and the Cognitive Ergonomics of Health Disparities Linda S Gottfredson School of Education University of DE Kathy Stroh Diabetes Prevention amp Control Program DPH DE Eileen Sparling Center for Disabilities Studies University of DE ID: 219872
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Slide1
Spearman and the Cognitive Ergonomics of Health Disparities
Linda S. Gottfredson, School of Education, University of DEKathy Stroh, Diabetes Prevention & Control Program, DPH, DEEileen Sparling, Center for Disabilities Studies, University of DE
International Society for Intelligence Research, Limassol, Cyprus, December 8, 2011Slide2
TodaySpearman’s g (people)Spearman’s
g loading (tasks)Diabetes epidemic ($$$$)Wishful thinking (them)Realistic strategy (us)Pilot data
RejectedNeglected
Non-adherence
Knowledge, not
g
Diabetes a
g
-loaded job
Cognitive ergonomicsSlide3
Exploding health care costs
Fast death, or death by parts (eyes, feet, heart…)Patient error & non-adherenceCognitive limitations of patientsHigh cognitive demands of diabetes self-care
+
Diabetes up & up, younger & youngerSlide4
Exploding health care costs
Fast death, or death by parts (eyes, feet, heart…)Patient error & non-adherenceCognitive limitations of patientsHigh cognitive demands of diabetes self-care
+
Diabetes up & up, younger & younger
Current health policy?
Access to care + Motivate + Educate Slide5
‘Enlightened’ Opinion
Individual differences =“Inequalities”OpinionInputs Bad
InputsUnacceptableOutcomes T1Bad
Outcomes T2Back-sliding
g
“Low literacy among highly educated too”
“See, it can’t be
g
!”
XSlide6
The reality
Gradual growth
Wide variation
Adult patients
$$$
~IQ 80
John B CarrollSlide7
Resolute ignorance about
gGradual growth
Wide variation
Health policy & practice?
No see
No hear
No say
No insult
So, patients dieSlide8
‘Enlightened’ Opinion
Individual differences“Inequalities”OpinionInputs Bad
InputsUnacceptableOutcomes T1Bad
Outcomes T2Back-sliding
g
“Low literacy among highly educated too”
“See, it can’t be
g
!”Slide9
Neglected—the patient’s job
Individual differences“Inequalities”OpinionInputs Bad
InputsUnacceptableJob to be doneComplexity(
g loading)Much is inherent
Outcomes T1
Bad
Outcomes T2
Back-sliding
gSlide10
Neglected—the patient’s job
Individual differences“Inequalities”OpinionInputs Bad
InputsUnacceptableJob to be doneComplexity(
g loading)Much is inherent
Outcomes T1
Bad
Outcomes T2
Back-sliding
g
Simple task
Complex task
g
levels meet
g
loadingsSlide11
Current Strategy
Access to care + Motivate +
Educate g
loadings rise; g levels won’tNeglected Reality
Patient error & non-adherence
Patient error & non-adherence
Disparities generatorSlide12
No hope? So, give up???
It’s the
g loadings, stupid!!
No!!Slide13
CollaboratorsConference venue
Coordinate meds & eating
The patient’s reality
Check feet
Don’t stress
Meds
Exercise, except when…
Monitor sugar
Proper diet
Sick day rules
Count carbs
Read labels
Adjust insulin
Do A if low,
Do B if high
Eye exam
Interpret readings
What’s a carb??
Call 911 for C, but doctor for D
System no longer on auto-pilotSlide14
TitleCollaboratorsConference venue
Coordinate meds & eating
The health provider’s reality
Check feet
Don’t stress
Meds
Exercise, except when…
Monitor sugar
Proper diet
Sick day rules
Count carbs
Read labels
Adjust insulin
Do A if low,
Do B if high
Eye exam
Interpret readings
What’s a carb??
Call 911 for C, but doctor for D
You mean I have to
measure
stuff?!
My blood sugar is 154 over 90.
I don’t eat sugar any more. Just pasta.
It’s low fat, so it’s healthy.
I skipped lunch so I could have a big dinner.
Can I still eat donuts?
Never tested my sugar because I never figured out my meter.
Patient fails to take controlSlide15
AADE7™ + 1
Teaching to take controlSlide16
Serial by topic
Abstract
DecontextualizedFastConcentrated
One-size-fits-allNo scaffolding~No practice~No assessment
Self-management education today
g
Cognitive overloadSlide17
Neglected job elements
Core tasks:InterdependenceCriticalityResponsibilityExtinguish old habitsWork conditions:Time pressure
DistractionsPredictabilityInterferences in-situRest breaks
g
C
ognitive complexity
Cognitive interferencesSlide18
Cognitive ergonomics project (9 FQHC clinics)
J
ob analysis of diabetes
Evaluation
T
raining modules for self-care
Clinic service delivery
R & D
I & E
todaySlide19
Cognitive ergonomics project (9 FQHC clinics)
Keep system under controlCognitive complexityCritical incidents Cognitive task analysis
J
ob analysis of diabetes
Evaluation
T
raining modules for self-care
Clinic service delivery
R & D
I & ESlide20
Cognitive ergonomics project (9 FQHC clinics)
Keep system under controlCognitive complexityCritical incidents Cognitive task analysis
J
ob analysis of diabetes
Evaluation
T
raining modules for self-care
Clinic service delivery
R & D
I & E
Accident preventionSlide21
Cognitive ergonomics project (9 FQHC clinics)
Keep system under controlCognitive complexityCritical incidents Cognitive task analysis
J
ob analysis of diabetes
Evaluation
T
raining modules for self-care
Clinic service delivery
R & D
I & E
g
loading
Criticality
PrioritySlide22
Cognitive ergonomics project (9 FQHC clinics)
Keep system under controlCognitive complexityCritical incidents Cognitive task analysis
J
ob analysis of diabetes
Evaluation
T
raining modules for self-care
Clinic service delivery
R & D
I & E
g
loading
Criticality
Priority
More cognitively accessibleSlide23
Cognitive ergonomics project (9 FQHC clinics)
Keep system under controlCognitive complexityCritical incidents Cognitive task analysis
Clinics lo-SES
medical “home” (facilitate)Patients high cost
l
ow
g
(assess)
J
ob analysis of diabetes
Evaluation
T
raining modules for self-care
Clinic service delivery
R & D
I & E
g
loading
Criticality
Priority
Elderly tooSlide24
Cognitive ergonomics project (9 FQHC clinics)
Keep system under controlCognitive complexityCritical incidents Cognitive task analysis
Clinics lo-SES
medical “home” (facilitate)Patients high cost
l
ow
g
(assess)
J
ob analysis of diabetes
Evaluation
T
raining modules for self-care
Clinic service delivery
R & D
I & E
g
loading
Criticality
Cognitive support
PrioritySlide25
Cognitive ergonomics project (9 FQHC clinics)
Keep system under controlCognitive complexityCritical incidents Cognitive task analysis
Clinics lo-SES
“medical home” (create)Patients high cost
l
ow
g
(assess)
Costs
ED visits
Hospitalizations
Patient outcomes Glucose control
Complications
J
ob analysis of diabetes
Evaluation
T
raining modules for self-care
Clinic service delivery
R & D
I & E
g
loading
Criticality
PrioritySlide26
Recognize when sugar too high or low
Take correct action when sugar to low
Call doctor if sugar persistently high
Criticality rankings (pilot data)
Ranked by 30 diabetes health providers (MD, RN, RNP, RD, CDE, other)
System unstable,
restore control Slide27
Eat correct serving sizes
Recognize signs to stop exercise
Take meds in correct amount & time
Criticality rankings
Ranked by 30 diabetes health providers (MD, RN, RNP, RD, CDE, other)
Maintain system
control Slide28
Identify barriers to self-care
Criticality rankings
Ranked by 30 diabetes health providers (MD, RN, RNP, RD, CDE, other)
Identify hazardsSlide29
Critical incidents
From 30 diabetes health providers (MD, RN, RNP, RD, CDE, other)
Took meds on time, —but delayed meal BG crash—but ate only a salad BG crash
Causal nexus
(food, meds, blood sugar)Slide30
Critical incidents
From 30 diabetes health providers (MD, RN, RNP, RD, CDE, other)
Sick & not eating,—so took no insulin (T1) DKA—but took same dose BG crash
Shift rule when conditions changeSlide31
Critical incidents
From 30 diabetes health providers (MD, RN, RNP, RD, CDE, other)
Ate prophylactically to “prevent” low blood sugar, did not test blood sugar, got no exercise,
chronic high sugar
incubating, unseen damage
One cause
One effect
One tacticSlide32
Critical incidents
From 30 diabetes health providers (MD, RN, RNP, RD, CDE, other)
Did not control diet
chronic high sugar
poor wound healing
Feared treatment
hospitalized for necrotic foot
One goal
(avoid immediate pain)
One tactic
(avoid medical treatment)Slide33
High
g
loadings are expensive.1. When cognitive budget is small, spend it wisely.
2
. Focus on critical tasks
3. Teach
g-
efficiently
4. Supply
g
supportSlide34
Advice and questions?