Validation of the Subjective Numeracy Scale: effects of low numeracy on comprehension of risk communications and utility elicitations

Illustrating Cancer Risk: Patient Risk Communication Preferences and Interest regarding a Novel BRCA1/2 Genetic Risk Modifier Test

INTRODUCTION

Genetic risk modifier testing (GRMT), an emerging form of genetic testing based on common single nucleotide polymorphisms and polygenic risk scores, has the potential to refine estimates of BRCA1/2 mutation carriers' breast cancer risks. However, for women to benefit from GRMT, effective approaches for communicating this novel risk information are needed.

OBJECTIVE

To evaluate patient preferences regarding risk communication materials for GRMT.

METHODS

We developed four separate presentations (panel of genes, icon array, verbal risk estimate, graphical risk estimate) of hypothetical GRMT results, each using varying risk communication strategies to convey different information elements including number of risk modifier variants present, variant prevalence among BRCA1/2 carriers, and implications and uncertainties of test results for cancer risk. Thirty BRCA1/2 carriers evaluated these materials (randomized to low, moderate, or high breast cancer risk versions). Qualitative and quantitative data were obtained through in-person interviews.

RESULTS

Across risk versions, participants preferred the presentation of the graphical risk estimate, often in combination with the verbal risk estimate. Interest in GRMT was high; 76.7% of participants wanted their own GRMT. Participants valued the potential for GRMT to clarify their cancer susceptibility and provide actionable information. Many (65.5%) anticipated that GRMT would make risk management decisions easier.

CONCLUSIONS

Women with BRCA1/2 mutations could be highly receptive to GRMT, and the minimal amount of necessary information to be included in result risk communication materials includes graphical and verbal estimates of future cancer risk. Findings will inform clinical translation of GRMT in a manner consistent with patients' preferences.

Testing patient-informed approaches for visually depicting the hemoglobin A1c value to patients with poorly controlled diabetes: a randomized, controlled trial

Background

Patients’ understanding of the hemoglobin A1c (HbA1c) has been linked to better diabetes care outcomes (glycemic control, self-care). This is concerning given low documented rates of HbA1c understanding. In this non-blinded, randomized trial, we compared two formats for communicating the HbA1c, selected based on input from people with diabetes, to standard presentation to assess their impact on participants’ glycemic control and diabetes-related perceptions.

Methods

To design the tested formats, we interviewed 25 patients with diabetes and reviewed a range of possible formats, including color-based scales and graphs. The interviews were recorded, transcribed, and subjected to thematic analysis. Synthesizing interviewees’ feedback, we selected two formats, one using a combination of words and colors (Words) and one using a color-coded graph (Graph), for further evaluation. We then randomized adults with poorly controlled diabetes to receive mailed information on their current diabetes control in one of three ways: 1) standard lab report (control), 2) Words format, or 3) Graph format. The primary outcome was HbA1c change at 6 months. Also examined were changes in participants’ diabetes-related perceptions and choice of participation incentive.

Results

Of the 234 enrolled participants, 76.9% were Black, and their median baseline HbA1c was 9.1% (interquartile range 8.4–10.4). There were no between-arm differences in HbA1c change (− 1.04% [SD 2.2] Control vs. -0.59% [SD 2.0] Words vs. -0.54% [SD 2.1] Graph, p > 0.05 for all comparisons). Participants in the Words arm had an increase in the accuracy of their perceptions of diabetes seriousness (p = 0.04) and in the number of participants reporting a diabetes management goal (p = 0.01).

Conclusions

The two patient-informed communication formats did not differentially impact glycemic control among adults with inadequately controlled diabetes. However, a significant proportion of participants in the Words arm had an increase in the accuracy of their perception of diabetes seriousness, a potential mediating factor in positive diabetes-related behavioral changes. With increasing use of patient-facing online portals, thoughtfully designed approaches for visually communicating essential, but poorly understood, information like the HbA1c to patients have the potential to facilitate interpretation and support self-management.

Clinical trial registration

Prospectively registered as NCT01886170.

Behavioral Determinants of Target Shifting and Deterrence in an Analog Cyber-Attack Game

This study examines how exploiting biases in probability judgment can enhance deterrence using a fixed allocation of defensive resources. We investigate attacker anchoring heuristics for conjunctive events with missing information to distort attacker estimates of success for targets with equal defensive resources. We designed and conducted a behavioral experiment functioning as an analog cyber attack with multiple targets requiring three stages of attack to successfully acquire a target. Each stage is associated with a probability of successfully attacking a layer of defense, reflecting the allocation of resources for each layer. There are four types of targets that have nearly equal likelihood of being successfully attacked, including one type with equally distributed success probabilities over every layer and three types with success probabilities that are concentrated to be lowest in the first, second, or third layer. Players are incentivized by a payoff system that offers a reward for successfully attacked targets and a penalty for failed attacks. We collected data from a total of 1,600 separate target selections from 80 players and discovered that the target type with the lowest probability of success on the first layer was least preferred among attackers, providing the greatest deterrent. Targets with equally distributed success probabilities across layers were the next least preferred among attackers, indicating greater deterrence for uniform-layered defenses compared to defenses that are concentrated at the inner (second or third) levels. This finding is consistent with both attacker anchoring and ambiguity biases and an interpretation of failed attacks as near misses.

Improving Cancer Patients' Insurance Choices (I Can PIC): A Randomized Trial of a Personalized Health Insurance Decision Aid

BACKGROUND

Many cancer survivors struggle to choose a health insurance plan that meets their needs because of high costs, limited health insurance literacy, and lack of decision support. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial.

MATERIALS AND METHODS

Eligible individuals (18-64 years, diagnosed with cancer for ≤5 years, English-speaking, not Medicaid or Medicare eligible) were randomized to I Can PIC or an attention control health insurance worksheet. Primary outcomes included health insurance knowledge, decisional conflict, and decision self-efficacy after completing I Can PIC or the control. Secondary outcomes included knowledge, decisional conflict, decision self-efficacy, health insurance literacy, financial toxicity, and delayed care at a 3-6-month follow-up.

RESULTS

A total of 263 of 335 eligible participants (79%) consented and were randomized; 206 (73%) completed the initial survey (106 in I Can PIC; 100 in the control), and 180 (87%) completed a 3-6 month follow-up. After viewing I Can PIC or the control, health insurance knowledge and a health insurance literacy item assessing confidence understanding health insurance were higher in the I Can PIC group. At follow-up, the I Can PIC group retained higher knowledge than the control; confidence understanding health insurance was not reassessed. There were no significant differences between groups in other outcomes. Results did not change when controlling for health literacy and employment. Both groups reported having limited health insurance options.

CONCLUSION

I Can PIC can improve cancer survivors' health insurance knowledge and confidence using health insurance. System-level interventions are needed to lower financial toxicity and help patients manage care costs.

IMPLICATIONS FOR PRACTICE

Inadequate health insurance compromises cancer treatment and impacts overall and cancer-specific mortality. Uninsured or underinsured survivors report fewer recommended cancer screenings and may delay or avoid needed follow-up cancer care because of costs. Even those with adequate insurance report difficulty managing care costs. Health insurance decision support and resources to help manage care costs are thus paramount to cancer survivors' health and care management. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. I Can PIC provides health insurance information, supports patients through managing care costs, offers a list of financial and emotional support resources, and provides a personalized cost estimate of annual health care expenses across plan types.

Protocol paper: Stepped wedge cluster randomized trial translating the ABCS into optimizing cardiovascular care for people living with HIV

People living with HIV (PWH) are at higher risk for cardiovascular disease (CVD) and stroke in comparison to their non-infected counterparts. The ABCS (aspirin-blood pressure control-cholesterol control-smoking cessation) reduce atherosclerotic (ASCVD) risk in the general population, but little is known regarding strategies for promoting the ABCS among PWH. Guided by the Consolidated Framework for Implementation Research (CFIR), we designed multilevel implementation strategies that target PWH and their clinicians to promote appropriate use of the ABCS based on a 10-year estimated ASCVD risk. Implementation strategies include patient coaching, automated texting, peer phone support, academic detailing and audit and feedback for the patient's clinician. We are evaluating implementation through a stepped wedge cluster randomized trial based on the Reach-Effectiveness-Adoption-Maintenance/Qualitative-Evaluation-for-Systematic-Translation (RE-AIM/QuEST) mixed methods framework that integrates quantitative and qualitative assessments. The primary outcome is change in ASCVD risk. Findings will have important implications regarding strategies for reducing ASCVD risk among PWH.

Do clinicians convey what they intend? Lay interpretation of verbal risk labels used in decision encounters

OBJECTIVE

To assess the numerical probabilities that individuals associate with frequently-used verbal labels relating to treatment outcomes and their association with medical context, age, gender, educational level, health literacy, and numeracy.

METHODS

Verbal labels (N = 11) were extracted from N = 90 audiotaped decision encounters in oncology. Three hundred Dutch adults, as proxies for newly-diagnosed cancer patients, assigned numerical probabilities to the labels in the context of cancer recurrence or nausea, and completed questions on their socio-demographic characteristics, health literacy and numeracy.

RESULTS

We found considerable variation in how individuals interpreted the verbal labels. Participants' probability estimates of verbal labels was lower in the context of (the more serious) cancer recurrence compared to (less serious) nausea. Lower numerate participants differentiated less between labels. There was no association between participants' estimates and age, gender, educational level or health literacy.

CONCLUSION

There is considerable variation in how individuals interpret verbal labels frequently-used in decision encounters. Individuals seem to take base rates and severity of outcomes into account. Verbal labels may be less helpful to lower numerate individuals.

PRACTICE IMPLICATIONS

To minimize misinterpretation and to improve patient-clinician decision making about health and care, we recommend to avoid the use of verbal labels only.

Prior breast density awareness, knowledge, and communication in a health system-embedded behavioral intervention trial

BACKGROUND

Breast density is an important breast cancer risk factor and a focus of recent national and state health policy efforts. This article describes breast density awareness, knowledge, and communication among participants in a health system-embedded trial with clinically elevated breast cancer risk 1 year before state-mandated density disclosure.

METHODS

Trial participants' demographics and prior health history were ascertained from electronic health records. The proportions of women reporting prior breast density awareness, knowledge of density's masking effect, and communication with a provider about their own breast density were calculated using baseline interview data collected from 2017 to 2018. Multiple logistic regression was used to estimate associations between women's characteristics and density awareness, knowledge, and communication.

RESULTS

Although the overwhelming majority of participants had heard of breast density (91%) and were aware of breast density's masking effect (87%), only 60% had ever discussed their breast density with a provider. Annual mammography screening was associated with prior breast density awareness (odds ratio [OR], 2.97; 95% confidence interval [CI], 1.29-6.81), knowledge (OR, 2.83; 95% CI, 1.20-6.66), and communication (OR, 2.87; 95% CI, 1.34-6.16) compared with an infrequent or unknown screening interval. Receipt of breast biopsy was also associated with prior knowledge (OR, 1.60; 95% CI, 1.04-2.45) and communication (OR, 1.36; 95% CI, 1.00-1.85).

CONCLUSIONS

Breast density awareness and knowledge are high among insured women participating in clinical research, even in the absence of mandated density disclosure. Patient-provider communication about personal density status is less common, particularly among women with fewer interactions with breast health specialists.

Health numeracy skills of medical students:cross-sectional and controlled before-and-after study

BACKGROUND

Although numeracy, defined as understanding and handling numbers, is an important skill for the medical profession, it is not clear whether it changes during graduate medical education and whether it can be improved by specific interventions. The objective of this study was to assess objective and subjective numeracy levels at different stages of medical education and explore whether a research methodology/statistics course improves numeracy levels in a longer period.

METHODS

We performed cross-sectional and controlled before-and-after studies. First-year sociology students and first- to sixth-year medical students from the in the cross sectional study and two groups of first-year medical students in a controlled before-and-after study. The intervention was a course on biostatistics and research methodology using blended approach. Numeracy was measured using Subjective Numeracy Scale (Cronbach α = 0.70) and Numeracy Understanding in Medicine instrument (Cronbach α = 0.75).

RESULTS

Whereas first-year medical students did not differ from first-year sociology students in objective numeracy, medicine students had higher results on subjective numeracy. Students from higher years of medical school had generally higher subjective and objective numeracy scores. In the controlled before-and-after study, the intervention group improved more in subjective numeracy (median difference on a 0-8 scale = 0.5, 95% CI 0.3 to 0.7 vs - 0.4, 95% CI - 0.4 to - 0.1, P < 0.001) but not in objective numeracy.

CONCLUSIONS

Although the numeracy levels at the beginning of the medical school are within the range of non-medical population, both objective and subjective numeracy improve during the higher years of medical school. Curriculum during medical school may help in numeracy increase, while research methodology training may help to increase subjective but not objective numeracy skills.

Multiple health literacy dimensions are associated with physicians' efforts to achieve shared decision-making

OBJECTIVES

Shared decision-making (SDM) in health care is widely encouraged. However, for SDM to occur patients need to be able to obtain, understand and apply medical information. Our aim was to assess the relationship between health literacy (HL), numeracy and SDM (using French translations of validated measures).

METHODS

A cross-sectional survey using a self-administered online questionnaire was proposed to all members of the Seintinelles association. Several scales were used to measure HL (FCCHL and 3HLQ/SILS), numeracy (SNS-3), the SDM process (CollaboRATE) and explore their inter-relationships.

RESULTS

Data from 2 299 respondents (96.7% women, 46.1% with a history of cancer) were analysed. All measurement scales showed adequate psychometric properties. Functional HL, communicative HL and numeracy were positively associated with SDM while no significant relation was observed between critical HL and SDM. Furthermore, perceived difficulties in asking physicians' questions and deprivation were negatively associated with SDM.

CONCLUSION

Patient support to reach SDM requires high levels of HL, particularly in the functional and communicative domains. Efforts must be made to improve access and understanding of health information.

PRACTICE IMPLICATIONS

Brief self-reported measures could be used to screen for low levels of health literacy, tailor information accordingly and improve patient involvement in healthcare decision-making.

Association of Patient Perceptions of Cardiovascular Risk and Beliefs on Statin Drugs With Racial Differences in Statin Use: Insights From the Patient and Provider Assessment of Lipid Management Registry

Importance

African American individuals face higher atherosclerotic cardiovascular disease risk than white individuals; reasons for these differences, including potential differences in patient beliefs regarding preventive care, remain unknown.

Objective

To evaluate differences in statin use between white and African American patients and identify the potential causes for any observed differences.

Design, Setting, and Participants

Using the 2015 Patient and Provider Assessment of Lipid Management (PALM) Registry data, we compared statin use and dosing between African American and white outpatient adults who were potentially eligible for primary or secondary prevention statins. A total of 138 US community health care practices contributed to the data. Data analysis was conducted from March 2017 to May 2018.

Main Outcomes and Measures

Primary outcomes were use and dosing of statin therapy according to the 2013 American College of Cardiology/American Heart Association guideline by African American or white race. Secondary outcomes included lipid levels and patient-reported beliefs. Poisson regression was used to evaluate the association between race and statin undertreatment, a category combining people who were not taking a statin or those taking a dose intensity lower than recommended.

Results

A total of 5689 patients (806 [14.2%] African American) in the PALM registry were eligible for statin therapy. African American individuals were less likely than white individuals to be treated with a statin (570/807 [70.6%] vs 3654/4883 [74.8%]; P = .02). Among those treated, African American patients were less likely than white patients to receive a statin at guideline-recommended intensity (269 [33.3%] vs 2145 [43.9%], respectively; P < .001; relative risk, 1.07 [95% CI, 1.00-1.15]; P = .05, after adjustment for demographic and clinical factors). The median (interquartile range) low-density lipoprotein cholesterol levels of patients receiving treatment were higher among African American than white individuals (97.0 [76.0-121.0] mg/dL vs 85.0 [68.0-105.0] mg/dL; P < .001). African American individuals were less likely than white individuals to believe statins were safe (292 [36.2%] vs 2800 [57.3%]; P < .001) or effective (564 [70.0%] vs 3635 [74.4%]; P = .008) and were less likely to trust their clinician (663 [82.3%] vs 4579 [93.8%]; P < .001). Group differences in statin undertreatment were not significant after adjusting for demographic, clinical, and clinician factors, socioeconomic status, and patient beliefs (final adjusted relative risk, 1.03 [95% CI 0.96-1.11]; P = .35).

Conclusions and Relevance

African American individuals were less likely to receive guideline-recommended statin therapy. Demographic, clinical, socioeconomic, belief-related, and clinician differences contributed to observed differences and represent potential targets for intervention.

A Systematic Review of Patient-Facing Visualizations of Personal Health Data

OBJECTIVES

As personal health data are being returned to patients with increasing frequency and volume, visualizations are garnering excitement for their potential to facilitate patient interpretation. Evaluating these visualizations is important to ensure that patients are able to understand and, when appropriate, act upon health data in a safe and effective manner. The objective of this systematic review was to review and evaluate the state of the science of patient-facing visualizations of personal health data.

METHODS

We searched five scholarly databases (PubMed, Embase, Scopus, ACM Digital Library [Association for Computing Machinery Digital Library], and IEEE Computational Index [Institute of Electrical and Electronics Engineers Computational Index]) through December 1, 2018 for relevant articles. We included English-language articles that developed or tested one or more patient-facing visualizations for personal health data. Three reviewers independently assessed quality of included articles using the Mixed methods Appraisal Tool. Characteristics of included articles and visualizations were extracted and synthesized.

RESULTS

In 39 articles included in the review, there was heterogeneity in the sample sizes and methods for evaluation but not sample demographics. Few articles measured health literacy, numeracy, or graph literacy. Line graphs were the most common visualization, especially for longitudinal data, but number lines were used more frequently in included articles over past 5 years. Article findings suggested more patients understand the number lines and bar graphs compared with line graphs, and that color is effective at communicating risk, improving comprehension, and increasing confidence in interpretation.

CONCLUSION

In this review, we summarize types and components of patient-facing visualizations and methodologies for development and evaluation in the reviewed articles. We also identify recommendations for future work relating to collecting and reporting data, examining clinically actionable boundaries for diverse data types, and leveraging data science. This work will be critically important as patient access of their personal health data through portals and mobile devices continues to rise.

Intensity of Lipid Lowering With Statin Therapy in Patients With Cerebrovascular Disease Versus Coronary Artery Disease: Insights from the PALM Registry

Background Current treatment guidelines strongly recommend statin therapy for secondary prevention. However, it remains unclear whether patients' perceptions of cardiovascular risk, beliefs on cholesterol, or the intensity of prescribed statin therapy differs for patients with coronary artery disease (CAD) versus cerebrovascular disease (CeVD) versus both CAD and CeVD (CAD&CeVD). Methods and Results The PALM (Patient and Provider Assessment of Lipid Management) registry collected data on statin use, intensity, and core laboratory low-density lipoprotein cholesterol levels for 3232 secondary prevention patients treated at 133 US clinics. Among individuals with CeVD only (n=403), CAD only (n=2202), and CeVD&CAD (n=627), no significant differences were observed in patient-perceived cardiovascular disease risk, beliefs on cholesterol lowering, or perceived effectiveness and safety of statin therapy. However, patients with CeVD only were less likely to receive any statin therapy (76.2% versus 86.2%; adjusted odds ratio 0.64, 95% CI 0.45-0.91), or guideline-recommended statin intensity (34.6% versus 50.4%; adjusted odds ratio 0.60, 95% CI 0.45-0.81) than those with CAD only. Individuals with CeVD only were also less likely to achieve low-density lipoprotein cholesterol <100 mg/dL (59.2% versus 69.7%; adjusted odds ratio 0.79, 95% CI 0.64-0.99) than individuals with CAD alone. There were no significant differences in the use of any statin therapy or guideline-recommended statin intensity between individuals with CAD&CeVD and those with CAD only. Conclusions Despite lack of significant differences in patient-perceived cardiovascular risk or statin beliefs, patients with CeVD were significantly less likely to receive higher intensity statin or achieve low-density lipoprotein cholesterol <100 mg/dL than those with CAD only.

Association Between Perceived Skin Cancer Risk Reduction and Sunscreen Use

BACKGROUND

Understanding factors that influence people to use sunscreen would allow clinicians to counsel patients in a way that is influential. Perceived efficacy of sunscreen has been associated with sunscreen use, but it is unclear whether the degree of efficacy is important.

OBJECTIVE

To determine whether larger perceived efficacy of sunscreen (larger skin cancer risk reduction) is associated with increased sunscreen use.

MATERIALS AND METHODS

A cohort of 131 patients with a history of skin cancer visiting a Mohs micrographic surgery center were surveyed.

RESULTS

Participants believed sunscreen would reduce their risk of basal cell carcinoma (BCC) by 61.1% (95% confidence interval [CI] = 56.4-65.9), squamous cell carcinoma (SCC) by 59.4% (95% CI = 54.6-64.2), and melanoma by 59.5% (95% CI = 54.8-64.3). Perceived magnitude of risk reduction of BCC, SCC, and melanoma was significant independent predictors of sunscreen use (BCC: odds ratio [OR] 3.5, 95% CI 1.1-11.2, p = .04. Squamous cell carcinoma: OR 2.8, 95% CI 1.0-7.6, p = .05. Melanoma: OR 5.0, 95% CI 1.8-14.2, p = .002).

CONCLUSION

Larger perceived skin cancer (BCC, SCC, and melanoma) risk reduction was associated with increased sunscreen use.

Are Healthcare Choices Predictable? The Impact of Discrete Choice Experiment Designs and Models

BACKGROUND

Lack of evidence about the external validity of discrete choice experiments (DCEs) is one of the barriers that inhibit greater use of DCEs in healthcare decision making.

OBJECTIVES

To determine whether the number of alternatives in a DCE choice task should reflect the actual decision context, and how complex the choice model needs to be to be able to predict real-world healthcare choices.

METHODS

Six DCEs were used, which varied in (1) medical condition (involving choices for influenza vaccination or colorectal cancer screening) and (2) the number of alternatives per choice task. For each medical condition, 1200 respondents were randomized to one of the DCE formats. The data were analyzed in a systematic way using random-utility-maximization choice processes.

RESULTS

Irrespective of the number of alternatives per choice task, the choice for influenza vaccination and colorectal cancer screening was correctly predicted by DCE at an aggregate level, if scale and preference heterogeneity were taken into account. At an individual level, 3 alternatives per choice task and the use of a heteroskedastic error component model plus observed preference heterogeneity seemed to be most promising (correctly predicting >93% of choices).

CONCLUSIONS

Our study shows that DCEs are able to predict choices-mimicking real-world decisions-if at least scale and preference heterogeneity are taken into account. Patient characteristics (eg, numeracy, decision-making style, and general attitude for and experience with the health intervention) seem to play a crucial role. Further research is needed to determine whether this result remains in other contexts.

Parents of newborns in the NICU enrolled in genome sequencing research: hopeful, but not naïve

Purpose:

In 2014, our institution launched a randomized control trial (RCT) comparing rapid genome sequencing (GS) to standard clinical evaluations of infants with suspected genetic disorders. This study aimed to understand parental response to the use of GS for their newborn babies.

Methods:

23 of 128 parents whose infant had enrolled in the RCT completed a retrospective survey and interview addressing attitudes about GS and responses to receiving diagnostic information. We also collected information about participants’ genetic literacy, genetic knowledge, numeracy, and symptoms of anxiety and depression.

Results:

The majority reported positive, 13 (56.5%), or neutral, 4 (17.4%), feelings when approached about GS for their infant and 100% felt that GS was generally beneficial. The 12 participants who had received a unifying diagnosis for their child’s symptoms described personal utility of the information. Some reported the diagnosis led to changes in medical care. Participants showed understanding of some of the psychological risks of GS. For example, 21 (91.3%) agreed or strongly agreed that genetic testing could reveal disturbing results.

Conclusion:

Parents who enrolled their newborn in a RCT of GS demonstrated awareness of a psychological risk, but generally held positive beliefs about GS and perceived the benefits outweighed the risk.

Right-wing ideology and numeracy: A perception of greater ability, but poorer performance

Right-wing ideology and cognitive ability, including objective numeracy, have been found to relate negatively. Although objective and subjective numeracy correlate positively, it is unclear whether subjective numeracy relates to political ideology in the same way. Replicating and extending previous research, across two samples of American adults (ns= 455, 406), those who performed worse on objective numeracy tasks scored higher on right-wing authoritarianism (RWA) and social dominance orientation (SDO), and they self-identified as more conservative on general, social, and economic continua. Controlling for objective numeracy, subjective numeracy related positively to measures of right-wing ideologies. In other words, those who strongly (vs. weakly) endorsed right-wing ideologies believed they are good with numbers yet performed worse on numeracy tasks. We discuss implications for the opposing direction of associations between ideology with objective versus subjective numeracy and similarities with literature on overconfidence.

Talking about treatment benefits, harms, and what matters to patients in radiation oncology: an observational study

Background

Shared decision making is associated with improved patient outcomes in radiation oncology. Our study aimed to capture how shared decision-making practices–namely, communicating potential harms and benefits and discussing what matters to patients–occur in usual care.

Methods

We invited a convenience sample of clinicians and patients in a radiation oncology clinic to participate in a mixed methods study. Prior to consultations, clinicians and patients completed self-administered questionnaires. We audio-recorded consultations and conducted qualitative content analysis. Patients completed a questionnaire immediately post-consultation about their recall and perceptions.

Results

11 radiation oncologists, 4 residents, 14 nurses, and 40 patients (55% men; mean age 64, standard deviation or SD 9) participated. Patients had a variety of cancers; 30% had been referred for palliative radiotherapy. During consultations (mean length 45 min, SD 16), clinicians presented a median of 8 potential harms (interquartile range 6–11), using quantitative estimates 17% of the time. Patients recalled significantly fewer harms (median recall 2, interquartile range 0–3, t(38) = 9.3, p < .001). Better recall was associated with discussing potential harms with a nurse after seeing the physician (odds ratio 7.5, 95% confidence interval 1.3–67.0, p = .04.) Clinicians initiated 63% of discussions of harms and benefits while patients and families initiated 69% of discussions about values and preferences (Chi-squared(1) = 37.8, p < .001). 56% of patients reported their clinician asked what mattered to them.

Conclusions

Radiation oncology clinics may wish to use interprofessional care and initiate more discussions about what matters to patients to heed Jain’s (2014) reminder that, “a patient isn’t a disease with a body attached but a life into which a disease has intruded.”

Use of a Decision Aid for Patients Considering Peritoneal Dialysis and In-Center Hemodialysis: A Randomized Controlled Trial

RATIONALE & OBJECTIVE

Annually, about 100,000 US patients face the difficult choice between the most common dialysis types, in-center hemodialysis and peritoneal dialysis. This study evaluated the value of a new decision aid to assist in the choice of dialysis modality.

STUDY DESIGN

A parallel-group randomized controlled trial to test the efficacy of the decision aid on decision-making outcomes.

SETTING & PARTICIPANTS

English-speaking US adults with advanced chronic kidney disease and internet access enrolled in 2015.

INTERVENTION

Participants randomly assigned to the decision aid intervention received information about chronic kidney disease, peritoneal dialysis, and hemodialysis and a value clarification exercise through the study website using their own electronic devices. Participants in the control arm were only required to complete the control questionnaire. Questionnaire responses were used to assess differences across arms in decision-making outcomes.

OUTCOMES

Treatment preference, decisional conflict, decision self-efficacy, knowledge, and preparation for decision making.

RESULTS

Of 234 consented participants, 94 (40.2%) were lost to follow-up before starting the study. Among the 140 (70 in each arm) who started the study, 7 were subsequently lost to follow-up. Decision aid users had lower decisional conflict scores (42.5 vs 29.1; P<0.001) and higher average knowledge scores (90.3 vs 76.5; P<0.001). Both arms had high decisional self-efficacy scores independent of decision aid use. Uncertainty about choice of dialysis treatment declined from 46% to 16% after using the decision aid. Almost all (>90%) users of the decision aid reported that it helped in decision making.

LIMITATIONS

Limited generalizability from the study of self-selected study participants who had to have internet access, speak English, and have computer literacy. High postrandomization loss to follow-up. Evaluation of only short-term outcomes.

CONCLUSIONS

The decision aid improves decision-making outcomes immediately after use. Implementation of the decision aid in clinical practice may allow further assessment of its effects on patient engagement and empowerment in choosing a dialysis modality.

FUNDING

This study was funded through a Patient Centered Outcomes Research Institute (PCORI) award (#1109).

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT02488317.

Impact of including quantitative information in a decision aid for colorectal cancer screening: A randomized controlled trial

OBJECTIVE

Guidelines recommend that decision aids provide quantitative information about risks and benefits of available options. Impact of providing this information is unknown.

METHODS

Randomized trial comparing two decision aids about colorectal cancer (CRC) screening with colonoscopy or fecal immunochemical test (FIT). 688 primary care patients due for CRC screening viewed a decision aid that uses words only (Verbal arm) vs. one that provides quantitative information (Quantitative arm). Main outcomes included perceived CRC risk, intent to be screened, and test preference, measured before and after viewing decision aid, and screening uptake at six months. Analyses were performed with ANCOVA and logistic regression.

RESULTS

Compared to the Verbal arm, those in the Quantitative arm had a larger increase in intent to undergo FIT (p = 0.011) and were more likely to switch their preferred test from non-FIT to FIT (28% vs. 19%, p = .010). There were decreases in perceived risk in the Verbal Arm but not the Quantitative Arm (p = 0.004). There was no difference in screening uptake. Numeracy did not moderate any effects.

CONCLUSIONS

Quantitative information had relatively minor impact and no clearly negative effects, such as reducing uptake.

PRACTICE IMPLICATIONS

Quantitative information may be useful but not essential for patients viewing decision aids.

Health Coaching Has Differential Effects on Veterans with Limited Health Literacy and Numeracy: a Secondary Analysis of ACTIVATE

BACKGROUND

Health coaching is an effective behavior change strategy. Understanding if there is a differential impact of health coaching on patients with low health literacy has not been well investigated.

OBJECTIVE

To determine whether a telephone coaching intervention would result in similar improvements in enrollment in prevention programs and patient activation among Veterans with low versus high health literacy (specifically, reading literacy and numeracy).

DESIGN

Secondary analysis of a randomized controlled trial.

PARTICIPANTS

Four hundred seventeen Veterans with at least one modifiable risk factor: current smoker, BMI ≥ 30, or < 150 min of moderate physical activity weekly.

METHODS

A single-item assessment of health literacy and a subjective numeracy scale were assessed at baseline. A logistic regression and general linear longitudinal models were used to examine the differential impact of the intervention compared to control on enrollment in prevention programs and changes in patient activation measures (PAM) scores among patients with low versus high health literacy.

RESULTS

The coaching intervention resulted in higher enrollment in prevention programs and improvements in PAM scores compared to usual care regardless of baseline health literacy. The coaching intervention had a greater effect on the probability of enrollment in prevention programs for patients with low numeracy (intervention vs control difference of 0.31, 95% CI 0.18, 0.45) as compared to those with high numeracy (0.13, 95% CI - 0.01, 0.27); the low compared to high differential effect was clinically, but not statistically significant (0.18, 95% CI - 0.01, 0.38; p = 0.07). Among patients with high numeracy, the intervention group had greater increases in PAM as compared to the control group at 6 months (mean difference in improvement 4.8; 95% CI 1.7, 7.9; p = 0.003). This led to a clinically and statistically significant differential intervention effect for low vs high numeracy (- 4.6; 95% CI - 9.1, - 0.15; p = 0.04).

CONCLUSIONS

We suggest that health coaching may be particularly beneficial in behavior change strategies in populations with low numeracy when interpretation of health risk information is part of the intervention. CLINICALTRIALS.

GOV IDENTIFIER

NCT01828567.

Reaping the Benefits and Avoiding the Risks: Unrealistic Optimism in the Health Domain

People's perceptions of benefits and risks play a key role in their acceptance or rejection of medical interventions, yet these perceptions may be poorly calibrated. This online study with N = 373 adults aged 19-76 years focused on unrealistic optimism in the health domain. Participants indicated how likely they were to experience benefits and risks associated with medical conditions and completed objective and subjective numeracy scales. Participants exhibited optimistic views about the likelihood of experiencing the benefits and the side effects of treatment options described in the scenarios. Objective and subjective numeracy were not associated with more accurate ratings. Moreover, participants' underestimation of the risks was significantly greater than their overestimation of the benefits. From an applied perspective, these results suggest that clinicians may need to ensure that patients do not underestimate risks of medical interventions, and that they convey realistic expectations about the benefits that can be obtained with certain procedures.

Understanding Patients' Preferences: A Systematic Review of Psychological Instruments Used in Patients' Preference and Decision Studies

BACKGROUND

Research has been mainly focused on how to elicit patient preferences, with less attention on why patients form certain preferences.

OBJECTIVES

To assess which psychological instruments are currently used and which psychological constructs are known to have an impact on patients' preferences and health-related decisions including the formation of preferences and preference heterogeneity.

METHODS

A systematic database search was undertaken to identify relevant studies. From the selected studies, the following information was extracted: study objectives, study population, design, psychological dimensions investigated, and instruments used to measure psychological variables.

RESULTS

Thirty-three studies were identified that described the association between a psychological construct, measured using a validated instrument, and patients' preferences or health-related decisions. We identified 33 psychological instruments and 18 constructs, and categorized the instruments into 5 groups, namely, motivational factors, cognitive factors, individual differences, emotion and mood, and health beliefs.

CONCLUSIONS

This review provides an overview of the psychological factors and related instruments in the context of patients' preferences and decisions in healthcare settings. Our results indicate that measures of health literacy, numeracy, and locus of control have an impact on health-related preferences and decisions. Within the category of constructs that could explain preference and decision heterogeneity, health locus of control is a strong predictor of decisions in several healthcare contexts and is useful to consider when designing a patient preference study. Future research should continue to explore the association of psychological constructs with preference formation and heterogeneity to build on these initial recommendations.

Evaluation of the intensive outpatient clinic: study protocol for a prospective study of high-cost, high-need patients in the University of Utah Health system

INTRODUCTION

The University of Utah (UofU) Health intensive outpatient clinic (IOC) is a primary care clinic for medically complex (high-cost, high-need) patients with Medicaid. The clinic consists of a multidisciplinary care team aimed at providing coordinated, comprehensive and patient-centred care. The protocol outlines the quantitative design of an evaluation study to determine the IOC's effects on reducing healthcare utilisation and costs, as well as improving patient-reported health outcomes and quality of care.

METHODS AND ANALYSIS

High-risk patients, with high utilisation and multiple chronic illnesses, were identified in the Medicaid ACO population managed by the UofU Health plans for IOC eligibility. A prospective, case-control study design is being used to match 100 IOC patients to 200 control patients (receiving usual care within the UofU) based on demographics, health utilisation and medical complexity for evaluating the primary outcome of change in healthcare utilisation and costs. For the secondary outcomes of patient health and care quality, a prepost design will be used to examine within-person change across the 18 months of follow-up (ie, before and after IOC intervention). Logistic regression and hierarchical, longitudinal growth modelling are the two primary modelling approaches.

ETHICS AND DISSEMINATION

This work has received ethics approval by the UofU Institutional Review Board. Results from the evaluation of primary and secondary outcomes will be disseminated in scientific research journals and presented at national conferences.

The Impact of a Risk-Based Breast Cancer Screening Decision Aid on Initiation of Mammography Among Younger Women: Report of a Randomized Trial

Background. Guidelines recommend that initiation of breast cancer screening (BCS) among women aged 40 to 49 years include a shared decision-making process. The objective of this study is to evaluate the effect of a breast cancer screening patient decision-aid (BCS-PtDA) on the strength of the relationship between individual risk and the decision to initiate BCS, knowledge, and decisional conflict. Methods. We conducted a randomized clinical trial of a BCS-PtDA that included individual risk estimates compared with usual care. Participants were women 39 to 48 years of age with no previous mammogram. Primary outcomes were strength of association between breast cancer risk and mammography uptake at 12 months, knowledge, and decisional conflict. Results. Of 204 participants, 65% were Black, the median age (interquartile range [IQR]) was 40.0 years (39.0–42.0), and median (IQR) breast cancer lifetime risk was 9.7% (9.2–11.1). Women who received mammography at 12 months had higher breast cancer lifetime risk than women who had not in both intervention (mean, 95% CI): 12.2% (10.8–13.6) versus 10.5% (9.8–11.2), P = 0.04, and control groups: 11.8% (10.4–13.1) versus 9.9% (9.2–10.6), P = 0.02. However, there was no difference between groups in the strength of association between mammography uptake and breast cancer risk (P = 0.87). Follow-up knowledge (0–5) was greater in the intervention versus control group (mean, 95% CI): 3.84 (3.5–4.2) versus 3.17 (2.8–3.5), P = 0.01. There was no change in decisional conflict score (1–100) between the intervention versus control group (mean, 95% CI): 24.8 (19.5–30.2) versus 32.4 (25.9–39.0), P = 0.07. Conclusions. The BCS-PtDA improved knowledge but did not affect risk-based decision making regarding age of initiation of BCS. These findings indicate the complexity of changing behaviors to incorporate objective risk in the medical decision-making process.

Religious Identity and Health Inequalities in Canada

In the past few decades, most new immigrants to Canada have originated from non-Christian countries. During the same period, the unaffiliation rates have sharply increased in Canada. This paper investigates whether there are any health inequalities associated with religious identity, including also the individuals who do not identify with organized religion in the analysis. The study uses the Canadian General Social Survey of 2012 (N = 23,093), focused on Caregiving and Care-receiving. Employing multivariate regression analysis and controlling for a large set of characteristics inclusive of the degree of religious commitment, individuals who identify as Protestant are found at a physical and mental health advantage, compared with Roman Catholics and most other groups. On the other hand, individuals who identify as Jehovah's Witnesses are found at a considerable physical health disadvantage. Among the unaffiliated individuals, those who have retained some ties with organized religion without formally identifying with it are found at a mental health disadvantage compared with all religious groups, as well as the secular individuals who are strictly committed to their nonreligious views. Possible causes and various implications are discussed.

Estimating everyday risk: Subjective judgments are related to objective risk, mapping of numerical magnitudes and previous experience

We aimed to investigate individual differences that associate with peoples' acute risk perception for activities such as walking and giving birth, including objective risk and the mapping of numerical magnitudes. The Amazon Mechanical Turk platform was used, with 284 participants recruited (40% female) ranging between 19 and 68 years. Participants had to indicate the positions of (1) the relative death risk of activities on a horizontal-line with 'very low risk of death' and 'very high risk of death' as left and right anchors respectively and (2), numerical magnitudes on a horizontal-line ranging 0-1000. The MicroMort framework was used to index acute risk of death (one/million chance of dying from an accident). Previous experience with the activities, handedness, along with risk propensity and unrealistic optimism were also measured. Linear mixed-effects modelling was used to investigate predictors of subjective MicroMort judgments. Individuals subjectively judged activities to be riskier if the activity was objectively riskier, if they over-estimated on the numerical task (more so for low-risk activities as compared to high-risk), or if they had not experienced the activity previously. The observed relationship between the number line task and everyday risk judgments is in keeping with the idea of a common magnitude representation system. In conclusion, individuals are able to discriminate between activities varying in risk in an absolute sense, however intuition for judging the relative differences in risk is poor. The relationship between the misjudging of both risks and numerical magnitudes warrants further investigation, as may inform the development of risk communication strategies.

Health Literacy and 1-Year Mortality: Mechanisms of Association in Adults Hospitalized for Cardiovascular Disease

OBJECTIVE

To test theorized patient-level mediators in the causal pathway between health literacy (HL) and 1-year mortality in adults with cardiovascular disease (CVD).

PATIENTS AND METHODS

A total of 3000 adults treated at Vanderbilt University Hospital from October 11, 2011, through December 18, 2015, for acute coronary syndrome or acute decompensated heart failure (ADHF) participated in the Vanderbilt Inpatient Cohort Study. Participants completed a bedside-administered survey and consented to health record review and longitudinal follow-up. Multivariable mediation models examined the direct and indirect effects of HL (a latent variable with 4 indicators) with 1-year mortality after discharge (dichotomous). Hypothesized mediators included social support, health competence, health behavior, comorbidity index, type of CVD diagnosis, and previous-year hospitalizations.

RESULTS

Of the 2977 patients discharged from the hospital (60% male; mean age, 61 years; 83% non-Hispanic white, 37% admitted for ADHF), 17% to 23% had inadequate HL depending on the measure, and 10% (n=304) died within 1 year. The total effect of lower HL on 1-year mortality (adjusted odds ratio [AOR]=1.31; 95% CI, 1.01-1.69) was decomposed into an indirect effect (AOR=1.50; 95% CI, 1.35-1.67) via the mediators and a nonsignificant direct effect (AOR=0.87; 95% CI, 0.66-1.14). Each SD decrease in HL was associated with an absolute 3.2 percentage point increase in the probability of 1-year mortality via mediators admitted for ADHF, comorbidities, health behavior, health competence, and previous-year hospitalizations (listed by contribution to indirect effect).

CONCLUSION

Patient-level factors link low HL and mortality. Health competence and health behavior are modifiable mediators that could be targeted by interventions post hospitalization for CVD.

Preferences of Patients and Pharmacists with Regard to the Management of Drug-Drug Interactions: A Choice-Based Conjoint Analysis

Introduction

The management of drug–drug interactions (DDIs) is a complex process in which risk–benefit assessments should be combined with the patient’s perspective.

Objective

The aim of this study was to determine patients’ and pharmacists’ preferences regarding DDI management.

Methods

We conducted a choice-based conjoint survey about a fictitious DDI concerning the combination of a cardiovascular drug and an antibiotic for pneumonia. Patients and pharmacists had to choose 12 times between two management options. The options were described by five attributes, including risk, benefit and practical consequences. Each attribute could have two different levels, which were varied over the choice tasks. Latent class analysis was used to identify potential classes of respondents with distinct patterns of similar preferences.

Results

In total, 298 patients and 178 pharmacists completed the questionnaire. The latent class model for both patients and pharmacists resulted in three classes. For patients, in one class the most importance was attached to avoiding switch of medication (class probability 20%), in a second class to fewer adverse events (41%), and in a third class to blood sampling (39%). For pharmacists, again one class attached the highest importance to avoiding switch of medication (31%). The other classes gave priority to curing pneumonia (31%) and avoiding blood sampling (38%).

Conclusion

The results showed diverging preferences regarding DDI management among both patients and pharmacists. Different groups attached different value to risk and benefit versus practical considerations. Awareness of existing variability in preferences among and between pharmacists and patients is a step towards shared decision making in DDI management.

Electronic supplementary material

The online version of this article (doi:10.1007/s40264-017-0601-7) contains supplementary material, which is available to authorized users.

Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial

Care for patients transitioning from chronic kidney disease to kidney failure often falls short of meeting patients' needs. The PREPARE NOW study is a cluster randomized controlled trial studying the effectiveness of a pragmatic health system intervention, 'Patient Centered Kidney Transition Care,' a multi-component health system intervention designed to improve patients' preparation for kidney failure treatment. Patient-Centered Kidney Transition Care provides a suite of new electronic health information tools (including a disease registry and risk prediction tools) to help providers recognize patients in need of Kidney Transitions Care and focus their attention on patients' values and treatment preferences. Patient-Centered Kidney Transition Care also adds a 'Kidney Transitions Specialist' to the nephrology health care team to facilitate patients' self-management empowerment, shared-decision making, psychosocial support, care navigation, and health care team communication. The PREPARE NOW study is conducted among eight [8] outpatient nephrology clinics at Geisinger, a large integrated health system in rural Pennsylvania. Four randomly selected nephrology clinics employ the Patient Centered Kidney Transitions Care intervention while four clinics employ usual nephrology care. To assess intervention effectiveness, patient reported, biomedical, and health system outcomes are collected annually over a period of 36 months via telephone questionnaires and electronic health records. The PREPARE NOW Study may provide needed evidence on the effectiveness of patient-centered health system interventions to improve nephrology patients' experiences, capabilities, and clinical outcomes, and it will guide the implementation of similar interventions elsewhere.

TRIAL REGISTRATION

NCT02722382.

Study protocol: a cluster randomized controlled trial of web-based decision support tools for increasing BRCA1/2 genetic counseling referral in primary care

BACKGROUND

BRCA1 and BRCA2 mutations confer a substantial breast risk of developing breast cancer to those who carry them. For this reason, the United States Preventative Services Task Force (USPSTF) has recommended that all women be screened in the primary care setting for a family history indicative of a mutation, and women with strong family histories of breast or ovarian cancer be referred to genetic counseling. However, few high-risk women are being routinely screened and fewer are referred to genetic counseling. To address this need we have developed two decision support tools that are integrated into clinical care.

METHOD

This study is a cluster randomized controlled trial of high-risk patients and their health care providers. Patient-provider dyads will be randomized to receive either standard education that is supplemented with the patient-facing decision aid, RealRisks, and the provider-facing Breast Cancer Risk Navigation Toolbox (BNAV) or standard education alone. We will assess these tools' effectiveness in promoting genetic counseling uptake and informed and shared decision making about genetic testing.

DISCUSSION

If found to be effective, these tools can help integrate genomic risk assessment into primary care and, ultimately, help expand access to risk-appropriate breast cancer prevention options to a broader population of high-risk women.

TRIAL REGISTRATION

This trial is retrospectively registered with ClinicalTrials.gov Identifier: NCT03470402 : 20 March 2018.

A New Measure of Health Numeracy: Brief Medical Numbers Test (BMNT)

BACKGROUND

Approximately half of Americans have inadequate health literacy, which leads to poorer health outcomes. Health numeracy is an important component of literacy, which reflects one's ability to understand and manipulate numbers. This is especially important for transplant candidates, as adherence to medical recommendations is essential for posttransplant care. Although validated measures of numeracy exist, they can be inconvenient and time consuming to administer.

OBJECTIVE

The Brief Medical Numbers Test (BMNT) was created in 2011 to quickly assess the health numeracy of a patient during presurgical psychiatric transplant evaluations. The purpose of this study was to evaluate the reliability and validity of the BMNT for this use via retrospective chart review.

METHODS

There were 293 patients referred over a 2-year period for a presurgical psychiatric evaluation. The evaluation consisted of a semistructured interview and completion of several measures, including the BMNT, a measure of health literacy, and a brief test of cognitive functioning.

RESULTS

The BMNT had acceptable internal consistency (α = .71), convergent validity with health literacy and cognitive functioning, and predictive validity with surgical outcomes.

CONCLUSIONS

Preliminary data suggests the BMNT is a reliable and valid measure of health numeracy in patients being evaluated for transplant.

Cognitive Style and Frame Susceptibility in Decision-Making

The susceptibility of decision-makers' choices to variations in option framing has been attributed to individual differences in cognitive style. According to this view, individuals who are prone to a more deliberate, or less intuitive, thinking style are less susceptible to framing manipulations. Research findings on the topic, however, have tended to yield small effects, with several studies also being limited in inferential value by methodological drawbacks. We report two experiments that examined the value of several cognitive-style variables, including measures of cognitive reflection, subjective numeracy, actively open-minded thinking, need for cognition, and hemispheric dominance, in predicting participants' frame-consistent choices. Our experiments used an isomorph of the Asian Disease Problem and we manipulated frames between participants. We controlled for participants' sex and age, and we manipulated the order in which choice options were presented to participants. In Experiment 1 (N = 190) using an undergraduate sample and in Experiment 2 (N = 316) using a sample of Amazon Mechanical Turk workers, we found no significant effect of any of the cognitive-style measures taken on predicting frame-consistent choice, regardless of whether we analyzed participants' binary choices or their choices weighted by the extent to which participants preferred their chosen option over the non-chosen option. The sole factor that significantly predicted frame-consistent choice was framing: in both experiments, participants were more likely to make frame-consistent choices when the frame was positive than when it was negative, consistent with the tendency toward risk aversion in the task. The present findings do not support the view that individual differences in people's susceptibility to framing manipulations can be substantially accounted for by individual differences in cognitive style.

Numerate decision makers don’t use more effortful strategies unless it pays: A process tracing investigation of skilled and adaptive strategy selection in risky decision making

The present study investigated skilled and adaptive strategy selection in risky decision making. We proposed that people with high objective numeracy, a strong predictor of general decision making skill, would have a broad repertoire of choice strategies and adaptively select these strategies depending on the importance of the decision. Thus more objectively numerate people would maximize their effort (e.g., invest more time) in important, high-payoff decisions and switch to a simple, fast heuristic strategy in trivial decisions. Subjective numeracy would, by contrast, be more closely related to interest in problem solving for its own sake and would not yield such an effect of importance. Participants made twelve high-payoff choices and twelve low-payoff choices in binary two-outcome gambles framed as gains. We measured objective and subjective numeracy using standard measures. Results showed that people with high subjective numeracy generally maximized the expected value (EV) in all decisions. In contrast, participants with high objective numeracy maximized EV only when choice problems were meaningful (i.e., they could result in high payoffs). When choice problems were trivial (i.e., choosing the normatively better option would not result in a large payoff), more objectively numerate participants made choices consistent with faster, more frugal heuristic strategies.

Cancer genetic counseling communication with low-income Chinese immigrants

As genetics and genomics become part of mainstream medicine, these advances have the potential to either reduce or exacerbate health disparities. Relatively, little research has explored the quality of genetic counseling communication experienced by limited English proficiency patients, especially Chinese Americans. We observed and audio recorded genetic counseling appointments (n = 40) of low-income, limited English-proficient Chinese patients (n = 25) and conducted post-visit interviews (n = 17) using stimulated recall to examine patient understanding of the communication. Standard techniques based in grounded theory, including iterative data review and multiple coders, were used to analyze observation fieldnotes and interview transcripts and to identify these themes: (1) strong beliefs in environmental causes of cancer and skepticism about genetic causes, (2) willingness to undergo genetic testing despite skepticism of hereditary cause of cancer, (3) misunderstanding of key information needed to make informed decisions about testing and screening/prevention options, (4) variable quality of medical interpretation, and (5) selective family communication about cancer and genetic counseling and testing. Together, these themes describe substantial gaps in communication and identify the need for genetic counseling techniques and skills that enable counselors to communicate more effectively across language, literacy, and culture. Understanding the mechanisms of inheritance and the implications of genetic test results can be challenging for anyone, and it is exceptionally daunting for those who have limited English proficiency and/or low literacy. For Chinese immigrant patients to reap the full benefits of genetic counseling and testing, effective communication is essential. Research on interventions to improve communication is needed to ensure that disparities do not widen as genomic medicine reaches a more diverse population.

Decision making in advanced heart failure: bench, bedside, practice, and policy

This is an exciting time for patient-centered care. The window of opportunity appears to be open for the medical culture to accept the importance of the patients' values, goals and preferences in guiding medical decisions. Heart failure guidelines are changing to include language around shared decision making for major procedures and end-of-life care. However, while the cultural norms appear to be moving in this direction, the science regarding how to best deliver patient centered care (basic, clinical, delivery, and policy) is still developing. This article will provide a broad overview of the science of decision making in advanced heart failure using a translational science framework.

Use of feedback to improve mental number line representations in primary care clinics

BACKGROUND

As patients become more engaged in decisions regarding their medical care, they must weigh the potential benefits and harms of different treatments. Patients who are low in numeracy may be at a disadvantage when making these decisions, as low numeracy is correlated with less precise representations of numerical magnitude. The current study looks at the feasibility of improving number representations. The aim of this study was to evaluate whether providing a small amount of feedback to adult subjects could improve performance on a number line placement task and to determine characteristics of those individuals who respond best to this feedback.

METHODS

Subjects from two outpatient clinic waiting rooms participated in a three phase number line task. Participants were asked to place numbers on a computerized number line ranging from 0 to 1000 in pre-test, feedback, and post-test phases. Generalized estimating equations were used to model log-transformed scores and to test whether 1) performance improved after feedback, and 2) the degree of improvement was associated with age, education level or subjective numeracy.

RESULTS

There was an overall improvement in task performance following the feedback. The average percent absolute error was 7.32% (SD: 6.00) for the pre-test and 5.63% (SD: 3.71) for the post-test. There was a significant interaction between college education and post-test improvement. Only subjects without some college education improved with feedback.

CONCLUSIONS

Adults who do not have higher levels of education improve significantly on a number line task when given feedback.

The relationship between low perceived numeracy and cancer knowledge, beliefs, and affect

Low numeracy may skew patient perceptions of information about cancer. This paper examines the relationship between self-reported measures of perceived numeracy and cancer knowledge, beliefs, and affect, using results from 3,052 respondents to the 2007 Health Information National Trends Survey (HINTS-3). Chi-squared tests were used to identify differences in responses between high- and low-numeracy groups using three measures of perceived numeracy. Multivariable logistic regression models were used to evaluate the association between the three perceived numeracy measures and cancer information overload, cancer fatalism, cancer prevention knowledge, and cancer worry. Respondents with low perceived numeracy as expressed by discomfort with medical statistics were more likely to report information overload, to display fatalistic attitudes towards cancer, to lack knowledge about cancer prevention, and to indicate that they worried about cancer more frequently. After controlling for sociodemographic characteristics, this measure of perceived numeracy remained significantly associated with information overload, fatalism, lower prevention knowledge, and worry. The other measures of perceived numeracy, which measured understanding and use of health statistics, were not associated with cancer perceptions. Our findings suggest that individuals with low perceived numeracy broadly differ from individuals with high perceived numeracy in their perceptions of cancer and cancer prevention. By improving our understanding of how perceived numeracy affects patient perceptions of cancer, health providers can improve educational strategies and targeted health messaging.

Predictors of Medication Continuity in Children With ADHD

OBJECTIVES

To identify predictors of attention-deficit/hyperactivity disorder (ADHD) medication continuity, hypothesizing greater continuity among children with (1) greater child acceptance of treatment, (2) parent belief in longer time course for ADHD, (3) positive differential between parent-perceived need for and concerns about medication, and (4) greater parent-perceived alliance with their child's doctor.

METHODS

We conducted a prospective longitudinal cohort of 89 children aged 6 to 10 years old newly treated for ADHD by 1 of 44 pediatricians in 11 practices. Parents completed validated surveys on their beliefs about ADHD and medicine. We audited charts and obtained pharmacy dispensing records. In our analyses, we examined the relationship between predictor variables (eg, sociodemographic and clinical characteristics, quality of care, and belief measures) and short-term (first 90 days after starting medication) and long-term (91-450 days) medication continuity as defined by the number of days covered with medication.

RESULTS

Children had a median of 81% of days covered over 0 to 90 days and 54% of days covered over 91 to 450 days after starting medicine. In the first 90 days, medication coverage related to child age, satisfaction with information about medicine, medication titration, symptom reduction, parent beliefs about control over symptoms, uncertainty about treating with medicine, and working alliance. Long-term medication continuity related to child acceptance of treatment and differential between parent-perceived need for and concerns about medication at 3 months, not baseline factors.

CONCLUSIONS

Adherence is a process that can change over time in response to experiences with treatment. Interventions are needed to promote productive interactions between pediatricians and families in support of continuity.

Limitations of the S-TOFHLA in measuring poor numeracy: a cross-sectional study

Background

Although the Short Test of Functional Health Literacy in Adults (S-TOFHLA) is widely used, misidentification of individuals with low health literacy (HL) in specific HL dimensions, like numeracy, is a concern. We examined the degree to which individuals scored as “adequate” HL on the S-TOFHLA would be considered as having low HL by two additional numerical measures.

Methods

English-speaking adults aged 45–75 years were recruited from a large, urban academic medical center and a community foodbank in the United States. Participants completed the S-TOFHLA, the Subjective Numeracy Scale (SNS), and the Graphical Literacy Measure (GL), an objective measure of a person’s ability to interpret numeric information presented graphically. Established cut-points or a median split classified participants and having high and low numeracy.

Results

Participants (n = 187), on average were: aged 58 years; 63% female; 70% Black/African American; and 45% had a high school degree or less. Of those who scored “adequate” on the S-TOFHLA, 50% scored low on the SNS and 40% scored low on GL. Correlation between the S-TOFHLA and the SNS Total was moderate (r = 0.22, n = 186, p = 0.01), while correlation between the S-TOFHLA and the GL Total was large (r = 0.53, n = 187, p ≤ 0.01).

Conclusions

Findings suggest that the S-TOFHLA may not capture an individuals’ HL in the dimension of numeracy. Efforts are needed to develop more encompassing and practical strategies for identifying those with low HL for use in research and clinical practice.

Trial registration

NCT02151032 (retrospectively registered: May 30, 2014).

Numeracy, Health Literacy, Cognition, and 30-Day Readmissions among Patients with Heart Failure

BACKGROUND

Numeracy, health literacy, and cognition are important for chronic disease management. Prior studies have found them to be associated with poorer selfcare and worse clinical outcomes, but limited data exists in the context of heart failure (HF), a condition that requires patients to monitor their weight, fluid intake, and dietary salt, especially in the posthospitalization period.

OBJECTIVE

To examine the relationship between numeracy, health literacy, and cognition with 30-day readmissions among patients hospitalized for acute decompensated HF (ADHF).

DESIGN, SETTING, PATIENTS

The Vanderbilt Inpatient Cohort Study is a prospective longitudinal study of adults hospitalized with acute coronary syndromes and/or ADHF. We studied 883 adults hospitalized with ADHF.

MEASUREMENTS

During their hospitalization, a baseline interview was performed in which demographic characteristics, numeracy, health literacy, and cognition were assessed. Through chart review, clinical characteristics were determined. The outcome of interest was 30-day readmission to any acute care hospital. To examine the association between numeracy, health literacy, cognition, and 30-day readmissions, multivariable Poisson (log-linear) regression was used.

RESULTS

Of the 883 patients admitted for ADHF, 23.8% (n = 210) were readmitted within 30 days; 33.9% of the study population had inadequate numeracy skills, 24.6% had inadequate/marginal literacy skills, and 53% had any cognitive impairment. Numeracy and cognition were not associated with 30-day readmissions. Though (objective) health literacy was associated with 30-day readmissions in unadjusted analyses, it was not in adjusted analyses.

CONCLUSIONS

Numeracy, health literacy, and cognition were not associated with 30-day readmission among this sample of patients hospitalized with ADHF.

The impact of vaccination and patient characteristics on influenza vaccination uptake of elderly people: A discrete choice experiment

OBJECTIVES

To improve information for patients and to facilitate a vaccination coverage that is in line with the EU and World Health Organization goals, we aimed to quantify how vaccination and patient characteristics impact on influenza vaccination uptake of elderly people.

METHODS

An online discrete choice experiment (DCE) was conducted among 1261 representatives of the Dutch general population aged 60 years or older. In the DCE, we used influenza vaccination scenarios based on five vaccination characteristics: effectiveness, risk of severe side effects, risk of mild side effects, protection duration, and absorption time. A heteroscedastic multinomial logit model was used, taking scale and preference heterogeneity (based on 19 patient characteristics) into account.

RESULTS

Vaccination and patient characteristics both contributed to explain influenza vaccination uptake. Assuming a base case respondent and a realistic vaccination scenario, the predicted uptake was 58%. One-way changes in vaccination characteristics and patient characteristics changed this uptake from 46% up to 61% and from 37% up to 95%, respectively. The strongest impact on vaccination uptake was whether the patient had been vaccinated last year, whether s/he had experienced vaccination side effects, and the patient's general attitude towards vaccination.

CONCLUSIONS

Although vaccination characteristics proved to influence influenza vaccination uptake, certain patient characteristics had an even higher impact on influenza vaccination uptake. Policy makers and general practitioners can use these insights to improve their communication plans and information regarding influenza vaccination for individuals aged 60 years or older. For instance, physicians should focus more on patients who had experienced side effects due to vaccination in the past, and policy makers should tailor the standard information folder to patients who had been vaccinated last year and to patient who had not.

Numeracy of multiple sclerosis patients: A comparison of patients from the PERCEPT study to a German probabilistic sample

OBJECTIVE

A shared decision-making approach is suggested for multiple sclerosis (MS) patients. To properly evaluate benefits and risks of different treatment options accordingly, MS patients require sufficient numeracy - the ability to understand quantitative information. It is unknown whether MS affects numeracy. Therefore, we investigated whether patients' numeracy was impaired compared to a probabilistic national sample.

METHODS

As part of the larger prospective, observational, multicenter study PERCEPT, we assessed numeracy for a clinical study sample of German MS patients (N=725) with a standard test and compared them to a German probabilistic sample (N=1001), controlling for age, sex, and education. Within patients, we assessed whether disease variables (disease duration, disability, annual relapse rate, cognitive impairment) predicted numeracy beyond these demographics.

RESULTS

MS patients showed a comparable level of numeracy as the probabilistic national sample (68.9% vs. 68.5% correct answers, P=0.831). In both samples, numeracy was higher for men and the highly educated. Disease variables did not predict numeracy beyond demographics within patients, and predictability was generally low.

CONCLUSION

This sample of MS patients understood quantitative information on the same level as the general population.

PRACTICE IMPLICATIONS

There is no reason to withhold quantitative information from MS patients.

Numeracy Predicts Risk of Pre-Hospital Decision Delay: a Retrospective Study of Acute Coronary Syndrome Survival

BACKGROUND

Many patients delay seeking medical attention during acute coronary syndromes (ACS), profoundly increasing their risk for death and major disability. Although research has identified several risk factors, efforts to improve patient decision making have generally been unsuccessful, prompting a call for more research into psychological factors.

PURPOSE

The purpose of this study is to estimate the relationship between ACS decision delay and numeracy, a factor closely related to general decision making skill and risk literacy.

METHODS

About 5 days after experiencing ACS, 102 survivors (mean age = 58, 32-74) completed a questionnaire including measures of numeracy, decision delay, and other relevant factors (e.g., anxiety, depression, symptom severity, knowledge, demographics).

RESULTS

Low patient numeracy was related to longer decision delay, OR = 0.64 [95 % confidence interval (CI) 0.44, 0.92], which was in turn related to higher odds of positive troponin on arrival at the hospital, OR = 1.37 [95 % CI 1.01, 2.01]. Independent of the influence of all other assessed factors, a patient with high (vs. low) numeracy was about four times more likely to seek medical attention within the critical first hour after symptom onset (i.e., OR_high-low = 3.84 [1.127, 11.65]).

CONCLUSIONS

Numeracy may be one of the largest decision delay risk factors identified to date. Results accord with theories emphasizing potentially pivotal roles of patient deliberation, denial, and outcome understanding during decision making. Findings suggest that brief numeracy assessments may predict which patients are at greater risk for life-threatening decision delay and may also facilitate the design of risk communications that are appropriate for diverse patients who vary in risk literacy.

Graphics help patients distinguish between urgent and non-urgent deviations in laboratory test results

Objective: Most electronic health record systems provide laboratory test results to patients in table format. We tested whether presenting such results in visual displays (number lines) could improve understanding.

Materials and Methods: We presented 1620 adults recruited from a demographically diverse Internet panel with hypothetical results from several common laboratory tests, first showing near-normal results and then more extreme values. Participants viewed results in either table format (with a “standard range” provided) or one of 3 number line formats: a simple 2-color format, a format with diagnostic categories such as “borderline high” indicated by colored blocks, and a gradient format that used color gradients to smoothly represent increasing risk as values deviated from standard ranges. We measured respondents’ subjective sense of urgency about each test result, their behavioral intentions, and their perceptions of the display format.

Results: Visual displays reduced respondents’ perceived urgency and desire to contact health care providers immediately for near-normal test results compared to tables but did not affect their perceptions of extreme values. In regression analyses controlling for respondent health literacy, numeracy, and graphical literacy, gradient line displays resulted in the greatest sensitivity to changes in test results.

Discussion: Unlike tables, which only tell patients whether test results are normal or not, visual displays can increase the meaningfulness of test results by clearly defining possible values and leveraging color cues and evaluative labels.

Conclusion: Patient-facing displays of laboratory test results should use visual displays rather than tables to increase people’s sensitivity to variations in their results.

Information Mismatch: Cancer Risk Counseling with Diverse Underserved Patients

As genetics and genomics become part of mainstream Medicine, these advances have the potential to reduce or exacerbate health disparities. Gaps in effective communication (where all parties share the same meaning) are widely recognized as a major contributor to health disparities. The purpose of this study was to examine GC-patient communication in real time, to assess its effectiveness from the patient perspective, and then to pilot intervention strategies to improve the communication. We observed 64 English-, 35 Spanish- and 25 Chinese-speaking (n = 124) public hospital patients and 10 GCs in 170 GC appointments, and interviewed 49 patients who were offered testing using the audio recordings to stimulate recall and probe specific aspects of the communication. Data analyses were conducted using grounded theory methods and revealed a fundamental mismatch between the information provided by GCs and the information desired and meaningful to patients. Several components of the communication that contributed to this mismatch and often resulted in ineffective communication included: (1) too much information; (2) complex terminology and conceptually difficult presentation of information; (3) information perceived as not relevant by the patient; (4) unintentional inhibition of patient engagement and question-asking; (5) vague discussions of screening and prevention recommendations. Our findings indicate a need to transform the standard model of genetic counseling communication using evidence-based principles and strategies from other fields of Medicine. The high rates of limited health literacy in the US, increasing access of diverse populations to genetic services, and growing complexity of genetic information have created a perfect storm. If not directly addressed, this convergence is likely to exacerbate health disparities in the genomic age.

Tablet-Based Patient-Centered Decision Support for Minor Head Injury in the Emergency Department: Pilot Study

BACKGROUND

The Concussion or Brain Bleed app is a clinician- and patient-facing electronic tool to guide decisions about head computed tomography (CT) use in patients presenting to the emergency department (ED) with minor head injury. This app integrates a patient decision aid and clinical decision support (using the Canadian CT Head Rule, CCHR) at the bedside on a tablet computer to promote conversations around individualized risk and patients' specific concerns within the ED context.

OBJECTIVE

The objective of this study was to describe the use of the Concussion or Brain Bleed app in a high-volume ED and to establish preliminary efficacy estimates on patient experience, clinician experience, health care utilization, and patient safety. These data will guide the planning of a larger multicenter trial testing the effectiveness of the Concussion or Brain Bleed app.

METHODS

We conducted a prospective pilot study of adult (age 18-65 years) patients presenting to the ED after minor head injury who were identified by participating clinicians as low risk by the CCHR. The primary outcome was patient knowledge regarding the injury, risks, and CT use. Secondary outcomes included patient satisfaction, decisional conflict, trust in physician, clinician acceptability, system usability, Net Promoter scores, head CT rate, and patient safety at 7 days.

RESULTS

We enrolled 41 patients cared for by 29 different clinicians. Patient knowledge increased after the use of the app (questions correct out of 9: pre-encounter, 3.3 vs postencounter, 4.7; mean difference 1.4, 95% CI 0.8-2.0). Patients reported a mean of 11.7 (SD 13.5) on the Decisional Conflict Scale and 92.5 (SD 12.0) in the Trust in Physician Scale (both scales range from 0 to 100). Most patients were satisfied with the app's clarity of information (35, 85%), helpfulness of information (36, 88%), and amount of information (36, 88%). In the 41 encounters, most clinicians thought the information was somewhat or extremely helpful to the patient (35, 85%), would want to use something similar for other decisions (27, 66%), and would recommend the app to other providers (28, 68%). Clinicians reported a mean system usability score of 85.1 (SD 15; scale from 0 to 100 with 85 in the "excellent" acceptability range). The total Net Promoter Score was 36.6 (on a scale from -100 to 100). A total of 7 (17%) patients received a head CT in the ED. No patients had a missed clinically important brain injury at 7 days.

CONCLUSIONS

An app to help patients assess the utility of CT imaging after head injury in the ED increased patient knowledge. Nearly all clinicians reported the app to be helpful to patients. The high degree of patient satisfaction, clinician acceptability, and system usability support rigorous testing of the app in a larger multicenter trial.

Design for the Illiterate: A Scoping Review of Tools for Improving the Health Literacy of Electronic Health Resources

Nearly 1 in 5 people living in the United States cannot read at even a basic level, a condition which greatly affects health outcomes. Despite this, most electronic health resources are reliant not only on text, but on complex reading and text manipulation that may result in poorer outcomes and reduced usage by patients with reduced literacy. This paper aims to synthesize findings and best practices across health literacy research, product design and games for health to support the development of electronic health resources which are less reliant on text to communicate health information. This synthesis involves the implantation of visual means of communication, as well as leveraging the strengths of planned interactions modeled after patient-caregiver communication. Through adopting these techniques, it is hoped that the concept of a health-literate system of healthcare can be extend from direct care settings and into the electronic design space.

Toward Meaningful Care Plan Clinical Decision Support: Feasibility and Effects of a Simulated Pilot Study

BACKGROUND

Clinical decision support (CDS) tools-with easily understood and actionable information, at the point of care-are needed to help registered nurses (RNs) make evidence-based decisions. Not clear are the optimal formats of CDS tools. Thorough, preclinical testing is desirable to avoid costly errors associated with premature implementation in electronic health records.

OBJECTIVE

The aims of this study were to determine feasibility of the protocol designed to compare multiple CDS formats and evaluate effects of numeracy and graph literacy on RN adoption of best practices and care planning time in a simulated environment.

METHODS

In this pilot study, 60 RNs were randomly assigned to one of four CDS conditions (control, text, text + graph, and text + table) and asked to adjust the plan of care for two patient scenarios over three shifts. Fourteen best practices were identified for the two patients and sent as suggestions with evidence to the three CDS groups. Best practice adoption rates, care planning time, and their relationship to the RN's numeracy and graph literacy scores were assessed.

RESULTS

CDS groups had a higher adoption rate of best practices (p < .001) across all shifts and decreased care planning time in shifts 2 (p = .01) and 3 (p = .02) compared with the control group. Higher numeracy and graph literacy were associated with shorter care planning times under text + table (p = .05) and text + graph (p = .01) conditions. No significant differences were found between the three CDS groups on adoption rate and care planning time.

DISCUSSION

This pilot study shows the feasibility of our protocol. Findings show preliminary evidence that CDS improves the efficiency and effectiveness of care planning decisions and that the optimal format may depend on individual RN characteristics. We recommend a study with sufficient power to compare different CDS formats and assess the impact of potential covariates on adoption rates and care planning time.

Decision aid use during post-biopsy consultations for localized prostate cancer

BACKGROUND

Decision Aids (DAs) effectively translate medical evidence for patients but are not routinely used in clinical practice. Little is known about how DAs are used during patient-clinician encounters.

OBJECTIVE

To characterize the content and communicative function of high-quality DAs during diagnostic clinic visits for prostate cancer.

PARTICIPANTS

252 men newly diagnosed with localized prostate cancer who had received a DA, 45 treating physicians at 4 US Veterans Administration urology clinics.

METHODS

Qualitative analysis of transcribed audio recordings was used to inductively develop categories capturing content and function of all direct references to DAs (booklet talk). The presence or absence of any booklet talk per transcript was also calculated.

RESULTS

Booklet talk occurred in 55% of transcripts. Content focused on surgical procedures (36%); treatment choice (22%); and clarifying risk classification (17%). The most common function of booklet talk was patient corroboration of physicians' explanations (42%), followed by either physician or patient acknowledgement that the patient had the booklet. Codes reflected the absence of DA use for shared decision-making. In regression analysis, predictors of booklet talk were fewer years of patient education (P = .027) and more time in the encounter (P = .027). Patient race, DA type, time reading the DA, physician informing quality and physician age did not predict booklet talk.

CONCLUSIONS

Results show that good decision aids, systematically provided to patients, appeared to function not to open up deliberations about how to balance benefits and harms of competing treatments, but rather to allow patients to ask narrow technical questions about recommended treatments.