalonia, Spain
  • 1997
    • University of Maryland, Baltimore
      • Department of Pediatrics
      Baltimore, MD, United States