Brian J. Zikmund-Fisher

The impact of the format of graphical presentation on health-related knowledge and treatment choices.

OBJECTIVE To evaluate the ability of six graph formats to impart knowledge about treatment risks/benefits to low and high numeracy individuals. METHODS Participants were randomized to receive numerical information about the risks and benefits of a hypothetical medical treatment in one of six graph formats. Each described the benefits of taking one of two drugs, as well as the risks of experiencing side effects. Main outcome variables were verbatim (specific numerical) and gist (general impression) knowledge. Participants were also asked to rate their perceptions of the graphical format and to choose a treatment. RESULTS 2412 participants completed the survey. Viewing a pictograph was associated with adequate levels of both types of knowledge, especially for lower numeracy individuals. Viewing tables was associated with a higher likelihood of having adequate verbatim knowledge vs. other formats (p<0.001) but lower likelihood of having adequate gist knowledge (p<0.05). All formats were positively received, but pictograph was trusted by both high and low numeracy respondents. Verbatim and gist knowledge were significantly (p<0.01) associated with making a medically superior treatment choice. CONCLUSION Pictographs are the best format for communicating probabilistic information to patients in shared decision making environments, particularly among lower numeracy individuals. PRACTICE IMPLICATIONS Providers can consider using pictographs to communicate risk and benefit information to patients of different numeracy levels.

Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers

BackgroundMaking evidence-based decisions often requires comparison of two or more options. Research-based evidence may exist which quantifies how likely the outcomes are for each option. Understanding these numeric estimates improves patients’ risk perception and leads to better informed decision making. This paper summarises current “best practices” in communication of evidence-based numeric outcomes for developers of patient decision aids (PtDAs) and other health communication tools.MethodAn expert consensus group of fourteen researchers from North America, Europe, and Australasia identified eleven main issues in risk communication. Two experts for each issue wrote a “state of the art” summary of best evidence, drawing on the PtDA, health, psychological, and broader scientific literature. In addition, commonly used terms were defined and a set of guiding principles and key messages derived from the results.ResultsThe eleven key components of risk communication were: 1) Presenting the chance an event will occur; 2) Presenting changes in numeric outcomes; 3) Outcome estimates for test and screening decisions; 4) Numeric estimates in context and with evaluative labels; 5) Conveying uncertainty; 6) Visual formats; 7) Tailoring estimates; 8) Formats for understanding outcomes over time; 9) Narrative methods for conveying the chance of an event; 10) Important skills for understanding numerical estimates; and 11) Interactive web-based formats. Guiding principles from the evidence summaries advise that risk communication formats should reflect the task required of the user, should always define a relevant reference class (i.e., denominator) over time, should aim to use a consistent format throughout documents, should avoid “1 in x” formats and variable denominators, consider the magnitude of numbers used and the possibility of format bias, and should take into account the numeracy and graph literacy of the audience.ConclusionA substantial and rapidly expanding evidence base exists for risk communication. Developers of tools to facilitate evidence-based decision making should apply these principles to improve the quality of risk communication in practice.

The Role of Clinical Uncertainty in Treatment Decisions for Diabetic Patients with Uncontrolled Blood Pressure

Context Why do clinicians fail to intensify antihypertensive therapy when a patients blood pressure is elevated? Contribution This study involved 1169 diabetic patients seen by 92 primary care providers at 9 Veterans Affairs facilities. All had elevated triage blood pressures, but only half received antihypertensive treatment intensification by providers. Patient reports of home blood pressures or repeated blood pressures by providers within normal limits and discussion of medication issues decreased the likelihood of antihypertensive intensification at clinic visits. Implication Uncertainty about true blood pressure values may underlie many reasons why physicians do not intensify antihypertensive therapy. The Editors Despite some recent improvements in blood pressure control, the number of patients with inadequate control remains high and contributes to excess morbidity and mortality, especially among patients at high risk from complications of hypertension (18). Several studies have suggested that clinical inertiathe failure by providers to initiate or intensify therapy (medication intensification) in the face of apparent need to do sois a main contributor to poor control of hypertension (912). Although the failure to intensify treatment medications for patients with elevated blood pressures at visits has been well documented (5, 6, 1218), factors underlying what seems to be clinical inertia have been studied less systematically. When providers are queried after clinic visits about the lack of medication intensification for elevated blood pressure, they variously report that the patients true blood pressure was lower than the clinic blood pressure reading, that other patient concerns precluded attention on blood pressure management, and that patient adherence should be improved before medication intensification (6, 17). Some studies have examined the role of various clinical and patient factors in intensification decisions (6, 8, 17, 19, 20), but no study has used a detailed conceptual model to comprehensively examine the relative contribution of a broad array of potential patient, provider, organizational, and visit-specific contributors to a medication intensification decision. In addition, although a frequently cited reason for deferring medication changes is that the clinic blood pressure does not reflect the patients true blood pressure (21, 22), this clinical uncertainty and its effects have not been explored. To better understand factors underlying apparent clinical inertia for hypertension, we designed the ABATe (Addressing Barriers to Treatment for Hypertension) study to examine treatment change decisions for diabetic primary care patients with elevated triage blood pressures before a primary care visit. We defined elevated blood pressure for this population to be 140/90 mm Hg, a value well above guideline targets for diabetic patients and one clearly requiring some type of action (4). Our goals were to assess how often patients presenting with an elevated triage blood pressure received medication intensification or were scheduled for close follow-up and the role that clinical uncertainty about blood pressure, competing demands and prioritization, medication-related factors, and care organization play in treatment change decisions. Methods Conceptual Model On the basis of theories of patient, provider, and organization behavior (2336), we developed a conceptual modelthe hypertension clinical action modelto examine decisions that drive treatment change (medication intensification or prompt blood pressure follow-up) for elevated blood pressure (Figure 1). The model, developed by 2 internists and 3 PhD-level methodologists in conjunction with development of ABATe and before data collection, proposes such treatment change decisions at a visit are based on 4 main conceptual domains: clinical uncertainty (Is the patients blood pressure truly elevated? Does the clinic blood pressure reflect the true blood pressure?), competing demands and prioritization (What other problems need to be addressed at this visit? Is blood pressure management a priority for this particular patient? Does the provider place priority on blood pressure management in general?), medication-related factors (Should adherence be addressed first? Is the medication regimen too complex? Will the patient accept another medication?), and care organization (Is there sufficient time to address hypertension? Are staff available for follow-up?). In addition, as part of grant development, we hypothesized that the following factors would lead to a lower probability of treatment change: uncertainty about whether the patients visit blood pressure reflected their true blood pressure (clinical uncertainty), comorbid conditions unrelated to hypertension and diabetes (37), a lower priority placed by the provider on the importance of treating elevated blood pressure, a higher number of baseline medications, perceived medication adherence problems, shorter clinic visit times, and lack of staff to follow up for blood pressure medication adjustment. Figure 1. Hypertension clinical action model. Design Setting We conducted a prospective cohort study of patients with scheduled primary care visits at 9 Veterans Affairs facilities located in 3 midwestern states. These facilities varied in size and structure, with 3 large academic-affiliated medical centers, 1 large nonacademic medical center, and 1 large and 4 small community-based outpatient clinics. From 15 February 2005 to 14 February 2006, approximately 33500 diabetic patients visited primary care providers (including residents) in these facilities (range per facility, 1050 to 9200 diabetic patients). The institutional review boards of all participating facilities approved the study protocol. Both patients and providers gave written informed consent before participating. Providers received a

Decision-making processes for breast, colorectal, and prostate cancer screening: the DECISIONS survey.

50 bookstore gift card, and patients received a

Prostate cancer screening decisions: Results from the National Survey of Medical Decisions (DECISIONS study)

10 department store gift card for completing initial surveys. Providers were told that the study was about diabetes and hypertension, with the purpose being to study challenges in treating patients with diabetes and ways to overcome these challenges so that quality of care can be enhanced. Primary Care Providers We invited all nonresident primary care providers with patient care responsibility at least 2 half-days per week to participate in the study. Of the eligible 126 providers approached, 104 consented to participate, for an overall recruitment rate of 83% (median facility-level recruitment rate, 88%). By the time recruitment started, 12 providers had stopped working at their facility or changed their patient care responsibilities, leaving 92 primary care providers still eligible to participate (range per facility, 2 to 28 providers; median, 8). Patients As specified by our institutional review board protocols, potentially eligible patients were referred to study staff by triage personnel. During the enrollment periods at each facility, study staff screened all referred patients who presented for a scheduled visit to participating primary care providers and whose lowest triage systolic blood pressure was 140 mm Hg or greater or whose lowest triage diastolic blood pressure was 90 mm Hg or greater (Figure 2). In each of the facilities, triage staff routinely used an electronic cuff to check the patients blood pressure before the provider visit. Triage policies specified that a second blood pressure measurement should be obtained if the first blood pressure was elevated. In addition to the triage blood pressure, study staff screened patients for the following inclusion criteria: the participant confirmed a diagnosis of diabetes, the participating provider was the primary provider of diabetes care for the participant, and the participant spoke English. Patients with impaired decision-making ability (for example, dementia and traumatic brain injury) or terminal disease and residents of nursing homes were excluded. Of the 1556 patients approached by study staff, 213 were ineligible (Figure 2) and 1169 provided written informed consent to participate in the study (approached and eligible, 87%; median facility-level recruitment rate, 89%). We enrolled a median of 14 patients per provider (range, 1 to 16 patients) from February 2005 to March 2006. Recruitment time per facility varied from 4 to 12 months. Figure 2. Study flow diagram. PCP = primary care provider. *Diabetic patients presenting for a primary care visit to 1 of 92 participating providers were referred for eligibility assessment if their lowest triage blood pressure was140/90 mm Hg. *Number of responses varied by individual item. Our prespecified sample size calculations stipulated that we needed at least 11 patients from 80 physicians across 8 sites (that is, 880 patients) to detect a moderate difference in treatment change (about 12%) when competing demands were or were not present. Data Sources We included data from 5 sources in our analysis (Table 1). First, a baseline survey completed by all providers provided variables assessing provider prioritization to blood pressure management, general provider characteristics, and availability of ancillary support for blood pressure management. Second, providers completed a brief visit survey for each patient after the same clinic session in which they saw the patient (completion rate, 99%). This survey provided information on which issues were discussed during the visit, the providers blood pressure goal for the patient, and whether medications were changed during the visit. Third, a patient survey conducted at enrollment provided sociodemographic characteristics, self-reported adherence and difficulty with medications, and self-management practices (completion rate, 91%). Fourth, review of electronic medical records documented free text blood pressure values and notes on actions taken at the enrollment visit. Finally, patient age, prescribed medications and th

A Matter of Perspective: Choosing for Others Differs from Choosing for Yourself in Making Treatment Decisions

Background Patients should understand the risks and benefits of cancer screening in order to make informed screening decisions. Objectives To evaluate the extent of informed decision making in patient-provider discussions for colorectal (CRC), breast (BrCa), and prostate (PCa) cancer screening. Setting National sample of US adults identified by random-digit dialing. Design Cross-sectional survey conducted between November 2006 and May 2007. Participants English-speaking US adults aged 50 y and older who had discussed cancer screening with a health care provider within the previous 2 y. Measurements Cancer screening survey modules that asked about demographic characteristics, cancer knowledge, the importance of various sources of information, and self-reported cancer screening decision-making processes. Results Overall, 1082 participants completed 1 or more of the 3 cancer modules. Although participants generally considered themselves well informed about screening tests, half or more could not correctly answer even 1 open-ended knowledge question for any given module. Participants consistently overestimated risks for being diagnosed with and dying from each cancer and overestimated the positive predictive values of prostate-specific antigen tests and mammography. Providers were the most highly rated information source, usually initiated screening discussions (64%–84%), and often recommended screening (73%–90%). However, participants reported that providers elicited their screening preferences in only 31% (CRC women) to 57% (PCa) of discussions. Although more than 90% of the discussions addressed the pros of screening, only 19% (BrCa) to 30% (PCa) addressed the cons of screening. Limitations Recall bias is possible because screening process reports were not independently validated. Conclusions Cancer screening decisions reported by patients who discussed screening with their health care providers consistently failed to meet criteria for being informed. Given the high ratings for provider information and frequent recommendations for screening, providers have important opportunities to ensure that informed decision making occurs for cancer screening decisions.

Communicating Side Effect Risks in a Tamoxifen Prophylaxis Decision Aid: The Debiasing Influence of Pictographs

BACKGROUND Guidelines recommend informing patients about the risks and benefits of prostate cancer screening. We evaluated the medical decision-making process for prostate-specific antigen (PSA) testing. METHODS We conducted a telephone survey of a randomly selected national sample of 3010 English-speaking US adults 40 years and older. Included in the survey were 375 men who had either undergone or discussed (with health care providers [HCPs]) PSA testing in the previous 2 years. We asked subjects about sociodemographic characteristics, prostate cancer screening discussion features, prostate cancer knowledge, and the importance of various decision factors and sources of information. RESULTS Overall, 69.9% of subjects discussed screening before making a testing decision, including 14.4% who were not tested. Health care providers most often (64.6%) raised the idea of screening, and 73.4% recommended PSA testing. Health care providers emphasized the pros of testing in 71.4% of discussions but infrequently addressed the cons (32.0%). Although 58.0% of subjects felt well-informed about PSA testing, 47.8% failed to correctly answer any of the 3 knowledge questions. Only 54.8% of subjects reported being asked for their screening preferences. An HCP recommendation (odds ratio, 2.67; 95% confidence interval, 1.08-6.58) was the only discussion characteristic associated with testing. Valuing HCP information was also associated with testing (odds ratio, 1.26; 95% confidence interval, 1.04-1.54). CONCLUSIONS Recommendations and information from HCPs strongly influenced testing decisions. However, most prostate cancer screening decisions did not meet criteria for shared decision making because subjects did not receive balanced discussions of decision consequences, had limited knowledge, and were not routinely asked for their preferences.

The DECISIONS Study: A Nationwide Survey of United States Adults Regarding 9 Common Medical Decisions

AbstractBACKGROUND: Many people display omission bias in medical decision making, accepting the risk of passive nonintervention rather than actively choosing interventions (such as vaccinations) that result in lower levels of risk. OBJECTIVE: Testing whether people’s preferences for active interventions would increase when deciding for others versus for themselves. RESEARCH DESIGN: Survey participants imagined themselves in 1 of 4 roles: patient, physician treating a single patient, medical director creating treatment guidelines, or parent deciding for a child. All read 2 short scenarios about vaccinations for a deadly flu and treatments for a slow-growing cancer. PARTICIPANTS: Two thousand three hundred and ninety-nine people drawn from a demographically stratified internet sample. MEASURES: Chosen or recommended treatments. We also measured participants’ emotional response to our task. RESULTS: Preferences for risk-reducing active treatments were significantly stronger for participants imagining themselves as medical professionals than for those imagining themselves as patients (vaccination: 73% [physician] & 63% [medical director] vs 48% [patient], Ps<.001; chemotherapy: 68% & 68% vs 60%, Ps<.012). Similar results were observed for the parental role (vaccination: 57% vs 48%, P=.003; chemotherapy: 72% vs 60%, P<.001). Reported emotional reactions were stronger in the responsible medical professional and parental roles yet were also independently associated with treatment choice, with higher scores associated with reduced omission tendencies (OR=1.15 for both regressions, Ps<.01). CONCLUSIONS: Treatment preferences may be substantially influenced by a decision-making role. As certain roles appear to reinforce “big picture” thinking about difficult risk tradeoffs, physicians and patients should consider re-framing treatment decisions to gain new, and hopefully beneficial, perspectives.

Improving understanding of adjuvant therapy options by using simpler risk graphics.

OBJECTIVE To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers. METHODS We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge. RESULTS Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels. CONCLUSIONS Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations. PRACTICE IMPLICATIONS Including graphs in risk communications is essential to support an informed treatment decision-making process.

Use of the Internet and Ratings of Information Sources for Medical Decisions: Results from the DECISIONS Survey:

Background Patient involvement is required before patients’ preferences can be reflected in the medical care they receive. Furthermore, patients are a vital link between physicians’ assessments of patients’ needs and actual implementation of appropriate care. Yet no study has specifically examined how and when a representative sample of patients considered, discussed, and made medical decisions. Objective To identify decision prevalence and decision-making processes regarding 1) initiation of prescription medications for hypertension, hypercholesterolemia, or depression; 2) screening tests for colorectal, breast, or prostate cancer; and 3) surgeries for knee or hip replacement, cataracts, or lower back pain. Design Computer-assisted telephone interview survey. Setting Nationally representative sample of US adults in households with telephones. Participants 3010 English-speaking adults age 40 and older identified using a stratified random sample of telephone numbers. Measurements Estimated prevalence of medical decisions, defined as the patient having initiated medications, been screened, or had surgery within the past 2 years or having discussed these actions with a health care provider during the same interval, as well as decision-specific data regarding patient knowledge, attitudes and patient-provider interactions. Results 82.2% of the target population reported making at least 1 medical decision in the preceding 2 years. The proportion of decisions resulting in patient action varied dramatically both across decision type (medications [61 %] v. screening [83%] v. surgery [44%]; P < 0.001), and within each category (e.g., blood pressure medications [76%] v. cholesterol medications [55%] vs. depression medications [48%]; P < 0.001). Respondents reported making more decisions if they had a primary care provider or poorer health status and fewer decisions if they had lower education, were male, or were under age 50. Limitations Retrospective self-reports may incorporate recall biases. Conclusions Medical decisions with significant life-saving, quality of life, and cost implications are a pervasive part of life for most US adults. The DECISIONS dataset provides a rich research environment for exploring factors influencing when and how patients make common medical decisions.