Interpretation of graphic data by patients in a general medicine clinic

Effect of different visual presentations on the comprehension of prognostic information: a systematic review

Background

Understanding prognostic information can help patients know what may happen to their health over time and make informed decisions. However, communicating prognostic information well can be challenging.

Purpose

To conduct a systematic review to identify and synthesize research that has evaluated visual presentations that communicate quantitative prognostic information to patients or the public.

Data sources

MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC and the Cochrane Central Register of Controlled Trials (CENTRAL) (from inception to December 2020), and forward and backward citation search.

Study selection

Two authors independently screened search results and assessed eligibility. To be eligible, studies required a quantitative design and comparison of at least one visual presentation with another presentation of quantitative prognostic information. The primary outcome was comprehension of the presented information. Secondary outcomes were preferences for or satisfaction with the presentations viewed, and behavioral intentions.

Data extraction

Two authors independently assessed risk of bias and extracted data.

Data synthesis

Eleven studies (all randomized trials) were identified. We grouped studies according to the presentation type evaluated. Bar graph versus pictograph (3 studies): no difference in comprehension between the groups. Survival vs mortality curves (2 studies): no difference in one study; higher comprehension in survival curve group in another study. Tabular format versus pictograph (4 studies): 2 studies reported similar comprehension between groups; 2 found higher comprehension in pictograph groups. Tabular versus free text (3 studies): 2 studies found no difference between groups; 1 found higher comprehension in a tabular group.

Limitations

Heterogeneity in the visual presentations and outcome measures, precluding meta-analysis.

Conclusions

No visual presentation appears to be consistently superior to communicate quantitative prognostic information.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01612-9.

Differential roles of comorbidity burden and functional status in elderly and non-elderly patients with infections in general wards

BACKGROUND

Differential roles of comorbidity burden, functional status and severity of illness in elderly and non-elderly patients admitted to general wards with infections in terms of short-term and long-term mortality remain poorly understood and worth further investigation.

METHODS

From 2011 to 2013, patients admitted to general wards with a main diagnosis of infections were included and their Barthel index, Charlson comorbidity index and Pitt bacteremia score were collected to evaluate their association with in-hospital and 1-year outcomes of the study cohort. Age stratification was applied for all outcome analysis.

RESULTS

A total of 2481 patients were identified, with main diagnoses of pneumonia (57%), urinary tract infection (28%) and intra-abdominal infection (18%). In-hospital mortality occurred in 291 (12%) of the population and was independently predicted by Barthel index ≤50 (odds ratio [OR] 5.67 and 2.73, respectively) and Charlson comorbidity index >2 (OR 1.49 and 2.87, respectively) in both elderly and non-elderly patients. Among 2190 hospital survivors, Barthel index ≤50 (hazard ratio [HR] 1.38) and Charlson comorbidity index >2 (HR 1.96) were associated with a higher hazard of 1-year mortality in elderly patients. However, only Charlson comorbidity index >2 (HR 2.87) was a significant characteristic of non-elderly patients to be correlated with higher 1-year mortality.

CONCLUSION

This study found that functional status on admission was predictive of in-hospital mortality of general patients with infections irrespective of age groups; however, it played a differential role in 1-year mortality in between elderly and non-elderly patients, emphasizing the importance of functional assessment among the elderly.

Short- and long-term prognosis of critically-ill patients referred to the ICU from the Emergency Department of a tertiary hospital

BACKGROUND AND OBJECTIVE

A frequent source of critically-ill patients admitted to the ICU is the Emergency Department. It is essential to analyse the short-term prognosis of these patients, but also their evolution after their discharge from the hospital, since this is one of the major concerns of these patients. The aim of this study is to describe the epidemiological characteristics of patients admitted to the ICU from the Emergency Department and to analyse their outcome.

PATIENTS AND METHOD

This consisted of an observational prospective cohorts study which included 269 Emergency Department patients consecutively admitted to the ICU over an 18-month period. Factors associated with hospital mortality were presented as an odds ratio (OR) and factors associated with long-term mortality were presented as a hazard ratio (HR). A P-value lower than .05 was accepted as significant. The overall survival was analysed on the basis of the Kaplan-Meier curves.

RESULTS

Hospital mortality was 15%, ICU complications where the variables with the greatest impact on short-term mortality: acute renal failure (OR 22.7) and respiratory distress syndrome (OR 51.2). After hospital discharge, the cumulative mortality at 12, 24 and 36 months was 6, 11 and 15%, respectively. The degree of functional dependence (HR 3.7), cancer (HR 3.4) and arrhythmias (HR 2.4) were factors related to long-term mortality.

CONCLUSIONS

The short-term outcome of ICU patients is related to age and comorbidity, but more significantly to the characteristics of the acute illness. However, the long-term outcome is more closely associated with the patients' characteristics.

Methods for Performing Survival Curve Quality-of-Life Assessments

BACKGROUND

Many medical decisions involve an implied choice between alternative survival curves, typically with differing quality of life. Common preference assessment methods neglect this structure, creating some risk of distortions.

METHODS

Survival curve quality-of-life assessments (SQLA) were developed from Gompertz survival curves fitting the general population's survival. An algorithm was developed to generate relative discount rate-utility (DRU) functions from a standard survival curve and health state and an equally attractive alternative curve and state. A least means squared distance algorithm was developed to describe how nearly 3 or more DRU functions intersect. These techniques were implemented in a program called X-Trade and tested.

RESULTS

SQLA scenarios can portray realistic treatment choices. A side effect scenario portrays one prototypical choice, to extend life while experiencing some loss, such as an amputation. A risky treatment scenario portrays procedures with an initial mortality risk. A time trade scenario mimics conventional time tradeoffs. Each SQLA scenario yields DRU functions with distinctive shapes, such as sigmoid curves or vertical lines. One SQLA can imply a discount rate or utility if the other value is known and both values are temporally stable. Two SQLA exercises imply a unique discount rate and utility if the inferred DRU functions intersect. Three or more SQLA results can quantify uncertainty or inconsistency in discount rate and utility estimates. Pilot studies suggested that many subjects could learn to interpret survival curves and do SQLA.

LIMITATIONS

SQLA confuse some people. Compared with SQLA, standard gambles quantify very low utilities more easily, and time tradeoffs are simpler for high utilities. When discount rates approach zero, time tradeoffs are as informative and easier to do than SQLA.

CONCLUSIONS

SQLA may complement conventional utility assessment methods.

Simple and multistate survival curves: can people learn to use them?

OBJECTIVE AND SAMPLE: This investigation assessed the comprehension of survival curves in a community sample of 88 young and middle-aged adults when several aspects of good practice for graphical communication were implemented, and it compared comprehension for alternative presentation formats. DESIGN, METHOD, and

MEASUREMENTS

After reading worked examples of using survival curves that provided explanation and answers, participants answered questions on survival data for pairs of treatments. Study 1 compared presenting survival curves for both treatments on the same figure against presentation via 2 separate figures. Study 2 compared presenting data for 3 possible outcome states via a single "multistate" figure for each treatment against presenting each outcome on a separate figure (with both treatments on the same figure). Both studies compared alternative forms of questioning (e.g., "number alive" versus "number dead"). Numeracy levels (self-rated and objective measures) were also assessed.

RESULTS

Comprehension was generally good--exceeding 90% correct answers on half the questions--and was similar across alternative graphical formats. Lower accuracy was observed for questions requiring a calculation but was significantly lower only when the requirement for calculation was not explicit (13%-28% decrements in performance). In study 1, this effect was most acute for those with lower levels of numeracy. Subjective (self-rated) numeracy and objective (measured) numeracy were both moderate positive predictors of overall task accuracy (r ≈ 0.3).

CONCLUSIONS

A high degree of accuracy in extracting information from survival curves is possible, as long as any calculations that are required are made explicit (e.g., finding differences between 2 survival rates). Therefore, practitioners need not avoid using survival curves in discussions with patients, although clear and explicit explanations are important.

Validation of a Predictive Model for Survival in Patients With Advanced Cancer: Secondary Analysis of RTOG 9714

Background

The objective of this study was to validate a simple predictive model for survival of patients with advanced cancer.

Methods

Previous studies with training and validation datasets developed a model predicting survival of patients referred for palliative radiotherapy using three readily available factors: primary cancer site, site of metastases and Karnofsky performance score (KPS). This predictive model was used in the current study, where each factor was assigned a value proportional to its prognostic weight and the sum of the weighted scores for each patient was survival prediction score (SPS). Patients were also classified according to their number of risk factors (NRF). Three risk groups were established. The Radiation Therapy and Oncology Group (RTOG) 9714 data was used to provide an additional external validation set comprised of patients treated among multiple institutions with appropriate statistical tests.

Results

The RTOG external validation set comprised of 908 patients treated at 66 different radiation facilities from 1998 to 2002. The SPS method classified all patients into the low-risk group. Based on the NRF, two distinct risk groups with significantly different survival estimates were identified. The ability to predict survival was similar to that of the training and previous validation datasets for both the SPS and NRF methods.

Conclusions

The three variable NRF model is preferred because of its relative simplicity.

The effect of alternative graphical displays used to present the benefits of antibiotics for sore throat on decisions about whether to seek treatment: a randomized trial

BACKGROUND

We conducted an Internet-based randomized trial comparing four graphical displays of the benefits of antibiotics for people with sore throat who must decide whether to go to the doctor to seek treatment. Our objective was to determine which display resulted in choices most consistent with participants' values.

METHODS AND FINDINGS

This was the first of a series of televised trials undertaken in cooperation with the Norwegian Broadcasting Company. We recruited adult volunteers in Norway through a nationally televised weekly health program. Participants went to our Web site and rated the relative importance of the consequences of treatment using visual analogue scales (VAS). They viewed the graphical display (or no information) to which they were randomized and were asked to decide whether to go to the doctor for an antibiotic prescription. We compared four presentations: face icons (happy/sad) or a bar graph showing the proportion of people with symptoms on day three with and without treatment, a bar graph of the average duration of symptoms, and a bar graph of proportion with symptoms on both days three and seven. Before completing the study, all participants were shown all the displays and detailed patient information about the treatment of sore throat and were asked to decide again. We calculated a relative importance score (RIS) by subtracting the VAS scores for the undesirable consequences of antibiotics from the VAS score for the benefit of symptom relief. We used logistic regression to determine the association between participants' RIS and their choice. 1,760 participants completed the study. There were statistically significant differences in the likelihood of choosing to go to the doctor in relation to different values (RIS). Of the four presentations, the bar graph of duration of symptoms resulted in decisions that were most consistent with the more fully informed second decision. Most participants also preferred this presentation (38%) and found it easiest to understand (37%). Participants shown the other three presentations were more likely to decide to go to the doctor based on their first decision than everyone based on the second decision. Participants preferred the graph using faces the least (14.4%).

CONCLUSIONS

For decisions about going to the doctor to get antibiotics for sore throat, treatment effects presented by a bar graph showing the duration of symptoms helped people make decisions more consistent with their values than treatment effects presented as graphical displays of proportions of people with sore throat following treatment.

CLINICAL TRIALS REGISTRATION

ISRCTN58507086.

Perceptions of risk in adults with a low or high risk profile of developing type 2 diabetes; a cross-sectional population-based study

OBJECTIVE

To compare the perceived seriousness and risk of type 2 diabetes among low risk with high risk profile non-diabetic subjects and examine the relationship of perceived risk with multiple self-reported risk indicators.

METHODS

A cross-sectional population-based study among 4435 low risk profile and 2607 high risk profile non-diabetic residents of the Hoorn region, participating in a stepwise type 2 diabetes screening study. Main outcome measures were perceived seriousness and risk of diabetes in subjects categorized (low vs. high risk profile) using the Symptom Risk Questionnaire.

RESULTS

85.0% of the low risk and 81.2% of the high risk profile subjects perceived diabetes as a moderate to very serious disease. About half (43.0%) of all 7042 subjects reported that they do not know their risk of having diabetes. The mean perceived risk of having diabetes was slightly lower for the low risk compared with the high risk profile subjects (difference = 2.8%; 95% confidence interval [CI] = 1.8% to 3.8%; P < 0.001). This difference was mostly explained by having a parent or sibling with diabetes, frequent thirst and claudication (difference = 0.6%; 95% CI = -0.7% to 1.9%). Interestingly, perceived risk decreased with increasing age within both groups (P for trend < 0.001).

CONCLUSIONS

Both low risk and high risk profile subjects perceive diabetes as a serious disease. Even among those at high risk profile for type 2 diabetes, almost half appeared not to know their risk. Perceived risk of having diabetes was slightly lower for the low risk compared with the high risk profile subjects. Furthermore, perceived risk decreases with increasing age.

PRACTICE IMPLICATIONS

This study points to a greater need to effectively address people's (mis)perceptions, and how to raise the awareness and understanding of type 2 diabetes and its risk factors in the general population in order to influence early detection and healthy lifestyle changes.

Interventions to improve risk communication in clinical genetics: systematic review

OBJECTIVE

Effective risk communication may enable clients to participate effectively in decision-making about their health and health care. A systematic review of existing literature on risk communication in genetics, and its effects on key outcomes for clients, was undertaken.

METHOD

Systematic searching of six electronic databases and data extraction from included studies; narrative synthesis of results.

RESULTS

Twenty-eight studies were included, principally from cancer genetics. Sixteen communication interventions have been evaluated, generally showing improvements in cognitive outcomes for users, such as knowledge, understanding and risk perception, and without adverse effects on anxiety, cancer-related worry and depression. However, often it was the supportive or emotional elements of counselling that provided benefits to users, rather than the informational or educational elements. Similar results were found in 12 further studies of decision aids which also appear to achieve shorter consultations that can focus more on the supportive elements of counselling.

CONCLUSION

For both communication models and decision aids, the supportive or emotional elements of counselling provided more benefits to users than the informational or educational elements.

PRACTICE IMPLICATIONS

Debate is required on how to strike a balance between the medical model, its agenda and perceived requirements to disclose or discuss a range of issues and the sometimes competing goals of addressing users' concerns, needs for support, issues of loss and relationship problems.

Numeric, verbal, and visual formats of conveying health risks: suggested best practices and future recommendations

Perception of health risk can affect medical decisions and health behavior change. Yet the concept of risk is a difficult one for the public to grasp. Whether perceptions of risk affect decisions and behaviors often relies on how messages of risk magnitudes (i.e., likelihood) are conveyed. Based on expert opinion, this article offers, when possible, best practices for conveying magnitude of health risks using numeric, verbal, and visual formats. This expert opinion is based on existing empirical evidence, review of papers and books, and consultations with experts in risk communication. This article also discusses formats to use pertaining to unique risk communication challenges (e.g., conveying small-probability events, interactions). Several recommendations are suggested for enhancing precision in perception of risk by presenting risk magnitudes numerically and visually. Overall, there are little data to suggest best practices for verbal communication of risk magnitudes. Across the 3 formats, few overall recommendations could be suggested because of 1) lack of consistency in testing formats using the same outcomes in the domain of interest, 2) lack of critical tests using randomized controlled studies pitting formats against one another, and 3) lack of theoretical progress detailing and testing mechanisms why one format should be more efficacious in a specific context to affect risk magnitudes than others. Areas of future research are provided that it is hoped will help illuminate future best practices.

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

BACKGROUND

In a companion article, the authors describe the Subjective Numeracy Scale (SNS), a self-assessment of numerical aptitude and preferences for numbers that correlates strongly with objective numeracy.

OBJECTIVE

The objective of this article is to validate the Subjective Numeracy Scale using measures of subjects' capacity to recall and comprehend complex risk statistics and to complete utility elicitations.

RESEARCH DESIGN

The study is composed of 3 general public surveys: 2 administered via the Web and 1 by paper and pencil. Subjects. Studies 1 and 3 surveyed 862 and 1234 people, respectively, recruited via a nationwide commercial Internet survey panel. Study 2 involved 245 people who completed paper-and-pencil surveys in a Veterans Administration hospital.

MEASURES

The authors tested whether one's score on the SNS predicted the likelihood of correct recall and interpretation of risk information (studies 1 and 2A) or the likelihood of effectively completing a time tradeoff or person-tradeoff utility elicitation (studies 2B and 3). In Studies 1 and 2, the authors also tested whether an objective test of quantitative ability would predict performance.

RESULTS

In all studies, survey participants with higher SNS scores performed significantly better than other respondents. The predictive ability of the SNS approached that observed for objective numeracy.

CONCLUSIONS

The SNS effectively predicts both risk comprehension and completion of utility elicitations without requiring survey participants to complete time-consuming and stress-inducing mathematics tests. The authors encourage the use of the SNS in a variety of health services research contexts.

Mortality versus survival graphs: improving temporal consistency in perceptions of treatment effectiveness

OBJECTIVE

Previous research has demonstrated that people perceive treatments as less effective when survival graphs show fewer years of data versus more data. We tested whether using mortality graphs would reduce this temporal inconsistency bias.

METHODS

A demographically diverse sample of 1461 Internet users read about a hypothetical disease and then were randomized to view either survival or mortality graphs that showed either 5 years of data or 15 years of treatment outcomes data. Participants identified the most effective treatment, provided ratings comparing the effectiveness of two treatments, and answered comprehension questions.

RESULTS

Treatment effectiveness ratings varied significantly between respondents seeing the 5 year and 15 year survival graphs even though the relative risk reduction was the same in both cases. This variation was significantly reduced in the mortality graph conditions. Responses on comprehension measures were mixed: viewers of mortality graphs were less able to identify which treatment was more effective but better able to correctly report individual data points.

CONCLUSIONS

Perceptions of treatment effectiveness appear more temporally consistent with mortality graphs than with survival graphs.

PRACTICE IMPLICATIONS

All line-based risk graphics (whether framed in survival or mortality terms) should highlight duration information to facilitate improved comprehension of treatment effectiveness.

Presenting risk information to people with diabetes: evaluating effects and preferences for different formats by a web-based randomised controlled trial

OBJECTIVE

Web-based patient information is widespread and information on the benefits and risks of treatments is often difficult to understand. We therefore evaluated different risk presentation formats - numerical, graphical and others - addressing the pros and cons of tight control versus usual treatment approaches for diabetes.

METHOD

DESIGN

Randomised controlled trial.

SETTING

Online. Publicity disseminated via Diabetes UK.

PARTICIPANTS

People with diabetes or their carers.

INTERVENTIONS

Control group information based on British Medical Journal 'Best Treatments'. Four intervention groups received enhanced information resources: (1) detailed numerical information (absolute/relative risk, numbers-needed-to-treat); (2) 'anchoring' to familiar risks or descriptions; (3) graphical (bar charts, thermometer scales, crowd figure formats); (4) combination of 1-3.

OUTCOMES

Decision conflict scale (DCS, a measure of uncertainty); satisfaction with information; further free text responses for qualitative content analysis.

RESULTS

Seven hundred and ten people visited the website and were randomised. Five hundred and eight completed the questionnaire for quantitative data. Mean DCS scores ranged from 2.12 to 2.24 for the five randomisation groups, indicating neither clear delay or vacillation about decisions (usually DCS>2.5) nor tending to make decisions (usually DCS<2.0). There were no statistically significant effects of the interventions on DCS, or satisfaction with information. Two hundred and fifty-six participants provided responses for qualitative analysis: most found graphical representations helpful, specifically bar chart formats; many found other graphic formats (thermometer style, crowd figures/smiley faces) and 'anchoring' information unhelpful, and indicated information overload. Many negative experiences with healthcare indicate a challenging context for effective information provision and decision support.

CONCLUSION

Online evaluation of different risk representation formats was feasible. There was a lack of intervention effects on quantitative outcomes, perhaps reflecting already well-informed participants from the Diabetes UK patient organisation. The large qualitative dataset included many comments about what participants found helpful as formats for communicating risk information.

PRACTICE IMPLICATIONS

These findings assist the design of online decision aids and the representation of risk information. The challenge is to provide more information, in appropriate and clear formats, but without risking information overload. Interactive web designs hold much promise to achieve this.

Design features of graphs in health risk communication: a systematic review

This review describes recent experimental and focus group research on graphics as a method of communication about quantitative health risks. Some of the studies discussed in this review assessed effect of graphs on quantitative reasoning, others assessed effects on behavior or behavioral intentions, and still others assessed viewers' likes and dislikes. Graphical features that improve the accuracy of quantitative reasoning appear to differ from the features most likely to alter behavior or intentions. For example, graphs that make part-to-whole relationships available visually may help people attend to the relationship between the numerator (the number of people affected by a hazard) and the denominator (the entire population at risk), whereas graphs that show only the numerator appear to inflate the perceived risk and may induce risk-averse behavior. Viewers often preferred design features such as visual simplicity and familiarity that were not associated with accurate quantitative judgments. Communicators should not assume that all graphics are more intuitive than text; many of the studies found that patients' interpretations of the graphics were dependent upon expertise or instruction. Potentially useful directions for continuing research include interactions with educational level and numeracy and successful ways to communicate uncertainty about risk.

What's time got to do with it? Inattention to duration in interpretation of survival graphs

Reports of randomized clinical trials often use survival curves to summarize clinical outcomes over time and graphically demonstrate evidence of treatment effectiveness. Survival curves can also be used in patient communications to display how health risks accumulate over time. In a randomized survey experiment, administered online, we tested whether people viewing survival curves appropriately adjust their risk perceptions to account for the duration shown. Internet users (N= 864) were recruited from a demographically balanced U.S. panel. Participants read about a hypothetical disease and then viewed one of four survival graphs that displayed mortality risks with and without treatment. Survival graphs showed either a visually large or visually small difference between treatments and were labeled to represent either 5-year or 15-year risk statistics. Participants then provided ratings of disease seriousness, as well as treatment effectiveness for each possible treatment. Variations in ratings corresponded more with visual dissimilarity than with changes in the statistical risk exhibited, with participants perceiving somewhat greater disease seriousness and significant differences in treatment effectiveness in large visual difference graphs. We conclude that when people interpret survival curves, they often fail to sufficiently account for the timeframe represented and perceive more risk and larger differences when identical risks are displayed over longer periods of time. We recommend that all presentations of survival graphics, whether to patients, physicians, or scientists, emphasize duration information (e.g., in the title) and remind readers that attending to graph axis labels is the only way to pierce these visual illusions.

Risk-attitude and patient treatment preferences

Women's treatment preferences for lupus nephritis vary widely even after adjusting for sociodemographic factors and disease severity. Attitude toward risk may partially explain interpatient variability in treatment preference. The objective of this study was to examine the association between 'risk-attitude' and patient treatment preferences in lupus nephritis. Sixty-five premenopausal women with systemic lupus erythematosus were interviewed. Patient preferences for cyclophosphamide versus azathioprine for the treatment of lupus nephritis were ascertained using an Adaptive Conjoint Analysis questionnaire. Risk-attitude was ascertained by asking patients to choose between a pair of lotteries having the same expected value but differing in spread (the difference between the worst and best outcomes). Respondents preferring the wider spread were classified as relatively more risk-seeking and those preferring the narrower spread were classified as relatively more risk-averse. Twenty-eight percent of respondents were classified as relatively more risk-seeking. Risk-seeking women were more likely to prefer cyclophosphamide for the treatment of lupus nephritis compared with risk-averse women [least square mean (+/- SD) preference for cyclophosphamide 63 +/- 3 among risk-seeking women versus 55 +/- 2 among risk-averse women (P < 0.03)]. The association between risk attitude and treatment preference persisted asthe probabilities of adverse events were varied to reflect the range of risks reported in the literature. Our results suggest that patients' relative risk-attitudes, as measured by a lottery task, are related to their treatment preferences. Differences in risk-attitude may help explain the inter-patient variability in treatment preferences.

Patient comprehension of information for shared treatment decision making: state of the art and future directions

How does the way that information is presented potentially influence patients' consent for health treatments, in a shared decision making process? The goal of this paper is to present an overview of selected recent literature concerning patient health information presentation/use for treatment decision making. Recent work with patient populations has begun to extend early cognitive psychological work showing systematic biases in thinking. Key research findings are organized by type of format (probability, graphic, and qualitative/quantitative dimensions). The applied literature on this topic is amenable to only limited integration in regard to key findings, and relatively few novel approaches to improving information comprehension have been described in the health literature. Promising approaches being proposed, developed, and tested are described, such as enhanced-access computerized patient choice modules, "debiasing" techniques, and tailoring of information. Additional theoretical and practical issues are discussed, as well as selected policy implications of current knowledge.

Cancer patients' preferences for communicating clinical trial quality of life information: a qualitative study

Health-related quality of life (HRQL) is a prevalent outcome measure in clinical trials, but it is not known how best to communicate HRQL results to new patients with cancer. The purpose was to explore cancer patients' attitudes toward, and preferences for, 10 visual and written formats for communicating HRQL information. Using standardized qualitative methods, six focus groups were held (two groups in each of three cancer centres) with patients who had completed treatment for cancer at least 6 months earlier. Groups were stratified according to patients' education. To ensure consistency across centres, group moderators used the same detailed guide, training video, and props. Three investigators independently coded the resulting transcripts. Participants also rated each of the 10 presentation formats as to their perceived usefulness. Fourteen men and 19 women with a variety of cancer diagnoses participated; 13 (39%) participated in the three lower-education groups and 20 (61%) in the three higher-education groups. We found that simple formats (simple graphs or written text) were generally preferred to more complex graphical information, regardless of educational level. The same format was rated favourably by the highest proportion of participants in both the high (85%) and low (85%) education level groups. Individual patients, however, varied as to which visual format they most preferred. Patients did not wish to receive HRQL information out of context or without explanation. We conclude that cancer patients desire HRQL information, but vary in their preferences for its communication. Simple formats are generally preferred.

What patient population does visit-based sampling in primary care settings represent?

BACKGROUND

Evaluations of outpatient interventions often rely on consecutive sampling of clinic visitors, and assume that study results generalize to the population of patients cared for.

OBJECTIVE

The representativeness of such visit-based sampling compared with the population of patients seen during the same year, in terms of sociodemographic and clinical characteristics of the user groups that visit-based sampling yielded were assessed.

METHODS

One thousand five hundred forty-six continuing patients visiting the primary care firms in an urban VA medical center were consecutively sampled, and visit frequencies were compared for these patients with subsets of the patient population. Administrative and survey data was then used to describe the types of patients visit-based sampling most represented compared with the types of patients sampled less frequently.

RESULTS

The average sampled patient visited the firms significantly more often than patients in the reference population (18.7 vs. 9.5). Sampled patients were significantly older (>55 years), in poorer health (higher prevalence of cancer, stroke, hypertension), less likely to smoke, and more likely to be single than the average patient visiting the firms (P<0.05). Adjusting for age and sickness, frequent visitors were more apt to have experienced continuity of care during the prior year, to prefer VA care, and to be unemployed.

CONCLUSIONS

Consecutive visit-based sampling actually selected patients with a visit pattern more typical of the patient population visiting four or more times a year. Studies using sampling of consecutive visitors will typically under-represent low users of care and should account for the degree to which results may not generalize to the broader practice population.

Effect of framing as gain versus loss on understanding and hypothetical treatment choices: survival and mortality curves

BACKGROUND

Presentation of information using survival or mortality (i.e., incidence) curves offers a potentially powerful method of communication because such curves provide information about risk over time in a relatively simple graphic format. However, the effect of framing as survival versus mortality on understanding and treatment choice is not known.

METHODS

In this study, 451 individuals awaiting jury duty at the Philadelphia City Courthouse were randomized to receive 1 of 3 questionnaires: (1) survival curves, (2) mortality curves, or (3) both survival and mortality curves. Each questionnaire included a brief description of a hypothetical treatment decision, survival curve graphs and/or mortality curve graphs presenting the outcome of the treatment, and questions measuring understanding of the information contained in the graphs and preference for undergoing treatment. After completing a brief practice exercise, participants were asked to answer questions assessing their ability to interpret single points on a curve and the difference between curves, and then to decide whether they would choose to undergo preventive surgery for 3 different scenarios in which the benefit of surgery varied.

RESULTS

Participants who received only survival curves or who received both survival and mortality curves were significantly more accurate in answering questions about the information than participants who received only mortality curves (P < 0.05). For 2 of the 3 treatment presentations, participants who received only mortality curves were significantly less likely to prefer preventive surgery than participants who received survival curves only or both survival and mortality curves (P < 0.05). The effect of framing on understanding was greatest among participants with less than a college education and among non-Caucasian participants.

CONCLUSION

Framing graphic risk information as chance of death over time results in lower levels of understanding and less interest in preventive surgery than framing as chance of survival over time.

Understanding risk and lessons for clinical risk communication about treatment preferences

This paper defines risk and its component elements and describes where clinical practice may be starting from in terms of what is reported in the literature about understanding risks and the information requirements of consumers. It notes briefly how theoretical models in the literature contribute to our understanding by providing a basis from which to summarise current evidence about the effects of healthcare interventions which address risks and risk behaviour. The situations or types of interventions in which risk related interventions are most effective are described, but a significant caveat is noted about the types of outcomes which have been reported in the literature and which are most appropriate to evaluate. The effects of "framing" variations in the information given to consumers and the ethical dilemmas these raise for a debate about "informed choice" in healthcare programmes are discussed. In response to both the practical and ethical dilemmas that arise from the current evidence, some of the areas where attention should be focused in the future are outlined so that both health gain and informed choice might be achieved. These include the use of decision aids, although their implementation is not widespread at present. Lessons from the current literature on how further progress can be made towards improved communication, discussion between professionals and consumers, and enhancing informed choice are discussed.

Identifying patient preferences for communicating risk estimates: a descriptive pilot study

BACKGROUND

Patients increasingly seek more active involvement in health care decisions, but little is known about how to communicate complex risk information to patients. The objective of this study was to elicit patient preferences for the presentation and framing of complex risk information.

METHOD

To accomplish this, eight focus group discussions and 15 one-on-one interviews were conducted, where women were presented with risk data in a variety of different graphical formats, metrics, and time horizons. Risk data were based on a hypothetical woman's risk for coronary heart disease, hip fracture, and breast cancer, with and without hormone replacement therapy. Participants' preferences were assessed using likert scales, ranking, and abstractions of focus group discussions.

RESULTS

Forty peri- and postmenopausal women were recruited through hospital fliers (n = 25) and a community health fair (n = 15). Mean age was 51 years, 50% were non-Caucasian, and all had completed high school. Bar graphs were preferred by 83% of participants over line graphs, thermometer graphs, 100 representative faces, and survival curves. Lifetime risk estimates were preferred over 10 or 20-year horizons, and absolute risks were preferred over relative risks and number needed to treat.

CONCLUSION

Although there are many different formats for presenting and framing risk information, simple bar charts depicting absolute lifetime risk were rated and ranked highest overall for patient preferences for format.

The effectiveness of one-to-one risk communication interventions in health care: a systematic review

OBJECTIVES

To assess whether risk-communication interventions are associated with changes in patient knowledge, attitudes, and behaviors, and to identify aspects of these interventions that modify these effects.

DESIGN

Systematic review.

DATA SOURCES

96 studies from the period 1985-1996 retrieved by electronic searching of eight databases, hand searching of four journals, contacting key authors, and reference list searching.

MAIN OUTCOME MEASURES

The effect size of the principal outcome was identified from each study. Outcomes measuring behavioral change were preferred; if these were not available, knowledge, anxiety, or risk perceptions were used, according to the focus of the study. Data were available to calculate the principal effect sizes for 82 of the studies.

ANALYSIS

Meta-regression.

RESULTS

The methodologic qualities of the studies varied. Nevertheless, risk-communication interventions generally had positive (beneficial) effects. Interventions addressing treatment choices were associated with larger effects than were those in other contexts, such as prevention or screening. Interventions using individual risk estimates were associated with larger effects than were those using more general risk information. Two design variables were identified as effect modifiers: randomized controlled trials were associated with smaller effects than other designs, and dichotomous outcomes were associated with larger effects than continuous outcomes.

CONCLUSIONS

Risk communication interventions may be most productive if they include individual risk estimates in the discussion between professional and patient. Patient decisions about treatment appear more amenable to change by these interventions than attendance for screening or modification of risky behavior.

Evidence-informed patient choice. Practical issues of involving patients in decisions about health care technologies

Evidence-informed patient choice involves providing people with research-based information about the effectiveness of health care options and promoting their involvement in decisions about their treatment. Although the concept seems desirable, the processes and outcomes of evidence-informed patient choice are poorly understood, and it should be carefully evaluated.

Partnerships with patients: the pros and cons of shared clinical decision-making

The traditional style of medical decision-making in which doctors take sole responsibility for treatment decisions is being challenged. Attempts are being made to promote shared decision-making in which patients are given the opportunity to express their values and preferences and to participate in decisions about their care. Critics of shared decision-making argue that most patients do not want to participate in decisions; that revealing the uncertainties inherent in medical care could be harmful; that it is not feasible to provide information about the potential risks and benefits of all treatment options; and that increasing patient involvement in decision-making will lead to greater demand for unnecessary, costly or harmful procedures which could undermine the equitable allocation of health care resources. This article examines the evidence for and against these claims. There is considerable evidence that patients want more information and greater involvement, although knowledge about the circumstances in which shared decision-making should be encouraged, and the effects of doing so, is sparse. There is an urgent need for more research into patients' information needs and preferences and for the development and evaluation of decision-support mechanisms to enable patients to become informed participants in treatment decisions.

Admission decisions in emergency department chest pain patients at low risk for myocardial infarction: patient versus physician preferences

STUDY OBJECTIVE

Patient involvement in medical decisionmaking is accepted as an ethical and a legal imperative. Medical decisions are based in part on individuals' knowledge and acceptance of risk of adverse consequences. It is unclear whether actions taken to protect against low risk of poor outcome reflect patient or physician preferences. We sought to test the hypothesis that emergency department chest pain patients presented with a hypothetical situation involving a low risk of myocardial infarction are more willing than ED physicians to accept the risk associated with discharge from the hospital.

METHODS

We prospectively surveyed 89 ED patients with chest pain and a cohort of physicians in the ED who had been presented a hypothetical case in which the risk of AMI was quoted as 5% and the risk of death or disability if the patient was discharged was 1% and .2% if the patient was admitted. All the patients had presented to the ED with a chief complaint of chest pain; the 31 physicians, all residents, were approached at a teaching conference separate from their clinical duties.

RESULTS

Twenty-eight patients (31%), compared with 2 physicians (6%), chose discharge for the hypothetical patient with chest pain (25% difference; 95% confidence interval [CI], 6% to 41%). Forty-four patients (49%), compared with 30 physicians (97%), correctly identified the risks associated with admission and discharge (46% difference; 95% CI, 29% to 63%). Of the subjects who correctly identified the risks, 19 patients (43%) preferred discharge, compared with 1 physician (3%) (40% difference; 95% CI, 18% to 60%).

CONCLUSION

ED patients with chest pain appear to be more likely than physicians to accept a small risk of poor outcome in a hypothetical circumstance. Many patients cannot identify the risks associated with their decision.

Older patients' willingness to trade off urologic adverse outcomes for a better chance at five-year survival in the clinical setting of prostate cancer

OBJECTIVE

To assess whether patients report a willingness to trade-off urologic adverse outcomes--urinary incontinence and total impotence--for a better chance of 5-year survival in the clinical setting of prostate cancer; and, if so, whether patients' current levels of symptoms of urinary incontinence, impotence, and frequency of sexual activity influence their decisions.

DESIGN

Structured interviews with a convenience sample of male patients.

SETTING

A university-based Department of Veterans Affairs Medical Center.

PATIENTS

One hundred sixty-three patients seen consecutively in General Medical Clinic at the Department of Veterans Affairs Medical Center in Portland, Oregon, were enrolled in the study. Mean age of the patients was 65.2 years (SD = 10.6, range - 35-84); mean level of formal education completed was 13 years (SD = 2.7, range = 5-19).

MEASUREMENTS

In a hypothetical clinical setting of prostate cancer, patients were offered a choice of two procedures--Treatment A (surgery: worse short-term, better long-term survival) and Treatment B (radiation therapy: better short-term, worse long-term survival)--with varying benefit/risk trade-offs in time. Patients were presented with pairs of treatment curves that were developed from research data on survival for surgery versus radiation therapy for stage II prostate cancer confined to the prostate gland. Treatments were not identified to control for labeling effects. Patients were asked their willingness to accept a chance of immediate mortality for better 5-year survival in one of four treatment curve comparisons. Of those who accepted the net beneficial procedure, we then inquired as to whether urologic complications--urinary incontinence and wearing an appliance to collect urine or total impotence--altered the acceptability of that treatment.

RESULTS

Ninety-four percent (153/163) of patients were willing to choose Treatment A (worse short-term, better long-term survival) on one of the four scenarios; the remainder (10/163) were unwilling to take Treatment A (worse short-term, better long-term survival) on any of the four scenarios. Sixty-two percent (95/153) of patients were willing to accept a 100% chance of urinary incontinence; 83% (127/153) were willing to accept a 100% chance of impotence (chi-square = 16.8 with 1 df, P = .0001).

CONCLUSIONS

Our results in an older male veteran population suggest than many patients are more concerned with long-term survival in the clinical setting of prostate cancer than with short-term treatment risks. In addition, patients are more willing to accept an impotence outcome than a urinary incontinence outcome, but this result was not related to patients' reported frequency of sexual activity.

The effect of physician's explanations on patients' treatment preferences: five-year survival data

OBJECTIVE

To evaluate the influence of physicians' explanations on patients' choices.

SETTING

A university-based Department of Veterans Affairs Medical Center.

PARTICIPANTS

136 patients seen in a continuity-care general medicine clinic.

MEASUREMENTS AND RESULTS

Patients were randomized to two groups [Limited Explanation (LE) and Extensive Explanation (EE)] and asked to choose between two alternative treatments (differing in short-term vs long-term survival benefits) for an unidentified medical condition, based on the information given in the explanations. LE consisted of a brief orientation to graphs summarizing the treatment results, while EE consisted of a detailed verbal description of the graphs. Significantly (p < 0.001) more patients receiving EE changed their preferences across the three pairs of five-year survival curves, compared with patients receiving LE. Of the patients receiving EE, 57% reported either medium-term (year 0-to-intercept or intercept-to-year 5) data or the average life expectancy for the five-year period contained in the curves (ALE-5) as most influencing their decision making; whereas 78% of patients receiving LE reported only endpoint (year 0 or year 5) data as most influencing their preferences.

CONCLUSIONS

The patients' treatment preferences for long-term vs short-term survival benefits were influenced by the amounts of verbal explanation provided to them about five-year survival graphs summarizing treatment results. The patients appeared to minimize the importance of medium-range data when those data were not specifically pointed out to them.

Patient preferences: survival vs quality-of-life considerations

OBJECTIVE

To assess whether patients can weigh risk comparisons involving mortality and quality of life in an understandable manner based on their willingness to accept risks of complications.

DESIGN

Cross-sectional survey of patients.

SETTING

University-based Department of Veterans Affairs Medical Center.

PARTICIPANTS

230 men patients seen in a general medicine clinic.

MEASUREMENTS

Two survival graphs were used. Each graph contained survival curves for two alternative unidentified treatments for an unidentified medical condition. Graph 2 contained one curve that had a life expectancy that was 14% higher than the life expectancy of the corresponding curve in graph 1. Respondents were randomly assigned one of the two graphs and were asked to indicate which treatment they preferred and what risk of a change in their quality of life (urinary incontinence or importance) they were willing to accept to achieve longer survival. Patients were also asked whether they had a history of urinary incontinence or impotence.

RESULTS AND CONCLUSIONS

Patients tended to be unwilling to accept worse quality of life to achieve increased survival over time. For both curve comparisons, significantly more (p < 0.01) patients accepted a treatment associated with higher mortality to avoid a 100% chance of incontinence than to avoid a 100% chance of impotence. Of the 75% (172/230) of patients reporting willingness to accept risk of either urinary incontinence or total impotence or both, 62% reported having at least some symptoms related to urinary incontinence or impotence. Of the 58 patients not willing to accept the complication risks, only 11% reported a history of urinary incontinence or impotence. The results show that patients are able to make distinctions about severity of morbidity, men are less willing to accept the risk of urinary incontinence than that of total impotence, and men patients who are symptomatic with urinary incontinence or impotence are more willing to accept the risks of treatment than are asymptomatic patients.

Patients' and physicians' interpretations of graphic data displays

To assess how patients' and physicians' treatment preferences are influenced by graphic data displays (five-year survival curves), a cross-sectional survey of patients, physicians, and medical students was done in a university-based Department of Veterans Affairs Medical Center. Participants in the study were 119 patients seen in a general medicine clinic, 43 physicians, and 67 medical students. Three five-year survival graphs were used. Each graph contained survival curves for two alternative unidentified treatments for an unidentified medical condition. Graph 1 was a baseline graph used in previous studies of framing effects. Graph 2 contained one survival curve having an area under the curve that was 24% greater than that in graph 1. Graph 3 contained one survival curve that had an area under the curve that was 42% greater than that in graph 1. Respondents were asked to indicate which treatment they preferred for each graph and which aspects of the five-year survival curves most influenced their choices. Respondents did not receive numerical data about the difference between the areas under the two curves. Most patients did not change their preferences across the three graphs. A significantly larger (p < or = 0.0001) proportion of physicians and medical students than of patients changed their preferences across the three graphs.(ABSTRACT TRUNCATED AT 250 WORDS)