Helping Doctors and Patients Make Sense of Health Statistics

Development, implementation, and evaluation of a curriculum for medical students on conflicts of interest and communicating risk

Background: Insufficient risk competence of physicians, conflicts of interests from interactions with pharmaceutical companies, and the often distorted presentation of benefits and risks of therapies compromise the advising of patients by physicians in the framework of shared decision-making. An important cause of this is that teaching on this subject is mostly lacking, or fragmented when it does take place [1], [2], [3], [4]. Even though the German National Competence-Based Catalog of Learning Goals in Medicine defines learning goals on the topics of conflicts of interest and communication of risk, there are no classes that integrate both topics. Our goal was to develop a model curriculum to teach conflicts of interest and communication of risk that would integrate statistical know-how, communicational competency on the presentation of benefits and risks, and the meaning and management of conflicts of interest. Project Description: The development of the curriculum took place according to the six-step cycle of Kern et al [5]. An integrated curriculum was conceptualized, piloted, and adapted with the support of experts for the topics of shared decision-making, conflicts of interest, and communication of risk. The final version of the curriculum was implemented at the medical schools of Mainz and Heidelberg and evaluated by the students. Results: The final curriculum consists of 19 lesson units. The contents are the fundamentals of statistics, theory of risk communication, practical exercises on communication of risk, and the fundamentals of the mechanisms of effect of conflicts of interest, recognition of distortions in data, and introductions to professional management of conflicts of interest. The course was implemented three times at two different medical schools with a total of 32 students, and it was positively rated by most of the 27 participating students who evaluated it on the 1-6 German school grading scale (mean: 1.4; SD: 0.49; range: 1-2). Discussion: The curriculum we developed fills a gap in the current medical education. The innovative concept, which sensibly connects the transmission of theory and practice, was positively received by the students. The next steps are an evaluation of the curriculum by means of a two-center randomized study and the implementation at German and international medical schools. The process should be accompanied by continuous evaluation and further improvement.

Understanding Health Risk Comprehension: The Role of Math Anxiety, Subjective Numeracy, and Objective Numeracy

Background. Numeracy skills are important for medical decision making as lower numeracy is associated with misinterpreting statistical health risks. Math anxiety, characterized by negative emotions about numerical tasks, and lower subjective numeracy (i.e., self-assessments of numerical competence) are also associated with poor risk comprehension. Objective. To explore independent and mediated associations of math anxiety, numerical ability, and subjective numeracy with risk comprehension and to ascertain whether their associations are specific to the health domain. Methods. Objective numeracy was measured with a 14-item test. Math anxiety and subjective numeracy were assessed with self-report scales. Risk comprehension was measured with a 12-item test. In experiment 1, risk comprehension items were limited to scenarios in the health domain. In experiment 2, participants were randomly assigned to receive numerically equivalent risk comprehension items in either a health or nonhealth domain. Results. Linear regression analyses revealed that individuals with higher objective numeracy were more likely to respond correctly to the risk comprehension items, as were individuals with higher subjective numeracy. Higher math anxiety was associated with a lower likelihood of correct responding when controlling for objective numeracy but not when controlling for subjective numeracy. Mediation analyses indicated that math anxiety may undermine risk comprehension in 3 ways, including through 1) objective numeracy, 2) subjective numeracy, and 3) objective and subjective numeracy in serial, with subjective numeracy mediating the association between objective numeracy and risk comprehension. Findings did not differ by domain. Conclusions. Math anxiety, objective numeracy, and subjective numeracy are associated with risk comprehension through unique pathways. Education initiatives for improving health risk comprehension may be most effective if jointly aimed at tackling numerical ability as well as negative emotions and self-evaluations related to numeracy.

When Does the Incremental Risk Format Aid Informed Medical Decisions? The Role of Learning, Feedback, and Number of Treatment Options

Background. Informed medical decisions require understanding the benefits and risks of treatments. This entails comparing treatment outcomes to a control group. The incremental risk format has been recommended as it directly visualizes the differences between treatment and control group in 1 graph, whereas they have to be calculated from 2 separate graphs in the total risk format. We investigated when the incremental risk format aids understanding. Methods. In 2 experiments, participants received information about medical treatments, either as incremental or total risk format. We assessed verbatim knowledge (precise quantitative knowledge), gist knowledge (knowledge of essential meaning), and evaluations of the formats. Study 1 (N = 99) consisted of only 1 trial with medical information and also assessed recall. Study 2 (N = 222) assessed learning across multiple trials and also varied the presence of feedback and the number of treatment options. Results. In study 1, the incremental risk format (v. total risk format) led to worse knowledge, recall, and evaluations. In study 2, participants learned to understand the incremental risk format over time, resulting in comparable verbatim knowledge and evaluations as in the total risk format, as well as in even better gist knowledge. Feedback and number of treatment options did not moderate the effect of risk format. Limitations. The studies were conducted with nonpatient samples, and study 2 employed hypothetical treatments. Conclusions. The incremental risk format was initially less understandable than the total risk format. After a short learning period, however, the incremental risk format resulted in better gist knowledge and was comparable otherwise, which suggests that participants had to get used to that format. This has important implications for the study of new formats.

Comprehensive survey among statistical members of medical ethics committees in Germany on their personal impression of completeness and correctness of biostatistical aspects of submitted study protocols

OBJECTIVES

To assess biostatistical quality of study protocols submitted to German medical ethics committees according to personal appraisal of their statistical members.

DESIGN

We conducted a web-based survey among biostatisticians who have been active as members in German medical ethics committees during the past 3 years.

SETTING

The study population was identified by a comprehensive web search on websites of German medical ethics committees.

PARTICIPANTS

The final list comprised 86 eligible persons. In total, 57 (66%) completed the survey.

QUESTIONNAIRE

The first item checked whether the inclusion criterion was met. The last item assessed satisfaction with the survey. Four items aimed to characterise the medical ethics committee in terms of type and location, one item asked for the urgency of biostatistical training addressed to the medical investigators. The main 2×12 items reported an individual assessment of the quality of biostatistical aspects in the submitted study protocols, while distinguishing studies according to the German Medicines Act (AMG)/German Act on Medical Devices (MPG) and studies non-regulated by these laws.

PRIMARY AND SECONDARY OUTCOME MEASURES

The individual assessment of the quality of biostatistical aspects corresponds to the primary objective. Thus, participants were asked to complete the sentence 'In x% of the submitted study protocols, the following problem occurs', where 12 different statistical problems were formulated. All other items assess secondary endpoints.

RESULTS

For all biostatistical aspects, 45 of 49 (91.8%) participants judged the quality of AMG/MPG study protocols much better than that of 'non-regulated' studies. The latter are in median affected 20%-60% more often by statistical problems. The highest need for training was reported for sample size calculation, missing values and multiple comparison procedures.

CONCLUSIONS

Biostatisticians being active in German medical ethics committees classify the biostatistical quality of study protocols as low for 'non-regulated' studies, whereas quality is much better for AMG/MPG studies.

Teaching Conflicts of Interest and Shared Decision-Making to Improve Risk Communication: a Randomized Controlled Trial

BACKGROUND

Risk communication is a core aspect of a physician's work and a fundamental prerequisite for successful shared decision-making. However, many physicians are not able to adequately communicate risks to patients due to a lack of understanding of statistics as well as inadequate management of conflicts of interest (COI).

OBJECTIVE

To evaluate the effects of an integrated curriculum encompassing COI and shared decision-making on the participants' risk communication competence, that is, their competence to advise patients on the benefits and harms of diagnostic or therapeutic interventions.

DESIGN

A rater-blind randomized controlled trial with a 30 (± 1)-week follow-up conducted from October 2016 to June 2017 at two German academic medical centers.

PARTICIPANTS

Sixty-three medical students in their fourth or fifth year.

INTERVENTIONS

Participants received either a newly developed 15-h curriculum or a course manual adapted from teaching as usual.

MAIN MEASURES

Primary outcome: change in risk communication performance in a video-observed structured clinical examination (VOSCE).

KEY RESULTS

Participants were 25.7 years old on average (SD 3.6); 73% (46/63) were female. Increase in risk communication performance was significantly higher in the intervention group with post-intervention Cohen's d of 2.35 (95% confidence interval (CI) 1.62 to 3.01, p < 0.01) and of 1.83 (CI 1.13 to 2.47, p < 0.01) 30 (± 1) weeks later. Secondary outcomes with the exception of frequency of interactions with the pharmaceutical industry also showed relevant improvements in the intervention as compared with the control group (d between 0.91 and 2.04 (p < 0.001)).

CONCLUSIONS

Our results show that an integrated curriculum encompassing COI and risk communication leads to a large and sustainable increase in risk communication performance. We interpret the large effect sizes to be a result of the integration of topics that are usually taught separately, leading to a more effective organization of knowledge.

TRIAL REGISTRATION

The trial is registered in the International Clinical Trials Registry with the trial number DRKS00010890.

Communicating cancer risk in the primary care consultation when using a cancer risk assessment tool: Qualitative study with service users and practitioners

Background

Cancer risk assessment tools are designed to help detect cancer risk in symptomatic individuals presenting to primary care. An early detection of cancer risk could mean early referral for investigations, diagnosis and treatment, helping to address late diagnosis of cancer. It is not clear how best cancer risk may be communicated to patients when using a cancer risk assessment tool to assess their risk of developing cancer.

Objective

We aimed to explore the perspectives of service users and primary care practitioners on communicating cancer risk information to patients, when using QCancer, a cancer risk assessment tool.

Design

A qualitative study involving the use of individual interviews and focus groups.

Setting and participants

Conducted in primary care settings in Lincolnshire with a convenience sample of 36 participants (19 service users who were members of the public) and 17 primary care practitioners (general practitioners and practice nurses).

Results

Participants suggested ways to improve communication of cancer risk information: personalizing risk information; involving patients in use of the tool; sharing risk information openly; and providing sufficient time when using the tool during consultations.

Conclusion

Communication of cancer risk information is complex and difficult. We identified strategies for improving communication with patients involving cancer risk estimations in primary care consultations.

Is it really always only the others who are to blame? GP's view on medical overuse. A questionnaire study

BACKGROUND

Medical overuse is a common problem in health care. Preventing unnecessary medicine is one of the main tasks of General Practice, so called quaternary prevention. We aimed to capture the current opinion of German General Practitioners (GPs) to medical overuse.

METHODS

A quantitative online study was conducted. The questionnaire was developed based on a qualitative study and literature search. GPs were asked to estimate prevalence of medical overuse as well as to evaluate drivers and solutions of medical overuse. GPs in Bavaria were recruited via email (750 addresses). A descriptive data analysis was performed. Additionally the association between doctors' attitudes and (1) demographic variables and (2) interest in campaigns against medical overuse was assessed.

RESULTS

Response rate was 18%. The mean age was 54 years, 79% were male and 68% have worked as GP longer than 15 years. Around 38% of medical services were considered as medical overuse and nearly half of the GPs (47%) judged medical overuse to be the more important problem than medical underuse. Main drivers were seen in "patients´ expectations" (76%), "lack of a primary care system" (61%) and "defensive medicine" (53%), whereas "disregard of evidence/guidelines" (15%) and "economic pressure on the side of the doctor" (13%) were not weighted as important causes. Demographic variables did not have an important impact on GPs´ response pattern. GPs interested in campaigns like "Choosing Wisely" showed a higher awareness for medical overuse, although these campaigns were only known by 50% of the respondents.

DISCUSSION

Medical overuse is an important issue for GPs. Main drivers were searched and found outside their own sphere of responsibility. Campaigns as "Choosing Wisely" seem to have a positive effect on GPs attitude, but knowledge is still limited.

Patients' Experiences of Cardiovascular Health Education and Risk Communication: A Qualitative Synthesis

Coronary heart disease (CHD) has no cure, and patients with myocardial infarction are at high risk for further cardiac events. Health education is a key driver for patients' understanding and motivation for lifestyle change, but little is known about patients' experience of such education. In this review, we aimed to explore how patients with CHD experience health education and in particular risk communication. A total of 2,221 articles were identified through a systematic search in five databases. 40 articles were included and synthesized using thematic analysis. Findings show that both "what" was communicated, and "the way" it was communicated, had the potential to influence patients' engagement with lifestyle changes. Communication about the potential of lifestyle change to reduce future risk was largely missing causing uncertainty, anxiety, and, for some, disengagement with lifestyle change. Recommendations for ways to improve health education and risk communication are discussed to inform international practice.

Do Preferred Risk Formats Lead to Better Understanding? A Multicenter Controlled Trial on Communicating Familial Breast Cancer Risks Using Different Risk Formats

PURPOSE

Counselees' preferences are considered important for the choice of risk communication format and for improving patient-centered care. We here report on counselees' preferences for how risks are presented in familial breast cancer counseling and the impact of this preferred format on their understanding of risk.

PATIENTS AND METHODS

As part of a practice-based randomized controlled trial, 326 unaffected women with a family history of breast cancer received their lifetime risk in one of five presentation formats after standard genetic counseling in three Dutch familial cancer clinics: 1) in percentages, 2) in frequencies ("X out of 100"), 3) in frequencies plus graphical format (10×10 human icons), 4) in frequencies and 10-year age-related risk and 5) in frequencies and 10-year age-related risk plus graphical format. Format preferences and risk understanding (accuracy) were assessed at 2-week follow-up by a questionnaire, completed by 279/326 women.

RESULTS

The most preferred risk communication formats were numbers combined with verbal descriptions (37%) and numbers only (26%). Of the numerical formats, most (55%) women preferred percentages. The majority (73%) preferred to be informed about both lifetime and 10-year age-related risk. Women who had received a graphical display were more likely to choose a graphical display as their preferred format. There was no significant effect between the intervention groups with regard to risk accuracy. Overall, women given risk estimates in their preferred format had a slightly better understanding of risk.

CONCLUSION

The results suggest that the accuracy of breast cancer risk estimation is slightly better for women who had received this information in their preferred format, but the risk format used had no effect on women's risk accuracy. To meet the most frequent preference, counselors should consider providing a time frame of reference (eg, risk in the next 10 years) in a numerical format, in addition to lifetime risk.

Medical graduate views on statistical learning needs for clinical practice: a comprehensive survey

BACKGROUND

This paper seeks to contribute to a reputable evidence base for required competencies across different topics in statistics and probability (statistical topics) in preparing medical graduates for clinical practice. This is in order to inform the prioritization of statistical topics within future undergraduate medical curricula, while exploring the need for preparing tomorrow's doctors to be producers, and not merely consumers, of statistics.

METHODS

We conducted a comprehensive online survey from July 2013 to August 2014 for a target group of 462 medical graduates with current or prior experience of teaching undergraduate medical students of the University of Edinburgh of whom 278 (60.2%) responded. Statistical topics were ranked by proportion of respondents who identified the practice of statistics, performing statistical procedures or calculations using appropriate data, as a required competency for medical schools to provide in preparing undergraduate medical students for clinical practice. Mixed effects analyses were used to identify potential predictors for selection of the above competency and to compare the likelihood of this selection for a range of statistical topics versus critical appraisal.

RESULTS

Evidence was gleaned from medical graduates' experiences of clinical practice for the need for, not only a theoretical understanding of statistics and probability but also, the ability to practice statistics. Nature of employment and statistical topic were highly significant predictors of choice of the practice of statistics as a required competency ((F = 3.777, p < 0.0005) and (F = 45.834, p < 0.0005), respectively). The most popular topic for this competency was graphical presentation of data (84.3% of respondents) in contrast to cross-over trials for the competency understanding the theory only (70.5% of respondents). Several topics were found to be more popular than critical appraisal for competency in the practice of statistics.

CONCLUSIONS

The model of medical graduates as mere consumers of statistics is oversimplified. Contrary to what has been suggested elsewhere, statistical learning opportunities in undergraduate medicine should not be restricted to development of critical appraisal skills. Indeed, our findings support development of learning opportunities for undergraduate medical students as producers of statistics across a wide range of statistical topics.

Public Health and Online Misinformation: Challenges and Recommendations

The internet has become a popular resource to learn about health and to investigate one's own health condition. However, given the large amount of inaccurate information online, people can easily become misinformed. Individuals have always obtained information from outside the formal health care system, so how has the internet changed people's engagement with health information? This review explores how individuals interact with health misinformation online, whether it be through search, user-generated content, or mobile apps. We discuss whether personal access to information is helping or hindering health outcomes and how the perceived trustworthiness of the institutions communicating health has changed over time. To conclude, we propose several constructive strategies for improving the online information ecosystem. Misinformation concerning health has particularly severe consequences with regard to people's quality of life and even their risk of mortality; therefore, understanding it within today's modern context is an extremely important task.

Reference frame and emotions may contribute to discrepancies in patient and clinician risk estimates in Long QT syndrome

OBJECTIVE

Patients and clinicians need to have similar understandings of cardiac risk, so patients can make informed decisions. The aim of this study was to assess the concordance of risk estimates between Long-QT-Syndrome (LQTS) patients and an experienced clinician.

METHODS

This cross-sectional study included 86 LQTS patients recruited from a clinical registry. Participants completed two questions on their risk of cardiac arrest; likelihood (1=very-unlikely to 5=very-likely), and chance (%), and an experienced clinician computed the same based on risk factors.

RESULTS

30% and 55% of patients had concordant perceptions with the clinician estimate on the chance and likelihood questions respectively. The patients who overestimated their risk (%) had significantly greater emotional responses and concerns about their LQTS. 22 (29%) patients reported a risk of 50% or greater, in contrast to the clinician's risk estimates not exceeding 30%.

CONCLUSION

Many LQTS patients had discordant risk perceptions to the clinician's. Patients and clinicians may have different frames of reference, and patients' estimates are linked with emotions.

PRACTICAL IMPLICATIONS

Clinicians need to take into account LQTS patients' different frame of reference when discussing risk information. This will support shared decision making.

Preferences regarding the way of use and design of a work ability prognosis support tool: a focus group study among professionals

PURPOSE

To explore the preferable way of use and design of a work ability prognosis support tool for insurance physicians (IPs) and labour experts (LEs), based on a prediction model for future changes in work ability among individuals applying for a work disability benefit.

METHODS

We conducted three focus groups with professionals of the Dutch Social Security Institute (17 IPs and 7 LEs). Data were audio recorded and qualitatively analysed according to the main principles of thematic analysis.

RESULTS

Clarity and ease of use were mentioned as important features of the tool. Most professionals preferred to make their own judgement during the work disability assessment interview with the claimant and afterwards verify their evaluation with the tool. Concerning preferences on the design of the tool, dividing work disability claimants into categories based on the outcome of the prediction model was experienced as the most straightforward and clear way of presenting the results. Professionals expected that this encourages them to use the tool and act accordingly.

CONCLUSIONS

The tool should be easy to access and interpret, to increase the chance that professionals will use it. This way it can optimally help professionals making accurate prognoses of future changes in work ability.Implications for rehabilitationA work ability prognosis support tool based on a prediction model for changes in work ability at one-year follow-up can help occupational health professionals in making accurate prognosis of individuals applying for a work disability benefit.To be used in occupational health practice, these tools should have a simple and easy-to-use design.Graphical risk presentation can be used to provide intuitive meaning to numerical information and support users' understanding.Taking professionals' preferences into account when developing these tools encourages professionals to use the tools and act accordingly.

How confident are medical students about making clinical decisions relying on the evidence? A cross-sectional questionnaire study

Objective: Giving information and providing advice on diagnostic tests is one of the tasks physicians must carry out personally. To do so, they must evaluate the evidence and integrate their findings into everyday practice. Clinical decisions should be based on evidence. How well current medical education prepares for such evidence-based clinical decision-making is largely unclear. Therefore, it was examined how confident medical students are in clinical decision-making based on evidence using epidemiological data. It was examined whether the decision-making confidence increases the higher the semester. Further questions were whether scientifically active medical students show higher decision-making confidence and whether the representation of figures as pictograms rather than tables positively influences the decision-making confidence. Methods: An online survey of the medical students of the Friedrich-Alexander-University Erlangen-Nürnberg was carried out. Respondents were presented with three clinical decision-making situations in random order for evaluation in the form of screening scenarios. In each case, the decision-making confidence also had to be specified. The scenarios contained only epidemiological data on existing screening tests. For each scenario, the numbers were presented as a table or a pictogram in a random fashion. In order to avoid false confidence resulting from preconceived opinions neither the illnesses nor the screening tests were mentioned by name. Results: Answers from 171 students were evaluated. Decision-making confidence in dealing with the numbers does not increase in higher semesters (r_Pearson =0.018, p=0.41). Scientific work is not associated with a higher decision-making confidence (t(169)=-1.26, p=0.11, d=-0.19). Presentation as a pictogram leads to a higher decision-making confidence compared to tables (Pictogram: M=2.33, SD=1.07, Table with numbers: M=2.64, SD=1.11, t(511)=3.21, p<0.01, d=0.28). Conclusions: Medical students from higher semesters show no higher decision-making confidence compared to medical students from lower semesters. Curricular events and scientific work, such as a doctoral thesis, do not seem to strengthen the required skills sufficiently. If evidence is presented in the form of pictograms, this seems to improve student confidence in decision-making.

Communication on the Science-Policy Interface: An Overview of Conceptual Models

This article focuses on scholarly discourse on the science-policy interface, and in particular on questions regarding how this discourse can be understood in the course of history and which lessons we can learn. We aim to structure the discourse, show kinships of different concepts, and contextualize these concepts. For the twentieth century we identify three major phases that describe interactions on the science policy interface: the “linear phase” (1960s–1970s) when science informed policy-making in a unidirectional manner, the “interactive phase” (1970–2000s) when both sides found themselves in a continuous interaction, and the “embedded phase” (starting from the 2000s) when citizens’ voices come to be involved within this dialogue more explicitly. We show that the communicative relationship between science and policy-making has become more complex over time with an increasing number of actors involved. We argue that better skill-building and education can help to improve communication within the science-policy interface.

Effects of apixaban compared with warfarin as gain in event-free time - a novel assessment of the results of the ARISTOTLE trial

BACKGROUND

A novel approach to determine the effect of a treatment is to calculate the delay of event, which estimates the gain of event-free time. The aim of this study was to estimate gains in event-free time for stroke or systemic embolism, death, bleeding events, and the composite of these events, in patients with atrial fibrillation randomized to either warfarin or apixaban in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial (ARISTOTLE).

DESIGN

The ARISTOTLE study was a randomized double-blind trial comparing apixaban with warfarin.

METHODS

Laplace regression was used to estimate the delay in time to the outcomes between the apixaban and the warfarin group in 6, 12, 18 and 22 months of follow-up.

RESULTS

The gain in event-free time for apixaban versus warfarin was 181 (95% confidence interval 76 to 287) days for stroke or systemic embolism and 55 (-4 to 114) days for death after 22 months of follow-up. The corresponding gains in event-free times for major and intracranial bleeding were 206 (130 to 281) and 392 (249 to 535) days, respectively. The overall gain for the composite of all these events was a gain of 116 (60 to 171) days.

CONCLUSIONS

In patients with atrial fibrillation, 22 months of treatment with apixaban, as compared with warfarin, provided gains of approximately 6 months in event-free time for stroke or systemic embolism, 7 months for major bleeding and 13 months for intracranial bleeding.

GRADE guidelines 27: how to calculate absolute effects for time-to-event outcomes in summary of findings tables and Evidence Profiles

OBJECTIVES

To provide GRADE guidance on how to prepare Summary of Findings tables and Evidence Profiles for time-to-event outcomes with a focus on the calculation of the corresponding absolute effect estimates.

STUDY DESIGN AND SETTING

This guidance was justified by a research project identifying frequent errors and limitations in the presentation of time-to-event outcomes in the Summary of Findings tables. We developed this guidance through an iterative process that included membership consultation, feedback, presentation, and discussion at meetings of the GRADE Working Group.

RESULTS

Review authors need to carefully consider the definition of the outcome of interest; although often the event is used as label for the outcome of interest (e.g., death or mortality), the event-free survival (e.g., overall survival) is reported throughout individual studies. Review authors should calculate the absolute effect correctly, either for the event or absence of the event. We also provide examples on how to calculate the absolute effects for events and the absence of events for various baseline or control group risks and time points.

CONCLUSIONS

This article aids in the development of Summary of Findings tables and Evidence Profiles, including time-to-event outcomes, and addresses the most common scenarios when calculating absolute effects in order to provide an accurate interpretation.

Medical Students' Knowledge and Attitudes Toward Shared Decision Making: Results From a Multinational, Cross-Sectional Survey

Introduction. We aimed to conduct a multinational cross-sectional online survey of medical students' attitudes toward, knowledge of, and experience with shared decision making (SDM). Methods. We conducted the survey from September 2016 until May 2017 using the following: 1) a convenience sample of students from four medical schools each in Canada, the United States, and the Netherlands (n = 12), and 2) all medical schools in the United Kingdom through the British Medical School Council (n = 32). We also distributed the survey through social media. Results. A total of 765 students read the information sheet and 619 completed the survey. Average age was 24, 69% were female. Mean SDM knowledge score was 83.6% (range = 18.8% to 100%; 95% confidence interval [CI] = 82.8% to 84.5%). US students had the highest knowledge scores (86.2%, 95% CI = 84.8% to 87.6%). The mean risk communication score was 57.4% (range = 0% to 100%; 95% CI = 57.4% to 60.1%). Knowledge did not vary with age, race, gender, school, or school year. Attitudes were positive, except 46% believed SDM could only be done with higher educated patients, and 80.9% disagreed that physician payment should be linked to SDM performance (increased with years in training, P < 0.05). Attitudes did not vary due to any tested variable. Students indicated they were more likely than experienced clinicians to practice SDM (72.1% v. 48.8%). A total of 74.7% reported prior SDM training and 82.8% were interested in learning more about SDM. Discussion. SDM knowledge is high among medical students in all four countries. Risk communication is less well understood. Attitudes indicate that further research is needed to understand how medical schools deliver and integrate SDM training into existing curricula.

Heuristics for designing user-centric drug products: Lessons learned from Human Factors and Ergonomics

Even the most effective drug product may be used improperly and thus ultimately prove ineffective if it does not meet the perceptual, motor and cognitive capacities of its target users. Currently, no comprehensive guideline for systematically designing user‐centric drug products that would help prevent such limitations exists. We have compiled a list of approximate but nonetheless useful strategies—heuristics—for implementing a user‐centric design of drug products and drug product portfolios. First, we present a general heuristic for user‐centric design based on the framework of Human Factors and Ergonomics (HF/E). Then we demonstrate how to implement this general heuristic for older drug users (i.e., patients and caregivers aged 65 years and older) and with respect to three specific challenges (use‐cases) of medication management: (A) knowing what drug product to take/administer, (B) knowing how and when to take/administer it, and (C) actually taking/administering it. The presented heuristics can be applied prospectively to include existing knowledge about user‐centric design at every step during drug discovery, pharmaceutical drug development, and pre‐clinical and clinical trials. After a product has been released to the market, the heuristics may guide a retrospective analysis of medication errors and barriers to product usage as a basis for iteratively optimizing both the drug product and its portfolio over their life cycle.

How is cervical cancer screening information communicated in UK websites? Cross-sectional analysis of content and quantitative presentation formats

OBJECTIVES

To investigate whether UK websites about cervical cancer screening targeted to the public include (1) information about benefits and risks of screening, possible screening results and cervical cancer statistics, (2) quantitative presentation formats recommended in the risk communication literature and (3) appeals for participation and/or informed decision-making.

DESIGN

Cross-sectional analysis of websites using a comprehensive checklist of information items on screening benefits, risks, possible results and cervical cancer statistics.

OUTCOME MEASURES

We recorded the number of websites that contained each of the information items, and the presentation format used for probabilistic information (no quantification provided, verbal quantifiers only, different types of numerical formats and/or graphs). We also recorded the number of websites containing appeals for participation and/or informed decision-making.

SETTING

Websites were identified through the most common Google search terms used in the UK to find information on cervical screening, according to GoogleTrends and a commercial internet-monitoring programme. Two additional websites were identified by the authors as relevant.

RESULTS

After applying exclusion criteria, 14 websites were evaluated, including websites of public and private health service providers, charities, a medical society and a pharmacy. The websites mentioned different benefits, risks of screening and possible results. However, specific content varied between websites. Probabilistic information was often presented using non-recommended formats, including relative risk reductions to express screening benefits, and verbal quantifiers without numbers to express risks. Appeals for participation were present in most websites, with almost half also mentioning informed decision-making.

CONCLUSIONS

UK websites about cervical cancer screening were generally balanced. However, benefits and risks were presented using different formats, potentially hindering comparisons. Additionally, recommendations from the literature to facilitate understanding of quantitative information and facilitate informed decisions were often not followed. Designing websites that adhere to existing recommendations may support informed screening uptake.

Benefits and harms of selective oestrogen receptor modulators (SERMs) to reduce breast cancer risk: a cross-sectional study of methods to communicate risk in primary care

BACKGROUND

In Australia, evidence-based guidelines recommend that women consider taking selective oestrogen receptor modulators (SERMs) to reduce their risk of breast cancer. In practice, this requires effective methods for communicating the harms and benefits of taking SERMs so women can make an informed choice.

AIM

To evaluate how different risk presentations influence women's decisions to consider taking SERMs.

DESIGN AND SETTING

Cross-sectional, correlational study of Australian women in general practice.

METHOD

Three risk communication formats were developed that included graphics, numbers, and text to explain the reduction in breast cancer risk and risk of side effects for women taking SERMs (raloxifene or tamoxifen). Women aged 40-74 years in two general practices were shown the risk formats using vignettes of hypothetical women at moderate or high risk of breast cancer and asked to choose 'If this was you, would you consider taking a SERM?' Descriptive statistics and predictors (risk format, level of risk, and type of SERM) of choosing SERMs were determined by logistic regression.

RESULTS

A total of 288 women were recruited (an 88% response rate) between March and May 2017. The risk formats that showed a government statement and an icon array were associated with a greater likelihood of considering SERMs relative to one that showed a novel expected frequency tree. Risk formats for raloxifene and for the high-risk vignettes were also more strongly associated with choosing to consider SERMs. No associations were found with any patient demographics.

CONCLUSION

Specific risk formats may lead to more women considering taking SERMs to reduce breast cancer risk, especially if they are at high risk of the condition. Raloxifene may be a more acceptable SERM to patients.

Uncertainty in health care: Towards a more systematic program of research

OBJECTIVE

To promote a more systematic approach to research on uncertainty in health care, and to explore promising starting points and future directions for this research.

METHODS

We examine three fundamental aspects of medical uncertainty that a systematic research program should ideally address: its nature, effects, and communication. We summarize key insights from past empirical research and explore existing conceptual models that can help guide future research.

RESULTS

A diverse body of past research on medical uncertainty has produced valuable empirical insights and conceptual models that provide useful starting points for future empirical and theoretical work. However, these insights need to be more fully developed and integrated to answer remaining questions about what uncertainty is, how it affects people, and how and why it should be communicated.

CONCLUSION

Uncertainty in health care is an extremely important but incompletely understood phenomenon. Improving our understanding of the many important aspects of uncertainty in health care will require a more systematic program of research based upon shared, integrative conceptual models and active, collaborative engagement of the broader research community.

PRACTICE IMPLICATIONS

A more systematic approach to investigating uncertainty in health care can help elucidate how the clinical communication of uncertainty might be improved.

How Do Women Interpret the NHS Information Leaflet about Cervical Cancer Screening?

Background. Organized screening programs often rely on written materials to inform the public. In the United Kingdom, women invited for cervical cancer screening receive a leaflet from the National Health Service (NHS) to support screening decisions. However, information about screening may be too complex for people to understand, potentially hindering informed decision making. Objectives. We aimed to identify women's difficulties in interpreting the leaflet used in England and negative and positive responses to the leaflet. Methods. We used a sequential mixed-methods design involving 2 steps: cognitive think-aloud interviews (n = 20), followed by an England-wide survey (n = 602). Data were collected between June 2017 and December 2018, and participants included women aged 25 to 64 y with varying sociodemographics. Results. Interview results revealed misunderstandings concerning screening results, benefits, and additional tests and treatment, although participants tended to react positively to numerical information. Participants were often unfamiliar with the potential harms associated with screening (i.e., screening risks), key aspects of human papillomavirus, and complex terms (e.g., dyskaryosis). Survey results indicated that interpretation difficulties were common (M correct items = 12.5 of 23). Lower understanding was associated with lower educational level (β's >0.15, P's <0.001), lower numeracy scores (β = 0.36, P < 0.001), and nonwhite ethnicity (β = 0.10, P = 0.007). The leaflet was evaluated positively overall. Conclusions. Despite previous user testing of the leaflet, key information may be too complex for some recipients. As a consequence, they may struggle to make informed decisions about screening participation based on the information provided. We discuss implications for the improvement of communications about screening and decision support.

How to Get Rid of the Belief Bias: Boosting Analytical Thinking via Pragmatics

The previous research attempts to reduce the influence of the belief bias on deductive thinking have often been unsuccessful and, when they succeeded, they failed to replicate. In this paper, we propose a new way to see an old problem. Instead of considering the analytical abilities of the respondent, we focus on the communicative characteristics of the experimental task. By changing the pragmatics into play through a subtle manipulation of the instruction of the syllogism problem, we obtained a strong improvement in the accuracy of the performance in both untrained and trained in logic respondents. We suggest that current models of deductive thinking should be broadened to consider also communicative understanding as part of the processing of the problem.

Ratio Format Shapes Health Decisions: The Practical Significance of the "1-in-X" Effect

Prior research found that "1-in-X" ratios led to higher and less accurate subjective probability than "N-in-X*N" ratios or other formats, even though they featured the same mathematical information. It is unclear, however, whether the effect transfers into health decisions, and the practical significance of the effect is undetermined. Based on previous findings and risk communication theories, we hypothesized that the 1-in-X effect would occur and transfer into relevant decisions. We also tested whether age, gender, and education differences would moderate the 1-in-X effect on decision making. We conducted 3 well-powered experiments ( n = 1912) using a sample from the general adult UK population to test our hypotheses, estimated the effect, and excluded a possible methodological explanation for such a transfer. In hypothetical scenarios, participants decided whether to travel to Kenya given the chance of contracting malaria (experiment 1) and whether to take recommended steroids given the side effects (experiments 2 and 3). Across the experiments, we replicated a small to medium 1-in-X effect on the perceived probability (Hedge's g = -0.36; 95% confidence interval [CI], -0.47 to -0.24; z = -6.18; P < 0.001) and found a small effect on subsequent decisions (odds ratio = 1.32; 95% CI, 1.10-1.59; z = 2.99; P = 0.003). The perceived probability fully mediated the effect of the ratio format on decision. Age, gender, and education did not moderate the 1-in-X effect on decision. We argue that a high prevalence of 1-in-X ratios in medical communication makes these small changes clinically relevant. Therefore, to communicate information accurately, 1-in-X ratios should not be used or at least used cautiously in medical communication.

Understanding Statistical Hypothesis Testing: The Logic of Statistical Inference

Statistical hypothesis testing is among the most misunderstood quantitative analysis methods from data science. Despite its seeming simplicity, it has complex interdependencies between its procedural components. In this paper, we discuss the underlying logic behind statistical hypothesis testing, the formal meaning of its components and their connections. Our presentation is applicable to all statistical hypothesis tests as generic backbone and, hence, useful across all application domains in data science and artificial intelligence.

Systematic evaluation of written health information on PSA based screening in Germany

Background

Prostate-specific antigen (PSA) based screening for early detection of prostate cancer is common although it is associated with both benefits and potential harms (e.g., the risk of overdiagnosis). Evidence-based health information could help individuals make informed decisions about whether to undergo PSA testing or not. This evaluation aimed to determine whether the written health information materials available in Germany provide appropriate information for informed decision-making on PSA based screening.

Methods

A list of criteria was developed and used to systematically assess the quality of information on the benefits and harms of prostate cancer screening included in written health information materials. Fourteen information materials identified by information requests and online searches were evaluated independently by two of three reviewers. Consensus was achieved with a third reviewer.

Results

Of the 14 information materials evaluated, 10 (71%) list the ability to reduce the absolute risk of death from prostate cancer as a benefit of PSA testing, 9 (64%) point out the risks of follow-up diagnostics, 13 (93%) describe the risks of the available prostate cancer treatments, and all 14 specify the risk of overdiagnosis. The minority provide numerical data on benefits and risks. Partially mismatched framing was identified in four cases: two information materials report only the relative frequencies of benefits, and two report only the absolute frequencies of harms. Half of the materials encouraged participation using downplaying or frightening language.

Conclusions

The majority of health information materials in Germany describe the benefits and harms of PSA based screening, including overdiagnosis, but often lack adequate balance, neutrality and numbers.

Assessing the quality and communicative aspects of patient decision aids for early-stage breast cancer treatment: a systematic review

Purpose

Decision aids (DAs) support patients in shared decision-making by providing balanced evidence-based treatment information and eliciting patients’ preferences. The purpose of this systematic review was to assess the quality and communicative aspects of DAs for women diagnosed with early-stage breast cancer.

Methods

Twenty-one currently available patient DAs were identified through both published literature (MEDLINE, Embase, CINAHL, CENTRAL, and PsycINFO) and online sources. The DAs were reviewed for their quality by using the International Patient Decision Aid Standards (IPDAS) checklist, and subsequently assessed to what extent they paid attention to various communicative aspects, including (i) information presentation, (ii) personalization, (iii) interaction, (iv) information control, (v) accessibility, (vi) suitability, and (vii) source of information.

Results

The quality of the DAs varied substantially, with many failing to comply with all components of the IPDAS criteria (mean IPDAS score = 64%, range 31–92%). Five aids (24%) did not include any probability information, 10 (48%) presented multimodal descriptions of outcome probabilities (combining words, numbers, and visual aids), and only 2 (10%) provided personalized treatment outcomes based on patients and tumor characteristics. About half (12; 57%) used interaction methods for eliciting patients’ preferences, 16 (76%) were too lengthy, and 5 (24%) were not fully accessible.

Conclusions

In addition to the limited adherence to the IPDAS checklist, our findings suggest that communicative aspects receive even less attention. Future patient DA developments for breast cancer treatment should include communicative aspects that could influence the uptake of DAs in daily clinical practice.

Electronic supplementary material

The online version of this article (10.1007/s10549-019-05351-4) contains supplementary material, which is available to authorized users.

Numeracy and Interpretation of Prognostic Estimates in Intracerebral Hemorrhage Among Surrogate Decision Makers in the Neurologic ICU

OBJECTIVE

Clinicians caring for patients with intracerebral hemorrhage must often discuss prognosis and goals of care with their patients' surrogate decision makers, and may make numeric estimates of likelihood of survival and functional independence, informed by validated prediction models. Surrogates' prognostic estimates are often discordant with physicians', suggesting that physicians' numeric statements may not be accurately interpreted. We sought to assess the relationship between numeracy and interpretation of prognostic estimates in intracerebral hemorrhage among surrogate decision makers. We also assessed surrogates' application of prognostic estimates to decisions regarding goals of care.

DESIGN

Single-center, survey-based, cross-sectional study.

SETTING

Twenty-two-bed neurologic ICU at an urban, academic hospital.

SUBJECTS

Surrogate decision makers for patients admitted to the neurologic ICU.

INTERVENTIONS

Participants completed a survey containing five clinical vignettes describing patients with nontraumatic intracerebral hemorrhage. For each patient, numerical estimates of survival and functional independence were explicitly provided, based on the validated outcome risk stratification scale (intracerebral hemorrhage score) and the Prediction of Functional Outcome in Patients with Primary Intracerebral Hemorrhage score.

MEASUREMENTS AND MAIN RESULTS

Participants were asked to make their own prognostic estimates, as well as to describe their preferred goals of care for each hypothetical patient. Respondent demographics were collected, and numeracy was assessed using a modified Lipkus 11-item scale. Poor numeracy was common (42 of 96 total subjects) in this relatively highly educated population. Most prognostic estimates (55%) made by surrogates were discordant with the provided estimates. High numeracy correlated with better concordance (odds ratio, 23.9 [5.57-97.64]; p < 0.001), independent of several factors, including level of education and religion. Numeracy also affected goals-of-care decisions made by surrogates.

CONCLUSIONS

Poor numeracy is common among surrogate decision makers in an intensive care setting and poses a barrier to communication between surrogates and clinicians regarding prognosis and goals of care.

Patient-Level Trajectories and Outcomes After Low-Dose CT Screening in the National Lung Screening Trial

BACKGROUND

Shared decision-making is an essential element of low-dose CT (LDCT) screening for lung cancer. Understanding patient-level outcomes from the National Lung Screening Trial (NLST) is critical to effectively communicate risks and benefits of screening to patients.

METHODS

We performed a secondary analysis of data collected in the NLST. We determined outcomes of each LDCT scan performed in the NLST (downstream evaluation, complications, lung cancer diagnoses), and compared outcomes at the test level with outcomes calculated at the patient level for those randomized to LDCT screening. To assess the impact of COPD on patient outcomes, we compared outcomes among patients with and without COPD.

RESULTS

Of 75,138 LDCT scans, 14.2% led to a diagnostic study and 1.5% to an invasive procedure, with 0.3% of LDCT scans resulting in a procedure-related complication and 0.1% in a serious complication. Among 24,453 patients who underwent LDCT screening, 30.5% underwent a diagnostic study and 4.2% an invasive procedure, with 0.9% of screened patients experiencing a procedure-related complication and 0.3% a serious complication. Patients with COPD (defined by self-report) were more likely to need a diagnostic study (adjusted OR [aOR], 1.29; P < .01) and an invasive procedure (aOR, 1.41; P < .01) and more likely to experience a complication (aOR, 1.83; P < .01) and a serious complication (aOR, 1.78; P = .01). Patients with COPD also were more likely to be diagnosed with lung cancer (aOR, 1.43; P < .01).

CONCLUSIONS

We provide important patient-level data from the NLST that can be used to guide shared decision-making. The risk-to-benefit ratio of screening may vary significantly in some patients, such as those with COPD, in whom both risks and benefits of screening may be increased.

Cancer screening risk literacy of physicians in training: An experimental study

We investigated what factors may foster or hinder physicians' cancer screening risk literacy-specifically the ability to understand evidence regarding screening effectiveness and make evidence-based recommendations to patients. In an experiment, physicians in training (interns and residents) read statistical information about outcomes from screening for cancer, and had to decide whether to recommend it to a patient. We manipulated the effectiveness of the screening (effective vs. ineffective at reducing mortality) and the demand of the patient to get screened (demand vs. no demand). We assessed participants' comprehension of the presented evidence and recommendation to the patient, as well as a-priori screening beliefs (e.g., that screening is always a good choice), numeracy, science literacy, knowledge of screening statistics, statistical education, and demographics. Stronger positive a-priori screening beliefs, lower knowledge of screening statistics, and lower numeracy were related to worse comprehension of the evidence. Physicians recommended against the ineffective screening but only if they showed good comprehension of the evidence. Physicians' recommendations were further based on the perceived benefits from screening but not on perceived harms, nor the patient's demands. The current study demonstrates that comprehension of cancer screening statistics and the ability to infer the potential benefits for patients are essential for evidence-based recommendations. However, strong beliefs in favor of screening fostered by promotion campaigns may influence how physicians evaluate evidence about specific screenings. Fostering physician numeracy skills could help counteract such biases and provide evidence-based recommendations to patients.

Translating Cognitive Vulnerability Theory Into Improved Adolescent Depression Screening: A Receiver Operating Characteristic Approach

Traditionally, screening research tests how well a given symptom inventory can identify a concurrent depressive episode. Although developmental psychopathology could inform screening protocols for a myriad of depression outcomes (e.g., prospective depressive episodes), approaches typically used in research make it difficult to translate these findings. Using a translational analytic approach and multiwave longitudinal study design, we examined how screening for cognitive vulnerabilities (rumination, dysfunctional attitudes, and attributional style) may improve our ability to identify concurrent depressive episodes, prospective depressive episodes, first lifetime episodes of depression, and recurrent major depressive episodes. There were 473 sixth-grade (early adolescents) and ninth-grade (middle adolescents; AgeM = 13.15, AgeSD = 1.62) students who completed baseline self-report cognitive vulnerability and depressive symptom measures. At baseline and every 6 months for 3 years, pediatric depression interviews were completed by the caregiver and youth. A receiver operating characteristic (ROC) approach was utilized to test our aims. Distinct algorithms best forecasted our depression outcomes. Rumination and attributional style emerged as unique and incrementally valid predictors for prospective episodes after controlling for baseline depressive symptoms. Rumination was the only unique predictor for first lifetime depressive episodes. For recurrent major depression, rumination in early adolescence and attributional style in middle adolescence served as incremental predictors beyond baseline depressive symptoms. Proposed cutoffs and diagnostic likelihood ratios are offered for algorithms for each depression outcome. Assessing cognitive vulnerability represents a feasible method to improve depression screening initiatives. Using an ROC-informed approach can help prevention initiatives better leverage the considerable gains made within developmental psychopathology research.

Preferences of Patients and At-risk Individuals for Preventive Approaches to Rheumatoid Arthritis

Effective treatments for rheumatoid arthritis (RA) are available and can lead to remission for some patients, but most patients remain on potentially toxic and expensive medications in the long term. Interest is increasingly turning to the disease phases preceding the development of RA that represent opportunities for preventive interventions. At-risk target populations include individuals with genetic and environmental risk factors, those who have developed systemic autoimmunity, and those who have developed clinically suspect symptoms (eg, arthralgias without synovitis, or an early arthritis). Ongoing prospective studies will inform the development of increasingly accurate predictive tools to identify individuals at risk of developing RA. Furthermore, a range of preventive approaches has been suggested, including lifestyle modification (eg, smoking cessation) and pharmacologic interventions (eg, hydroxychloroquine, methotrexate, abatacept, rituximab) that are currently the subject of randomized controlled trials. As prediction and prevention of RA evolve, it is increasingly likely that individuals at risk (including asymptomatic individuals) may be faced with complex decisions about whether to accept assessment of their risk status or to take a preventive intervention associated with risk of serious adverse events and uncertain benefit. Acceptance of preventive medication in other contexts can be low. For example, <25% of women at high risk of breast cancer are willing to take preventive hormonal treatments. Actual uptake is lower still. Patients' beliefs and preferences predict treatment uptake and adherence. Before the dream of preventing RA can become reality, health care providers need to understand the perspectives of individuals in the target population and to identify barriers and facilitators for this approach. This commentary reviews what is currently known about the perspectives of patients and individuals at risk about predictive and preventive approaches for RA and identifies gaps to be addressed to inform the development of efficient preventive strategies.

Talking about risk in the context of genomic tests (TARGET): development and evaluation of an educational program for clinicians

Purpose

Gene expression profiling (GEP) test scores calculate risks of recurrence and likely benefit of adjuvant chemotherapy in ER-positive, HER2-negative, early-stage breast cancer. As health literacy and numeracy skills in the general population are poor, healthcare professionals (HCPs) require a wide repertoire of communication skills to explain clearly risk of recurrence scores (RSs) and uncertainty. We developed and evaluated an educational program for HCPs discussing GEP test results and adjuvant treatment.

Methods

Eight-hour workshops contained elements aimed at improving knowledge, communication skills and self-awareness; these included the science underpinning GEP tests, an interactive risk psychology lecture, exercises and facilitated group discussions regarding seven filmed scenarios involving discussions about high, intermediate and low RSs. Attendees were recorded explaining RSs with patient simulators pre and post workshop. Researchers, blinded to time point, analysed recordings using a study-specific scoring system. Primary objective outcomes were improvements post workshop in HCPs’ competence and confidence when communicating 17 pre-specified key information areas. We estimated odds ratios (OR) using conditional logistic regression to compare pre- and post-workshop scores.

Results

65 HCPs attended. Objective analyses revealed significant positive shifts post workshop which included explaining GEP tests (OR 2.98; 95% CI 1.38–6.42; P = .001), recurrence RSs (OR 3.99; 95% CI 1.72–9.25; P < .001), benefits of chemotherapy (OR 3.99; 95% CI 1.82–8.75; P < .001; and harms OR 2.31; 95% CI 1.37–3.92; P < .001) using jargon free language (OR 5.29; 95% CI 2.27–12.35; P < .001). Patient simulator assessments also showed significant improvements as did HCPs’ self-assessments and ratings of their self-confidence when discussing different GEP tests with diverse patient types (P < .001).

Conclusion

These short, intensive, interactive TARGET workshops significantly improved HCPs’ communication about GEP results in ways likely to promote more informed decision-making by patients about chemotherapy.

Electronic supplementary material

The online version of this article (10.1007/s10549-019-05316-7) contains supplementary material, which is available to authorised users.

Women's perception, attitudes, and intended behavior towards predictive epigenetic risk testing for female cancers in 5 European countries: a cross-sectional online survey

BACKGROUND

Epigenetic markers might be used for risk-stratifying cancer screening and prevention programs in the future. Although the clinical utility of consequent epigenetic tests for risk stratification is yet to be proven, successful adoption into clinical practice also requires the public's acceptance of such tests. This cross-sectional online survey study sought to learn for the first time about European women's perceptions, attitudes, and intended behavior regarding a predictive epigenetic test for female cancer (breast, ovarian, cervical, and endometrial) risks.

METHODS

1675 women (40-75 years) from five European countries (Czech Republic, Germany, United Kingdom, Italy, Sweden), drawn from online panels by the survey sampling company Harris Interactive (Germany), participated in an online survey where they first received online leaflet information on a predictive epigenetic test for female cancer risks and were subsequently queried by an online questionnaire on their desire to know their female cancer risks, their perception of the benefit-to-harm ratio of an epigenetic test predicting female cancer risks, reasons in favor and disfavor of taking such a test, and their intention to take a predictive epigenetic test for female cancer risks.

RESULTS

Most women desired information on each of their female cancer risks, 56.6% (95% CI: 54.2-59.0) thought the potential benefits outweighed potential harms, and 75% (72.0-77.8) intended to take a predictive epigenetic test for female cancer risks if freely available. Results varied considerably by country with women from Germany and the Czech Republic being more reserved about this new form of testing than women from the other three European countries. The main reason cited in favor of a predictive epigenetic test for female cancer risks was its potential to guide healthcare strategies and lifestyle changes in the future, and in its disfavor was that it may increase cancer worry and coerce unintended lifestyle changes and healthcare interventions.

CONCLUSIONS

A successful introduction of predictive epigenetic tests for cancer risks will require a balanced and transparent communication of the benefit-to-harm ratio of healthcare pathways resulting from such tests in order to curb unjustified expectations and at the same time to prevent unjustified concerns.

The Barrier to Informed Choice in Cancer Screening: Statistical Illiteracy in Physicians and Patients

An efficient health care requires both informed doctors and patients. Our current healthcare system falls short on both counts. Most doctors and patients do not understand the available medical evidence. To illustrate the extent of the problem in the setting of cancer screening: In a representative sample of some 5000 women in nine European countries, 92% overestimated the reduction of breast cancer mortality by mammography by a factor of 10-200, or did not know. For a similar sample of about 5000 men with respect to PSA screening, this number was 89%. Of more than 300 US citizens who regularly attended one or more cancer screening test, more than 90% had never been informed about the biggest harms of screening-overdiagnosis and overtreatment-by their physicians. Among 160 German gynecologists, some 80% did not understand the positive predictive value of a positive mammogram, with estimates varying between 1 and 90%. In a national sample of 412 US primary care physicians, 47% mistakenly believed that if more cancers are detected by a screening test, this proves that the test saves lives, and 76% wrongly thought that if screen-detected cancers have better 5-year survival rates than cancers detected by symptoms, this would prove that the screening test saves lives. And of 20 German gynecologists, not a single one provided a woman with all information on the benefits and harms of cancer screening required in order to make an informed choice. Why is risk literacy so scarce in health care? One frequently discussed explanation assumes that people suffer from cognitive deficits that make them predictably irrational and basically hopeless at dealing with risks, so that they need to be "nudged" into healthy behavior. Yet research has demonstrated that the problem lies less in stable cognitive deficits than in how information is presented to physicians and patients. This includes biased reporting in medical journals, brochures, and the media that uses relative risks and other misleading statistics, motivated by conflicts of interest and defensive medicine that do not promote informed physicians and patients. What can be done? Every medical school should teach its students how to understand evidence in general and health statistics in particular. To cultivate informed patients, elementary and high schools should start teaching the mathematics of uncertainty-statistical thinking. Guidelines about complete and transparent reporting in journals, brochures, and the media need to be better enforced, and laws need to be changed in order to protect patients and doctors alike against the practice of defensive medicine instead of encouraging it. A critical mass of informed citizens will not resolve all healthcare problems, but it can constitute a major triggering factor for better care.

"I Was Trying to Do the Maths": Exploring the Impact of Risk Communication in Discrete Choice Experiments

BACKGROUND

Risk is increasingly used as an attribute in discrete choice experiments (DCEs). However, risk and probabilities are complex concepts that can be open to misinterpretation, potentially undermining the robustness of DCEs as a valuation method. This study aimed to understand how respondents made benefit-risk trade-offs in a DCE and if these were affected by the communication of the risk attributes.

METHODS

Female members of the public were recruited via local advertisements to participate in think-aloud interviews when completing a DCE eliciting their preferences for a hypothetical breast screening programme described by three attributes: probability of detecting a cancer; risk of unnecessary follow-up; and cost of screening. Women were randomised to receive risk information as either (1) percentages or (2) percentages and icon arrays. Interviews were digitally recorded then transcribed to generate qualitative data for thematic analysis.

RESULTS

Nineteen women completed the interviews (icon arrays n = 9; percentages n = 10). Analysis revealed four key themes where women made references to (1) the nature of the task; (2) their feelings; (3) their experiences, for instance making analogies to similar risks; and (4) economic phenomena such as opportunity costs and discounting.

CONCLUSION

Most women completed the DCE in line with economic theory; however, violations were identified. Women appeared to visualise risk whether they received icon arrays or percentages only. Providing clear instructions and graphics to aid interpretation of risk and qualitative piloting to verify understanding is recommended. Further investigation is required to determine if the process of verbalising thoughts changes the behaviour of respondents.

[The role of biostatistics in institutional review boards]

Research in humans is associated with risks. These risks are only justifiable if an independent institutional review board (IRB) has evaluated the planned research in terms of scientific integrity. Only scientifically sound research can be considered ethical. A biostatistician should be a member of the IRB to assure adequate evaluation of fundamental topics like design, sample size estimation, and statistical analysis of the study.This paper presents core biostatistical concepts following the current guidelines of the International Council of Harmonization (ICH E6 and ICH E9). We discuss important pitfalls based on examples from published clinical trials. Furthermore, we discuss new concepts like estimands and their relevance for biostatisticians working in IRBs. Finally, we discuss the role of biostatisticians in IRBs and present thoughts on the way they should be trained.

Nurse-led coaching of shared decision-making for women with ductal carcinoma in situ in breast care centers: A cluster randomized controlled trial

BACKGROUND

Women with breast cancer demand informed shared decision-making. Guidelines support these claims.

OBJECTIVES

To investigate whether an informed shared decision-making intervention for women with 'ductal carcinoma in situ' comprising an evidence-based decision aid with nurse-led decision coaching enhances the extent of the mutual shared decision-making behavior of patients and professionals regarding treatment options, and to analyze implementation barriers.

DESIGN

Cluster randomized controlled trial with accompanying process evaluation.

SETTING

Certified breast care centers in Germany.

PARTICIPANTS

Women with ductal carcinoma in situ and no previous history of breast cancer facing a primary treatment decision.

METHODS

Sixteen breast centers were randomized to intervention or standard care to recruit 192 patients (partially-blinded). All coaching sessions and physician consultations were videotaped to assess the primary outcome 'extent of patient involvement in shared decision-making' using the MAPPIN-Odyad observer instrument (scores 0 to 4). Secondary endpoints included the sub-measures of the MAPPIN-inventory (MAPPIN-Onurse, MAPPIN-Ophysician, MAPPIN-Opatient, MAPPIN-Qnurse, MAPPIN-Qpatient and MAPPIN-Qphysician), 'informed choice', 'decisional conflict' and 'duration of consultations'. Primary intention-to-treat analyses were on cluster level comparing means of cluster values using t-tests. An accompanying process evaluation was conducted comprising 1) analysis of all video recordings with focus on procedures and intervention fidelity and 2) field notes of researchers and feedback from professionals and patients assessed by questionnaires and interviews with focus on barriers and facilitators for implementation at different time points.

RESULTS

Due to protracted recruitment, the study was terminated after 14 centers had included 64 patients (intervention group 36, control group 28). Patient participation in informed shared decision-making was significantly higher in the intervention group (mean (SD) score 2.29 (0.56) vs. 0.42 (0.51) in the control group; difference 1.88 (95% CI 1.26-2.50, p < 0.0001). 47.7% women in the intervention group made informed choices, but none in the control group, difference 47.7% (95% CI 12.6-82.7%, p = 0.016). In the intervention group physician consultations lasted 12.8 (6.6) min. vs. 24.3 (6.3) min. in the control group. Physicians' attitudes, false incentives and structural barriers hindered implementation of informed shared decision-making. Nurses appreciated their new roles.

CONCLUSIONS

Informed shared decision-making is not yet implemented in German breast care centers. Nurse-led decision coaching grounded on evidence-based patient information enhances informed shared decision-making. Trial registration No. ISRCTN46305518.

Communicating uncertainty in cancer prognosis: A review of web-based prognostic tools

Objective To review how web-based prognosis tools for cancer patients and clinicians describe aleatory (risk estimates) and epistemic (imprecision in risk estimates) uncertainties. Methods We reviewed prognostic tools available online and extracted all uncertainty descriptions. We adapted an existing classification and classified each extracted statement by presentation of uncertainty. Results We reviewed 222 different prognostic risk tools, which produced 772 individual estimates. When describing aleatory uncertainty, almost all (90%) prognostic tools included a quantitative description, such as "chances of survival after surgery are 10%", though there was heterogeneity in the use of percentages, natural frequencies, and use of graphics. Only 14% of tools described epistemic uncertainty. Of those that did, most used a qualitative prefix such as "about" or "up to", while 22 tools described quantitative descriptions using confidence intervals or ranges. Conclusions Considerable heterogeneity exists in the way uncertainties are communicated in cancer prognostic tools. Few tools describe epistemic uncertainty. This variation is predominately explained by a lack of evidence and consensus in risk communication, particularly for epistemic uncertainty. Practice Implications As precision medicine seeks to improve prognostic estimates, the community may not be equipped with the tools to communicate the results accurately and effectively to clinicians and patients.

Communicative aspects of decision aids for localized prostate cancer treatment - A systematic review

CONTEXT

Despite increasing interest in the development and use of decision aids (DAs) for patients with localized prostate cancer (LPC), little attention has been paid to communicative aspects (CAs) of such tools.

OBJECTIVE

To identify DAs for LPC treatment, and review these tools for various CAs.

MATERIALS AND METHODS

DAs were identified through both published literature (MEDLINE, Embase, CINAHL, CENTRAL, and PsycINFO; 1990-2018) and online sources, in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Identified DAs were reviewed for the International Patient Decision Aid Standards criteria, and analyzed on CAs, including information presentation, personalization, interaction, information control, accessibility, suitability, and source of information. Nineteen DAs were identified.

RESULTS

International Patient Decision Aid Standards scores varied greatly among DAs. Crucially, substantial variations in use of CAs by DAs were identified: (1) few DAs used visual aids to communicate statistical information, (2) none were personalized in terms of outcome probabilities or mode of communication, (3) a minority used interactive methods to elicit patients' values and preferences, (4) most included biased cross tables to compare treatment options, and (5) issues were observed in suitability and accessibility that could hinder implementation in clinical practice.

CONCLUSIONS

Our review suggests that DAs for LPC treatment could be further improved by adding CAs such as personalized outcome predictions and interaction methods to the DAs. Clinicians who are using or developing such tools might therefore consider these CAs in order to enhance patient participation in treatment decision-making.

"The median isn't the message": How to communicate the uncertainties of survival prognoses to cancer patients in a realistic and hopeful way

This study investigated how doctors communicate the uncertainties of survival prognoses to patients recently diagnosed with life‐threatening cancer, and suggests ways to improve this communication. Two hundred thirty‐eight Norwegian oncologists and general practitioners (GPs) participated in Study 1. The study included both a scenario and a survey. The scenario asked participants to respond to a hypothetical patient who wanted to know how long (s)he could be expected to live. There were marked differences in responses within both groups, but few differences between the GPs and oncologists. There was a strong reluctance among doctors to provide patients with a prognosis. Even when they were presented with a statistically well‐founded right‐skewed survival curve, only a small minority provided hope by communicating the variation in survival time. In Study 2, 177 healthy students rated their preferences for different ways of receiving information regarding the uncertainty of a survival prognosis. Participants who received an explicitly described right‐skewed survival curve believed that they would feel more hopeful. These participants also obtained a more realistic understanding of the variation in survival than those who did not receive this information. Based on the findings of the two studies and on extant psychological research, the author suggests much‐needed guidelines for communicating survival prognoses in a realistic and optimistic way to patients recently diagnosed with life‐threatening cancer. In particular, the guidelines emphasise that the doctor explains the often strongly right‐skewed variation in survival time, and thereby providing the patient with realistic hope.

The impact of personalised risk information compared to a positive/negative result on informed choice and intention to undergo colonoscopy following colorectal Cancer screening in Scotland (PERICCS) - a randomised controlled trial: study protocol

BACKGROUND

In Scotland a new, easier to complete bowel screening test, the Faecal Immunochemical Test (FIT), has been introduced. This test gives more accurate information about an individual's risk of having colorectal cancer (CRC), based on their age and gender, and could lead to fewer missed cancers compared to the current screening test. However, there is no evidence of the effect on colonoscopy uptake of providing individuals with personalised risk information following a positive FIT test. The objectives of the study are: 1) To develop novel methods of presenting personalised risk information in an easy-to-understand format using infographics with involvement of members of the public 2) To assess the impact of different presentations of risk information on informed choice and intention to take up an offer of colonoscopy after FIT 3) To assess participants' responses to receiving personal risk information (knowledge, attitudes to screening/risk, emotional responses including anxiety).

METHODS

Adults (age range 50-74) registered on the Scottish Bowel Screening database will be invited by letter to take part. Consenting participants will be randomised to one of three groups to receive hypothetical information about their risk of cancer, based on age, gender and faecal haemoglobin concentration: 1) personalised risk information in numeric form (e.g. 1 in 100) with use of infographics, 2) personalised information described as 'highest', 'moderate' or 'lowest' risk with use of infographics, and 3) as a 'positive' test result, as is current practice. Groups will be compared on informed choice, intention to have a colonoscopy, and satisfaction with their decision. Follow-up semi-structured qualitative interviews will be conducted, by telephone, with a small number of consenting participants (n = 10 per group) to explore the acceptability/readability and any potential negative impact of the risk information, participants' understanding of risk factors, attitudes to the different scenarios, and reasons for reported intentions.

DISCUSSION

Proving personalised risk information and allowing patient choice could lead to improved detection of CRC and increase patient satisfaction by facilitating informed choice over when/whether to undergo further invasive screening. However, we need to determine whether/how informed choice can be achieved and assess the potential impact on the colonoscopy service.

TRIAL REGISTRATION

The trial is registered on www.isrctn.com on 08/12/2017. Registration no: ISRCTN14254582.

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.

Numeracy and Risk Literacy: What Have We Learned so Far?

Numerical skills are essential to make informed decisions in our daily life. Unfortunately, many people lack basic numeracy, which limits their ability to accurately interpret risks (i.e., risk literacy). In this paper, we provide an overview of research investigating the role of numeracy in two prominent domains, where most research was concentrated, health and finance. We summarize what has been learned so far in these domains and suggest promising venues for future research. We conclude that it is important to conduct interventions to improve numeracy in less numerate individuals and to help them make informed decisions and achieve better life outcomes.

Juror comprehension of forensic expert testimony: A literature review and gap analysis

Forensic scientists and commentators including academics and statisticians have been embroiled in a debate over the best way to present evidence in the courtroom. Various forms of evidence presentation, both quantitative and qualitative, have been championed, yet amidst the furor over the most "correct" or "accurate" way to present evidence, the perspective of the fact-finder is often lost. Without comprehension, correctness is moot. Unbeknownst to many forensic practitioners, there is a large, though incomplete, body of literature from the cognitive psychology domain that explores the question of what jurors understand when forensic scientists testify. This body of work has begun to test different proposed methods of testimony in an effort to understand which are most effective at communicating the strength of evidence that is intended by the expert. This article is a review of that literature that is intended for the forensic scientist community. Its aim is to educate that community on the findings of completed studies and to identify suggestions for further research that will inform changes in testimony delivery and ensure that any modifications can be implemented with confidence in their effectiveness.