The framing effect of relative and absolute risk

How to talk to parents

Effective communication with the child and his/her parents is of paramount importance in our daily work in paediatric radiology to establish a trusting relationship and enhance satisfaction for both patients and physicians. Although communication skills and empathy can be effectively taught, and efforts have been made in this area in medical schools, there is still much room for improvement, as communication skills tend to decline throughout medical training. Certain methods are valuable for conducting effective consultations with both the child and the parents, not only when breaking bad news. Paying attention to non-verbal cues can improve our understanding of the family's thoughts and enhance our ability to communicate through all channels. Rethinking the general environment of the department and consultation/ultrasound rooms may also promote effective communication. Having basic knowledge of intercultural communication and strategies for communicating with families with low literacy skills can also be beneficial. In paediatric interventional radiology, specific techniques can be used to better explain the procedure and the concept of risk and to address the family's anxiety.

How Difference Tasks Are Affected by Probability Format, Part 2: A Making Numbers Meaningful Systematic Review

Background. To evaluate the effect of data presentation format on communication of health probabilities, the Making Numbers Meaningful team undertook a systematic review. Purpose. This article presents evidence about difference tasks, in which a reader examines information to evaluate differences between probabilities, such as the effect of a therapy on the chance of recurrence. This article covers the effect of format on 5 outcomes: 1) perceptions of or feelings about effectiveness, 2) behavioral intentions or behaviors, 3) trust, 4) preference for the format, and 5) discrimination. Data Sources. MEDLINE, Embase, CINAHL, the Cochrane Library, PsycINFO, ERIC, ACM Digital Library; hand search. Finding Selection. Experimental/quasi-experimental studies comparing 2 or more formats for presenting quantitative health information. This article covers 205 findings from 101 unique studies reported in 84 articles. Data Extraction. Dual extraction of information on stimulus, task, and perceptual, affective, cognitive, and behavioral outcomes. Data Synthesis. Evidence is moderate to strong that behavioral intention is affected more by relative differences than absolute ones, by numerator-only graphics than part-to-whole graphics, by messages with anecdotes than without, and by information about what others chose. Evidence is strong that perceived and felt effectiveness is affected more by relative differences than by absolute ones and more by numerator-only graphics rather than part-to-whole graphics. For graphic preferences, bar charts were preferred to icon arrays and graphics with data labels to graphics without. Other comparisons had weak or insufficient evidence. Limitations. The detailed approach to evidence syntheses provides narrowly targeted evidence rather than broad statements. Conclusions. Moderate to strong evidence can be derived on effects of probability difference format on behavioral intention, perceived or felt effectiveness, and preference for format.

Highlights

Communicating relative risk differences as opposed to absolute risk differences, using numerator-only instead of part-to-whole graphics, and including anecdotes or information about others' decisions will all increase intentions to engage in a behavior.Relative risks (rather than absolute risk differences) and numerator-only graphics (rather than part-to-whole) will also increase felt and perceived effectiveness.To illustrate probability differences, people tend to prefer bar charts over icon arrays and graphics with labels over those without.All findings regarding the impact of different presentation formats for probability differences on trust produced insufficient evidence.

Estimating an adjusted risk difference in a cluster randomized trial with individual-level analyses

In cluster randomized trials (CRTs) with a binary outcome, intervention effects are usually reported as odds ratios, but the CONSORT statement advocates reporting both a relative and an absolute intervention effect. With a simulation study, we assessed several methods to estimate a risk difference (RD) in the framework of a CRT with adjustment on both individual- and cluster-level covariates. We considered both a conditional approach (with the generalized linear mixed model [GLMM]) and a marginal approach (with the generalized estimating equation [GEE]). For both approaches, we considered the Gaussian, binomial, and Poisson distributions. When considering the binomial or Poisson distribution, we used the g-computation method to estimate the RD. Convergence problems were observed with the GEE approach, especially with low intra-cluster coefficient correlation values, small number of clusters, small mean cluster size, high number of covariates, and prevalences close to 0. All methods reported no bias. The Gaussian distribution with both approaches and binomial and Poisson distributions with the GEE approach had satisfactory results in estimating the standard error. Results for type I error and coverage rates were better with the GEE than GLMM approach. We recommend using the Gaussian distribution because of its ease of use (the RD is estimated in one step only). The GEE approach should be preferred and replaced with the GLMM approach in cases of convergence problems.

Chat Generative Pre-Trained Transformer (ChatGPT) - 3.5 Responses Require Advanced Readability for the General Population and May Not Effectively Supplement Patient-Related Information Provided by the Treating Surgeon Regarding Common Questions About Rotator Cuff Repair

PURPOSE

To investigate the accuracy of Chat Generative Pre-Trained Transformer (ChatGPT)'s responses to frequently asked questions prior to rotator cuff repair surgery.

METHODS

The 10 most common frequently asked questions related to rotator cuff repair were compiled from 4 institution websites. Questions were then input into ChatGPT-3.5 in 1 session. The provided ChatGPT-3.5 responses were analyzed by 2 orthopaedic surgeons for reliability, quality, and readability using the Journal of the American Medical Association Benchmark criteria, the DISCERN score, and the Flesch-Kincaid Grade Level.

RESULTS

The Journal of the American Medical Association Benchmark criteria score was 0, indicating the absence of reliable source material citations. The mean Flesch-Kincaid Grade Level was 13.4 (range, 11.2-15.0). The mean DISCERN score was 43.4 (range, 36-51), indicating that the quality of the responses overall was considered fair. All responses cited making final decision-making to be made with the treating physician.

CONCLUSIONS

ChatGPT-3.5 provided substandard patient-related information in alignment with recommendations from the treating surgeon regarding common questions around rotator cuff repair surgery. Additionally, the responses lacked reliable source material citations, and the readability of the responses was relatively advanced with a complex language style.

CLINICAL RELEVANCE

The findings of this study suggest that ChatGPT-3.5 may not effectively supplement patient-related information in the context of recommendations provided by the treating surgeon prior to rotator cuff repair surgery.

Scope, Methods, and Overview Findings for the Making Numbers Meaningful Evidence Review of Communicating Probabilities in Health: A Systematic Review

Background. The format in which probabilities are presented influences comprehension and interpretation. Purpose. To develop comprehensive evidence-based guidance about how to communicate probabilities in health and to identify strengths and weaknesses in the literature. This article presents methods for the review of probability communication and is accompanied by several results articles. Data Sources. MEDLINE, Embase, CINAHL, the Cochrane Library, PsycINFO, ERIC, ACM Digital Library; hand search of 4 journals. Study Selection. Two reviewers conducted screening to identify experimental and quasi-experimental research that compared 2 or more formats for presenting quantitative health information to patients or lay audiences. Data Extraction. In our conceptual framework, people make sense of a stimulus (data in a data presentation format) by performing cognitive tasks, resulting in perceptual, affective, cognitive, or behavioral responses measured as 1 of 14 distinct outcomes. The study team developed custom instruments to extract concepts, conduct risk-of-bias evaluation, and evaluate individual findings for credibility. Data Synthesis. Findings were grouped into tables by task and outcome for evidence synthesis. Limitations. Reviewer error could have led to missing relevant studies despite having 2 independent reviewers screening each article. The granular data extraction and syntheses slowed the work and may have made it less replicable. Credibility was evaluated by only 2 experts. Conclusions. After reviewing 26,793 titles and abstracts, we identified 316 articles about probability communication. Data extraction produced 1,119 individual findings, which were grouped into 37 evidence tables, each containing evidence on up to 10 data presentation format comparisons. The Making Numbers Meaningful project required novel methods for classifying and synthesizing research, which reveal patterns of strength and weakness in the probability communication literature.

Highlights

The Making Numbers Meaningful project conducted a comprehensive systematic review of experimental and quasi-experimental research that compared 2 or more formats for presenting quantitative health information to patients or other lay audiences. The current article focuses on probability information.Based on a conceptual taxonomy, we reviewed studies based on the cognitive tasks required of participants, assessing 14 distinct possible outcomes.Our review identified 316 articles involving probability communications that generated 1,119 distinct research findings, each of which was reviewed by multiple experts for credibility.The overall pattern of findings highlights which probability communication questions have been well researched and which have not. For example, there has been far more research on communicating single probabilities than on communicating more complex information such as trends over time, and there has been a large amount of research on the effect of communication approaches on behavioral intentions but relatively little on behaviors.

Pitfalls of reasoning in hospital-based transfusion medicine

INTRODUCTION

Hospital-based transfusion involves hundreds of daily medical decisions. Medical decision-making under uncertainty is susceptible to cognitive biases which can lead to systematic errors of reasoning and suboptimal patient care. Here we review common cognitive biases that may be relevant for transfusion practice.

MATERIALS AND METHODS

Biases were selected based on categorical diversity, evidence from healthcare contexts, and relevance for transfusion medicine. For each bias, we provide background psychology literature, representative clinical examples, considerations for transfusion medicine, and strategies for mitigation.

RESULTS

We report seven cognitive biases relating to memory (availability heuristic, limited memory), interpretation (framing effects, anchoring bias), and incentives (search satisficing, sunk cost fallacy, feedback sanction).

CONCLUSION

Pitfalls of reasoning due to cognitive biases are prominent in medical decision making and relevant for hospital transfusion medicine. An awareness of these phenomena might stimulate further research, encourage corrective measures, and motivate nudge-based interventions to improve transfusion practice.

The impact of nontransparent health communication during the COVID-19 pandemic on vaccine-hesitant people's perception of vaccines

Background

Although transparency is crucial for building public trust, public health communication during the COVID-19 pandemic was often nontransparent.

Methods

In a cross-sectional online study with COVID-19 vaccine-hesitant German residents (N = 763), we explored the impact of COVID-19 public health communication on the attitudes of vaccine-hesitant individuals toward vaccines as well as their perceptions of incomprehensible and incomplete information. We also investigated whether specific formats of public health messaging were perceived as more trustworthy.

Results

Of the 763 participants, 90 (11.8%) said they had become more open-minded toward vaccines in general, 408 (53.5%) reported no change, and 265 (34.7%) said they had become more skeptical as a result of public health communication on COVID-19 vaccines. These subgroups differed in how incomprehensible they found public health communication and whether they thought information had been missing. Participants' ranking of trustworthy public health messaging did not provide clear-cut results: the fully transparent message, which reported the benefit and harms in terms of absolute risk, and the nontransparent message, which reported only the benefit in terms of relative risk were both considered equally trustworthy (p = 0.848).

Discussion

Increased skepticism about vaccines during the COVID-19 pandemic may have partly been fueled by subpar public health communication. Given the importance of public trust for coping with future health crises, public health communicators should ensure that their messaging is clear and transparent.

Ethical Considerations in Neuroprognostication Following Acute Brain Injury

Neuroprognostication following acute brain injury (ABI) is a complex process that involves integrating vast amounts of information to predict a patient's likely trajectory of neurologic recovery. In this setting, critically evaluating salient ethical questions is imperative, and the implications often inform high-stakes conversations about the continuation, limitation, or withdrawal of life-sustaining therapy. While neuroprognostication is central to these clinical "life-or-death" decisions, the ethical underpinnings of neuroprognostication itself have been underexplored for patients with ABI. In this article, we discuss the ethical challenges of individualized neuroprognostication including parsing and communicating its inherent uncertainty to surrogate decision-makers. We also explore the population-based ethical considerations that arise in the context of heterogenous prognostication practices. Finally, we examine the emergence of artificial intelligence-aided neuroprognostication, proposing an ethical framework relevant to both modern and longstanding prognostic tools.

Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations

Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.

The impact of influences in a medical screening programme invitation: a randomized controlled trial

BACKGROUND

Invitations to screening programmes may include influences that are intending to increase the participation rates. This study had two objectives: (i) to assess if different categories of influences had a significant effect on the intention to participate in a screening programme for a fictitious disease and (ii) whether participants were aware of the influences, and if the intention to participate was associated to this awareness.

METHODS

A seven-armed randomized controlled trial. Six hundred passers-by were randomly allocated to receive one of seven pamphlets inviting to a fictitious screening programme (neutral, relative risk reductions, misrepresentation of harms, pre-booked appointment, recommendation of participation, fear appeals, all combined). Participants were surveyed to assess (i) intention to participate (ITP) in the screening programme and (ii) awareness of an exerted influence. Chi-squared test was used to calculate the effect of the influences on ITP and the association of ITP with indicating awareness of an exerted influence and correctly locating an influence.

RESULTS

Five hundred and eighty-nine participants were included for analysis. ITP was significantly increased (P < 0.05) in three pamphlets (misrepresentation of harms, fear appeals, all combined) [adjusted odds ratio (OR) 4.84, 95% confidence interval (CI): 2.54-9.23; OR 2.45, 95% CI: 1.31-4.59; OR 9.02, 95% CI: 4.44-18.34]. A percentage of 60.0-78.3 participants did not indicate awareness. Awareness was associated with a decreased ITP for those who could locate the influence (OR 0.39, 95% CI: 0.21-0.72) and those who failed to locate the influence (OR 0.47, 95% CI: 0.30-0.74).

CONCLUSION

The application of influences should be carefully considered for interventions where an informed choice is desired.

Understanding what patients and physicians need to improve their decision-making about antenatal corticosteroids in late preterm gestation: a qualitative framework analysis

BACKGROUND

It is unclear whether the benefits of administration of antenatal corticosteroids in late preterm gestation outweigh its harms. We sought to understand whether patients and physicians need increased support to decide whether to administer antenatal corticosteroids in late preterm gestation, and their informational needs and preferences for decision-making roles related to this intervention; we also wanted to know if creation of a decision-support tool would be useful.

METHODS

We conducted individual, semistructured interviews with pregnant people, obstetricians and pediatricians in Vancouver, Canada, in 2019. Using a qualitative framework analysis method, we coded, charted and interpreted interview transcripts into categories that formed an analytical framework.

RESULTS

We included 20 pregnant participants, 10 obstetricians and 10 pediatricians. We organized codes into the following categories: informational needs to decide whether to administer antenatal corticosteroids; preferences for decision-making roles regarding this treatment; the need for support to make this treatment decision; and the preferred format and content of a decision-support tool. Pregnant participants wanted to be involved in decision-making about antenatal corticosteroids in late preterm gestation. They wanted information on the medication, respiratory distress, hypoglycemia, parent-neonate bonding and long-term neurodevelopment. There was variation in physician counselling practices, and in how patients and physicians perceived the balance of treatment harms and benefits. Responses suggested a decision-support tool may be useful. Participants desired clear descriptions of risk magnitude and uncertainty.

INTERPRETATION

Pregnant people and physicians would likely benefit from increased support to consider the harms and benefits of antenatal corticosteroids in late preterm gestation. Creation of a decision-support tool may be useful.

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

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

Mortality Burden and Life-Years Lost Across the Age Spectrum for Adults Living with CKD

Key Points

Limited data exist to inform younger persons with CKD how their risk for mortality compares with equivalently aged individuals without CKD. Compared with the general population without CKD, the age-stratified risk for mortality was highest in younger individuals with CKD. From a lifetime perspective, the estimated reduction of lifespan secondary to CKD was greatest at younger ages.

Background

Younger individuals living with CKD face a lifetime at risk for complications and mortality. Limited data exist to inform individual patients with CKD across the lifespan how their risk for mortality compares with equivalently aged individuals without CKD, particularly at younger ages. The objective of this study was to provide age-specific contexts to the risk of mortality associated with a diagnosis of CKD.

Methods

We created a pooled study cohort using participants with CKD enrolled in the Chronic Renal Insufficiency Cohort along with participants aged 21–75 years included in the 1999–2008 National Health and Nutrition Examination Survey surveys. Age-stratified mortality rates, along with unadjusted and adjusted hazard ratios (HRs) for mortality, were generated to compare differences between those with and without CKD. The mean life-years lost (LYL) relating to CKD was calculated using Centers for Disease Control and Prevention life tables.

Results

A total of 16,725 participants were included. Mortality rates were higher in those with CKD at all ages. The adjusted age-stratified HR for mortality in those with CKD versus without was highest in the 21–35 years strata (HR [95% confidence interval (CI)], 4.9 [2.8 to 8.6])) and lowest in the 65–75 years strata (HR [95% CI], 2.0 [1.7 to 2.3]). The mean LYL secondary to CKD was inversely related with increasing age.

Conclusions

Compared with age-matched peers without CKD, the age-stratified risk for mortality and LYL associated with a diagnosis of CKD is highest in younger individuals. Further research is needed to elucidate the societal and personal costs of premature mortality associated with CKD in young adults.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic comparison of risky choices in humans and monkeys

The past decades have seen tremendous progress in fundamental studies on economic choice in humans. However, elucidation of the underlying neuronal processes requires invasive neurophysiological studies that are met with difficulties in humans. Monkeys as evolutionary closest relatives offer a solution. The animals display sophisticated and well-controllable behavior that allows to implement key constructs of proven economic choice theories. However, the similarity of economic choice between the two species has never been systematically investigated. We investigated compliance with the independence axiom (IA) of expected utility theory as one of the most demanding choice tests and compared IA violations between humans and monkeys. Using generalized linear modeling and cumulative prospect theory (CPT), we found that humans and monkeys made comparable risky choices, although their subjective values (utilities) differed. These results suggest similar fundamental choice mechanism across these primate species and encourage to study their underlying neurophysiological mechanisms.

Air quality change and public perception during the COVID-19 lockdown in India

This study aims at analyzing the change in air quality following the COVID-19 lockdown in India and its perception by the general public. Air quality data for 100 days recorded at 193 stations throughout India were analyzed between 25th March to 17th May 2020. A nationwide online survey was conducted to obtain public perceptions of air quality improvement (n = 1750). On average, approximately 40% improvement in the air quality index was observed, contributed by a reduction in 40% of PM₁₀, 44% of PM_2.5, 51% of NO₂ and 21% of SO₂. There was a significant difference between the levels of all the pollutants before and after the lockdown (p < 0.05), except ozone. The correlation between PM₁₀ and PM_2.5 with ozone was significant after the lockdown period, indicating that a significant portion of the particulates present in the atmosphere after the lockdown period is secondary. The values of PM_2.5/PM₁₀ were found to be >0.5 in North East states and this observation points to the long-distance transport of PM_2.5 from other places. The survey for public perception showed that 60% of the respondents perceived improvement in air quality. Household emissions were perceived to be a significant source of pollution after the lockdown. An odds ratio (OR) of 17 (95%, CI: 6.42, 47.04) indicated a very high dependence of perception on actual air quality. OR between air quality and health improvement was 5.2 (95%, CI: 2.69, 10.01), indicating significant health improvement due to air quality improvement. Google Trends analysis showed that media did not influence shaping the perception. There was a significant improvement in the actual and perceived air quality in India after the COVID-19-induced lockdown. PM₁₀ levels had the most decisive influence in shaping public perception.

Rationality and cognitive bias in captive gorillas' and orang-utans' economic decision-making

Human economic decision-making sometimes appears to be irrational. Partly, this is due to cognitive biases that can lead to suboptimal economic choices and context-dependent risk-preferences. A pertinent question is whether such biases are part of our evolutionary heritage or whether they are culturally acquired. To address this, we tested gorillas (Gorilla gorilla gorilla) and orang-utans (Pongo abelii) with two risk-assessment experiments that differed in how risk was presented. For both experiments, we found that subjects increased their preferences for the risky options as their expected gains increased, showing basic understanding of reward contingencies and rational decision-making. However, we also found consistent differences in risk proneness between the two experiments, as subjects were risk-neutral in one experiment and risk-prone in the other. We concluded that gorillas and orang-utans are economically rational but that their decisions can interact with pre-existing cognitive biases which modulates their risk-preference in context-dependent ways, explaining the variability of their risk-preference in previous literature.

A review of risk concepts and models for predicting the risk of primary stroke

Predicting an individual's risk of primary stroke is an important tool that can help to lower the burden of stroke for both the individual and society. There are a number of risk models and risk scores in existence but no review or classification designed to help the reader better understand how models differ and the reasoning behind these differences. In this paper we review the existing literature on primary stroke risk prediction models. From our literature review we identify key similarities and differences in the existing models. We find that models can differ in a number of ways, including the event type, the type of analysis, the model type and the time horizon. Based on these similarities and differences we have created a set of questions and a system to help answer those questions that modelers and readers alike can use to help classify and better understand the existing models as well as help to make necessary decisions when creating a new model.

Fracture risk in Asian-Canadian women is significantly over-estimated by the Canadian Association of Radiologists-Osteoporosis Canada risk prediction tool: retrospective cohort study

Fracture risk calculators may not be accurate for all ethnicity groups. The Manitoba bone density registry was used to test the Canadian CAROC tool for predicting fracture risk in Asian-Canadian women. The tool significantly over-estimated fracture risk, suggesting that it may not be ideal for Asian-Canadian patients.

PURPOSE

Health risk prediction tools based on largely White populations may lead to treatment inequity when applied to non-White populations where outcome rates differ. We examined the calibration of the Canadian Association of Radiologists-Osteoporosis Canada (CAROC) fracture risk prediction tool in self-identified Asian-Canadian women.

METHODS

Retrospective cohort study of women over age 50 using the Manitoba BMD Registry. At first BMD, the intake questionnaire collected self-identification of ethnicity and fracture risk factors. 10-year fracture risk was estimated using CAROC and categorized into low, medium, or high fracture risk. Linked administrative databases identified incident osteoporotic fractures. Observed fracture rates were compared between White and Asian-Canadians and compared to the original CAROC risk stratification.

RESULTS

There were 63,632 and 1703 women who self-identified as White-Canadian or Asian-Canadian, respectively, covering approximately 600,000 patient-years follow-up. There were 6588 incident fractures; a similar percentage of patients were assigned to each risk stratum at baseline by CAROC. A progressive rise in 10-year observed fracture rates occurred for each CAROC stratum in the White-Canadian population but much lower fracture rates than predicted in Asian-Canadian patients (p &lt; 0.001). Fracture incidence rate ratios were 1.9-2.6 fold higher in White- vs Asian-Canadian patients for all strata (p &lt; 0.001). In the CAROC moderate and high-risk categories, observed fracture rates in Asian-Canadian patients were typically lower than predicted, indicating poor model calibration.

CONCLUSION

In Asian-Canadian women, observed osteoporosis fracture rates are lower than predicted when using the CAROC tool. Over-estimation of fracture risk may influence shared decision-making discussions.

Predictors of interest in predictive testing for rheumatoid arthritis among first degree relatives of rheumatoid arthritis patients

OBJECTIVES

There is increasing interest in prediction and prevention of RA. It is important to understand the views of those at risk to inform the development of effective approaches. First-degree relatives (FDRs) of RA patients are at increased risk of RA. This study assessed predictors of their interest in predictive testing for RA.

METHODS

Questionnaires were completed by RA patients (provided with their questionnaire by a healthcare professional) and their FDRs (provided with their questionnaire by their RA proband). FDR surveys assessed interest in taking a predictive test, demographic variables, perceived RA risk, attitudes about predictive testing, autonomy preferences, illness perceptions, avoidance coping and health anxiety. Patient surveys included demographic variables, disease impact, RA duration and treatment. Ordinal logistic regression examined the association between FDRs' characteristics and their interest in predictive testing. Generalized estimating equations assessed associations between patient characteristics and FDRs' interest in predictive testing.

RESULTS

Three hundred and ninety-six FDRs responded. Paired data from the RA proband were available for 292. The proportion of FDRs interested in predictive testing was 91.3%. Information-seeking preferences, beliefs that predictive testing can increase empowerment over health and positive attitudes about risk knowledge were associated with increased interest. Beliefs that predictive testing could cause psychological harm predicted lower interest. Patient characteristics of the proband were not associated with FDRs' interest.

CONCLUSIONS

FDRs' interest in predictive testing for RA was high, and factors associated with interest were identified. These findings will inform the development of predictive strategies and informational resources for those at risk.

Communicating Absolute Fracture Risk Reduction and the Acceptance of Treatment for Osteoporosis

Healthcare professionals frequently communicate the benefits of treatments as a relative risk reduction (RRR) in the likelihood of an event occurring. Here we evaluated whether presenting the benefits of osteoporosis treatment as a RRR in fractures compared with an absolute risk reduction (ARR) changed the patient's attitudes towards accepting treatment. We surveyed 160 individuals attending a specialised osteoporosis clinic for face-to-face consultations between May 2018 and Jan 2021. They were presented with information on RRR for the treatment being considered followed by ARR and after each question were asked about how likely they would be to start treatment on a 5-point scale (1 = very likely, 5 = very unlikely). Participants were less likely to accept treatment when it was presented as ARR (mean score 2.02 vs. 2.67, p < 0.001, 95% CI for difference - 0.82 vs - 0.47) and thirty-eight participants (23.7%) declined treatment with knowledge of their ARR when they would have accepted the same treatment based on the RRR. Individuals who declined treatment had a lower 5-year risk of fracture than those who accepted treatment (9.0 vs. 12.5%, p < 0.001, 95% CI - 5.0 to - 1.6) and as fracture risk decreased, the participant was less likely to accept treatment (Spearman r - 0.32, 95% CI - 0.46 to - 0.17, p ≤ 0.001). Whilst presentation of data as ARR more accurately reflects individual benefit and helps facilitate shared decision-making, clinicians should be aware that this will lead to a proportion of patients with lower fracture risk declining treatment for osteoporosis.

Making sense of harms and benefits: Assessing the numeric presentation of risk information in ACOG obstetrical clinical practice guidelines

OBJECTIVE

To assess the presentation of risk information in American College of Obstetricians and Gynecologists (ACOG) obstetrical Practice Bulletins.

METHODS

We reviewed B- and C-graded recommendations in Practice Bulletins published from January 2017 to March 2020. We calculated the proportion of recommendations and outcomes that were presented numerically and, of these, the proportion that were presented in accordance with best practices of risk communication - in absolute formats, or as absolute changes in risk from baseline risks. We categorized outcomes as harms or benefits to compare their risk presentation.

RESULTS

In 21 obstetrical Practice Bulletins, there were 125 recommendations, with 46 (37%) describing risks numerically. Sixteen of these 46 recommendations (35%) presented an absolute change in risk from a baseline risk. For harms, 65% were presented as absolute risks and 25% as relative risks. For benefits, this was 55% and 48% respectively.

CONCLUSION

Most recommendations do not present numeric risk information. Of those that do, most do not use absolute risk measures.

PRACTICE IMPLICATIONS

Obstetrical practice guidelines should present numerical risk information wherever possible to support recommendations, increasing the use of absolute risk formats and absolute changes from baseline risks to increase risk comprehension.

Evaluating the Association Between Low-Density Lipoprotein Cholesterol Reduction and Relative and Absolute Effects of Statin Treatment: A Systematic Review and Meta-analysis

IMPORTANCE

The association between statin-induced reduction in low-density lipoprotein cholesterol (LDL-C) levels and the absolute risk reduction of individual, rather than composite, outcomes, such as all-cause mortality, myocardial infarction, or stroke, is unclear.

OBJECTIVE

To assess the association between absolute reductions in LDL-C levels with treatment with statin therapy and all-cause mortality, myocardial infarction, and stroke to facilitate shared decision-making between clinicians and patients and inform clinical guidelines and policy.

DATA SOURCES

PubMed and Embase were searched to identify eligible trials from January 1987 to June 2021.

STUDY SELECTION

Large randomized clinical trials that examined the effectiveness of statins in reducing total mortality and cardiovascular outcomes with a planned duration of 2 or more years and that reported absolute changes in LDL-C levels. Interventions were treatment with statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) vs placebo or usual care. Participants were men and women older than 18 years.

DATA EXTRACTION AND SYNTHESIS

Three independent reviewers extracted data and/or assessed the methodological quality and certainty of the evidence using the risk of bias 2 tool and Grading of Recommendations, Assessment, Development and Evaluation. Any differences in opinion were resolved by consensus. Meta-analyses and a meta-regression were undertaken.

MAIN OUTCOMES AND MEASURES

Primary outcome: all-cause mortality. Secondary outcomes: myocardial infarction, stroke.

FINDINGS

Twenty-one trials were included in the analysis. Meta-analyses showed reductions in the absolute risk of 0.8% (95% CI, 0.4%-1.2%) for all-cause mortality, 1.3% (95% CI, 0.9%-1.7%) for myocardial infarction, and 0.4% (95% CI, 0.2%-0.6%) for stroke in those randomized to treatment with statins, with associated relative risk reductions of 9% (95% CI, 5%-14%), 29% (95% CI, 22%-34%), and 14% (95% CI, 5%-22%) respectively. A meta-regression exploring the potential mediating association of the magnitude of statin-induced LDL-C reduction with outcomes was inconclusive.

CONCLUSIONS AND RELEVANCE

The results of this meta-analysis suggest that the absolute risk reductions of treatment with statins in terms of all-cause mortality, myocardial infarction, and stroke are modest compared with the relative risk reductions, and the presence of significant heterogeneity reduces the certainty of the evidence. A conclusive association between absolute reductions in LDL-C levels and individual clinical outcomes was not established, and these findings underscore the importance of discussing absolute risk reductions when making informed clinical decisions with individual patients.

Ethics and the 2018 Practice Guideline on Disorders of Consciousness: A Framework for Responsible Implementation

The 2018 practice guideline on disorders of consciousness marks an important turning point in the care of patients with severe brain injury. As clinicians and health systems implement the guideline in practice, several ethical challenges will arise in assessing the benefits, harms, feasibility, and cost of recommended interventions. We provide guidance for clinicians when interpreting these recommendations and call on professional societies to develop an ethical framework to complement the guideline as it is implemented in clinical practice.

Adherence in leading medical journals to the CONSORT 2010 statement for reporting of binary outcomes in randomised controlled trials: cross-sectional analysis

Clinicians and lay people tend to overestimate the effectiveness of a treatment when only the relative effect is presented, particularly if the relative effect is large, but the absolute effect is small. In recognition of this problem, item 17b of The Consolidated Standards of Reporting Trials (CONSORT) 2010 statement stipulates authors present both absolute and relative effects for binary outcomes in randomised controlled trials (RCTs). Adherence to item 17b and the effect of differing levels of CONSORT endorsement by journals on adherence is not well known. We assessed the extent to which item 17b is adhered to in 258 RCTs published in five leading medical journals (Annals of Internal Medicine, BMJ, JAMA, The Lancet and The New England Journal of Medicine) between January and December 2019 that all endorsed the CONSORT statement to varying degrees. Only 53 of 258 (20.5%; 95% CI 15.8% to 26.0%) included studies adhered fully to item 17b. Proportional adherence was higher in journals that endorsed the statement more strictly (BMJ and JAMA, 47.4% [34.0% to 61.0%]) compared with journals less strict in their endorsement (NEJM and Ann Intern Med, 12.2% [7.0% to 19.3%]; The Lancet, 14.1% [7.3% to 23.8%]). Journals that only recommend author adherence to CONSORT had a greater proportion of studies reporting only relative effects in the main results section (62.6%) and abstract (64.2%) compared with journals that require authors to submit a completed checklist (24.6% and 29.8%, respectively). The majority of RCTs (79.5%) with binary primary outcomes published in five leading medical journals during 2019 do not report both absolute and relative effect estimates as per item 17b of the CONSORT guideline despite its universal endorsement. Differences in adherence were observed between journals that endorsed the CONSORT statement to differing extents.

The Science of Visual Data Communication: What Works

Effectively designed data visualizations allow viewers to use their powerful visual systems to understand patterns in data across science, education, health, and public policy. But ineffectively designed visualizations can cause confusion, misunderstanding, or even distrust-especially among viewers with low graphical literacy. We review research-backed guidelines for creating effective and intuitive visualizations oriented toward communicating data to students, coworkers, and the general public. We describe how the visual system can quickly extract broad statistics from a display, whereas poorly designed displays can lead to misperceptions and illusions. Extracting global statistics is fast, but comparing between subsets of values is slow. Effective graphics avoid taxing working memory, guide attention, and respect familiar conventions. Data visualizations can play a critical role in teaching and communication, provided that designers tailor those visualizations to their audience.

Effects of Message Presentation Type on GM Food Risk Perception, Similarity Judgment, and Attitude

Media play an important role in communicating scientific and health-related information, in turn, influencing audience risk perception. This study examined how genetically modified (GM) food news' presentation types - text-only, addition of photographs, or addition of infographics - can affect risk perception and attitude towards GM foods. Further, individuals' healthy eating involvement and perceived threat to GM foods were considered as individual difference variables influencing the level of perceived relevance to the GM food news. Results showed that news with infographics generally lowered risk perception and led individuals to perceive GM and non-GM foods more similarly in their safety on allergy, genetic changes, and organ toxicity.

Physician Perceptions on Quality of Life and Resuscitation Preferences for Extremely Early Newborns

OBJECTIVE

 The study aimed to explore physician views on whether extremely early newborns will have an acceptable quality of life (QOL), and if these views are associated with physician resuscitation preferences.

STUDY DESIGN

 We performed a cross-sectional survey of neonatologists and maternal fetal medicine (MFM) attendings, fellows, and residents at four U.S. medical centers exploring physician views on future QOL of extremely early newborns and physician resuscitation preferences. Mixed-effects logistic regression models examined association of perceived QOL and resuscitation preferences when adjusting for specialty, level of training, gender, and experience with ex-premature infants.

RESULTS

 A total of 254 of 544 (47%) physicians were responded. A minority of physicians had interacted with surviving extremely early newborns when they were ≥3 years old (23% of physicians in pediatrics/neonatology and 6% in obstetrics/MFM). The majority of physicians did not believe an extremely early newborn would have an acceptable QOL at the earliest gestational ages (11% at 22 and 23% at 23 weeks). The majority of physicians (73%) believed that having an extremely preterm infant would have negative effects on the family's QOL. Mixed-effects logistic regression models (odds ratio [OR], 95% confidence interval [CI]) revealed that physicians who believed infants would have an acceptable QOL were less likely to offer comfort care only at 22 (OR: 0.19, 95% CI: 0.05-0.65, p < 0.01) and 23 weeks (OR: 0.24, 95% CI: 0.07-0.78, p < 0.02). They were also more likely to offer active treatment only at 24 weeks (OR: 9.66, 95% CI: 2.56-38.87, p < 0.01) and 25 weeks (OR: 19.51, 95% CI: 3.33-126.72, p < 0.01).

CONCLUSION

 Physician views of extremely early newborns' future QOL correlated with self-reported resuscitation preferences. Residents and obstetric physicians reported more pessimistic views on QOL.

KEY POINTS

· Views of QOL varied by specialty and level of training.. · Contact with former extremely early newborns was limited.. · QOL views were associated with preferred resuscitation practices..

Completeness of reporting and risks of overstating impact in cluster randomised trials: a systematic review

Overstating the impact of interventions through incomplete or inaccurate reporting can lead to inappropriate scale-up of interventions with low impact. Accurate reporting of the impact of interventions is of great importance in global health research to protect scarce resources. In global health, the cluster randomised trial design is commonly used to evaluate complex, multicomponent interventions, and outcomes are often binary. Complete reporting of impact for binary outcomes means reporting both relative and absolute measures. We did a systematic review to assess reporting practices and potential to overstate impact in contemporary cluster randomised trials with binary primary outcome. We included all reports registered in the Cochrane Central Register of Controlled Trials of two-arm parallel cluster randomised trials with at least one binary primary outcome that were published in 2017. Of 73 cluster randomised trials, most (60 [82%]) showed incomplete reporting. Of 64 cluster randomised trials for which it was possible to evaluate, most (40 [63%]) reported results in such a way that impact could be overstated. Care is needed to report complete evidence of impact for the many interventions evaluated using the cluster randomised trial design worldwide.

COVID-19-related attitudes, risk perceptions, preventive behaviours and economic impact in sub-Saharan African countries: implementing a longitudinal phone-based survey protocol in rural Senegalese households

INTRODUCTION

Rural areas are considered safe havens against the increased spread of COVID-19 and associated restrictive measures, especially in contexts where public authorities are not in a position to systematically and substantially ease COVID-19-induced economic shocks. In the current sub-Saharan Africa context, still marked by uncertainty surrounding the spread of COVID-19, we present the protocol of an ongoing longitudinal study aimed at investigating COVID-19-related attitudes, risks perceptions, preventive behaviours and economic impact in rural areas in Senegal.

METHODS AND ANALYSIS

A prospective randomised longitudinal study of 600 households located in three semiurban villages and nine randomly selected rural villages in the Niakhar area (located 135 km East of Dakar). Three ad hoc phone surveys are administered to 600 heads of households, their housewives in charge of managing the household and a relative living temporarily in the household, respectively. In addition to sharing identical sets of questions on several topics (risks perceptions, attitudes to curfew, attitudes to vaccines, beliefs about COVID-19 infection), the three separate survey questionnaires also include other topics (economic impact, local preventive strategies) whose related questions differ between questionnaires. As analysing evolutions is the study's primary focus, data on all the topics covered will be collected in three waves unless the spread of COVID-19 by mid-2021 justifies extending data collection. The present article presents the study protocol and details about the implementation of the first wave of data collection which started in July 2020. The decision to wait before presenting the protocol was based on the unprecedented context the COVID-19 pandemic.

ETHICS AND DISSEMINATION

The survey's protocol was approved by the Senegalese National Ethical Committee for Research in Health (131/MSAS/CNERS/Sec) and received authorisation from both the Senegalese Ministry of Health (619/MSAS/DPRS/DR) and the French Commission on Information Technology and Liberties (CNIL 2220771).

Framing Benefits in Decision Aids: Effects of Varying Contextualizing Statements on Decisions About Sacubitril-Valsartan for Heart Failure

Background. Presenting numeric data alone may result in patients underappreciating clinically significant benefits. Contextualizing statements to counter this may raise concern about absence of neutrality. These issues arose during construction of a decision aid for sacubitril-valsartan, a heart failure medication associated with a ∼3% absolute reduction in 2-year mortality that carries high out-of-pocket cost. A contextualizing statement framing this as a "pretty big benefit" was incorporated. The impact of statements like this within decision aids is unknown. Objective. This online Qualtrics survey sought to deepen understanding of benefit framing by testing the impact of varying contextualizing statements within a decision aid for sacubitril-valsartan. Design. Participants were randomly assigned to receive one of six abbreviated versions of a decision aid for sacubitril-valsartan that varied only by contextualizing statement (ranging from strongly neutral to strongly positive and using relative and absolute risk reductions). Participants were asked to answer questions regarding the likelihood of taking the medication at a cost of $50/month and their perception of the drug's benefits. Results. A total of 1873 participants who were demographically similar to the heart failure population completed the survey. Fifty-four percent were willing to take sacubitril-valsartan at $50/month. Each of the five experimental contextualizing statements was compared with the baseline version; no significant differences were observed in reported likelihood of taking sacubitril-valsartan. After controlling for demographics and covariates, group assignment did not predict likelihood of taking the medication. Higher income, better self-reported health status, and younger age were associated with increased likelihood of taking sacubitril-valsartan. Limitations. This study used a hypothetical scenario and evaluated one method of delivering contextualizing statements. Conclusions. Contextualizing statements as tested within this decision aid did not affect decision making.

Problems with Using Polygenic Scores to Select Embryos

Companies have recently begun to sell a new service to patients considering in vitro fertilization: embryo selection based on polygenic scores (ESPS). These scores represent individualized predictions of health and other outcomes derived from genomewide association studies in adults to partially predict these outcomes. This article includes a discussion of many factors that lower the predictive power of polygenic scores in the context of embryo selection and quantifies these effects for a variety of clinical and nonclinical traits. Also discussed are potential unintended consequences of ESPS (including selecting for adverse traits, altering population demographics, exacerbating inequalities in society, and devaluing certain traits). Recommendations for the responsible communication about ESPS by practitioners are provided, and a call for a society-wide conversation about this technology is made. (Funded by the National Institute on Aging and others.).

Current Challenges When Using Numbers in Patient Decision Aids: Advanced Concepts

BACKGROUND

Decision aid developers have to convey complex task-specific numeric information in a way that minimizes bias and promotes understanding of the options available within a particular decision. Whereas our companion paper summarizes fundamental issues, this article focuses on more complex, task-specific aspects of presenting numeric information in patient decision aids.

METHODS

As part of the International Patient Decision Aids Standards third evidence update, we gathered an expert panel of 9 international experts who revised and expanded the topics covered in the 2013 review working in groups of 2 to 3 to update the evidence, based on their expertise and targeted searches of the literature. The full panel then reviewed and provided additional revisions, reaching consensus on the final version.

RESULTS

Five of the 10 topics addressed more complex task-specific issues. We found strong evidence for using independent event rates and/or incremental absolute risk differences for the effect size of test and screening outcomes. Simple visual formats can help to reduce common judgment biases and enhance comprehension but can be misleading if not well designed. Graph literacy can moderate the effectiveness of visual formats and hence should be considered in tool design. There is less evidence supporting the inclusion of personalized and interactive risk estimates.

DISCUSSION

More complex numeric information. such as the size of the benefits and harms for decision options, can be better understood by using incremental absolute risk differences alongside well-designed visual formats that consider the graph literacy of the intended audience. More research is needed into when and how to use personalized and/or interactive risk estimates because their complexity and accessibility may affect their feasibility in clinical practice.

Re-evaluation of gestational age as a predictor for subsequent preterm birth

BACKGROUND

To evaluate gestational age as a predictor of subsequent preterm birth.

MATERIALS AND METHODS

This was a retrospective birth cohort study to evaluate gestational age as a predictor of subsequent preterm birth. Participants were mothers who gave birth to their first two children in Western Australia, 1980-2015 (N = 255,151 mothers). For each week of final gestational age of the first birth, we calculated relative risks (RR) and absolute risks (AR) of subsequent preterm birth defined as final gestational age before 28, 32, 34 and <37 weeks. Risks were unadjusted to preserve risk factor profiles at each week of gestation.

RESULTS

The relative risks of second birth before 28, 32, and 34 weeks' gestation were all approximately twenty times higher for mothers whose first birth had a gestational age of 22 to 30 weeks compared to those whose first birth was at 40 weeks' gestation. The absolute risks of second birth before 28, 32, and 34 weeks' gestation for these mothers had upper confidence limits that were all less than 16.74%. The absolute risk of second birth before 37 weeks was highest at 32.11% (95% CI: 30.27, 34.02) for mothers whose first birth was 22 to 30 weeks' gestation. For all gestational ages of the first child, the lowest quartile and median gestational age of the second birth were at least 36 weeks and at least 38 weeks, respectively. Sensitivity and positive predictive values were all below 35%.

CONCLUSION

Relative risks of early subsequent birth increased markedly with decreasing gestational age of the first birth. However, absolute risks of clinically significant preterm birth (<28 weeks, <32 weeks, <34 weeks), sensitivity and positive predictive values remained low. Early gestational age is a strong risk factor but a poor predictor of subsequent preterm birth.

Postponement of cardiovascular outcomes by statin use: A systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

To estimate the average outcome postponement (gain in days to an event) for cardiovascular outcomes in a meta-analysis of randomized, controlled statin trials, including any myocardial infarction, any stroke and cardiovascular death.

DESIGN

Systematic review of large randomized, placebo-controlled trials of statin use, including a random-effects meta-analysis of all included trials.

DATA SOURCES

We searched MEDLINE (15 July 2019) and ClinicalTrials.gov (16 October 2019).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomized, placebo-controlled trials of statin use that included at least 1000 participants. We identified 15 cardiovascular outcomes that were reported in more than 2 trials.

RESULTS

We included 19 trials. The summary outcome postponements for the 15 cardiovascular outcomes varied between -1 and 38 days. For four major outcomes, the summary outcome postponement in days was as follows: cardiovascular mortality, 9.27 days (95% CI: 3.6 to 14.91; I²  = 72%; 9 trials) non-vascular and non-cardiovascular mortality, 1.5 days (95% CI: -2.2 to 5.3; I²  = 0%; 6 trials) any myocardial infarction 18.0 days (95% CI; 12.1 to 24.1; I²  = 92%; 15 trials); and any stroke, 6.1 days (95% CI; 2.86 to 9.39; I²  = 66%; 14 trials).

CONCLUSION

Statin treatment provided a small, average postponement of cardiovascular outcomes during trial duration.

The Risk of Heart Failure and Other Cardiovascular Hospitalizations After Early Stage Breast Cancer: A Matched Cohort Study

Background

Data are limited regarding the risk of heart failure (HF) requiring hospital-based care after early stage breast cancer (EBC) and its relationship to other types of cardiovascular disease (CVD).

Methods

We conducted a population-based, retrospective cohort study of EBC patients (diagnosed April 1, 2005–March 31, 2015) matched 1:3 on birth-year to cancer-free control subjects. We identified hospitalizations and emergency department visits for CVD through March 31, 2017. We used cumulative incidence function curves to estimate CVD incidence and cause-specific regression models to compare CVD rates between cohorts. All statistical tests were two-sided.

Results

We identified 78 318 EBC patients and 234 954 control subjects. The 10-year incidence of CVD hospitalization was 10.8% (95% confidence interval [CI] = 10.5% to 11.1%) after EBC and 9.1% (95% CI = 8.9% to 9.2%) in control subjects. Ischemic heart disease was the most common reason for CVD hospitalization after EBC. After regression adjustment, the relative rates compared with control subjects remained statistically significantly elevated for HF (hazard ratio [HR] = 1.21, 95% CI = 1.14 to 1.29, P < .001), arrhythmias (HR = 1.31, 95% CI = 1.23 to 1.39, P < .001), and cerebrovascular disease (HR 1.10, 95% CI = 1.04 to 1.17, P = .002) hospitalizations. It was rare for HF hospital presentations (2.9% of cases) to occur in EBC patients without recognized risk factors (age >60 years, hypertension, diabetes, prior CVD). Anthracycline and/or trastuzumab were used in 28 950 EBC patients; they were younger than the overall cohort with lower absolute rates of CVD, hypertension, and diabetes. However, they had higher relative rates of CVD in comparison with age-matched control subjects.

Conclusions

Atherosclerotic diagnoses, rather than HF, were the most common reasons for CVD hospitalization after EBC. HF hospital presentations were often preceded by risk factors other than chemotherapy, suggesting potential opportunities for prevention.

Postponement of Death by Pharmacological Heart Failure Treatment: A Meta-Analysis of Randomized Clinical Trials

BACKGROUND

Outcome postponement has been proposed as an effect measure for preventive drug treatment. It describes the average delay of the investigated unwanted clinical event, achieved by taking medication. The objective was to estimate postponement of death for the following heart failure medications compared to placebo: beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), ARB added to ACE inhibitors, aldosterone antagonists, ivabradine, and renin antagonists.

METHODS

We searched Medline and Embase from inception of databases until October 2017. Eligibility criteria were randomized placebo-controlled heart failure trials, including at least 1000 participants, with survival as a prespecified outcome and a minimum trial duration of 1 year. We calculated the outcome postponement by modeling the area between survival curves. This area was modeled on the basis of the hazard ratio or relative risk, the rate of mortality in the placebo group, and the trial duration. All results were standardized to a 3-year trial duration to ensure comparability between treatments.

RESULTS

We identified 14 eligible trials, with a total of 52,014 patients. The results in terms of postponement of all-cause mortality was: beta-blockers 43.7 days (95% confidence interval [95% CI], 20.8-66.5), ACE inhibitors 41.0 days (95% CI, 18.8-63.3), and aldosterone-antagonists 41.3 days (95% CI, 14.3,68.4).

CONCLUSION

The modeled outcome postponement estimates reiterate beta-blockers, ACE inhibitors, and aldosterone antagonists as the mainstay of heart failure treatment. Furthermore, ivabradine or ARBs added to ACE inhibitors results in no statistically significant gain in survival.

Designing clinical trials with (restricted) mean survival time endpoint: Practical considerations

BACKGROUND/AIMS

The difference in mean survival time, which quantifies the treatment effect in terms most meaningful to patients and retains its interpretability regardless of the shape of the survival distribution or the proportionality of the treatment effect, is an alternative endpoint that could be used more often as the primary endpoint to design clinical trials. The underuse of this endpoint is due to investigators' lack of familiarity with the test comparing the mean survival times and the lack of tools to facilitate trial design with this endpoint. The aim of this article is to provide investigators with insights and software to design trials with restricted mean survival time as the primary endpoint.

METHODS

A closed-form formula for the asymptotic power of the test of restricted mean survival time difference is presented. The effects of design parameters on power were evaluated for the mean survival time test and log-rank test. An R package which calculates the power or the sample size for user-specified parameter values and provides power plots for each design parameter is provided. The R package also calculates the probability that the restricted mean survival time is estimable for user-defined trial designs.

RESULTS

Under proportional hazards and late differences in survival, the power of the mean survival time test can approach that of the log-rank test if the restriction time is late. Under early differences, the power of the restricted mean survival time test is higher than that of the log-rank test. Duration of accrual and follow-up have little influence on the power of the restricted mean survival time test. The choice of restriction time, on the other hand, has a large impact on power. Because the power depends on the interplay among the design factors, plotting the relationship between each design parameter and power allows the users to select the designs most appropriate for their trial. When modification is necessary to ensure the difference in restricted mean survival time is estimable, the three available modifications all perform adequately in the scenarios studied.

CONCLUSION

The restricted mean survival time is a survival endpoint that is meaningful to investigators and to patients and at the same time requires less restrictive assumptions. The biggest challenge with this endpoint is selection of the restriction time. We recommend selecting a restriction time that is clinically relevant to the disease and the clinical setting of the trial of interest. The practical considerations and the R package provided in this work are readily available tools that researchers can use to design trials with restricted mean survival time as the primary endpoint.

Engaging patient partners in state-of-the-art allergy care: Finding balance when discussing risk

OBJECTIVE

To review risk communication in the context of shared decision making.

DATA SOURCES

Articles describing risk communication, shared decision making, and cost-effective healthcare delivery.

STUDY SELECTIONS

A narrative review detailing approaches to improve risk communication and shared decision making to optimize patient-centered cost-effective practice.

RESULTS

Risk communication must occur on a foundation of mutual trust and can be improved by keeping risk in perspective of everyday hazards, such as using pictograms when possible, providing numeric likelihoods of risks and benefits, and discussing absolute risks. Variability in patient-perceived quality of life for allergic and nonallergic health states may affect the health and economic outcomes of many allergy therapies. Shared decision making improves patient knowledge and risk perception, engagement, and adherence. Patient decision aids can be time-consuming to develop and validate, but their use is associated with a more accurate understanding of patient-oriented outcomes.

CONCLUSION

Communicating risk is complex, and validated patient decision aids using visual aids, presenting essential information, using knowledge checks, and incorporating values clarification can reduce decisional conflict and improve decisional self-efficacy.

Consumption of fruits and vegetables and cardiovascular mortality in renal transplant recipients: a prospective cohort study

BACKGROUND

It currently remains understudied whether low consumption of fruits and vegetables after kidney transplantation may be a modifiable cardiovascular risk factor. We aimed to investigate the associations between consumption of fruits and vegetables and cardiovascular mortality in renal transplant recipients (RTRs).

METHODS

Consumption of fruits and vegetables was assessed in an extensively phenotyping cohort of RTRs. Multivariable-adjusted Cox proportional hazards regression analyses were performed to assess the risk of cardiovascular mortality.

RESULTS

We included 400 RTRs (age 52 ± 12 years, 54% males). At a median follow-up of 7.2 years, 23% of RTRs died (53% were due to cardiovascular causes). Overall, fruit consumption was not associated with cardiovascular mortality {hazard ratio [HR] 0.82 [95% confidence interval (CI) 0.60-1.14]; P = 0.24}, whereas vegetable consumption was inversely associated with cardiovascular mortality [HR 0.49 (95% CI 0.34-0.71); P < 0.001]. This association remained independent of adjustment for several potential confounders. The association of fruit consumption with cardiovascular mortality was significantly modified by estimated glomerular filtration rate (eGFR; Pinteraction = 0.01) and proteinuria (Pinteraction = 0.01), with significant inverse associations in patients with eGFR > 45 mL/min/1.73 m2 [HR 0.56 (95% CI 0.35-0.92); P = 0.02] or the absence of proteinuria [HR 0.62 (95% CI 0.41-0.92); P = 0.02].

CONCLUSIONS

In RTRs, a relatively higher vegetable consumption is independently and strongly associated with lower cardiovascular mortality. A relatively higher fruit consumption is also associated with lower cardiovascular mortality, although particularly in RTRs with eGFR > 45 mL/min/1.73 m2 or an absence of proteinuria. Further studies seem warranted to investigate whether increasing consumption of fruits and vegetables may open opportunities for potential interventional pathways to decrease the burden of cardiovascular mortality in RTRs.

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.

Congenital cardiac surgery and parental perception of risk: a qualitative study

INTRODUCTION

The way risk is interpreted by parents of children undergoing congenital cardiac surgery is poorly documented. Literature suggests clinicians have concerns that parents may not understand the complexity of procedures. Conversely, some parents perceive an unnecessary over-emphasis of risks.

AIM

To explore how risk is encountered by parents of children who are undergoing cardiac surgery, in order to deliver effective and compassionate care.

METHODS

A qualitative approach was adopted. Interviews were undertaken with 18 parents (mothers n = 10; fathers n = 8). Recordings were transcribed verbatim and analysed using a constant comparative-based approach.

FINDINGS

Three themes emerged from the data: the nature of risk, reflecting the complexity of parental perception of risk and the influence of the doctor-parent relationship; presenting risk, highlighting the way in which risk is presented to and interpreted by parents; and risk and responsibility, examining the way in which parents engaged with risk and the impact of this on their relationship.

CONCLUSIONS

The way in which risk is perceived by parents is complex and multi-factorial. The doctor-parent relationship is key to parental engagement. However, parents manage risk and uncertainty through a number of mechanisms, including those perceived as being not rational. This can cause tension, particularly when required to engage in informed decision-making.

Postponement of Death by Statin Use: a Systematic Review and Meta-analysis of Randomized Clinical Trials

BACKGROUND

The average postponement of the outcome (gain in time to event) has been proposed as a measure to convey the effect of preventive medications. Among its advantages over number needed to treat and relative risk reduction is a better intuitive understanding among lay persons.

OBJECTIVES

To develop a novel approach for modeling outcome postponement achieved within a trial's duration, based on published trial data and to present a formalized meta-analysis of modeled outcome postponement for all-cause mortality in statin trials.

METHODS

The outcome postponement was modeled on the basis of the hazard ratio or relative risk, the mortality rate in the placebo group and the trial's duration. Outcome postponement was subjected to a meta-analysis. We also estimated the average outcome postponement as the area between Kaplan-Meier curves. Statin trials were identified through a systematic review.

RESULTS

The median modeled outcome postponement was 10.0 days (interquartile range, 2.9-19.5 days). Meta-analysis of 16 trials provided a summary estimate of outcome postponement for all-cause mortality of 12.6 days, with a 95% postponement interval (PI) of 7.1-18.0. For primary, secondary, and mixed prevention trials, respectively, outcome postponements were 10.2 days (PI, 4.0-16.3), 17.4 days (PI, 6.0-28.8), and 8.5 days (PI, 1.9-15.0).

CONCLUSIONS

The modeled outcome postponement is amenable to meta-analysis and may be a useful approach for presenting the benefits of preventive interventions. Statin treatment results in a small increase of average survival within the duration of a trial.

SYSTEMATIC REVIEW REGISTRATION

The systematic review was registered in PROSPERO [CRD42016037507] .

Understanding Measures of Association: A Primer With Examples From Rehabilitation Research

Understanding measures of associations, how they are calculated, what they mean, and how to compare them is an important part of understanding clinical and health research. The relative risk and odds ratio are the two most common used measures of association in medical research. The appropriate use of these statistics to estimate the association between treatment or risk factor and outcome in research studies depends on the methodology and design of the study. The aim of this article was to cover basics of odds ratio and relative risk as the most important measures for the association between an exposure and an outcome. We use a clinical scenario as an example of their uses and demonstrate their calculation.

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.