Trustbusters: The Prevalence and Predictors of Trust Violations in American Medicine

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Trustbusters The Prevalence and Predictors of
Trust Violations in American Medicine

• Mark J. Schlesinger, Yale University
• Nicole C. Quon, Yale University
• Bradford H. Gray, New York Academy of Medicine
• June 7, 2004

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Trust in the Health Care System

• Trust is important
• Qualitative literature
• Quantitative literature
• Our study
• Develops conceptual model
• Estimates psychological predictors of loss of
  trust
• Uses these predictors to explain socio
  -demographic differences in loss of trust

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A Conceptual Model of Disrupted Trust
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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process

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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process
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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process

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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process
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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process
At the Collective Level Two Mediating
Institutions
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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process
At the Collective Level Two Mediating
Institutions -- Role of regulations and
government involvement -- Role of markets and
consumer empowerment
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Data and Methods

• Consumer assessment dataset
• Experiences with hospitals (n2746)
• Experiences with health plans (n4969)
• Binary dependent variables on loss of trust
• Two stage logistic model
• First stage predicted expectations of plan and
  hospital performance
• Second stage used predicted expectations and
  other explanatory variables to explain loss of
  trust

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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process
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Predictors of Loss of Trust 1 Assessment of
Problem
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Predictors of Loss of Trust 1 Assessment of
Expectations
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Predictors of Loss of Trust 1 Assessment of
Problem
p-valuelt.01, p-value lt0.05, p-value lt0.10
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Predictors of Loss of Trust 1 Assessment of
Expectations
p-valuelt.01, p-value lt0.05, p-value lt0.10
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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process

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Predictors of Loss of Trust 2 Interpretation of
Problem
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Predictors of Loss of Trust 2 Interpretation of
Problem
p-valuelt.01, p-value lt0.05, p-value lt0.10
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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process
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Predictors of Loss of Trust 3 Adaptation of
Problem
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Predictors of Loss of Trust 3 Adaptation of
Problem
p-valuelt.01, p-value lt0.05, p-value lt0.10
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A Conceptual Model of Disrupted Trust
At the Individual Level A Three Stage Process
At the Collective Level Two Mediating
Institutions -- Role of regulations and
government involvement -- Role of markets and
consumer empowerment
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Predictors of Loss of Trust 4 Institutional
ContextRegulations and Markets
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Predictors of Loss of Trust 4 Institutional
ContextRegulations and Markets
p-valuelt.01, p-value lt0.05, p-value lt0.10
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Explaining Demographic Differences in Loss of
Trust
p-valuelt.01, p-value lt0.05, p-value lt0.10
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Explaining Demographic Differences in Loss of
Trust
p-valuelt.01, p-value lt0.05, p-value lt0.10
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Explaining Demographic Differences in Loss of
Trust
p-valuelt.01, p-value lt0.05, p-value lt0.10
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Key Conclusions

• Resilience of trust is a function of both
  expectations and experiences
• Psychological predictors of trust are very
  different for hospitals and health plans
• Choice bolsters trust in health plans and
  hospitals but perceived regulations have no
  impact
• Psychological predictors can explain some but not
  all differences in loss of trust

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First Stage Model Predictors

• Socio-demographic characteristics
• Age
• Gender
• Education
• Income
• Marital status
• Born in the United States
• English is primary language spoken at home
• Family size
• Full time work, part time work
• Worked in the health care sector
• Health status

• Other characteristics
• Type of insurance
• Features of health plan closed system, primary
  care provider, gatekeeping, pre-approval
• Patient prefers to make own medical care
  decisions
• Knowledge about how to navigate health care
  system
• Concerns about the health care system
• Social support

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Explaining Socio-Economic Differences in Loss of
Trust
p-valuelt.01, p-value lt0.05, p-value lt0.10
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Trust and Expectations