Helping Doctors and Patients Make Sense of Health Statistics

Shared decision making in mental health: prospects for personalized medicine

This paper describes the shared decision-making model, reviews its current status in the mental health field, and discusses its potential impact on personalized medicine. Shared decision making denotes a structured process that encourages full participation by patient and provider. Current research shows that shared decision making can improve the participation of mental health patients and the quality of decisions in terms of knowledge and values. The impact of shared decision making on adherence, illness self-management, and health outcomes remains to be studied. Implementing shared decision making broadly will require re-engineering the flow of clinical care in routine practice settings and much greater use of information technology Similar changes will be needed to combine genomic and other biological data with patients' values and preferences and with clinicians' expertise. The future of personalized medicine is dearly linked with our ability to create the infrastructure and cultural receptivity to these changes.

Training of patient and consumer representatives in the basic competencies of evidence-based medicine: a feasibility study

BACKGROUND

Evidence-based medicine (EBM) has become standard approach in medicine. Patients and health authorities increasingly claim active patient roles in decision making. Education to cope with these roles might be useful. We investigated the feasibility, acceptability and possible impact of EBM training courses for patient and consumer representatives.

METHODS

We designed a generic one-week EBM course based on previous experience with EBM courses for non-medical health professionals. A course specific competence test has been developed and validated to measure EBM skills. Formative and summative evaluation of the course comprised: 1) EBM skills; 2) individual learning goals; 3) self-reported implementation after six months using semi-structured interviews; 4) group-based feedback by content analysis. EBM skills' achievement was compared to results gathered by a group of undergraduate University students of Health Sciences and Education who had attended a comparable EBM seminar.

RESULTS

Fourteen EBM courses were conducted including 161 participants without previous EBM training (n = 54 self-help group representatives, n = 64 professional counsellors, n = 36 patient advocates, n = 7 others); 71% had a higher education degree; all but five finished the course. Most participants stated personal learning goals explicitly related to practicing EBM such as acquisition of critical appraisal skills (n = 130) or research competencies (n = 67). They rated the respective relevance of the course on average with 80% (SD 4) on a visual analogue scale ranging from 0 to 100%.Participants passed the competence test with a mean score of 14.7 (SD 3.0, n = 123) out of 19.5 points. The comparison group of students achieved a mean score of 14.4 (SD 3.3, n = 43). Group-based feedback revealed increases of self confidence, empowerment through EBM methodology and statistical literacy, and acquisition of new concepts of patient information and counselling. Implementation of EBM skills was reported by 84 of the 129 (65%) participants available for follow-up interviews. Barriers included lack of further support, limited possibilities to exchange experiences, and feeling discouraged by negative reactions of health professionals.

CONCLUSIONS

Training in basic EBM competencies for selected patient and consumer representatives is feasible and accepted and may affect counselling and advocacy activities. Implementation of EBM skills needs support beyond the training course.

The theory of planned behaviour in a randomized trial of a decision aid on cardiovascular risk prevention

OBJECTIVE

To assess the feasibility and outcome of measuring the theory of planned behaviour (TPB) in patients receiving routine counselling versus counselling with a decision aid (DA) during primary care consultation on cardiovascular risk prevention.

METHODS

A DA was developed, based on models of shared decision-making (SDM) and the TPB. We evaluated the impact of the intervention in a randomized controlled trial. Main outcomes were previously reported. To assess the intermediate social cognitive processes and our theoretical framework, we evaluated the impact of the intervention on a TPB scale.

RESULTS

The TPB scale showed satisfactory measurement properties. Factor analysis (main component analysis, confirmatory model) could mostly replicate the assumptions of the model. 44% of variance of the behavioural intention to adhere to the decision after counselling was explained in linear regression models. Of the TPB components, only attitude towards the decision and moral norm were significantly more positive in the intervention. No difference was found with regard to intention to adhere to the decision. High risk resulted in higher values of the TPB components in both groups.

CONCLUSION

Most DAs are developed and tested without explicitly referring to a theoretical model of psychosocial processes. The TPB may serve as a useful theoretical framework.

PRACTICE IMPLICATIONS

Trials on DAs demonstrate positive effects on psychological outcomes of patients without leading to better objective health results. Our study might contribute to an explanation: DAs might not cause stronger adherence to decisions even though one's attitude towards the decision becomes more positive.

Who profits from visual aids: overcoming challenges in people's understanding of risks [corrected]

Many people have difficulties grasping numerical concepts that are prerequisites for understanding treatment risk reduction. Visual aids have been proposed as a promising method for enhancing comprehension. In a survey of probabilistic, nationally representative samples in two different countries (United States and Germany), we compared the effectiveness of adding different types of visual aids (icon arrays and bar graphs representing either affected individuals only or the entire population at risk) to the numerical information in either an absolute or a relative risk reduction format. We also analyzed whether people's numeracy and graphical literacy skills affected the efficacy of the visual aids. Our results showed large improvements in accuracy both when icon arrays and when bar graphs were added to numerical information. Highest increases were achieved when the visual aids depicted the entire population at risk. Importantly, visual aids were most useful for the participants who had low numeracy but relatively high graphical literacy skills. Building on previous research showing that problems with understanding numerical information often do not reside in people's minds, but in the representation of the problem, our results show that visual aids help to modify incorrect expectations about treatment risk reduction. Our results have important implications for medical practice.

Developing web-based online support tools: the Dartmouth decision support software

TOPIC

This article discusses the development of Web-based online decision support tools intended for researchers examining the issue of shared decision making for the population of individuals with serious mental illnesses.

PURPOSE

The authors describe the background and use of decision support tools to facilitate shared decision-making between individuals diagnosed with a psychiatric condition and clinicians and describes a novel software platform that allows researchers and other system designers to build decision support systems.

CONCLUSIONS

In supporting ongoing research efforts, an online decision support tool appears to be useful for individuals facing preference-sensitive decisions and an online designer tool allows for rapid deployment of these research sites to support ongoing research efforts in shared decision making.

Socioeconomic status, statistical confidence, and patient-provider communication: an analysis of the Health Information National Trends Survey (HINTS 2007)

The increasing trend of exposing patients seeking health advice to numerical information has the potential to adversely impact patient-provider relationships especially among individuals with low literacy and numeracy skills. We used the HINTS 2007 to provide the first large scale study linking statistical confidence (as a marker of subjective numeracy) to demographic variables and a health-related outcome (in this case the quality of patient-provider interactions). A cohort of 7,674 individuals answered sociodemographic questions, a question on how confident they were in understanding medical statistics, a question on preferences for words or numbers in risk communication, and a measure of patient-provider interaction quality. Over thirty-seven percent (37.4%) of individuals lacked confidence in their ability to understand medical statistics. This was particularly prevalent among the elderly, low income, low education, and non-White ethnic minority groups. Individuals who lacked statistical confidence demonstrated clear preferences for having risk-based information presented with words rather than numbers and were 67% more likely to experience a poor patient-provider interaction, after controlling for gender, ethnicity, insurance status, the presence of a regular health care professional, and the language of the telephone interview. We will discuss the implications of our findings for health care professionals.

A catalogue of reporting guidelines for health research

Growing evidence demonstrates widespread deficiencies in the reporting of health research studies. The EQUATOR Network is an international initiative that aims to enhance the reliability and value of the published health research literature. EQUATOR provides resources, education and training to facilitate good research reporting and assists in the development, dissemination and implementation of robust reporting guidelines. This paper presents a collection of tools and guidelines available on the EQUATOR website (http://www.equator-network.org) that have been developed to increase the accuracy and transparency of health research reporting.

How numeracy influences risk comprehension and medical decision making

We review the growing literature on health numeracy, the ability to understand and use numerical information, and its relation to cognition, health behaviors, and medical outcomes. Despite the surfeit of health information from commercial and noncommercial sources, national and international surveys show that many people lack basic numerical skills that are essential to maintain their health and make informed medical decisions. Low numeracy distorts perceptions of risks and benefits of screening, reduces medication compliance, impedes access to treatments, impairs risk communication (limiting prevention efforts among the most vulnerable), and, based on the scant research conducted on outcomes, appears to adversely affect medical outcomes. Low numeracy is also associated with greater susceptibility to extraneous factors (i.e., factors that do not change the objective numerical information). That is, low numeracy increases susceptibility to effects of mood or how information is presented (e.g., as frequencies vs. percentages) and to biases in judgment and decision making (e.g., framing and ratio bias effects). Much of this research is not grounded in empirically supported theories of numeracy or mathematical cognition, which are crucial for designing evidence-based policies and interventions that are effective in reducing risk and improving medical decision making. To address this gap, we outline four theoretical approaches (psychophysical, computational, standard dual-process, and fuzzy trace theory), review their implications for numeracy, and point to avenues for future research.

Communicating treatment risk reduction to people with low numeracy skills: a cross-cultural comparison

OBJECTIVES

We sought to address denominator neglect (i.e. the focus on the number of treated and nontreated patients who died, without sufficiently considering the overall numbers of patients) in estimates of treatment risk reduction, and analyzed whether icon arrays aid comprehension.

METHODS

We performed a survey of probabilistic, national samples in the United States and Germany in July and August of 2008. Participants received scenarios involving equally effective treatments but differing in the overall number of treated and nontreated patients. In some conditions, the number who received a treatment equaled the number who did not; in others the number was smaller or larger. Some participants received icon arrays.

RESULTS

Participants-particularly those with low numeracy skills-showed denominator neglect in treatment risk reduction perceptions. Icon arrays were an effective method for eliminating denominator neglect. We found cross-cultural differences that are important in light of the countries' different medical systems.

CONCLUSIONS

Problems understanding numerical information often reside not in the mind but in the problem's representation. These findings suggest suitable ways to communicate quantitative medical data.

Good judgments do not require complex cognition

In their comment on Marewski et al. (good judgments do not require complex cognition, 2009) Evans and Over (heuristic thinking and human intelligence: a commentary on Marewski, Gaissmaier and Gigerenzer, 2009) conjectured that heuristics can often lead to biases and are not error free. This is a most surprising critique. The computational models of heuristics we have tested allow for quantitative predictions of how many errors a given heuristic will make, and we and others have measured the amount of error by analysis, computer simulation, and experiment. This is clear progress over simply giving heuristics labels, such as availability, that do not allow for quantitative comparisons of errors. Evans and Over argue that the reason people rely on heuristics is the accuracy-effort trade-off. However, the comparison between heuristics and more effortful strategies, such as multiple regression, has shown that there are many situations in which a heuristic is more accurate with less effort. Finally, we do not see how the fast and frugal heuristics program could benefit from a dual-process framework unless the dual-process framework is made more precise. Instead, the dual-process framework could benefit if its two “black boxes” (Type 1 and Type 2 processes) were substituted by computational models of both heuristics and other processes.

Public knowledge of benefits of breast and prostate cancer screening in Europe

Making informed decisions about breast and prostate cancer screening requires knowledge of its benefits. However, country-specific information on public knowledge of the benefits of screening is lacking. Face-to-face computer-assisted personal interviews were conducted with 10,228 persons selected by a representative quota method in nine European countries (Austria, France, Germany, Italy, the Netherlands, Poland, Russia, Spain, and the United Kingdom) to assess perceptions of cancer-specific mortality reduction associated with mammography and prostate-specific antigen (PSA) screening. Participants were also queried on the extent to which they consulted 14 different sources of health information. Correlation coefficients between frequency of use of particular sources and the accuracy of estimates of screening benefit were calculated. Ninety-two percent of women overestimated the mortality reduction from mammography screening by at least one order of magnitude or reported that they did not know. Eighty-nine percent of men overestimated the benefits of PSA screening by a similar extent or did not know. Women and men aged 50-69 years, and thus targeted by screening programs, were not substantially better informed about the benefits of mammography and PSA screening, respectively, than men and women overall. Frequent consulting of physicians (r = .07, 95% confidence interval [CI] = 0.05 to 0.09) and health pamphlets (r = .06, 95% CI = 0.04 to 0.08) tended to increase rather than reduce overestimation. The vast majority of citizens in nine European countries systematically overestimate the benefits of mammography and PSA screening. In the countries investigated, physicians and other information sources appear to have little impact on improving citizens' perceptions of these benefits.

The Challenge of Shared Decision Making Among Patients With Lower Literacy: A Framework for Research and Development

There have been major advances in techniques to increase patient involvement in health decisions with the benefits of greater involvement and shared decision making now widely recognized. However, there has been little attention in the development of tools and strategies to support patient participation among adults with lower literacy, a group with poor health knowledge, limited involvement in health decisions, and poor health outcomes. The authors put forward a framework to consider the different stages of shared health decision making and the tasks and skills required to achieve each stage. They consider where current research exists in the decision making literature and where more is needed if adults with limited literacy are to be better engaged in shared decision making in health care.

[Must immunomodulators be added to biological treatment in inflammatory bowel disease?]

Both biological agents and immunosuppressants are standard treatments in inflammatory bowel disease (IBD) and are frequently used in combination. Although this combination can increase therapeutic efficacy and help to prevent immunogenicity, concerns about the risk of adverse effects - particularly lymphoma - have been raised. IBD are obviously highly complex diseases, with many possible clinical scenarios, and there is no a universal treatment applicable to all patients. In this report we address this issue in a narrative review consisting of three parts. First, we provide a historical overview of the use of immunosuppressants and biological agents in IBD. Secondly, we review the available evidence, with both efficacy and safety considered in separate analyses. Thirdly, we propose different ways of using these drugs in the distinct clinical scenarios, both in Crohn's disease and in ulcerative colitis. Although the evidence is thoroughly reviewed, the main perspective is that of the practicing clinician.