Helping Doctors and Patients Make Sense of Health Statistics

How to design effective educational videos for teaching evidence-based medicine to undergraduate learners - systematic review with complementing qualitative research to develop a practicable guide

BACKGROUND

eLearning can be an effective tool to achieve learning objectives. It facilitates asynchronous distance learning, increasing flexibility for learners and instructors. In this context, the high educational value of videos provides an invaluable primary component for longitudinal digital curricula, especially for maintaining knowledge on otherwise rarely taught subjects. Although literature concerning eLearning evaluation exists, research comprehensively describing how to design effective educational videos is lacking. In particular, studies on the requirements and design goals of educational videos need to be complemented by qualitative research using grounded theory methodology.

METHODS

Due to the paucity of randomized controlled trials in this area, there is an urgent need to generate recommendations based on a broader fundament than a literature search alone. Thus, the authors have employed grounded theory as a guiding framework, augmented by Mayring's qualitative content analysis and commonly used standards. An adaptive approach was conducted based on a literature search and qualitative semi-structured interviews. Drawing on these results, the authors elaborated a guide for creating effective educational videos.

RESULTS

The authors identified 40 effective or presumedly effective factors fostering the success of video-based eLearning in teaching evidence-based medicine, providing a ready-to-use checklist. The information collected via the interviews supported and enriched much of the advice found in the literature.

DISCUSSION

To the authors' knowledge, this type of comprehensive guide for video-based eLearning needs has not previously been published. The interviews considerably contributed to the results. Due to the grounded theory-based approach, in particular, consensus was achieved without the presence of a formal expert panel. Although the guide was created with a focus on teaching evidence-based medicine, due to the general study selection process and research approach, the recommendations are applicable to a wide range of subjects in medical education where the teaching aim is to impart conceptual knowledge.

Why we should not "help bad choosers:" screening, nudging, and epistemic risk

One prominent line of support for nudging in screening programs is the claim that nudging can help 'bad choosers' - that is, it can help some patients make choices more in line with their own values and preferences. In this article, I argue that due to the presence of epistemic risk in many screening programs, the argument that nudging can help 'bad choosers' should be revised or rejected. Expanding on the work of Biddle, J. B. 2020. Epistemic risks in cancer screening: Implications for ethics and policy. Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 79: 101200.), I argue that epistemic risk undermines the argument that nudging can help to promote patient autonomy in the context of screening. Specifically, I argue that epistemic risk results in the inclusion of non-patient values and preferences in the screening process, which challenges the claim that nudging can help patients make choices more in line with their own values and preferences. I present four reasons to think epistemic risk undermines the argument in this way: (1) conflicting values; (2) lack of transparency; (3) limited autonomy in opting out; (4) unjustified manipulation. The presence of epistemic risk in screening programs means that nudging may not always be an effective means of promoting patient autonomy and informed consent. As such, epistemic risk poses significant challenges to at least one ethical justification of nudging in screening programs, and raises further questions about the role of nudging in promoting patient decision-making.

Fifteen-minute consultation: Empowering children, young people and families through shared decision-making: a practical guide

Shared decision-making (SDM) is a collaborative approach to healthcare decision-making that involves patients and healthcare professionals working together to make decisions that are informed by the best available medical evidence, as well as the patient's values, preferences and goals. The importance of SDM and the intricate interplay among parents, children and young people (CYP), and healthcare professionals are increasingly acknowledged as the crucial aspects of delivering high-quality paediatric care. While there is a substantial evidence base for SDM improving knowledge and reducing decisional conflict, the evidence for long-term measures such as improved health outcomes is limited and mainly inconclusive. To support healthcare teams in implementing SDM, the authors offer a practical guide to enhance decision-making processes and empower CYP and their families.

"R" you getting this? Factors contributing to the public's understanding, evaluation, and use of basic reproduction numbers for infectious diseases

BACKGROUND

We (1) examined the effects of evaluative labels and visual aids on people's understanding, evaluation, and use of the COVID-19 reproduction number (or "r-number"), (2) examined whether people's perceived susceptibility and (intended) adherence to preventive measures changed after being exposed to the r-number, and (3) explored whether these effects and changes depended on people's numeracy skills.

METHODS

In an online experiment, participants from a large Dutch representative sample (N = 1,168) received information about the COVID-19 r-number displayed on the corona dashboard of the Dutch Ministry of Health, Welfare and Sport. The r-number was either presented with or without a categorical line display (i.e., evaluative label) and with or without an icon-based tree diagram (i.e., visual aid) explaining how the number works. Regarding people's use of the statistic, we measured perceived susceptibility to COVID-19 and adherence (intention) to five preventive measures before and after exposure to the r-number. After exposure, we also measured participants' understanding, perceived usefulness, affective and cognitive evaluation, and objective numeracy.

RESULTS

About 56% of participants correctly interpreted the r-number, with highly numerate people having better understanding than less numerate people. Information about the r-number was perceived as more useful when presented with a visual aid. There were no differences across experimental conditions in people's understanding, affective, and cognitive evaluations. Finally, independent of experimental conditions, intention to adhere to preventive measures was higher after seeing the r-number, but only among highly numerate people.

CONCLUSIONS

Although evaluative labels and visual aids did not facilitate people's understanding and evaluation of the r-number, our results show that the statistic is perceived as useful and may be used to stimulate adherence to preventive measures. Policy makers and public health communicators are advised to clearly explain why they are giving these numbers to - especially - the less numerate people, but also how people could use them for behavior change to combat the spread of virus during a pandemic.

Evaluation of the Implementation of the Dutch Breast Cancer Surveillance Decision Aid including Personalized Risk Estimates in the SHOUT-BC Study: A Mixed Methods Approach

BACKGROUND

To improve Shared decision-making (SDM) regarding personalized post-treatment surveillance, the Breast Cancer Surveillance Decision Aid (BCS-PtDA), integrating personalized risk information, was developed and implemented in eight hospitals. The aim of this mixed-methods study was to (1) assess the implementation and participation rates, (2) identify facilitators and barriers for use by health care professionals (HCPs), (3) quantify the observed level of SDM, and (4) evaluate risk communication and SDM application in consultations.

METHODS

Implementation and participation rates and patients' BCS-PtDA use were calculated using hospital registry data and BCS-PtDA log data. HCPs' perspective on facilitators and barriers were collected using the MIDI framework. Observed SDM levels in consultation transcripts were quantified using the OPTION-5 scale. Thematic analysis was performed to assess consultation content.

RESULTS

The average PtDA implementation and participation rates were, respectively, 26% and 61%. HCPs reported that the PtDA supported choice awareness. Reported barriers for implementation were mainly increased workload and a lack of perceived benefits. The consultation analysis (n = 64) showed patients were offered a choice, but deliberation was lacking. Risk communication was generally adequate.

DISCUSSION

When the BCS-PtDA was used, patients were clearly given a choice regarding their post-treatment surveillance, but information provision and SDM application can be improved.

Motivated reasoning about climate change and the influence of Numeracy, Need for Cognition, and the Dark Factor of Personality

Human information processing is not always rational but influenced by prior attitudes, a phenomenon commonly known as motivated reasoning. We conducted two studies (N1 = 556, N2 = 1198; UK samples) investigating motivated reasoning in the context of climate change with a focus on individual differences as potential moderating factors. While previous research investigated motivated reasoning regarding the debate whether climate change is anthropogenic, we focused on current discourses about the effectiveness of different countermeasures. To this end, participants evaluated fictitious scientific data on the effectiveness of regulations to reduce CO2 emissions. In both studies, participants exhibited motivated reasoning as indicated by the observation that prior attitudes about CO2 reduction policies predicted evaluation of the scientific data. The degree of motivated reasoning was not related to individual difference variables, namely the ability to understand and reason with numbers (Numeracy), the willingness to show this ability (Need for Cognition), and the tendency to maximize one's individual utility (Dark Factor of Personality). However, numeracy was associated with a less biased interpretation of the presented information. Our research demonstrates that motivated reasoning is a general phenomenon, and points to numerical training as one way to improve reasoning.

Improving risk communication: a proof-of-concept randomised control trial assessing the impact of visual aids for neurosurgical consent

Introduction

Informed consent is a fundamental component in the work-up for surgical procedures. Statistical risk information pertaining to a procedure is by nature probabilistic and challenging to communicate, especially to those with poor numerical literacy. Visual aids and audio/video tools have previously been shown to improve patients' understanding of statistical information. In this study, we aimed to explore the impact of different methods of risk communication in healthy participants randomized to either undergo the consent process with visual aids or the standard consent process for lumbar puncture.

Material and methods

Healthy individuals above 18 years old were eligible. The exclusion criteria were prior experience of the procedure or relevant medical knowledge, lack of capacity to consent, underlying cognitive impairment and hospitalised individuals. After randomisation, both groups received identical medical information about the procedure of a lumbar puncture in a hypothetical clinical scenario via different means of consent. The control group underwent the standard consent process in current clinical practice (Consent Form 1 without any illustrative examples), whereas the intervention group received additional anatomy diagrams, the Paling Palette and the Paling perspective scale. Anonymised questionnaires were received to evaluate their perception of the procedure and its associated risks.

Results

Fifty-two individuals were eligible without statistically significant differences in age, sex, professional status and the familiarity of the procedure. Visual aids were noted to improve the confidence of participants to describe the risks by themselves (p = 0.009) and participants in the intervention group felt significantly less overwhelmed with medical information (p = 0.028). The enhanced consent process was found to be significantly more acceptable by participants (p = 0.03). There was a trend towards greater appropriateness (p = 0.06) and it appeared to have "good" usability (median SUS = 76.4), although this also did not reach statistical significance (p = 0.06).

Conclusion

Visual aids could be an appropriate alternative method for medical consent without being inferior regarding the understanding of the procedure, its risks and its benefits. Future studies could possibly compare or incorporate multiple interventions to determine the most effective tools in a larger scale of population including patients as well as healthy individuals.

Effect of Mortality alongside 5-Year Survival Rates and Incidence on the Public's Perceived Benefits of Cancer Screening and Screening Intention: A Web-Based Experimental Study

BACKGROUND

Mortality is critical information in evaluating the benefits of cancer screening. However, 5-y survival rates and incidence, without mortality, have been frequently communicated to the public. Based on the literature that people's perceptions and judgments can be altered by the way of presenting health statistics, the current study examined whether mortality alongside 5-y survival and incidence would influence laypeople's perceptions of the effectiveness of cancer screening and screening intention.

METHODS

In an online-based experimental survey conducted in South Korea in October 2022, 300 adults were randomly assigned to 1 of 2 groups (mortality: no v. yes) to be presented with 3 different cancers (A, B, and C). The perceived effectiveness of cancer screening and screening intention were measured using 7-point scales for each cancer.

RESULTS

Across all cancers, participants in the no-mortality group perceived cancer screening to be more effective and were more willing to undergo screening compared with those in the mortality group, although the results were not statistically significant on the intention.

CONCLUSIONS

In general, mortality had an effect of decreasing the perceived effectiveness of cancer screening and screening intention compared with no mortality, although the effect on the intention was not statistically significant.

IMPLICATIONS

When communicating the benefits of cancer screening to the public, mortality statistics may play a role in mitigating the potentially inflated perception of the benefits of cancer screening and screening intention.

HIGHLIGHTS

Five-year survival rates, either alone or with incidence rates, are frequently communicated to the public in the context of the benefits of cancer screening.However, 5-y survival rates can sometimes be inflated without a reduction in mortality.Including mortality statistics in communications decreased the perceived effectiveness of cancer screening and screening intentions.Mortality information needs to be communicated in the benefits of cancer screening.

Knowing When to Pass: The Effect of AI Reliability in Risky Decision Contexts

OBJECTIVE

This study manipulates the presence and reliability of AI recommendations for risky decisions to measure the effect on task performance, behavioral consequences of trust, and deviation from a probability matching collaborative decision-making model.

BACKGROUND

Although AI decision support improves performance, people tend to underutilize AI recommendations, particularly when outcomes are uncertain. As AI reliability increases, task performance improves, largely due to higher rates of compliance (following action recommendations) and reliance (following no-action recommendations).

METHODS

In a between-subject design, participants were assigned to a high reliability AI, low reliability AI, or a control condition. Participants decided whether to bet that their team would win in a series of basketball games tying compensation to performance. We evaluated task performance (in accuracy and signal detection terms) and the behavioral consequences of trust (via compliance and reliance).

RESULTS

AI recommendations improved task performance, had limited impact on risk-taking behavior, and were under-valued by participants. Accuracy, sensitivity (d'), and reliance increased in the high reliability AI condition, but there was no effect on response bias (c) or compliance. Participant behavior was only consistent with a probability matching model for compliance in the low reliability condition.

CONCLUSION

In a pay-off structure that incentivized risk-taking, the primary value of the AI recommendations was in determining when to perform no action (i.e., pass on bets).

APPLICATION

In risky contexts, designers need to consider whether action or no-action recommendations will be more influential to design appropriate interventions.

Moral reasoning behind the veil of ignorance: An investigation into perspective-taking accessibility in the context of autonomous vehicles

Perspective-taking (PT) accessibility has been recognized as an important factor in affecting moral reasoning, also playing a non-trivial role in moral investigation towards autonomous vehicles (AVs). A new proposal to deepen this effect leverages the principles of the veil of ignorance (VOI), as a moral reasoning device aimed to control self-interested decisions by limiting the access to specific perspectives and to potentially biased information. Throughout two studies, we deepen the role of VOI reasoning in the moral perception of AVs, disclosing personal and contingent information progressively throughout the experiment. With the use of the moral trilemma paradigm, two different VOI conditions were operationalized, inspired by the Original Position theory by John Rawls and the Equiprobability Model by John Harsanyi. Evidence suggests a significant role of VOI reasoning in affecting moral reasoning, which seems not independent from the order in which information is revealed. Coherently, a detrimental effect of self-involvement on utilitarian behaviours was detected. These results highlight the importance of considering PT accessibility and self-involvement when investigating moral attitudes towards AVs, since it can help the intelligibility of general concerns and hesitations towards this new technology.

Who shows the Unlikelihood Effect - and why?

Recent work shows that people judge an outcome as less likely when they learn the probabilities of all single pathways that lead to that outcome, a phenomenon termed the Unlikelihood Effect. The initial explanation for this effect is that the low pathway probabilities trigger thoughts that deem the outcome unlikely. We tested the alternative explanation that the effect results from people's erroneous interpretation and processing of the probability information provided in the paradigm. By reanalyzing the original experiments, we discovered that the Unlikelihood Effect had been substantially driven by a small subset of people who give extremely low likelihood judgments. We conducted six preregistered experiments, showing that these people are unaware of the total outcome probability and do formally incorrect calculations with the given probabilities. Controlling for these factors statistically and experimentally reduced the proportion of people giving extremely low likelihood judgments, reducing and sometimes eliminating the Unlikelihood Effect. Our results confirm that the Unlikelihood Effect is overall a robust empirical phenomenon, but suggest that the effect results at least to some degree from a few people's difficulties with encoding, understanding, and integrating probabilities. Our findings align with current research on other psychological effects, showing that empirical effects can be caused by participants engaging in qualitatively different mental processes.

Protecting mass-gathering events in a pandemic with testing tracks and transparent information: an experimental study with festival guests

Objective. To enable future open-air festivals during a pandemic, model festivals tested restricted access and behavioural rules to prevent SARS-CoV-2 transmissions. However, the uptake of health-protective measures depends on informed acceptance, meaning people are more likely to follow measures if they understand their effectiveness and related disease risks. Design and main outcome measures. With a series of online surveys, we studied risk perceptions of 6,500 festival guests and the association of perceived effectiveness of protective behaviours with reported compliance. In a scenario-based online experiment (N = 1,958) among festival guests, we tested the effect of informing transparently about the risk-reducing potential of protective measures at festivals on the intention to attend hypothetical events. Results. We found that guests tended to overestimate infection risks while still perceiving them as low. Self-reported mask wearing and distancing at and around the festivals could not be associated with the understanding of the measures' effectiveness. However, in addition to protective measures themselves, providing transparent information about their absolute risk-reducing effect increased intentions to attend festivals that employ varying protective measures. Conclusion. Our findings suggest that the acceptance of protected festivals can be influenced by transparent information about the effectiveness of protective measures. This calls for further research on evidence-based public health communications to improve their impact.

Policy makers believe money motivates more than it does

To motivate contributions to public goods, should policy makers employ financial incentives like taxes, fines, subsidies, and rewards? While these are widely considered as the classic policy approach, a substantial academic literature suggests the impact of financial incentives is not always positive; they can sometimes fail or even backfire. To test whether policy makers are overly bullish about financial incentives, we asked county heads, mayors, and municipal government representatives of medium-to-large towns in Germany to predict the effects of a financial incentive on COVID-19 vaccination, and tested the exact same incentive in a field experiment involving all 41,548 inhabitants (clustered in 10,032 addresses) of the German town of Ravensburg. Whereas policy makers overwhelmingly predict that the financial incentive will increase vaccination-by 15.3 percentage points on average-the same financial incentive yielded a precisely estimated null effect on vaccination. We discuss when financial incentives are most likely to fail, and conclude that it is critical to educate policy makers on the potential pitfalls of employing financial incentives to promote contributions to public goods.

Co-designing an online treatment decision aid for men with low-risk prostate cancer: Navigate

Objectives

To develop an online treatment decision aid (OTDA) to assist patients with low-risk prostate cancer (LRPC) and their partners in making treatment decisions.

Patients and methods

Navigate, an OTDA for LRPC, was rigorously co-designed by patients with a confirmed diagnosis or at risk of LRPC and their partners, clinicians, researchers and website designers/developers. A theoretical model guided the development process. A mixed methods approach was used incorporating (1) evidence for essential design elements for OTDAs; (2) evidence for treatment options for LRPC; (3) an iterative co-design process involving stakeholder workshops and prototype review; and (4) expert rating using the International Patient Decision Aid Standards (IPDAS). Three co-design workshops with potential users (n = 12) and research and web-design team members (n = 10) were conducted. Results from each workshop informed OTDA modifications to the OTDA for testing in the subsequent workshop. Clinician (n = 6) and consumer (n = 9) feedback on usability and content on the penultimate version was collected.

Results

The initial workshops identified key content and design features that were incorporated into the draft OTDA, re-workshopped and incorporated into the penultimate OTDA. Expert feedback on usability and content was also incorporated into the final OTDA. The final OTDA was deemed comprehensive, clear and appropriate and met all IPDAS criteria.

Conclusion

Navigate is an interactive and acceptable OTDA for Australian men with LRPC designed by men for men using a co-design methodology. The effectiveness of Navigate in assisting patient decision-making is currently being assessed in a randomised controlled trial with patients with LRPC and their partners.

Improving patient understanding of prenatal screening tests: Using naturally sampled frequencies, pictures, and accounting for individual differences

Objective

Health professionals must communicate prenatal screening test results effectively to patients, but these tests involve very low prevalence and high false positive risks; a situation known to be difficult for people to understand.

Methods

The present experiments evaluated the effectiveness of presenting prenatal screening test results for Trisomy 21, Trisomy 13, or DiGeorge Syndrome, using either naturally sampled frequencies or standard percentages. Participants were given a task of interpreting the posterior probability of an embryo having the condition.

Results

People were significantly better with naturally sampled frequencies. Numerical literacy and visuospatial ability significantly accounted for individual differences in performance within conditions. Participants nevertheless did not differ in ratings of how useful the different presentation formats were, suggesting a lack of awareness of how format influenced understanding. These results held regardless of whether the respondents were undergraduates (Experiment 1) or members of the general population recruited online (Experiment 2).

Conclusion

Using naturally sampled frequencies improves patient understanding of prenatal screening tests results, with low cost of implementation.

Innovation

Using realistic prenatal screening test results, these results show how to improve patient counseling via the use of naturally sampled frequencies.

Same same, but different: effects of likelihood framing on concerns about a medical disease in patients with somatoform disorders, major depression, and healthy people

BACKGROUND

Research has shown that patients with somatoform disorders (SFD) have difficulty using medical reassurance (i.e. normal results from diagnostic testing) to revise concerns about being seriously ill. In this brief report, we investigated whether deficits in adequately interpreting the likelihood of a medical disease may contribute to this difficulty, and whether patients' concerns are altered by different likelihood framings.

METHODS

Patients with SFD (N = 60), patients with major depression (N = 32), and healthy volunteers (N = 37) were presented with varying likelihoods for the presence of a serious medical disease and were asked how concerned they are about it. The likelihood itself was varied, as was the format in which it was presented (i.e. negative framing focusing on the presence of a disease v. positive framing emphasizing its absence; use of natural frequencies v. percentages).

RESULTS

Patients with SFD reported significantly more concern than depressed patients and healthy people in response to low likelihoods (i.e. 1: 100 000 to 1:10), while the groups were similarly concerned for likelihoods ⩾1:5. Across samples, the same mathematical likelihood caused significantly different levels of concern depending on how it was framed, with the lowest degree of concern for a positive framing approach and higher concern for natural frequencies (e.g. 1:100) than for percentages (e.g. 1%).

CONCLUSIONS

The results suggest a specific deficit of patients with SFD in interpreting low likelihoods for the presence of a medical disease. Positive framing approaches and the use of percentages rather than natural frequencies can lower the degree of concern.

Infographic summaries for clinical practice guidelines: results from user testing of the BMJ Rapid Recommendations in primary care

OBJECTIVES

Infographics have the potential to enhance knowledge translation and implementation of clinical practice guidelines at the point of care. They can provide a synoptic view of recommendations, their rationale and supporting evidence. They should be understandable and easy to use. Little evaluation of these infographics regarding user experience has taken place. We explored general practitioners' experiences with five selected BMJ Rapid Recommendation infographics suited for primary care.

METHODS

An iterative, qualitative user testing design was applied on two consecutive groups of 10 general practitioners for five selected infographics. The physicians used the infographics before clinical encounters and we performed hybrid think-aloud interviews afterwards. 20 interviews were analysed using the Qualitative Analysis Guide of Leuven.

RESULTS

Many clinicians reported that the infographics were simple and rewarding to use, time-efficient and easy to understand. They were perceived as innovative and their knowledge basis as trustworthy and supportive for decision-making. The interactive, expandable format was preferred over a static version as general practitioners focused mainly on the core message. Rapid access through the electronic health record was highly desirable. The main issues were about the use of complex scales and terminology. Understanding terminology related to evidence appraisal as well as the interpretation of statistics and unfamiliar scales remained difficult, despite the infographics.

CONCLUSIONS

General practitioners perceive infographics as useful tools for guideline translation and implementation in primary care. They offer information in an enjoyable and user friendly format and are used mainly for rapid, tailored and just in time information retrieval. We recommend future infographic producers to provide information as concise as possible, carefully define the core message and explore ways to enhance the understandability of statistics and difficult concepts related to evidence appraisal.

TRIAL REGISTRATION NUMBER

MP011977.

The effects of communicating uncertainty around statistics, on public trust

Uncertainty around statistics is inevitable. However, communicators of uncertain statistics, particularly in high-stakes and potentially political circumstances, may be concerned that presenting uncertainties could undermine the perceived trustworthiness of the information or its source. In a large survey experiment (Study 1; N = 10 519), we report that communicating uncertainty around present COVID-19 statistics in the form of a numeric range (versus no uncertainty) may lead to slightly lower perceived trustworthiness of the number presented but has no impact on perceived trustworthiness of the source of the information. We also show that this minimal impact of numeric uncertainty on trustworthiness is also present when communicating future, projected COVID-19 statistics (Study 2; N = 2,309). Conversely, we find statements about the mere existence of uncertainty, without quantification, can reduce both perceived trustworthiness of the numbers and of their source. Our findings add to others suggesting that communicators can be transparent about statistical uncertainty without undermining their credibility as a source but should endeavour to provide a quantification, such as a numeric range, where possible.

Ethical and legal implications of implementing risk algorithms for early detection and screening for oesophageal cancer, now and in the future

BACKGROUND

Oesophageal cancer has significant morbidity and mortality but late diagnosis is common since early signs of disease are frequently misinterpreted. Project DELTA aims to enable earlier detection and treatment through targeted screening using a novel risk prediction algorithm for oesophageal cancer (incorporating risk factors of Barrett's oesophagus including prescriptions for acid-reducing medications (CanPredict)), together with a non-invasive, low-cost sampling device (CytospongeTM). However, there are many barriers to implementation, and this paper identifies key ethical and legal challenges to implementing these personalised prevention strategies for Barrett's oesophagus/oesophageal cancer.

METHODS

To identify ethical and legal issues relevant to the deployment of a risk prediction tool for oesophageal cancer into primary care, we adopted an interdisciplinary approach, incorporating targeted informal literature reviews, interviews with expert collaborators, a multidisciplinary workshop and ethical and legal analysis.

RESULTS

Successful implementation raises many issues including ensuring transparency and effective risk communication; addressing bias and inequity; managing resources appropriately and avoiding exceptionalism. Clinicians will need support and training to use cancer risk prediction algorithms, ensuring that they understand how risk algorithms supplement rather than replace medical decision-making. Workshop participants had concerns about liability for harms arising from risk algorithms, including from potential bias and inequitable implementation. Determining strategies for risk communication enabling transparency but avoiding exceptionalist approaches are a significant challenge. Future challenges include using artificial intelligence to bolster risk assessment, incorporating genomics into risk tools, and deployment by non-health professional users. However, these strategies could improve detection and outcomes.

CONCLUSIONS

Novel pathways incorporating risk prediction algorithms hold considerable promise, especially when combined with low-cost sampling. However immediate priorities should be to develop risk communication strategies that take account of using validated risk algorithms, and to ensure equitable implementation. Resolving questions about liability for harms arising should be a longer-term objective.

How Do People Process Different Representations of Statistical Information? Insights into Cognitive Effort, Representational Inconsistencies, and Individual Differences

BACKGROUND

Graphical representation formats (e.g., icon arrays) have been shown to lead to better understanding of the benefits and risks of treatments compared to numbers. We investigate the cognitive processes underlying the effects of format on understanding: how much cognitive effort is required to process numerical and graphical representations, how people process inconsistent representations, and how numeracy and graph literacy affect information processing.

METHODS

In a preregistered between-participants experiment, 665 participants answered questions about the relative frequencies of benefits and side effects of 6 medications. First, we manipulated whether the medical information was represented numerically, graphically (as icon arrays), or inconsistently (numerically for 3 medications and graphically for the other 3). Second, to examine cognitive effort, we manipulated whether there was time pressure or not. In an additional intervention condition, participants translated graphical information into numerical information before answering questions. We also assessed numeracy and graph literacy.

RESULTS

Processing icon arrays was more strongly affected by time pressure than processing numbers, suggesting that graphical formats required more cognitive effort. Understanding was lower when information was represented inconsistently (v. consistently) but not if there was a preceding intervention. Decisions based on inconsistent representations were biased toward graphically represented options. People with higher numeracy processed quantitative information more efficiently than people with lower numeracy did. Graph literacy was not related to processing efficiency.

LIMITATIONS

Our study was conducted with a nonpatient sample, and the medical information was hypothetical.

CONCLUSIONS

Although graphical (v. numerical) formats have previously been found to lead to better understanding, they may require more cognitive effort. Therefore, the goal of risk communication may play an important role when choosing how to communicate medical information.

HIGHLIGHTS

This article investigates the cognitive processes underlying the effects of representation format on the understanding of statistical information and individual differences therein.Processing icon arrays required more cognitive effort than processing numbers did.When information was represented inconsistently (i.e., partly numerically and partly graphically), understanding was lower than with consistent representation, and decisions were biased toward the graphically represented options.People with higher numeracy processed quantitative information more efficiently than people with lower numeracy did.

The Lure of Beauty: People Select Representations of Statistical Information Largely Based on Attractiveness, Not Comprehensibility

OBJECTIVE

People differ in whether they understand graphical or numerical representations of statistical information better. However, assessing these skills is often not feasible when deciding which representation to select or use. This study investigates whether people choose the representation they understand better, whether this choice can improve risk comprehension, and whether results are influenced by participants' skills (graph literacy and numeracy).

METHODS

In an experiment, 160 participants received information about the benefits and side effects of painkillers using either a numerical or a graphical representation. In the "no choice" condition, the representation was randomly assigned to each participant. In the "choice" condition, participants could select the representation they would like to receive. The study assessed gist and verbatim knowledge (immediate comprehension and recall), accessibility of the information, attractiveness of the representation, as well as graph literacy and numeracy.

RESULTS

In the "choice" condition, most (62.5%) chose the graphical format, yet there was no difference in graph literacy or numeracy (nor age or gender) between people who chose the graphical or the numerical format. Whereas choice slightly increased verbatim knowledge, it did not improve gist or overall knowledge compared with random assignment. However, participants who chose a representation rated the representation as more attractive, and those who chose graphs rated them as more accessible than those without a choice.

LIMITATIONS

The sample consisted of highly educated undergraduate students with higher graph literacy than the general population. The task was inconsequential for participants in terms of their health.

CONCLUSIONS

When people can choose between representations, they fail to identify what they comprehend better but largely base that choice on how attractive the representation is for them.

HIGHLIGHTS

People differ systematically in whether they understand graphical or numerical representations of statistical information better. However, assessing these underlying skills to get the right representation to the right people is not feasible in practice. A simple and efficient method to achieve this could be to let people choose among representations themselves.However, our study showed that allowing participants to choose a representation (numerical v. graphical) did not improve overall or gist knowledge compared with determining the representation randomly, even though it did slightly improve verbatim knowledge.Rather, participants largely chose the representation they found more attractive. Most preferred the graphical representation, including those with low graph literacy.It would therefore be important to develop graphical representations that are not only attractive but also comprehensible even for people with low graph literacy.

From collective health to "personalized" medicine: bioethical challenges in preimplantation genetic testing from a North-South perspective

This article examines the scope and limitations of the precision medicine paradigm and its relationship with the collective health approach. To that end, it takes preimplantation genetic testing (PGT) as a paradigmatic example of technologies aimed at the "individualization" of health processes. In this regard, we review the characteristics and scientific and regulatory foundations of PGT technologies in Argentina, and discuss the next steps for their bioethical analysis. More specifically, we shed light on some of the conditions for their implementation from a north-south perspective. We propose three themes or problematic aspects as a synthesis of our analysis, related to biases in the production of knowledge, the values and interests underlying its uses, and the underlying epistemological assumptions of these technologies. Throughout the article, we review these dilemmas and suggest some issues that should be taken into account in future research.

Incidence of infections in patients with psoriatic arthritis and axial spondyloarthritis treated with biological or targeted disease-modifying agents: a systematic review and meta-analysis of randomised controlled trials, open-label studies and observational studies

OBJECTIVE

To estimate the incidence of infections among patients with psoriatic arthritis (PsA) or axial spondyloarthritis (axSpA), two distinct phenotypes included in the large group of spondyloarthritis (SpA), treated with tumour necrosis-factor-inhibitors, interleukin-17-inhibitors, Janus kinase-inhibitors, IL-23 or IL-12/23-inhibitors (IL-12/23i), phosphodiesterase 4-inhibitors or cytotoxic T-lymphocyte associated protein 4-Ig.

METHODS

A meta-analysis of randomised controlled trials (RCTs), open-label extension and observational studies was conducted. Serious infections were defined as infections that were life-threatening, required intravenous antibiotics and/or hospitalisation. Non-serious infections did not meet these severity criteria. The incidence rates (IR) were reported for each diagnosis by treatment class and study type using random-effect model to create a 95% CI.

RESULTS

Among 23 333 PsA patients and 11 457 axSpA patients, there were 1.09 serious infections per 100 patient-years (PY) (95% CI 0.85 to 1.35) with similar IR in PsA (0.96 per 100 PY 95% CI 0.69 to 1.28) and axSpA (1.09 per 100 PY 95% CI 0.76 to 1.46). The IR was lower in RCTs (0.77 per 100 PY 95% CI 0.41 to 1.20) compared with observational studies (1.68 per 100 PY 95% CI 1.03 to 2.47). In PsA patients, the lowest IR value was observed with IL-12/23i (0.29 per 100 PY 95% CI 0.00 to 1.03). There were 53.0 non-serious infections per 100 PY (95% CI 43.47 to 63.55) in 7257 PsA patients and 5638 axSpA patients. The IR was higher in RCTs (69.95 per 100 PY 95% CI 61.59 to 78.84) compared with observational studies (15.37 per 100 PY 95% CI 5.11 to 30.97).

CONCLUSION

Serious infections were rare events in RCTs and real-life studies. Non-serious infections were common adverse events, mainly in RCTs.

PROSPERO REGISTRATION NUMBER

CRD42020196711.

Decision Regret and Bother With the Addition of Androgen Deprivation Therapy to Definitive Radiation Treatment for Localized Prostate Cancer

PURPOSE

Androgen deprivation therapy (ADT) combined with radiation treatment (RT) is recommended by the National Comprehensive Cancer Network guidelines for unfavorable intermediate and high-risk localized prostate cancer. Although there is a variable survival benefit conferred by ADT, there are potential side effects to consider for patient decision-making. We aimed to assess the side effects and bother of adding ADT to RT, the degree of regret, and what overall survival (OS) benefit men would want to justify adding or extending the duration of ADT, after their experience with this treatment.

METHODS AND MATERIALS

Men receiving ADT with definitive RT completed a questionnaire asking about the side effects and degree of bother from ADT using a 4-point scale. They were also asked about regret, and what survival benefit would warrant ADT.

RESULTS

In the study, 846 patients received definitive RT, of whom 356 received ADT and were asked about their experience with ADT. Of these, 234 responded (66%). In 54%, ADT caused some bother, most commonly hot flushes (32%), fatigue (29%), and sexual problems (29%). Five percent regretted receiving ADT "quite a lot" or "very much." Approximately one-third of men deemed a 1% OS benefit from ADT worthwhile, whereas one-third (34%) would want a >10% OS benefit enough to justify choosing ADT again. In addition, 49% of patients who received short-term ADT would accept longer duration ADT for a 6% OS benefit.

CONCLUSIONS

Significant regret for ADT was low (5%). There was a clear dichotomy between those who deemed any OS benefit from ADT worthwhile versus those who needed a significant survival benefit to justify the side effects. Given that some men may change their opinion on the relative value of ADT after experiencing its effects, this study emphasizes the importance of revisiting patients after 6 months to given patients an opportunity to renegotiate their treatment.

BONEcheck: A digital tool for personalized bone health assessment

Objectives

Osteoporotic fracture is a significant public health burden associated with increased mortality risk and substantial healthcare costs. Accurate and early identification of high-risk individuals and mitigation of their risks is a core part of the treatment and prevention of fractures. Here we introduce a digital tool called 'BONEcheck' for personalized assessment of bone health.

Methods

The development of BONEcheck primarily utilized data from the prospective population-based Dubbo Osteoporosis Epidemiology Study and the Danish Nationwide Registry. BONEcheck has 3 modules: input data, risk estimates, and risk context. Input variables include age, gender, prior fracture, fall incidence, bone mineral density (BMD), comorbidities, and genetic variants associated with BMD.

Results

Based on the input variables, BONEcheck estimates the probability of any fragility fracture and hip fracture within 5 years, subsequent fracture risk, skeletal age, and time to reach osteoporosis. The probability of fracture is shown in both numeric and human icon array formats. The risk is also contextualized within the framework of treatment and management options on Australian guidelines, with consideration given to the potential fracture risk reduction and survival benefits. Skeletal age was estimated as the sum of chronological age and years of life lost due to a fracture or exposure to risk factors that elevate mortality risk.

Conclusions

BONEcheck is an innovative tool that empowers doctors and patients to engage in well-informed discussions and make decisions based on the patient's risk profile. Public access to BONEcheck is available via https://bonecheck.org and in Apple Store (iOS) and Google Play (Android).

Is it cognitive effort you measure? Comparing three task paradigms to the Need for Cognition scale

Measuring individual differences in cognitive effort can be elusive as effort is a function of motivation and ability. We report six studies (N = 663) investigating the relationship of Need for Cognition and working memory capacity with three cognitive effort measures: demand avoidance in the Demand Selection Task, effort discounting measured as the indifference point in the Cognitive Effort Discounting paradigm, and rational reasoning score with items from the heuristic and bias literature. We measured perceived mental effort with the NASA task load index. The three tasks were not correlated with each other (all r's < .1, all p's > .1). Need for Cognition was positively associated with effort discounting (r = .168, p < .001) and rational reasoning (r = .176, p < .001), but not demand avoidance (r = .085, p = .186). Working memory capacity was related to effort discounting (r = .185, p = .004). Higher perceived effort was related to poorer rational reasoning. Our data indicate that two of the tasks are related to Need for Cognition but are also influenced by a participant's working memory capacity. We discuss whether any of the tasks measure cognitive effort.

Strategies for communicating scientific evidence on healthcare to managers and the population: a scoping review

BACKGROUND

Health evidence needs to be communicated and disseminated in a manner that is clearly understood by decision-makers. As an inherent component of health knowledge translation, communicating results of scientific studies, effects of interventions and health risk estimates, in addition to understanding key concepts of clinical epidemiology and interpreting evidence, represent a set of essential instruments to reduce the gap between science and practice. The advancement of digital and social media has reshaped the concept of health communication, introducing new, direct and powerful communication platforms and gateways between researchers and the public. The objective of this scoping review was to identify strategies for communicating scientific evidence in healthcare to managers and/or population.

METHODS

We searched Cochrane Library, Embase®, MEDLINE® and other six electronic databases, in addition to grey literature, relevant websites from related organizations for studies, documents or reports published from 2000, addressing any strategy for communicating scientific evidence on healthcare to managers and/or population.

RESULTS

Our search identified 24 598 unique records, of which 80 met the inclusion criteria and addressed 78 strategies. Most strategies focused on risk and benefit communication in health, were presented by textual format and had been implemented and somehow evaluated. Among the strategies evaluated and appearing to yield some benefit are (i) risk/benefit communication: natural frequencies instead of percentages, absolute risk instead relative risk and number needed to treat, numerical instead nominal communication, mortality instead survival; negative or loss content appear to be more effective than positive or gain content; (ii) evidence synthesis: plain languages summaries to communicate the results of Cochrane reviews to the community were perceived as more reliable, easier to find and understand, and better to support decisions than the original summaries; (iii) teaching/learning: the Informed Health Choices resources seem to be effective for improving critical thinking skills.

CONCLUSION

Our findings contribute to both the knowledge translation process by identifying communication strategies with potential for immediate implementation and to future research by recognizing the need to evaluate the clinical and social impact of other strategies to support evidence-informed policies. Trial registration protocol is prospectively available in MedArxiv (doi.org/10.1101/2021.11.04.21265922).

Evaluating the Amyloidosis Speakers Bureau: the influence of amyloidosis patients' narratives on medical students' knowledge, attitudes, and behavioral intent

Background:  Amyloidosis is a complex multi-systemic disease. Lack of knowledge about amyloidosis and subsequent mis- or under-diagnosis are major obstacles to treatment, which result in life-threatening organ damage, morbidity, and mortality. Hence, the purpose of this study is to explore the effectiveness of amyloidosis patients' narratives on medical students. Methods:  The Amyloidosis Speakers Bureau (ASB) arranges for amyloidosis patients to speak about their diagnostic and treatment experiences with medical students. Using a randomized post-test only experiment, we compared the effectiveness of patients' narratives between two groups (treatment and control). Outcome measures included medical students' intent to actively communicate with patients, acquire knowledge about amyloidosis, and reconsider diagnoses when warranted. Results:  The treatment group (those who listened to an ASB patient speaker) had higher mean differences on all measures, including the desire to improve communication with patients, acquire and apply knowledge of amyloidosis, and willingness to reconsider diagnoses when symptoms are puzzling. Conclusions:  ASB patient educators widened awareness of an under-diagnosed disease. Listening to a patient's narrative was associated with positive attitudes toward communication with patients, interest in acquiring and applying knowledge of amyloidosis, and humility about diagnosis. Narrative and persuasion theory are used to explain this quantitative evidence of the power of patient narratives.

Understanding health behavior change by motivation and reward mechanisms: a review of the literature

The global rise of lifestyle-related chronic diseases has engendered growing interest among various stakeholders including policymakers, scientists, healthcare professionals, and patients, regarding the effective management of health behavior change and the development of interventions that facilitate lifestyle modification. Consequently, a plethora of health behavior change theories has been developed with the intention of elucidating the mechanisms underlying health behavior change and identifying key domains that enhance the likelihood of successful outcomes. Until now, only few studies have taken into account neurobiological correlates underlying health behavior change processes. Recent progress in the neuroscience of motivation and reward systems has provided further insights into the relevance of such domains. The aim of this contribution is to review the latest explanations of health behavior change initiation and maintenance based on novel insights into motivation and reward mechanisms. Based on a systematic literature search in PubMed, PsycInfo, and Google Scholar, four articles were reviewed. As a result, a description of motivation and reward systems (approach/wanting = pleasure; aversion/avoiding = relief; assertion/non-wanting = quiescence) and their role in health behavior change processes is presented. Three central findings are discussed: (1) motivation and reward processes allow to distinguish between goal-oriented and stimulus-driven behavior, (2) approach motivation is the key driver of the individual process of behavior change until a new behavior is maintained and assertion motivation takes over, (3) behavior change techniques can be clustered based on motivation and reward processes according to their functional mechanisms into facilitating (= providing external resources), boosting (= strengthening internal reflective resources) and nudging (= activating internal affective resources). The strengths and limitations of these advances for intervention planning are highlighted and an agenda for testing the models as well as future research is proposed.

Bayesian versus diagnostic information in physician-patient communication: Effects of direction of statistical information and presentation of visualization

BACKGROUND

Communicating well with patients is a competence central to everyday clinical practice, and communicating statistical information, especially in Bayesian reasoning tasks, can be challenging. In Bayesian reasoning tasks, information can be communicated in two different ways (which we call directions of information): The direction of Bayesian information (e.g., proportion of people tested positive among those with the disease) and the direction of diagnostic information (e.g., the proportion of people having the disease among those tested positive). The purpose of this study was to analyze the impact of both the direction of the information presented and whether a visualization (frequency net) is presented with it on patient's ability to quantify a positive predictive value.

MATERIAL AND METHODS

109 participants completed four different medical cases (2⨯2⨯4 design) that were presented in a video; a physician communicated frequencies using different directions of information (Bayesian information vs. diagnostic information). In half of the cases for each direction, participants were given a frequency net. After watching the video, participants stated a positive predictive value. Accuracy and speed of response were analyzed.

RESULTS

Communicating with Bayesian information led to participant performance of only 10% (without frequency net) and 37% (with frequency net) accuracy. The tasks communicated with diagnostic information but without a frequency net were correctly solved by 72% of participants, but accuracy rate decreased to 61% when participants were given a frequency net. Participants with correct responses in the Bayesian information version without visualization took longest to complete the tasks (median of 106 seconds; median of 13.5, 14.0, and 14.5 seconds in other versions).

DISCUSSION

Communicating with diagnostic information rather than Bayesian information helps patients to understand specific information better and more quickly. Patients' understanding of the relevance of test results is strongly dependent on the way the information is presented.

Heuristics and biases in medical decision-making under uncertainty: The case of neuropronostication for consciousness disorders

Neuropronostication for consciousness disorders can be very complex and prone to high uncertainty. Despite notable advancements in the development of dedicated scales and physiological markers using innovative paradigms, these technical progressions are often overshadowed by factors intrinsic to the medical environment. Beyond the scarcity of objective data guiding medical decisions, factors like time pressure, fatigue, multitasking, and emotional load can drive clinicians to rely more on heuristic-based clinical reasoning. Such an approach, albeit beneficial under certain circumstances, may lead to systematic error judgments and impair medical decisions, especially in complex and uncertain environments. After a brief review of the main theoretical frameworks, this paper explores the influence of clinicians' cognitive biases on clinical reasoning and decision-making in the challenging context of neuroprognostication for consciousness disorders. The discussion further revolves around developing and implementing various strategies designed to mitigate these biases and their impact, aiming to enhance the quality of care and the patient safety.

Numeracy, gist, literal thinking and the value of nothing in decision making

The onus on the average person is greater than ever before to make sense of large amounts of readily accessible quantitative information, but the ability and confidence to do so are frequently lacking. Many people lack practical mathematical skills that are essential for evaluating risks, probabilities and numerical outcomes such as survival rates for medical treatments, income from retirement savings plans or monetary damages in civil trials. In this Review, we integrate research on objective and subjective numeracy, focusing on cognitive and metacognitive factors that distort human perceptions and foment systematic biases in judgement and decision making. Paradoxically, an important implication of this research is that a literal focus on objective numbers and mechanical number crunching is misguided. Numbers can be a matter of life and death but a person who uses rote strategies (verbatim representations) cannot take advantage of the information contained in the numbers because 'rote' strategies are, by definition, processing without meaning. Verbatim representations (verbatim is only surface form, not meaning) treat numbers as data as opposed to information. We highlight a contrasting approach of gist extraction: organizing numbers meaningfully, interpreting them qualitatively and making meaningful inferences about them. Efforts to improve numerical cognition and its practical applications can benefit from emphasizing the qualitative meaning of numbers in context - the gist - building on the strengths of humans as intuitive mathematicians. Thus, we conclude by reviewing evidence that gist training facilitates transfer to new contexts and, because it is more durable, longer-lasting improvements in decision making.

'Skeletal Age' for mapping the impact of fracture on mortality

Background

Fragility fracture is associated with an increased risk of mortality, but mortality is not part of doctor-patient communication. Here, we introduce a new concept called 'Skeletal Age' as the age of an individual's skeleton resulting from a fragility fracture to convey the combined risk of fracture and fracture-associated mortality for an individual.

Methods

We used the Danish National Hospital Discharge Register which includes the whole-country data of 1,667,339 adults in Denmark born on or before January 1, 1950, who were followed up to December 31, 2016 for incident low-trauma fracture and mortality. Skeletal age is defined as the sum of chronological age and the number of years of life lost (YLL) associated with a fracture. Cox's proportional hazards model was employed to determine the hazard of mortality associated with a specific fracture for a given risk profile, and the hazard was then transformed into YLL using the Gompertz law of mortality.

Results

During the median follow-up period of 16 years, there had been 307,870 fractures and 122,744 post-fracture deaths. A fracture was associated with between 1 and 7 years of life lost, with the loss being greater in men than women. Hip fractures incurred the greatest loss of life years. For instance, a 60-year-old individual with a hip fracture is estimated to have a skeletal age of 66 for men and 65 for women. Skeletal Age was estimated for each age and fracture site stratified by gender.

Conclusions

We propose 'Skeletal Age' as a new metric to assess the impact of a fragility fracture on an individual's life expectancy. This approach will enhance doctor-patient risk communication about the risks associated with osteoporosis.

Funding

National Health and Medical Research Council in Australia and Amgen Competitive Grant Program 2019.

Crises information dissemination through social media in the UK and Saudi Arabia: A linguistic perspective

This study investigates health-promoting messages in British and Saudi officials' social-media discourse during the Coronavirus Disease 2019 (COVID-19) Pandemic. Taking discourse as a constructivist conception, we examined the crisis-response strategies employed by these officials on social media, and the role of such strategies in promoting healthy behaviors and compliance with health regulations. The study presents a corpus-assisted discourse analysis of the tweets of a Saudi health official and a British health official that focuses on keyness, speech acts, and metaphor. We found that both officials utilized clear communication and persuasive rhetorical tactics to convey the procedures suggested by the World Health Organization. However, there were some differences in how the two officials used speech acts and metaphors to achieve their goals. The British official used empathy as the primary communication strategy, while the Saudi official emphasized health literacy. The British official also used conflict-based metaphors such as war and gaming, whereas the Saudi official used metaphors that reflected life as a journey interrupted by the pandemic. Despite these differences, both officials utilized directive speech acts to tell audiences the procedures they should follow to achieve the desired conclusion of healing patients and ending the pandemic. In addition, rhetorical questions and assertions were used to direct people to perform certain behaviors favored. Interestingly, the discourse used by both officials contained characteristics of both health communication and political discourse. War metaphors, which were utilized by the British Health official, are a common feature in political discourse as well as in health-care discourse. Overall, this study highlights the importance of effective communication strategies in promoting healthy behaviors and compliance with health regulations during a pandemic. By analyzing the discourse of health officials on social media, we can gain insights into the strategies employed to manage a crisis and effectively communicate with the public.

Historical Review of the Use of Relative Risk Statistics in the Portrayal of the Purported Hazards of High LDL Cholesterol and the Benefits of Lipid-Lowering Therapy

The manner in which clinical trial investigators present their findings to healthcare providers and the public can have a substantial influence on their impact. For example, if a heart attack occurs in 2% of those in the placebo group and in 1% of those in the drug-treated group, the benefit to the treated population is only one percentage point better than no treatment. This finding is unlikely to generate much enthusiasm from the study sponsors and in the reporting of the findings to the public. Instead, trial directors can amplify the magnitude of the appearance of the treatment benefit by using the relative risk (RR) value of a 50% reduction of the risk of a heart attack, since one is 50% of two. By using the RR type of data analysis, clinical trial directors can promote the outcome of their trial in their publication and to the media as highly successful while minimizing or disregarding entirely the absolute risk (AR) reduction of only one percentage point. The practice of expressing the RR without the AR has become routinely deployed in the reporting of findings in many different areas of clinical research. We have provided a historical perspective on how this form of data presentation has become commonplace in the reporting of findings from randomized controlled trials (RCTs) on coronary heart disease (CHD) event monitoring and prevention over the past four decades. We assert that the emphasis on RR coupled with insufficient disclosure of AR in the reporting of RCT outcomes has led healthcare providers and the public to overestimate concerns about high cholesterol and to be misled as to the magnitude of the benefits of cholesterol-lowering therapy. The goal of this review is to prompt the scientific community to address this misleading approach to data presentation.

Impact of treatment adherence on the effectiveness and safety of oral anticoagulants in patients with atrial fibrillation: a retrospective cohort study

AIMS

The impact of adherence to oral anticoagulation has not been reported in terms of absolute risk, which would enhance patients' understanding and treatment adherence.

METHODS AND RESULTS

This retrospective cohort study analysed data from the National Health Insurance Database of Korea, from January 2010 to December 2018, on 84 227 patients with non-valvular atrial fibrillation (NVAF). The participants were analysed according to their overall adherence to oral anticoagulants (OACs) and further divided into four groups: non-vitamin K antagonist oral anticoagulant (NOAC) adherent, vitamin K antagonist (VKA) adherent, NOAC non-adherent, and VKA non-adherent. The incidence of ischaemic stroke, major bleeding, and death was compared between the four groups using risk difference, number needed to treat and number needed to harm. Among the participants, 50 178 were adherent to (OACs), while 34 049 were non-adherent. The incidence of major bleeding was higher in the adherent group (4.49%; 95% confidence interval, 4.11-4.85%) than in the non-adherent group (3.61%; 3.16-4.06%), and the incidence of ischaemic stroke was higher in the non-adherent group (7.68%; 7.08-8.33%) than in the adherent group (5.61%; 5.17-6.07%). In terms of risk difference, adherence to OACs increased the risk of major bleeding by 0.87% and decreased the risk of ischaemic stroke by 2.08%. This finding suggests that one additional major bleeding event occurred for every 115 adherent patients, and one additional ischaemic stroke event was prevented for every 48 adherent patients.

CONCLUSION

The benefits of OAC adherence in NVAF patients for ischaemic stroke prevention exceeding the risk of bleeding are shown more clearly in terms of absolute risk.

Questioning 'Informed Choice' in Medical Screening: The Role of Neoliberal Rhetoric, Culture, and Social Context

Participation in medical screening programs is presented as a voluntary decision that should be based on an informed choice. An informed choice is often emphasized to rely on three assumptions: (1) the decision-maker has available information about the benefits and harms, (2) the decision-maker can understand and interpret this information, and (3) the decision-maker can relate this information to personal values and preferences. In this article, we empirically challenge the concept of informed choice in the context of medical screening. We use document analysis to analyze and build upon findings and interpretations from previously published articles on participation in screening. We find that citizens do not receive neutral or balanced information about benefits and harms, yet are exposed to manipulative framing effects. The citizens have high expectations about the benefits of screening, and therefore experience cognitive strains when informed about the harm. We demonstrate that decisions about screening participation are informed by neoliberal arguments of personal responsibility and cultural healthism, and thus cannot be regarded as decisions based on individual values and preferences independently of context. We argue that the concept of informed choice serves as a power technology for people to govern themselves and can be considered an implicit verification of biopower.

Illusion of knowledge in statistics among clinicians: evaluating the alignment between objective accuracy and subjective confidence, an online survey

Healthcare professionals' statistical illiteracy can impair medical decision quality and compromise patient safety. Previous studies have documented clinicians' insufficient proficiency in statistics and a tendency in overconfidence. However, an underexplored aspect is clinicians' awareness of their lack of statistical knowledge that precludes any corrective intervention attempt. Here, we investigated physicians', residents' and medical students' alignment between subjective confidence judgments and objective accuracy in basic medical statistics. We also examined how gender, profile of experience and practice of research activity affect this alignment, and the influence of problem framing (conditional probabilities, CP vs. natural frequencies, NF). Eight hundred ninety-eight clinicians completed an online survey assessing skill and confidence on three topics: vaccine efficacy, p value and diagnostic test results interpretation. Results evidenced an overall consistent poor proficiency in statistics often combined with high confidence, even in incorrect answers. We also demonstrate that despite overconfidence bias, clinicians show a degree of metacognitive sensitivity, as their confidence judgments discriminate between their correct and incorrect answers. Finally, we confirm the positive impact of the more intuitive NF framing on accuracy. Together, our results pave the way for the development of teaching recommendations and pedagogical interventions such as promoting metacognition on basic knowledge and statistical reasoning as well as the use of NF to tackle statistical illiteracy in the medical context.

Caution with competitive gamification in medical education: unexpected results of a randomised cross-over study

BACKGROUND

To intrinsically motivate students in the long term, longitudinal e-learning systems combined with repeated testing and competitive gamification seem promising. The effects of this approach have never been closely examined in the field of evidence-based medicine. The authors investigated if a simple, competitive learning application enhances students' risk competence and intrinsic motivation.

METHODS

Participants were 5.-9. semester medical students (n = 48), recruited in an elective evidence-based medicine subject and randomly distributed to two groups (group 1: n = 23; group 2: n = 25). Both accessed a competitive evidence-based medicine quiz game. Following a cross-over design, each group practiced with one of two thematically different questionnaires A or B, before the allocation switched after one month. To analyse whether there was a measurable learning effect in the practiced topics, a paired t-test was performed with quantitative data from 3 e-tests. Students further reported their experience in evaluation surveys.

RESULTS

Students' improvements in e-test scores after training with the corresponding topics in the learning application can be attributed to chance. Even though the majority enjoyed playing and felt motivated to study, they invested a minimum of time and rejected competition.

CONCLUSION

The authors found no evidence for benefits of the investigated learning programme on students' risk competence or on their internal motivation. The majority disapproved the competitive concept, indicating adverse side effects of the applied gamification element. To intrinsically motivate more students, prospective learning programmes should favour complex and collaborative programmes over simple and competitive ones.

Modelling the Cost-Effectiveness of Diagnostic Tests

Diagnostic tests are used to determine whether a disease or condition is present or absent in a patient, who will typically be suspected of having the disease or condition due to symptoms or clinical signs. Economic evaluations of diagnostic tests (e.g. cost-effectiveness analyses) can be used to determine whether a test produces sufficient benefit to justify its cost. Evidence on the benefits conferred by a test is often restricted to its accuracy, which means mathematical models are required to estimate the impact of a test on outcomes that matter to patients and health payers. It is important to realise the case for introducing a new test may not be restricted to its accuracy, but extend to factors such as time to diagnosis and acceptability for patients. These and other considerations may mean the common modelling approach, the decision tree, is inappropriate for underpinning an economic evaluation. There are no consensus guidelines on how economic evaluations of diagnostic tests should be conducted-this article attempts to explore the common challenges encountered in economic evaluations, suggests solutions to those challenges, and identifies some areas where further methodological work may be necessary.

Reporting of absolute and relative risk measures in oral health and cardiovascular events studies: A systematic review

OBJECTIVES

To understand the magnitude of risk of health events, such as cardiovascular diseases (CVD), related to poor oral health, both relative and absolute risk measures should be reported. Our aim was to investigate the extent to which absolute and relative measures of risk are reported in longitudinal studies that assess the association between oral health indicators (OHIs) and CVD.

METHODS

A systematic search of longitudinal studies investigating the association of any OHI with CVD was carried out using the Embase, Medline and Cochrane library databases. The search covered each database from its inception date to August 2021. Data about reporting relative and absolute risks of the relationship between CVD and OHI from the abstract were extracted. If the relative risk for OHIs and CVD was reported in the abstract, then the underlying absolute risks were searched from the full text, and it was assessed whether it was similarly adjusted for confounding than was the relative risk in the abstract.

RESULTS

One hundred-six articles were included. From these, 85 (80%) studies reported the association of OHIs and CVD with one or more relative risks in the abstract. Of those 85 studies, the underlying absolute risks were accessible or calculable from the abstract or full text of 60 studies. However, of these 60 studies, in only 10 (12%), the underlying absolute risks were similarly adjusted, as were the relative risks in the abstract. The absolute risks of CVD by OHIs were rarely reported without corresponding relative risks in the abstract (n = 2, 2%). Median absolute risk difference in the CVD risk between exposure levels to which the first relative risk in the abstract referred was 1.8% (interquartile range 0.6-4.6, n = 63).

CONCLUSIONS

Focusing on relative risks over absolute risks was a common practice in literature. Reporting similarly adjusted underlying absolute risks of relative risks was rare in most studies, despite those being helpful for comprehending the magnitude of CVD-risk increase related to poor oral health. Current reporting practices could lead to an overinterpretation of risk increase of CVD related to poor oral health.

A Taxonomy of Non-honesty in Public Health Communication

This paper discusses the ethics of public health communication. We argue that a number of commonplace tools of public health communication risk qualifying as non-honest and question whether or not using such tools is ethically justified. First, we introduce the concept of honesty and suggest some reasons for thinking it is morally desirable. We then describe a number of common ways in which public health communication presents information about health-promoting interventions. These include the omission of information about the magnitude of benefits people can expect from health-promoting interventions, and failure to report uncertainty associated with the outcomes of interventions. Next we outline some forms of behaviour which are generally recognised by philosophers as being non-honest, including deception, manipulation, and so on. Finally, we suggest that many of the public health communicative practices identified earlier share features with the non-honest behaviours described and suggest this warrants reflection upon whether such non-honesty is justified by the goals of public health communication.

Medizinische Evidenz kompetent kommunizieren

Wie alle Patienten in Deutschland sollen auch jene in der Herzchirurgie, soweit wie möglich, in die klinische Entscheidungsfindung eingebunden werden. Was möglich ist, hängt – neben Patientenvoraussetzungen – maßgeblich von den kommunikativen Fähigkeiten und Werkzeugen ab, die der beratende Arzt einsetzt, um informiertes Entscheiden auf Basis der besten verfügbaren medizinischen Erkenntnisse zu ermöglichen. Anhand von Schlüsselherausforderungen strukturiert dieser narrative Überblick Lösungsansätze für die Nutzung medizinischer Evidenz in Entscheidungsprozessen: unbestimmte Bezugsrahmen, relative Risiken, komplexe Informationen zu Entscheidungsoptionen bis hin zur Interpretation vorangehender diagnostischer Testergebnisse. Die dargestellten Lösungsansätze stellen in die Versorgung integrierbare Werkzeuge dar. Sie erfordern eine Kompetenzstärkung des Fachpersonals und qualitätsgesicherte medizinische Informationsangebote.

Boosting for insight and/or boosting for agency? How to maximize accurate test interpretation with natural frequencies

BACKGROUND

Many physicians do not know how to accurately interpret test results using Bayes' rule. As a remedy, two kinds of interventions have been shown effective: boosting insight and boosting agency with natural frequencies. To boost insight, test statistics are provided in natural frequencies (rather than conditional probabilities), without instructions on how to use them. To boost agency, a training is provided on how to translate probabilities into natural frequencies and apply them in Bayes' rule. What has not been shown is whether boosting agency is sufficient or if representing test statistics in natural frequencies may additionally boost insight to maximize accurate test interpretation.

METHODS

We used a pre/posttest design to assess test interpretation accuracy of 577 medical students before and after a training on two Bayesian reasoning tasks, one providing conditional probabilities, the other natural frequencies. The pretest assessed baseline abilities versus the effect of natural frequencies to boost insight. After participants received a training on how to translate conditional probabilities into natural frequencies and how to apply them in Bayes' rule, test interpretation skills were assessed using the same tasks again, comparing the effects of training-induced agency with versus without additionally boosting insight (i.e., test statistics in natural frequencies versus conditional probabilities).

RESULTS

Compared to the test question formatted in conditional probabilities (34% correct answers), natural frequencies facilitated Bayesian reasoning without training (68%), that is, they increased insight. The training on how to use natural frequencies improved performance for tasks formatted in conditional probabilities (64%). Performance was maximal after training and with test statistics formatted in natural frequencies, that is, with a combination of boosting insight and agency (89%).

CONCLUSIONS

Natural frequencies should be used to boost insight and agency to maximize effective use of teaching resources. Thus, mandating that test statistics are provided in natural frequencies and adopting short trainings on how to translate conditional probabilities into natural frequencies and how to apply them in Bayes' rule will help to maximize accurate test interpretation.

TRIAL REGISTRATION

The study was a registered with the German Clinical Trial Registry ( DRKS00008723 ; 06/03/2015).

Self-fulfilling prophecies and machine learning in resuscitation science

INTRODUCTION

Growth of machine learning (ML) in healthcare has increased potential for observational data to guide clinical practice systematically. This can create self-fulfilling prophecies (SFPs), which arise when prediction of an outcome increases the chance that the outcome occurs.

METHODS

We performed a scoping review, searching PubMed and ArXiv using terms related to machine learning, algorithmic fairness and bias. We reviewed results and selected manuscripts for inclusion based on expert opinion of well-designed or key studies and review articles. We summarized these articles to explore how use of ML can create, perpetuate or compound SFPs, and offer recommendations to mitigate these risks.

RESULTS

We identify-four key mechanisms through which SFPs may be reproduced or compounded by ML. First, imperfect human beliefs and behavior may be encoded as SFPs when treatment decisions are not accounted for. Since patient outcomes are influenced by a myriad of clinical actions, many of which are not collected in data, this is common. Second, human-machine interaction may compound SFPs through a cycle of mutual reinforcement. Third, ML may introduce new SFPs stemming from incorrect predictions. Finally, historically correct clinical choices may become SFPs in the face of medical progress.

CONCLUSION

There is a need for broad recognition of SFPs as ML is increasingly applied in resuscitation science and across medicine. Acknowledging this challenge is crucial to inform research and practice that can transform ML from a tool that risks obfuscating and compounding SFPs into one that sheds light on and mitigates SFPs.

Prospective, longitudinal, multicenter study on the provision of information regarding sudden unexpected death in epilepsy to adults with epilepsy

OBJECTIVE

Despite increased awareness of the serious epilepsy complication sudden unexpected death in epilepsy (SUDEP), a substantial population of people with epilepsy (PWE) remain poorly informed. Physicians indicate concern that SUDEP information may adversely affect patients' health and quality of life. We examined SUDEP awareness and the immediate and long-term effects of providing SUDEP information to PWE.

METHODS

Baseline knowledge and behaviors among PWE and behavioral adjustments following the provision of SUDEP information were evaluated in a prospective, multicenter survey using the following validated scales: Neurological Disorders Depression Inventory for Epilepsy for depression symptoms, the EuroQoL five-dimension scale for health-related quality of life (HRQoL), a visual analog scale for overall health, the revised Epilepsy Stigma Scale for perceived stigma, and the Seizure Worry Scale for seizure-related worries. The prospective study collected data through semiquantitative interviews before (baseline), immediately after, and 3 months after the provision of SUDEP information.

RESULTS

In total, 236 participants (mean age = 39.3 years, range = 18-77 years, 51.7% women) were enrolled, and 205 (86.9%) completed long-term, 3-month follow-up. One patient died from SUDEP before follow-up. No worsening symptoms from baseline to 3-month follow-up were observed on any scale. At baseline, 27.5% of participants were aware of SUDEP. More than 85% of participants were satisfied with receiving SUDEP information. Three quarters of participants were not concerned by the information, and >80% of participants recommended the provision of SUDEP information to all PWE. Although most patients reported no behavioral adjustments, 24.8% reported strong behavioral adjustments at 3-month follow-up.

SIGNIFICANCE

The provision of SUDEP information has no adverse effects on overall health, HRQoL, depressive symptoms, stigma, or seizure worry among PWE, who appreciate receiving information. SUDEP information provision might improve compliance among PWE and reduce but not eliminate the increased mortality risk.

Explainable artificial intelligence for mental health through transparency and interpretability for understandability

The literature on artificial intelligence (AI) or machine learning (ML) in mental health and psychiatry lacks consensus on what "explainability" means. In the more general XAI (eXplainable AI) literature, there has been some convergence on explainability meaning model-agnostic techniques that augment a complex model (with internal mechanics intractable for human understanding) with a simpler model argued to deliver results that humans can comprehend. Given the differing usage and intended meaning of the term "explainability" in AI and ML, we propose instead to approximate model/algorithm explainability by understandability defined as a function of transparency and interpretability. These concepts are easier to articulate, to "ground" in our understanding of how algorithms and models operate and are used more consistently in the literature. We describe the TIFU (Transparency and Interpretability For Understandability) framework and examine how this applies to the landscape of AI/ML in mental health research. We argue that the need for understandablity is heightened in psychiatry because data describing the syndromes, outcomes, disorders and signs/symptoms possess probabilistic relationships to each other-as do the tentative aetiologies and multifactorial social- and psychological-determinants of disorders. If we develop and deploy AI/ML models, ensuring human understandability of the inputs, processes and outputs of these models is essential to develop trustworthy systems fit for deployment.

A Bayesian model to estimate the cutoff value of TSH for management of preterm birth

BACKGROUND

Determining a thyroid hormone cutoff value in pregnancy is challenging issue and several approaches have been introduced to optimize a utility function. We aimed to estimate the cutoff value of TSH using Bayesian method for prediction of preterm-birth.

METHODS

This study was a secondary-analysis of the population-based data collected prospectively within the framework of the Tehran Thyroid and Pregnancy Study. A total of 1,538 pregnant women attending prenatal clinics.

RESULTS

Using Bayesian method resulted a TSH-cutoff of (3.97mIU/L,95%CI:3.95-4.00) for distinguishing pregnant women at risk of preterm-birth. The cutoff was associated with acceptable positive predictive and negative predictive values (0.84,95% CI:0.80-0.88) and 0.92 (95%CI: 0.91-0.94), respectively). In women who were negative for thyroid peroxides antibody (TPOAb) with sufficient urinary iodine concentration (UIC), the TSH cutoff of 3.92 mIU/L(95%CI:3.70-4) had the highest predictive value; whereas in TPOAb positive women with insufficient UIC, the cutoff of 4.0 mIU/L(95%:CI 3.94-4) could better predict preterm birth. Cutoffs estimated in this study are close to the revised TSH value of 4.0mIU/L which is currently recommended by the American Thyroid Association.

CONCLUSION

Regardless of TPOAb status or iodine insufficiency, risk of preterm labor is increased in pregnant women with TSH value of > 3.92 mIU/L; these women may benefit from Levothyroxine (LT4) therapy for preventing preterm birth.

Development and Piloting of a Web-Based Tool to Teach Relative and Absolute Risk Reductions

Interpreting study results is an essential component of decision-making. Both laypeople and healthcare professionals often misinterpret treatment effects that are presented as relative risk reduction. Therefore, we developed and piloted a web-based tool to teach the difference between relative and absolute risk reductions. This project follows the UKMRC-guidance for complex interventions. The tool was developed based on adult learning and design theories. This was followed by a qualitative feasibility study focusing on acceptance, applicability, and comprehensibility with healthcare professionals and laypersons. We conducted think-aloud and semi-structured interviews and analysed them using qualitative content analysis. In addition, we explored calculation skills. Between January 2020 and April 2021, we conducted 22 interviews with 8 laypeople and 14 healthcare professionals from different settings. Overall, the tool proved to be feasible and relevant. With regard to comprehension, we observed an awareness of the interpretation of risk reduction, presented therapy effects were questioned more critically, and the influence of relative effects was recognized. Nevertheless, there were comprehension problems in some of the participants, especially with calculations in connection with low mathematical skills. The tool can be used to improve the interpretation of risk reductions in various target groups and to supplement existing educational programs.