Numeracy and framing bias in epilepsy

Mathematics Skills in Epilepsy: A Systematic Review and Meta-Analysis

Mathematics incorporates a broad range of skills, which includes basic early numeracy skills, such as subitizing and basic counting to more advanced secondary skills including mathematics calculation and reasoning. The aim of this review was to undertake a detailed investigation of the severity and pattern of early numeracy and secondary mathematics skills in people with epilepsy. Searches were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Twenty adult studies and 67 child studies were included in this review. Overall, meta-analyses revealed significant moderate impairments across all mathematics outcomes in both adults (g= -0.676), and children (g= -0.593) with epilepsy. Deficits were also observed for specific mathematics outcomes. For adults, impairments were found for mathematics reasoning (g= -0.736). However, two studies found that mathematics calculation was not significantly impaired, and an insufficient number of studies examined early numeracy skills in adults. In children with epilepsy, significant impairments were observed for each mathematics outcome: early numeracy (g= -0.383), calculation (g= -0.762), and reasoning (g= -0.572). The gravity of impairments also differed according to the site of seizure focus for children and adults, suggesting that mathematics outcomes were differentially vulnerable to the location of seizure focus.

Antiseizure Medication Withdrawal Practice Patterns: A Survey Among Members of the American Academy of Neurology and EpiCARE

Background and Objectives

To describe neurologist practice patterns, challenges, and decision support needs pertaining to withdrawal of antiseizure medications (ASMs) in patients with well-controlled epilepsy.

Methods

We sent an electronic survey to (1) US and (2) European physician members of the American Academy of Neurology and (3) members of EpiCARE, a European Reference Network for rare and complex epilepsies. Analyses included frequencies and percentages, and we showed distributions through histograms and violin plots.

Results

We sent the survey to 4,923 individuals; 463 consented, 411 passed eligibility questions, and 287 responded to at least 1 of these questions. Most respondents indicated that they might ever consider ASM withdrawal, with respondents treating mostly children being more likely ever to consider withdrawal (e.g., medical monotherapy: children 96% vs adults 81%; p < 0.05). The most important factors when making decisions included seizure probability (83%), consequences of seizures (73%), and driving (74%). The top challenges when making decisions included unclear seizure probability (81%), inadequate guidelines (50%), and difficulty communicating probabilities (45%). Respondents would consider withdrawal after a median of 2-year seizure freedom, but also responded that they would begin withdrawal on average only when the postwithdrawal seizure relapse risk in the coming 2 years was less than 15%-30%. Wide variation existed in the use of words or numbers in respondents' counsel methods, for example, percentages vs frequencies or probability of seizure freedom vs seizure. The most highly rated point-of-care methods to inform providers of calculated risk were Kaplan-Meier curves and showing percentages only, rather than pictographs or text recommendations alone.

Discussion

Most surveyed neurologists would consider withdrawing ASMs in seizure-free individuals. Seizure probability was the largest factor driving decisions, yet estimating seizure probabilities was the greatest challenge. Respondents on average indicated that they may withdraw ASM after a minimum seizure-free duration of 2 years, yet also on average were willing to withdraw when seizure risk decreased below 15%-30%, which is lower than most patients' postwithdrawal risk at 2-year seizure freedom and lower than the equivalent even of a first seizure of life. These findings will inform future efforts at developing decision support tools aimed at optimizing ASM withdrawal decisions.

Difficulties with mathematics experienced by adults with epilepsy in daily life: An online study

OBJECTIVE

Mathematics encompass a variety of skills, broadly grouped into basic numeracy to complex secondary mathematical skills. In children with epilepsy difficulties with mathematics are common and related to a multicomponent working memory capacity. Little is known about mathematical skills of adults with epilepsy in daily life. Hence, we aimed to compare basic and secondary mathematical skills of adults with epilepsy to controls, examine relations between mathematical skills and working memory, and explored relationships between mathematical skills and epilepsy variables (age of onset, seizure frequency, and anti-seizure medication).

METHODS

Eighty four people with epilepsy and 86 healthy controls completed questionnaires on their subjective experience of using mathematics and working memory skills in daily life: The Dyscalculia Checklist (DC) and Working Memory Questionnaire (WMQ; including attention, storage, and executive scales), respectively. Questionnaires also collected demographic and epilepsy variables.

RESULTS

Adults with epilepsy reported greater difficulties in basic and secondary mathematical skills on the DC compared with controls. Only one epilepsy variable, a younger age of epilepsy onset, related to higher DC scores (greater mathematical difficulties), but was not significantly related in regression analyses. Instead, the WMQ explained 33% of the variance on the DC; the poorer storage and attention (but not executive) on the WMQ were associated with the higher DC score, when demographic and epilepsy variables were accounted for.

SIGNIFICANCE

Adults with epilepsy reported significant difficulties with mathematics in daily life, which were not explained by epilepsy variables but by poor working memory. While our findings suggest that daily difficulties with mathematics may be comorbid with epilepsy rather than epilepsy related, it is important to be cognizant of mathematical difficulties experienced by patients with epilepsy as they have potential to impact understanding of numerical information provided in patient care, such as risks associated with different epilepsy treatments.

Best-worst scaling preferences among patients with well-controlled epilepsy: Pilot results

Epilepsy is a common, serious condition. Fortunately, seizure risk decreases with increasing seizure-free time on antiseizure medications (ASMs). Eventually, patients may consider whether to stop ASMs, which requires weighing treatment benefit versus burden. We developed a questionnaire to quantify patient preferences relevant to ASM decision-making. Respondents rated how concerning they would finding relevant items (e.g., seizure risks, side effects, cost) on a Visual Analogue Scale (VAS, 0-100) and then repeatedly chose the most and least concerning item from subsets (best-worst scaling, BWS). We pretested with neurologists, then recruited adults with epilepsy who were seizure-free at least one year. Primary outcomes were recruitment rate, and qualitative and Likert-based feedback. Secondary outcomes included VAS ratings and best-minus-worst scores. Thirty-one of 60 (52%) contacted patients completed the study. Most patients felt VAS questions were clear (28; 90%), easy to use (27; 87%), and assessed preferences well (25; 83%). Corresponding results for BWS questions were 27 (87%), 29 (97%), and 23 (77%). Physicians suggested adding a 'warmup' question showing a completed example and simplifying terminology. Patients suggested ways to clarify instructions. Cost, inconvenience of taking medication, and laboratory monitoring were the least concerning items. Cognitive side effects and a 50% seizure risk in the next year were the most concerning items. Twelve (39%) of patients made at least one 'inconsistent choice' for example ranking a higher seizure risk as lower concern compared with a lower seizure risk, though 'inconsistent choices' represented only 3% of all question blocks. Our recruitment rate was favorable, most patients agreed the survey was clear, and we describe areas for improvement. 'Inconsistent' responses may lead us to collapse seizure probability items into a single 'seizure' category. Evidence regarding how patients weigh benefits and harms may inform care and guideline development.

Education and Message Framing Increase Willingness to Undergo Research Lumbar Puncture: A Randomized Controlled Trial

Reluctance to undergo lumbar puncture (LP) is a barrier to neurological disease biomarker research. We assessed whether an educational intervention increased willingness to consider research LP and whether message framing modified intervention effectiveness. We randomly assigned 851 recruitment registry enrollees who had previously indicated they were unwilling to be contacted about studies requiring LP to gain or loss framed video educational interventions describing the procedure and the probability of experiencing adverse events. The gain framed intervention emphasized the proportion of individuals free of adverse events; the loss frame emphasized the proportion experiencing adverse events. The primary outcome for the study was the participant's post-intervention agreement to be contacted about studies requiring LP. Participants were mean (SD) age 60.1 years (15.7), 69% female (n = 591), and mostly college educated and white. Among the 699 participants who completed the study, 43% (95% CI: 0.39, 0.47; n = 301) changed their response to agree to be contacted about studies requiring LP. We estimated that participants randomized to the gain framed intervention had 67% higher odds of changing their response compared to those randomized to the loss frame (Odds Ratio = 1.67; 95% CI: 1.24, 2.26; p < 0.001). A classification and regression tree model identified participants' pre-intervention willingness as the strongest predictor of changing response. Education, in particular education that alerts participants to the probability of not experiencing adverse events, may be an effective tool to increase participation rates in research requiring LP.

Empirical relationships between numeracy and treatment decision making: A scoping review of the literature

OBJECTIVES

To determine what is known from the existing literature about empirical relationships between numeracy and the three stages of the treatment decision making process (information exchange, deliberation, and deciding on the treatment to implement). We also examined if, and how, numeracy was mentioned in relation to health literacy.

METHODS

A search of four databases returned 2772 records. After de-duplication and three levels of relevance screening, 38 primary studies were included in this review.

RESULTS

Relationships between numeracy and the information exchange stage have received greater attention than relationships between numeracy and the deliberation and deciding on the treatment to implement stages. The lack of overlap in the empirical relationships examined in studies, the measure(s) of numeracy used, and the characteristics of study populations, made findings difficult to compare. Multiple knowledge gaps and measurement-related problems were identified. Numeracy and health literacy have largely been treated as separate concepts.

CONCLUSION

More research is needed to better understand the importance of numeracy and health literacy to treatment decision making.

PRACTICE IMPLICATIONS

Decision aids designed for patients with different levels of health literacy may not meet the needs of patients with different levels of numeracy. The numeracy skills of health professionals require attention.

Health numeracy in Japan: measures of basic numeracy account for framing bias in a highly numerate population

BACKGROUND

Health numeracy is an important factor in how well people make decisions based on medical risk information. However, in many countries, including Japan, numeracy studies have been limited.

METHODS

To fill this gap, we evaluated health numeracy levels in a sample of Japanese adults by translating two well-known scales that objectively measure basic understanding of math and probability: the 3-item numeracy scale developed by Schwartz and colleagues (the Schwartz scale) and its expanded version, the 11-item numeracy scale developed by Lipkus and colleagues (the Lipkus scale).

RESULTS

Participants' performances (n = 300) on the scales were much higher than in original studies conducted in the United States (80% average item-wise correct response rate for Schwartz-J, and 87% for Lipkus-J). This high performance resulted in a ceiling effect on the distributions of both scores, which made it difficult to apply parametric statistical analysis, and limited the interpretation of statistical results. Nevertheless, the data provided some evidence for the reliability and validity of these scales: The reliability of the Japanese versions (Schwartz-J and Lipkus-J) was comparable to the original in terms of their internal consistency (Cronbach's α = 0.53 for Schwartz-J and 0.72 for Lipkus-J). Convergent validity was suggested by positive correlations with an existing Japanese health literacy measure (the Test for Ability to Interpret Medical Information developed by Takahashi and colleagues) that contains some items relevant to numeracy. Furthermore, as shown in the previous studies, health numeracy was still associated with framing bias with individuals whose Lipkus-J performance was below the median being significantly influenced by how probability was framed when they rated surgical risks. A significant association was also found using Schwartz-J, which consisted of only three items.

CONCLUSIONS

Despite relatively high levels of health numeracy according to these scales, numeracy measures are still important determinants underlying susceptibility to framing bias. This suggests that it is important in Japan to identify individuals with low numeracy skills so that risk information can be presented in a way that enables them to correctly understand it. Further investigation is required on effective numeracy measures for such an intervention in Japan.