Relatively little is known about why some patients are reluctant to engage in a collaborative discussion with physicians about their choices in health care. To explore this issue further, we conducted six focus-group sessions with forty-eight people in the San Francisco Bay Area. In the focus groups, we found that participants voiced a strong desire to engage in shared decision making about treatment options with their physicians. However, several obstacles inhibit those discussions. These include the fact that even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations; that physicians can be authoritarian; and that the fear of being categorized as "difficult" prevents patients from participating more fully in their own health care. We argue that physicians may not be aware of a need to create a safe environment for open communication to facilitate shared decision making. Rigorous measures of patient engagement, and of the degree to which health care decisions truly reflect patient preferences, are needed to advance shared decision making in clinical practice.

Under-representation of minority and female participants prompted the U.S. legislature to mandate the inclusion of women and minorities in federally funded research.Recruitment of minorities to participate in clinical trials continues to be challenging.Although Asian Americans constitute one of the major minority groups in the U.S.,

Patients with aMCI had lower medical expenditures than patients with AD dementia. Poor cognitive status was linearly associated with lower household income, higher medical expenditures, higher likelihood of nursing and home care services, and lower likelihood of outpatient visits.

Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010-12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care. I ncreasing patient engagement has been advocated as a top priority for improving health care quality.1 Providing patients with information about their clinical options and activating patients to participate in informed discussions regarding their care are the foundation of shared decision making and a potential mechanism for increasing patients' engagement in their care.These concepts are particularly relevant when preference-sensitive decisions are being made, such as the choice of method for colorectal cancer screening or of treatment for back pain. In preference-sensitive decisions, more than one available option exists, each of which carries different risks and benefits, and patients' treatment preferences can vary. 3Although many potential pathways may be taken to help facilitate preference-sensitive decisions, the use of decision aids has been a commonly proposed and studied intervention. Decision aids, which are specifically designed to provide patients with the information necessary to engage in shared decision making with their care providers, serve as an adjunct to clinical consultations. They come in a variety of formats, including video, print, and online.The use of decision aids has been shown to increase patients' knowledge of available treatment options and to help clarify patients' preferences. 4 For example, national clinical practice guidelines suggest that the decision to undergo colorectal cancer screening be a shared one between physicians and patients, because multiple efficacious screening methods are available. 2 Studies have shown that patients' preferences for specific methods of colorectal cancer screening vary, and the use of decision aids on this topic has been linked to increases in screening rates. 5 However, there is evidence that despite physi-

Background Understanding of cancer outcomes is limited by data fragmentation. We analyzed the information yielded by integrating breast cancer data from three sources: electronic medical records (EMRs) of two healthcare systems and the state registry. Methods We extracted diagnostic test and treatment data from EMRs of all breast cancer patients treated from 2000–2010 in two independent California institutions: a community-based practice (Palo Alto Medical Foundation) and an academic medical center (Stanford University). We incorporated records from the population-based California Cancer Registry (CCR), and then linked EMR-CCR datasets of Community and University patients. Results We initially identified 8210 University patients and 5770 Community patients; linked datasets revealed a 16% patient overlap, yielding 12,109 unique patients. The proportion of all Community patients, but not University patients, treated at both institutions increased with worsening cancer prognostic factors. Before linking datasets, Community patients appeared to receive less intervention than University patients (mastectomy: 37.6% versus 43.2%; chemotherapy: 35% versus 41.7%; magnetic resonance imaging (MRI): 10% versus 29.3%; genetic testing: 2.5% versus 9.2%). Linked Community and University datasets revealed that patients treated at both institutions received substantially more intervention (mastectomy: 55.8%; chemotherapy: 47.2%; MRI: 38.9%; genetic testing: 10.9%; p<0.001 for each three-way institutional comparison). Conclusion Data linkage identified 16% of patients who were treated in two healthcare systems and who, despite comparable prognostic factors, received far more intensive treatment than others. By integrating complementary data from EMRs and population-based registries, we obtained a more comprehensive understanding of breast cancer care and factors that drive treatment utilization.