Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles

BACKGROUND

Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids.

METHODS

Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team.

RESULTS

Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy.

DISCUSSION

Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.

Current Challenges When Using Numbers in Patient Decision Aids: Advanced Concepts

BACKGROUND

Decision aid developers have to convey complex task-specific numeric information in a way that minimizes bias and promotes understanding of the options available within a particular decision. Whereas our companion paper summarizes fundamental issues, this article focuses on more complex, task-specific aspects of presenting numeric information in patient decision aids.

METHODS

As part of the International Patient Decision Aids Standards third evidence update, we gathered an expert panel of 9 international experts who revised and expanded the topics covered in the 2013 review working in groups of 2 to 3 to update the evidence, based on their expertise and targeted searches of the literature. The full panel then reviewed and provided additional revisions, reaching consensus on the final version.

RESULTS

Five of the 10 topics addressed more complex task-specific issues. We found strong evidence for using independent event rates and/or incremental absolute risk differences for the effect size of test and screening outcomes. Simple visual formats can help to reduce common judgment biases and enhance comprehension but can be misleading if not well designed. Graph literacy can moderate the effectiveness of visual formats and hence should be considered in tool design. There is less evidence supporting the inclusion of personalized and interactive risk estimates.

DISCUSSION

More complex numeric information. such as the size of the benefits and harms for decision options, can be better understood by using incremental absolute risk differences alongside well-designed visual formats that consider the graph literacy of the intended audience. More research is needed into when and how to use personalized and/or interactive risk estimates because their complexity and accessibility may affect their feasibility in clinical practice.

Promoting Reflection on Medical Maximizing-Minimizing Preferences May Create Undesired Effects on Decisions About Low-Benefit and High-Benefit Care

Background

Medical maximizing-minimizing (MM) preferences predict a variety of medical decisions. We tested whether informing people about their MM preferences and asking them to reflect on the pros and cons of that preference would improve medical decisions when clear clinical recommendations exist.

Methods

We surveyed 1219 US adults age 40+ that were sampled to ensure a 50%/50% distribution of medical maximizers versus minimizers. Participants either received no MM feedback (Control) or received feedback about their MM type and instructions to reflect on how that MM type can be helpful in some circumstances and problematic in others (Reflection). All participants then completed five hypothetical decision scenarios regarding low-value care services (e.g., head computed tomography scan for mild concussion) and three about high-value care (e.g., flu vaccination).

Results

There were no significant differences between the Control and Reflection groups in five of eight scenarios. In three scenarios (two low-benefit and one high-benefit), we observed small effects in the nonhypothesized direction for the MM subgroup least likely to follow the recommendation (e.g., maximizers in the Reflection group were more likely to request low-benefit care).

Conclusions

Asking people to reflect on their MM preferences may be a counterproductive strategy for optimizing patient decision making around quality of care.

Using Narratives to Correct Forecasting Errors in Pediatric Tracheostomy Decision Making

PURPOSE

Parents who face goals-of-care tracheostomy decisions may lack an understanding of challenges affecting their child's and family's long-term quality of life (QOL) to accurately forecast possible outcomes for decision making. We sought to examine whether and how parents' narratives of the child's and family's long-term QOL influence parental tracheostomy decisions and forecasting.

METHOD

We recruited US adult Amazon Mechanical Turk participants (N = 1966) who self-reported having a child (<6 y old) or planning a pregnancy within 5 y. Participants read a vignette about making a tracheostomy decision for their hypothetical neurologically impaired baby. They were randomized to 1 of the following 4 conditions: 1) Baby QOL narratives, 2) Family QOL narratives, 3) Baby QOL + Family QOL narratives, and 4) control: no narratives. They then made a decision about whether or not to pursue tracheostomy, forecasted their concerns about the baby's and family's QOL, reported their values and social norm beliefs about tracheostomy, comfort care, and parental medical decision making, and completed individual differences scales and demographics.

RESULTS

Controlling for individual characteristics, participants in the Baby QOL and Baby QOL + Family QOL conditions were less likely to choose tracheostomy as compared with the control (odds ratio [OR] = 0.38 and 0.25, respectively, P < 0.001). Fewer participants in the Family QOL condition chose tracheostomy compared with the control, but this difference was not statistically significant (OR = 0.70, P = 0.11). Moreover, narratives increased pessimistic forecasting, which was associated with less interest in tracheostomy.

CONCLUSION

Narratives clarifying long-term implications of pursuing tracheostomy have the potential to influence forecasting and decisions. Narrative-based interventions may be valuable in other situations in which forecasting errors are common.

Vaccine Hesitancy and Concerns About Vaccine Safety and Effectiveness in Shanghai, China

INTRODUCTION

Rapidly urbanizing communities in middle-income countries could be sources of vaccine hesitancy, and may create hot spots of low vaccination coverage. This study characterizes vaccine hesitancy in Shanghai and identifies disparities in vaccine safety and efficacy concerns by residency status-a marker for recent migration into the city.

METHODS

Parents of children aged ≤18 years from immunization clinics in Shanghai were enrolled in summer 2019, with the data analyzed during winter 2019-2020. The paper questionnaire used the Parental Attitudes towards Childhood Vaccines scale, which included questions about vaccine safety and efficacy concerns. The primary independent variable was residency-whether an individual was a Shanghai local or a recent migrant (i.e., non-local). Linear regression models assessed the relationship between residency and vaccine safety and efficacy concerns.

RESULTS

Among 1,021 participants, 65.4% had local residency, and the remainder were urban non-locals (13.1%) or rural non-locals (21.5%). A majority of parents expressed concerns about vaccine side effects (73.8%), vaccine safety (63.9%), and vaccine effectiveness (52.4%). Compared with locals, rural non-locals were more concerned about vaccine side effects (β=0.26, 95% CI=0.07, 0.46), vaccine safety (β=0.42, 95% CI=0.19, 0.65), and vaccine effectiveness (β=0.37, 95% CI=0.16, 0.58).

CONCLUSIONS

Differences in vaccine hesitancy by residency could lead to geographical and sociodemographic disparities in vaccination coverage and outbreaks of vaccine-preventable disease.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Medical Maximizing-Minimizing Predicts Patient Preferences for High- and Low-Benefit Care

Purpose. People vary in their general preferences for more v. less health care, and the validated Medical Maximizing-Minimizing Scale (MMS) reliably measures this orientation. Medical maximizers (people scoring highly on the MMS) prefer to receive more health care visits, medications, tests, and treatments, whereas minimizers prefer fewer services. However, it is unclear how maximizing-minimizing preferences relate to willingness to pursue appropriate health care. We hypothesized that minimizers are at increased risk of rejecting evidence-based high-benefit care and that maximizers are at risk of wanting low-benefit care. Design. In total, 785 US adults recruited through an online panel expressed preferences to receive or forgo a health care intervention in 18 hypothetical scenarios. In 8 scenarios, the intervention was high benefit per evidence-based guidelines. In the remaining 10 scenarios, the intervention was low benefit. We assessed associations between participants' MMS score and their preferences for medical intervention in each scenario using regression analyses that adjusted for hypochondriasis, health risk tolerance, health status, and demographic variables. Results. MMS score was significantly associated with preferences in all 18 scenarios after adjusting for other variables. The MMS uniquely explained 11% of the variance in preferences for high-benefit care and 29% of the variance in preferences for low-benefit care. Differences between strong minimizers (10th percentile) and strong maximizers (90th percentile) across the 18 scenarios ranged from 5.6 to 32.3 points on a 1 to 100 preference scale. Conclusions. The MMS reliably predicts people's willingness to pursue appropriate care, both when appropriate care means taking high-benefit actions and when appropriate care means avoiding low-benefit actions. Targeting and tailoring messages according to maximizing-minimizing preferences might increase the effectiveness of both efforts to reduce overutilization of low-benefit services and campaigns to support uptake of high-benefit care.

Hilariously Bad News: Medical Improv as a Novel Approach to Teach Communication Skills for Bad News Disclosure

A targeted, improv-based exercise was developed as a novel skills training approach to bad news disclosure for medical professionals and trainees, focusing on specific characteristics that influence these conversations including nature of the bad news, implications, personal responsibility, and status differences.

Medical Maximizing-Minimizing Preferences in Relation to Low-Value Services for Older Women with Hormone Receptor-Positive Breast Cancer: A Qualitative Study

BACKGROUND

Multiple studies have demonstrated the safety of omitting therapies in older women with breast cancer. Despite de-implementation guidelines, up to 65% of older women continue to receive one or more of these low-value services. Previous work has investigated the role of both provider and patient attitudes as barriers to de-implementation; however, the importance of the patient's maximizing-minimizing preferences within this context remains unclear.

METHODS

In this qualitative study, we conducted 30 semi-structured interviews with women ≥ 70 years of age without a previous diagnosis of breast cancer to elicit perspectives on breast cancer treatment in relation to their medical maximizing-minimizing preferences, as determined by the single-item maximizer-minimizer elicitation question (MM1). We used an interpretive description approach in analysis to produce a thematic survey.

RESULTS

Participants were relatively evenly distributed across the MM1 (minimizer, n = 8; neutral, n = 13; maximizer, n = 9). Despite being told of recommendations allowing for the safe omission of sentinel lymph node biopsy and post-lumpectomy radiotherapy, maximizers consistently stated preferences for more medical intervention and aggressive therapies over minimizers and neutral individuals.

CONCLUSION

Medical maximizing-minimizing preferences in older women correspond with preferences for breast cancer treatment options that guidelines identify as potentially unnecessary. Increased awareness of patient-level variability in maximizing-minimizing preferences may be valuable in developing optimal intervention strategies to reduce utilization of low-value care.

"Cure" Versus "Clinical Remission": The Impact of a Medication Description on the Willingness of People Living with HIV to Take a Medication

Many people living with HIV (PLWHIV) state that they would be willing to take significant risks to be "cured" of the virus. However, how they interpret the word "cure" in this context is not clear. We used a randomized survey to examine whether PLWHIV had a different willingness to take a hypothetical HIV medication if it causes flu-like symptoms, but provides: (a) cure, (b) remission that was labeled "cure", or (c) remission. PLWHIV (n = 454) were more willing to take a medication that provided a "cure" versus a "remission" if the side effects lasted less than 1 year. PLWHIV were more willing to take a medication that provided a remission that was labeled "cure" versus a "remission" (p = 0.01) if the side effects lasted 2 weeks. Clinicians and researchers should be aware of the impact of the word "cure" and ensure that PLWHIV fully understand the possible outcomes of their treatment options.

Older adults' strategies for obtaining medication refills in hypothetical scenarios in the face of COVID-19 risk

Objective

To determine whether older adults would avoid going to the pharmacy (e.g., by restricting medications or requesting delivery) due to the risk of coronavirus disease (COVID-19). Our secondary objectives were to determine the types of medications that the older adults are more likely to restrict and to determine the factors that influence these decisions.

Design

Cross-sectional survey experiment in which participants read 6 scenarios, each stating that they had a 3-day supply of a particular medication remaining.

Setting and participants

National Web-based survey distributed to 1457 U.S. adults aged 65 years and older by Dynata from March 25, 2020, to April 1, 2020.

Outcome measures

Participants reported whether they would go to a pharmacy, have a medication delivered, or restrict the use of each medication. They reported their perceptions and experiences with COVID-19, health risk factors, preferences for more or less care (medical maximizer-minimizer), medication attitudes (beliefs about medicines questionnaire), health literacy, prescription insurance status, and demographics.

Results

Most participants (84%) were told to shelter in place, but only 12% reported attempting to obtain extra medications. Participants most often reported that they would go to the pharmacy to obtain each medication (ranging from tramadol 48.9% to insulin 64.9%) except for zolpidem, which they were most likely to restrict (45.4%). Participants who reported comorbidities that increased their risk of COVID-19 were just as likely to go to the pharmacy as those without. In multinomial logistic regression analyses, women and the oldest participants were more likely to seek delivery of medications. Restricting medications was most common for 2 symptom-focused medications (tramadol and zolpidem), and both demographic factors (e.g., gender) and beliefs (e.g., medical maximizing-minimizing preferences) were associated with such decisions.

Conclusion

Many older adults intend to continue to go to the pharmacy to obtain their medications during a pandemic, even those who have health conditions that further increase their risk for COVID-19.

Eliciting Medical Maximizing-Minimizing Preferences with a Single Question: Development and Validation of the MM1

The 10-item validated Medical Maximizer-Minimizer Scale (MMS-10) assesses patients' preferences for aggressive v. more passive approaches to health care. However, because many research or clinical situations do not allow for use of a 10-item scale, we developed a single-item maximizer-minimizer elicitation question (the MM1) based on our experiences describing the construct to patient groups, clinical researchers, and the public. In 2 large samples of US adults (N = 368 and N = 814), the correlation between MMS-10 scores and the MM1 was .52 and .60, respectively. Both measures were robust predictors of medical preferences in a set of 12 hypothetical scenarios, and both had strong (and roughly equivalent) associations with 7 self-report measures of health care utilization. Our results demonstrate that the MM1 is a valid, brief elicitation of maximizing-minimizing preferences that can be used in clinical or research contexts where the 10-item scale is infeasible.

What Helps People Make Values-Congruent Medical Decisions? Eleven Strategies Tested across 6 Studies

Background. High-quality health decisions are often defined as those that are both evidence informed and values congruent. A values-congruent decision aligns with what matters to those most affected by the decision. Values clarification methods are intended to support values-congruent decisions, but their effects on values congruence are rarely evaluated. Methods. We tested 11 strategies, including the 3 most commonly used values clarification methods, across 6 between-subjects online randomized experiments in demographically diverse US populations ( n1 = 1346, n2 = 456, n3 = 840, n4 = 1178, n5 = 841, n6 = 2033) in the same hypothetical decision. Our primary outcome was values congruence. Decisional conflict was a secondary outcome in studies 3 to 6. Results. Two commonly used values clarification methods (pros and cons, rating scales) reduced decisional conflict but did not encourage values-congruent decisions. Strategies using mathematical models to show participants which option aligned with what mattered to them encouraged values-congruent decisions and reduced decisional conflict when assessed. Limitations. A hypothetical decision was necessary for ethical reasons, as we believed some strategies may harm decision quality. Later studies used more outcomes and covariates. Results may not generalize outside US-based adults with online access. We assumed validity and stability of values during the brief experiments. Conclusions. Failing to explicitly support the process of aligning options with values leads to increased proportions of values-incongruent decisions. Methods representing more than half of values clarification methods commonly in use failed to encourage values-congruent decisions. Methods that use models to explicitly show people how options align with their values offer more promise for helping people make decisions aligned with what matters to them. Decisional conflict, while arguably an important outcome in and of itself, is not an appropriate proxy for values congruence.

Physicians' Perceptions of Proton Pump Inhibitor Risks and Recommendations to Discontinue: A National Survey

OBJECTIVE

To provide contemporary estimates of internists' perceptions of adverse effects associated with proton pump inhibitors (PPIs) and self-reported clinical use.

METHODS

We invited 799 internists, including specialists and postgraduate trainees, to complete an online survey. Topics included perceptions of PPI adverse effects (AEs) and effectiveness for upper gastrointestinal bleeding (UGIB) prevention, changes in prescribing, and management recommendations for patients using PPIs for gastroesophageal reflux disease or UGIB prevention. We used logistic regression to identify factors associated with appropriate PPI continuation in the scenario of a patient at high risk for UGIB.

RESULTS

Among 437 respondents (55% response rate), 10% were trainees and 72% specialized in general medicine, 70% were somewhat/very concerned about PPI AEs, and 76% had somewhat/very much changed their prescribing. A majority believed PPIs increase the risk for 6 of 12 AEs queried. Fifty-two percent perceived PPIs to be somewhat/very effective for UGIB prevention. In a gastroesophageal reflux disease scenario in which PPI can be safely discontinued, 86% appropriately recommended PPI discontinuation. However, in a high-risk UGIB prevention scenario in which long-term PPI use is recommended, 79% inappropriately recommended discontinuation. In this latter scenario, perceived effectiveness for bleeding prevention was strongly associated with continuing PPI (odds ratio 7.68, P < 0.001 for moderately; odds ratio 17.3, P < 0.001 for very effective). Other covariates, including concern about PPI AEs, had no significant association.

DISCUSSION

Most internists believe PPIs cause multiple AEs and recommend discontinuation even in patients at high risk for UGIB. Future interventions should focus on ensuring that PPIs are prescribed appropriately according to individual risks and benefits.

Disparities in risk perception of thyroid cancer recurrence and death

BACKGROUND

To the authors' knowledge, studies regarding risk perception among survivors of thyroid cancer are scarce.

METHODS

The authors surveyed patients who were diagnosed with differentiated thyroid cancer from the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County (2632 patients; 63% response rate). The analytic cohort was defined by a ≤5% risk of disease recurrence and mortality (1597 patients). Patients estimated their recurrence and mortality risks separately (increments of 10% and endpoints of ≤5% and ≥95%). Both outcomes were dichotomized between reasonably accurate estimates (risk perception of ≤5% or 10%) versus overestimation (risk perception of ≥20%). Multivariable logistic regression was used to identify factors associated with risk overestimation, and the relationships between overestimation and both worry and quality of life were evaluated.

RESULTS

In the current study sample, 24.7% of patients overestimated their recurrence risk and 12.5% overestimated their mortality risk. A lower educational level was associated with overestimating disease recurrence (≤high school diploma: odds ratio [OR], 1.64 [95% CI, 1.16-2.31]; and some college: OR, 1.36 [95% CI, 1.02-1.81]) and mortality (≤high school diploma: OR, 1.86 [95% CI, 1.18-2.93]) risk compared with those attaining at least a college degree. Hispanic ethnicity was found to be associated with overestimating recurrence risk (OR, 1.44, 95% CI 1.02-2.03) compared with their white counterparts. Worry about recurrence and death was found to be greater among patients who overestimated versus those who had a reasonably accurate estimate of their risk of disease recurrence and mortality, respectively (P < .001). Patients who overestimated mortality risk also reported a decreased physical quality of life (mean T score, 43.1; 95% CI, 41.6-44.7) compared with the general population.

CONCLUSIONS

Less educated patients and Hispanic patients were more likely to report inaccurate risk perceptions, which were associated with worry and a decreased quality of life.

Preferences for vaccination program attributes among parents of young infants in Shanghai, China

Compared to many other countries, China offers fewer pediatric vaccines. Future attempts to add mandatory vaccines may run counter to parents' preferences for shot-limiting. The aim of this study was to assess Chinese parents' preferences and willingness-to-pay (WTP) for programmatic attributes of vaccination services. Parents of young infants ≤3 months of age presenting at immunization clinics in Shanghai, China, in 2017 completed a discrete choice experiment (DCE) on vaccination program attributes: waiting time at the clinic, number of shots before 7 months, number of injections per visit, cost per visit, and location of the shot. We estimated preference utilities and WTP using logistic regression. In total, 590 completed the DCE. Caregivers expressed greater utility for less waiting time, fewer office visits, lower cost of vaccines, and fewer injections co-administered. Over the course of their child's first 6 months, parents were willing to pay 113 RMB ($17) to avoid an additional 10 minutes of waiting at each appointment (95% confidence interval [CI]: 213, 929), 474 RMB ($70) to avoid an additional office visit (95% CI: 241, 707), and 703 RMB ($104) to avoid an additional injection at each appointment (95% CI: 337, 1068). As China expands its list of publicly funded vaccines, public health officials will have to counter Chinese parents' strong preferences for limiting the total number of office visits and the number of injections administered at each visit, potentially through the use of combination vaccines.

Behavioral Intervention and Disposal of Leftover Opioids: A Randomized Trial

OBJECTIVES

Leftover prescription opioids pose risks to children and adolescents, yet many parents keep these medications in the home. Our objective in this study was to determine if providing a behavioral disposal method (ie, Nudge) with or without a Scenario-Tailored Opioid Messaging Program (STOMP) (risk-enhancement education) improves parents' opioid-disposal behavior after their children's use.

METHODS

Parents whose children were prescribed a short course of opioids were recruited and randomly assigned to the Nudge or control groups with or without STOMP. Parents completed surveys at baseline and 7 and 14 days. Main outcomes were (1) prompt disposal (ie, immediate disposal of leftovers after use) and (2) planned retention (intention to keep leftovers).

RESULTS

There were 517 parents who took part, and 93% had leftovers after use. Prompt disposal behavior was higher for parents who received both the STOMP and Nudge interventions (38.5%), Nudge alone (33.3%), or STOMP alone (31%) compared with controls (19.2%; P ≤ .02). Furthermore, the STOMP intervention independently decreased planned retention rates (5.6% vs 12.5% no STOMP; adjusted odds ratio [aOR] 0.40 [95% confidence interval (CI) 0.19-0.85]). Higher risk perception lowered the odds of planned retention (aOR 0.87 [95% CI 0.79-0.96]), whereas parental past opioid misuse increased those odds (aOR 4.44 [95% CI 1.67-11.79]).

CONCLUSIONS

Providing a disposal method nudged parents to dispose of their children's leftover opioids promptly after use, whereas STOMP boosted prompt disposal and reduced planned retention. Such strategies can reduce the presence of risky leftover medications in the home and decrease the risks posed to children and adolescents.

Prior Vaccination and Effectiveness of Communication Strategies Used to Describe Infectious Diseases

We tested the effect of prior vaccination on response to communication strategies in a hypothetical news article about an influenza pandemic. Vaccinated were more likely than nonvaccinated participants to plan future vaccination, and future vaccination intent was greater with certain communication strategies. Using these findings to target communication may increase vaccination rates.

Alternative option labeling impacts decision-making in noninvasive prenatal screening

Prenatal genetic screening should be an informed, autonomous patient choice. Extrinsic factors which influence patient decision-making threaten the ethical basis of prenatal genetic screening. Prior research in the area of medical decision-making has identified that labeling may have unanticipated effects on patient perceptions and decision-making processes. This Internet-administered study explored the impact of option labeling on the noninvasive prenatal screening (NIPS) selections of US adults. A total of 1,062 participants were recruited through Amazon Mechanical Turk (MTurk) and randomly assigned to one of three possible label sets reflecting provider-derived and industry-derived option labels used in prenatal screening. Multinomial logistic regression analysis showed option labeling had a statistically significant impact on the NIPS selections of study participants (p = .0288). Outcomes of the Satisfaction with Decision Scale (SWD) indicated option labels did not play a role in participant satisfaction with screening selection. The results of this study indicate a need for further evaluation of the impact NIPS option labeling has on patient screening decisions in real-world clinical interactions. Clinical providers and testing laboratories offering NIPS should give careful consideration to the option labels used with prenatal screening so as to minimize influence on patient screening selection and decision-making processes.

Cross-Sectional Psychological and Demographic Associations of Zika Knowledge and Conspiracy Beliefs Before and After Local Zika Transmission

Perceptions of infectious diseases are important predictors of whether people engage in disease-specific preventive behaviors. Having accurate beliefs about a given infectious disease has been found to be a necessary condition for engaging in appropriate preventive behaviors during an infectious disease outbreak, while endorsing conspiracy beliefs can inhibit preventive behaviors. Despite their seemingly opposing natures, knowledge and conspiracy beliefs may share some of the same psychological motivations, including a relationship with perceived risk and self-efficacy (i.e., control). The 2015-2016 Zika epidemic provided an opportunity to explore this. The current research provides some exploratory tests of this topic derived from two studies with similar measures, but different primary outcomes: one study that included knowledge of Zika as a key outcome and one that included conspiracy beliefs about Zika as a key outcome. Both studies involved cross-sectional data collections that occurred during the same two periods of the Zika outbreak: one data collection prior to the first cases of local Zika transmission in the United States (March-May 2016) and one just after the first cases of local transmission (July-August). Using ordinal logistic and linear regression analyses of data from two time points in both studies, the authors show an increase in relationship strength between greater perceived risk and self-efficacy with both increased knowledge and increased conspiracy beliefs after local Zika transmission in the United States. Although these results highlight that similar psychological motivations may lead to Zika knowledge and conspiracy beliefs, there was a divergence in demographic association.

Role of Patient Maximizing-Minimizing Preferences in Thyroid Cancer Surveillance

PURPOSE

To understand the effect of patient preferences on thyroid cancer surveillance intensity.

PATIENTS AND METHODS

Eligible patients diagnosed with thyroid cancer between January 1, 2014, and December 31, 2015, from the Georgia and Los Angeles County SEER registries were surveyed between February 2017 and October 2018 (N = 2,632; response rate, 63%). Patient reports on health care utilization in the past year and responses to the validated Medical Maximizer-Minimizer Scale were linked to SEER data in the 2,183 disease-free patients. Ordered logistic regression was performed using a cumulative logit with nonproportional odds.

RESULTS

Of disease-free patients, 31.6% were classified as minimizers, 42.5% as moderate maximizers, and 25.9% as strong maximizers. In the past year, 25.2%, 27.3%, and 38.5% of minimizers, moderate maximizers, and strong maximizers, respectively, had ≥ 4 doctor visits, and 18.3%, 24.9%, and 29.5%, respectively, had ≥ 2 neck ultrasounds. When controlling for age, sex, race and ethnicity, comorbidity, stage, and SEER site, strong maximizers (compared with minimizers) were significantly more likely to report ≥ 4 doctor visits (odds ratio [OR], 1.45; 95% CI, 1.10-1.92), ≥ 2 neck ultrasounds (OR, 1.58; 95% CI, 1.17-2.14), ≥ 1 radioactive iodine scan (OR, 1.73; 95% CI, 1.19-2.50), and ≥ 1 additional imaging study (OR, 2.06; 95% CI, 1.56-2.72).

CONCLUSION

Among patients with thyroid cancer who have been declared disease free, preference for a more maximal versus minimal approach to medical care is associated with increased number of physician visits and imaging tests. Because increased surveillance does not clearly correlate with improved outcomes, poses potential risks to patients, and contributes to increased healthcare costs, stronger consideration of the role of patient preferences is necessary when framing discussions on surveillance.