Patients' understanding of medical risks: implications for genetic counseling

Taxonomies for synthesizing the evidence on communicating numbers in health: Goals, format, and structure

Many people, especially those with low numeracy, are known to have difficulty interpreting and applying quantitative information to health decisions. These difficulties have resulted in a rich body of research about better ways to communicate numbers. Synthesizing this body of research into evidence-based guidance, however, is complicated by inconsistencies in research terminology and researcher goals. In this article, we introduce three taxonomies intended to systematize terminology in the literature, derived from an ongoing systematic literature review. The first taxonomy provides a systematic nomenclature for the outcome measures assessed in the studies, including perceptions, decisions, and actions. The second taxonomy is a nomenclature for the data formats assessed, including numbers (and different formats for numbers) and graphics. The third taxonomy describes the quantitative concepts being conveyed, from the simplest (a single value at a single point in time) to more complex ones (including a risk-benefit trade-off and a trend over time). Finally, we demonstrate how these three taxonomies can be used to resolve ambiguities and apparent contradictions in the literature.

How People Understand Risk Matrices, and How Matrix Design Can Improve their Use: Findings from Randomized Controlled Studies

Risk matrices are a common way to communicate the likelihood and potential impacts of a variety of risks. Until now, there has been little empirical work on their effectiveness in supporting understanding and decision making, and on how different design choices affect these. In this pair of online experiments (total n = 2699), we show that risk matrices are not always superior to text for the presentation of risk information, and that a nonlinear/geometric labeling scheme helps matrix comprehension (when the likelihood/impact scales are nonlinear). To a lesser degree, results suggested that changing the shape of the matrix so that cells increase in size nonlinearly facilitates comprehension as compared to text alone, and that comprehension might be enhanced by integrating further details about the likelihood and impact onto the axes of the matrix rather than putting them in a separate key. These changes did not affect participants' preference for reducing impact over reducing likelihood when making decisions about risk mitigation. We recommend that designers of risk matrices consider these changes to facilitate better understanding of relationships among risks.

Antenatal counselling for prospective parents whose fetus has a neurological anomaly: part 1, experiences and recommendations for service design

Prospective parents whose fetus is diagnosed with a neurological anomaly go through a complex range of emotions. They describe their discussions of antenatal counselling from health care professionals as focusing too much on the nature of the anomaly involving unintelligible medical terminology, when what they really want is a picture of the best- and worst-case scenarios. Whilst information on the level of risk for their fetus is important, it is not the parents' primary concern. When statistics for risk are given, they may not be as well understood as the health care professionals think. This review discusses the published evidence on antenatal counselling and recommendations for explaining risk to parents of fetuses with neurological anomalies. From this data we make recommendations for the organization of antenatal counselling services.

Genetic counseling and testing for Asian Americans: a systematic review

PURPOSE

Asian Americans have been understudied in the literature on genetic and genomic services. The current study systematically identified, evaluated, and summarized findings from relevant qualitative and quantitative studies on genetic health care for Asian Americans.

METHODS

A search of five databases (1990 to 2018) returned 8,522 unique records. After removing duplicates, abstract/title screening, and full text review, 47 studies met inclusion criteria. Data from quantitative studies were converted into "qualitized data" and pooled together with thematic data from qualitative studies to produce a set of integrated findings.

RESULTS

Synthesis of results revealed that (1) Asian Americans are under-referred but have high uptake for genetic services, (2) linguistic/communication challenges were common and Asian Americans expected more directive genetic counseling, and (3) Asian Americans' family members were involved in testing decisions, but communication of results and risk information to family members was lower than other racial groups.

CONCLUSION

This study identified multiple barriers to genetic counseling, testing, and care for Asian Americans, as well as gaps in the research literature. By focusing on these barriers and filling these gaps, clinical genetic approaches can be tailored to meet the needs of diverse patient groups, particularly those of Asian descent.

Health Literacy 2030: Is It Time to Redefine the Term?

For decades, health literacy has been used to describe the ability of individuals to locate, interpret, and apply health information to their decisions. The US Department of Health and Human Services has now proposed redefining the term to emphasize the role of society in providing accessible, comprehensible information. This redefinition would reflect a welcome shift to encompass the roles of those who communicate information, not simply those who seek it. However, redefining an accepted term would have serious negative effects on the indexing of the research literature and create difficulties interpreting studies conducted under the previous definition. Therefore, we strongly caution against redefining the accepted term. Instead, we propose introducing a new term-health information fluency-defined as universal effective use of health information. The old term can continue to be used to describe the set of concerns about individual skills, but by promoting the new term, the Department of Health and Human Services can encourage research into creating accurate, accessible health information that people can easily find, understand, and use to inform their decisions.

Medication Decision-making in Osteoporosis: Can We Explain Why Patients Do Not Take Their Osteoporosis Medications?

Patients at high risk of fracture often do not take medication for osteoporosis. Recent literature may give us some insights into why patients at high risk of fracture do not take medications for osteoporosis.

Exploring health literacy and preferences for risk communication among medical oncology patients

Objective

To explore adult medical oncology outpatients’ understanding of and preferences for the format of health risk information.

Methods

Two surveys, one assessing sociodemographic characteristics and a second survey examining perceptions of risk information.

Results

Of the 361 (74%) consenting patients, 210 completed at least one question on risk communication. 17% to 65% of patients understood numeric risk information, depending on the format of the information. More than 50% of people interpreted a “very good” chance of remission as greater than 80%, greater than 90% or 100%. The most preferred format of information was in both words and numbers (38% to 43%) followed by words alone (28% to 30%).

Conclusion

Numeric risk information is understood by 17% to 65% of respondents, depending on the format. Interpretation of verbal risk information is highly variable, posing a risk of misunderstanding. Provision of information in both words and numbers may assist in aiding comprehension.

Knowledge, experiences and attitudes concerning genetics among retinoblastoma survivors and parents

Clinical genetic services are increasingly providing a more nuanced understanding of genetic disease diagnostics and future risk for patients. Effectively conveying genetic information is essential for patients to make informed decisions. This is especially important for survivors of heritable cancers such as retinoblastoma (childhood eye cancer), where survivors who carry a germline mutation in the RB1 gene are at increased risk of second cancers in adulthood, and of passing on the disease risk to future offspring. We conducted focus groups with adult survivors of retinoblastoma and parents of children with retinoblastoma, to uncover their knowledge of, experiences with and attitudes about retinoblastoma genetics and related impacts of the cancer. Results revealed that participants understood that retinoblastoma was a genetic disease, but often misunderstood the implications of genetics on cancer phenotype and risk. Experiences with genetic testing and counseling were generally positive, however, participants reported challenges in accessing genetic information and psychosocial support. Participants suggested more educational resources, peer-to-peer counseling, and psychosocial support would enhance uptake of important genetic information. The results of the study will inform patient-oriented approaches to deliver comprehensive genetic healthcare.

How to Best Convey Information About Intensive/Comfort Care to the Family Members of Premature Infants to Enable Unbiased Perinatal Decisions

Background: As the infant's best interests are determined through the perinatal decisions of family members and physicians, it is important to understand the factors that affect such decisions. This paper investigated the separate and combined effects of various factors related to perinatal decision making and sought to determine the best way to convey information in an unbiased manner to family members. Methods: In total, 613 participants were consecutively recruited. Each participant completed a series of surveys. All responses to four items were examined via a latent class analysis (LCA) to identify subgroups of participants with similar preferences for intensive care (IC) and comfort care (CC) regarding their potentially premature infant. Multiple logistic regression analyses were applied to identify the sociodemographic predictors for the classification of participants into different subgroups. Results: χ²-tests indicated that perinatal decision making for Item 2 was influenced by framing information, whereas decision making wasn't affected by presentation modes. Furthermore, the endorsement rates of IC significantly decreased with the information increased from brief to detailed, regardless of framing or presentation mode. The LCA indicated that a 3-subgroup model, which included the IC, CC, and variation subgroups, was optimal. Logistic regression analyses demonstrated that, compared with the IC subgroup, negative framing, higher education, parenthood, and poor numeracy predicted participants' preferences for CC. Meanwhile, worrying about physical or mental disabilities predicted preferences for CC and sensitivity to the amount of information provided regarding treatment options (variation subgroup). Conclusions: Perinatal decision making is affected by many factors, suggesting that more detailed information, improved understandability of numerical data, and a neutral tone of voice regarding therapeutic outcomes would be helpful for the families of premature infants to make unbiased decisions. Our findings should be replicated in future research.

Impact of numeracy on understanding of prostate cancer risk reduction in PSA screening

Prostate-specific antigen (PSA) screening for prostate cancer in men of average risk remains controversial. Patients' ability to incorporate risk reduction data into their decision-making may depend on their numeracy. We assessed the impact of patients' numeracy on their understanding of the risk reduction benefits of PSA screening. Men attending a general internal medicine clinic were invited to complete a survey. Four versions of the survey each included a three-item numeracy test and PSA risk reduction data, framed one of four ways: absolute (ARR) versus relative risk reduction (RRR), with or without baseline risk (BR). Respondents were asked to adjust their perceived risk of prostate-cancer mortality using the data presented. Accuracy of risk reduction was evaluated relative to how risk data were framed. Among a total of 200 respondents, a majority incorrectly answered one or more of the numeracy items. Overall accuracy of risk adjustment was only 20%. Accuracy varied with data framing: when presented with RRR, respondents were 13% accurate without BR and 31% accurate with BR; when presented with ARR, they were 0% accurate without BR and 35% accurate with BR. Including BR data significantly improved accuracy for both RRR (P = 0.03) and ARR groups (P < 0.01). Accuracy was significantly related to numeracy; numeracy scores of 0, 1, 2, and 3 were associated with accuracy rates of six, five, nine, and 36 percent, respectively (P < 0.01). Overall, numeracy was significantly associated with the accuracy of interpreting quantitative benefits of PSA screening. Alternative methods of communicating risk may facilitate shared decision-making in the use of PSA screening for early detection of prostate cancer.

The decision: Relations to oneself, authority and vulnerability in the field of selective abortion

This article is about selective abortion. It concentrates on the existential, moral and social conditions that arise when pregnant women, using prenatal diagnosis (PND), are told that there is something seriously wrong with the foetuses that they are carrying. This is characterised as a micro state of emergency, where both normal cognitive categories and normative orders are dissolved. The analyses are anchored in the womens' own presentations and understandings of the processes and dilemmas related to the abortion decisions, and our most important empirical materials are interviews with women who have experienced them. Our main ambition is to show the relation between some important dimensions of the situation in which the abortion decision has to be made, and the special kind of authority on behalf of the women that presents itself. Of equal importance is the vulnerability of the pregnant women, resulting in a co-production of the women as both Sovereigns and Homo Sacer in the decision situation. We also analyse some of the experienced relations between the women and the foetuses, and how the women constitute themselves as moral subjects, with a particular emphasis on the motifs of sacrifice and self-sacrifice. It is a central argument in the article that we have to understand the specificity of the decision situation, without reducing it either to other phases (before or after) of the total processes of PND and selective abortion, or to general discourses of disability or normality. The specificity of the situation in which the abortion decision is made is a pivotal point in society's regulation (in a broad sense) of the field and in the constitution of the regime of selective abortion.

An introduction to behavioural decision-making theories for paediatricians

Behavioural decision-making theories provide insights into how people make choices under conditions of uncertainty. However, few have been studied in paediatrics. This study introduces these theories, reviews current research and makes recommendations for their application within the context of shared decision-making.

CONCLUSION

As parents are expected to share decision-making in paediatrics, it is critical that the fields of behavioural economics, communication and decision sciences merge with paediatric clinical ethics to optimise decision-making.

Impact of delivery models on understanding genomic risk for type 2 diabetes

BACKGROUND

Genetic information, typically communicated in-person by genetic counselors, can be challenging to comprehend; delivery of this information online--as is becoming more common--has the potential of increasing these challenges.

METHODS

To address the impact of the mode of delivery of genomic risk information, 300 individuals were recruited from the general public and randomized to receive genomic risk information for type 2 diabetes mellitus in-person from a board-certified genetic counselor or online through the testing company's website.

RESULTS

Participants were asked to indicate their genomic risk and overall lifetime risk as reported on their test report as well as to interpret their genomic risk (increased, decreased, or same as population). For each question, 59% of participants correctly indicated their risk. Participants who received their results in-person were more likely than those who reviewed their results on-line to correctly interpret their genomic risk (72 vs. 47%, p = 0.0002) and report their actual genomic risk (69 vs. 49%, p = 0.002).

CONCLUSIONS

The delivery of personal genomic risk through a trained health professional resulted in significantly higher comprehension. Therefore, if the online delivery of genomic test results is to become more widespread, further evaluation of this method of communication may be needed to ensure the effective presentation of results to promote comprehension.

Measuring patient tolerance for future adverse events in low-risk emergency department chest pain patients

STUDY OBJECTIVE

We assess emergency department (ED) patients' risk thresholds for preferring admission versus discharge when presenting with chest pain and determine how the method of information presentation affects patients' choices.

METHODS

In this cross-sectional survey, we enrolled a convenience sample of lower-risk acute chest pain patients from an urban ED. We presented patients with a hypothetical value for the risk of adverse outcome that could be decreased by hospitalization and asked them to identify the risk threshold at which they preferred admission versus discharge. We randomized patients to a method of numeric presentation (natural frequency or percentage) and the initial risk presented (low or high) and followed each numeric assessment with an assessment based on visually depicted risks.

RESULTS

We enrolled 246 patients and analyzed data on 234 with complete information. The geometric mean risk threshold with numeric presentation was 1 in 736 (1 in 233 with a percentage presentation; 1 in 2,425 with a natural frequency presentation) and 1 in 490 with a visual presentation. Fifty-nine percent of patients (137/234) chose the lowest or highest risk values offered. One hundred fourteen patients chose different thresholds for numeric and visual risk presentations. We observed strong anchoring effects; patients starting with the lowest risk chose a lower threshold than those starting with the highest risk possible and vice versa.

CONCLUSION

Using an expected utility model to measure patients' risk thresholds does not seem to work, either to find a stable risk preference within individuals or in groups. Further work in measurement of patients' risk tolerance or methods of shared decisionmaking not dependent on assessment of risk tolerance is needed.

Communication in early pregnancy ultrasound: avoiding misunderstandings

Pregnant women in the UK are usually offered at least two ultrasound scans during their pregnancy. While these almost certainly cause no physical harm to the baby, communicating the findings to the parents, whether there is a problem or not, carries real potential for confusion, worry and perhaps unnecessary intervention.

Using alternative statistical formats for presenting risks and risk reductions

BACKGROUND

The success of evidence-based practice depends on the clear and effective communication of statistical information.

OBJECTIVES

To evaluate the effects of using alternative statistical presentations of the same risks and risk reductions on understanding, perception, persuasiveness and behaviour of health professionals, policy makers, and consumers.

SEARCH STRATEGY

We searched Ovid MEDLINE (1966 to October 2007), EMBASE (1980 to October 2007), PsycLIT (1887 to October 2007), and the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2007, Issue 3). We reviewed the reference lists of relevant articles, and contacted experts in the field.

SELECTION CRITERIA

We included randomized and non-randomized controlled parallel and cross-over studies. We focused on four comparisons: a comparison of statistical presentations of a risk (eg frequencies versus probabilities) and three comparisons of statistical presentation of risk reduction: relative risk reduction (RRR) versus absolute risk reduction (ARR), RRR versus number needed to treat (NNT), and ARR versus NNT.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data, and assessed risk of bias. We contacted investigators to obtain missing information. We graded the quality of evidence for each outcome using the GRADE approach. We standardized the outcome effects using adjusted standardized mean difference (SMD).

MAIN RESULTS

We included 35 studies reporting 83 comparisons. None of the studies involved policy makers. Participants (health professionals and consumers) understood natural frequencies better than probabilities (SMD 0.69 (95% confidence interval (CI) 0.45 to 0.93)). Compared with ARR, RRR had little or no difference in understanding (SMD 0.02 (95% CI -0.39 to 0.43)) but was perceived to be larger (SMD 0.41 (95% CI 0.03 to 0.79)) and more persuasive (SMD 0.66 (95% CI 0.51 to 0.81)). Compared with NNT, RRR was better understood (SMD 0.73 (95% CI 0.43 to 1.04)), was perceived to be larger (SMD 1.15 (95% CI 0.80 to 1.50)) and was more persuasive (SMD 0.65 (95% CI 0.51 to 0.80)). Compared with NNT, ARR was better understood (SMD 0.42 (95% CI 0.12 to 0.71)), was perceived to be larger (SMD 0.79 (95% CI 0.43 to 1.15)).There was little or no difference for persuasiveness (SMD 0.05 (95% CI -0.04 to 0.15)). The sensitivity analyses including only high quality comparisons showed consistent results for persuasiveness for all three comparisons. Overall there were no differences between health professionals and consumers. The overall quality of evidence was rated down to moderate because of the use of surrogate outcomes and/or heterogeneity. None of the comparisons assessed behaviourbehaviour.

AUTHORS' CONCLUSIONS

Natural frequencies are probably better understood than probabilities. Relative risk reduction (RRR), compared with absolute risk reduction (ARR) and number needed to treat (NNT), may be perceived to be larger and is more likely to be persuasive. However, it is uncertain whether presenting RRR is likely to help people make decisions most consistent with their own values and, in fact, it could lead to misinterpretation. More research is needed to further explore this question.

Effects of game-like interactive graphics on risk perceptions and decisions

BACKGROUND

Many patients have difficulty interpreting risks described in statistical terms as percentages. Computer game technology offers the opportunity to experience how often an event occurs, rather than simply read about its frequency.

OBJECTIVE

. To assess effects of interactive graphics on risk perceptions and decisions.

DESIGN

. Electronic questionnaire. Participants and setting. Respondents (n = 165) recruited online or at an urban hospital. Intervention. Health risks were illustrated by either static graphics or interactive game-like graphics. The interactive search graphic was a grid of squares, which, when clicked, revealed stick figures underneath. Respondents had to click until they found a figure affected by the disease. Measurements. Risk feelings, risk estimates, intention to take preventive action.

RESULTS

. Different graphics did not affect mean risk estimates, risk feelings, or intention. Low-numeracy participants reported significantly higher risk feelings than high-numeracy ones except with the interactive search graphic. Unexpectedly, respondents reported stronger intentions to take preventive action when the intention question followed questions about efficacy and disease severity than when it followed perceived risk questions (65% v. 34%; P < 0.001). When respondents reported risk feelings immediately after using the search graphic, the interaction affected perceived risk (the longer the search to find affected stick figures, the higher the risk feeling: ρ = 0.57; P = 0.009). Limitations. The authors used hypothetical decisions.

CONCLUSIONS

. A game-like graphic that allowed consumers to search for stick figures affected by disease had no main effect on risk perception but reduced differences based on numeracy. In one condition, the game-like graphic increased concern about rare risks. Intentions for preventive action were stronger with a question order that focused first on efficacy and disease severity than with one that focused first on perceived risk.

Improving decisions for men with prostate cancer: translational outcomes research

PURPOSE

We established a method to present a health related quality of life instrument in a format more readily interpretable by men with prostate cancer.

MATERIALS AND METHODS

Men with clinically localized prostate adenocarcinoma treated with radical prostatectomy (220), external beam radiotherapy (56) or interstitial seed brachytherapy (60) were prospectively recruited into the study. We assessed health related quality of life outcomes prospectively at baseline and 24 months after treatment using validated instruments. We defined good, intermediate and poor function for sexual, urinary and bowel domains, including good-the best response for all items in that scale, poor-the worst response for any item and intermediate-all others. We then compared bother scores in men at each symptom level.

RESULTS

Men with good baseline urinary and bowel function had almost no related bother (mean +/- SD UCLA-PCI 98 +/- 9 and 99 +/- 8, respectively). Those with poor function had significant distress (mean UCLA-PCI 60 +/- 30 and 64 +/- 34) and those with intermediate function had moderate distress (mean UCLA-PCI 84 +/- 20 and 83 +/- 24, respectively). Effect size was clinically and statistically significant across groups for urinary and bowel function. Men with poor baseline sexual function had much more distress than those with intermediate function (mean UCLA-PCI 44 +/- 37 vs 71 +/- 26).

CONCLUSIONS

To enhance the clinical relevance of outcome analysis we grouped men by baseline function to help discern their likely levels of bother and function after treatment.

Prenatal testing for Down syndrome: comparison of screening practices in the UK and USA

Prenatal testing for Down Syndrome is a topic covered in every genetic counselor's training as it constitutes the main workload of genetic counselors in prenatal settings. Most Western countries nowadays offer some type of testing for Down Syndrome. However, practices vary according to country with regards to what tests are offered, insurance coverage and the legal situation concerning the option of terminating an affected pregnancy. In view of the growing interest in international genetic counseling issues, this article aims to compare prenatal testing practices in two English-speaking countries: the United Kingdom and the United States of America. A case will be presented to highlight some of the differences in practice. The topic underlines important implications for genetic counseling practice, such as patients' understanding of testing practices, risk perception, counseling provision and impact of prenatal testing results.

Interactive graphics for expressing health risks: development and qualitative evaluation

Recent findings suggest that interactive game-like graphics might be useful in communicating probabilities. We developed a prototype for a risk communication module, focusing on eliciting users' preferences for different interactive graphics and assessing usability and user interpretations. Feedback from five focus groups was used to design the graphics. The final version displayed a matrix of square buttons; clicking on any button allowed the user to see whether the stick figure underneath was affected by the health outcome. When participants used this interaction to learn about a risk, they expressed more emotional responses, both positive and negative, than when viewing any static graphic or numerical description of a risk. Their responses included relief about small risks and concern about large risks. The groups also commented on static graphics: arranging the figures affected by disease randomly throughout a group of figures made it more difficult to judge the proportion affected but often was described as more realistic. Interactive graphics appear to have potential for expressing risk magnitude as well as the feeling of risk. This affective impact could be useful in increasing perceived threat of high risks, calming fears about low risks, or comparing risks. Quantitative studies are planned to assess the effect on perceived risks and estimated risk magnitudes.

How should risk be communicated to children: a cross-sectional study comparing different formats of probability information

BACKGROUND

Newborn screening, which identifies inherited disorders and sometimes carrier status, will increasingly involve health professionals in the provision of appropriate information and support to children and their families. The ability to understand carrier results relies on an understanding of probabilistic terms. However, little is known about how best to convey probabilistic medical information to children. Research with adult populations suggests information format significantly affects comprehension. This study aimed to explore which presentation format is most effective in conveying probabilistic information to children.

METHODS

A probabilistic task based on the cup game was used to measure which of five different formats was associated with greatest understanding in children aged 7-11 years old (n = 106). Formats used were verbal labels (e.g. rarely, sometimes), percentages, proportion-word (e.g. 1 in X), proportion-notation (e.g. 1:X) and pie charts. There was also an additional mixed format condition. In each trial a picture was presented of three cups, each with a different probability depicted beneath it, and the child was asked to select which cup was most likely to contain the ball. Three trials were presented per format. Children also rated how certain they were that they had answered correctly.

RESULTS

There was a significant relationship between format and comprehension scores. Post hoc tests showed children performed significantly better when probability was presented as a pie chart, in comparison to percentages, proportion-notation, proportion-word and mixed format trials. Furthermore, most children (84%) got all trials correct for this format and children were significantly more certain that their response was correct in the pie chart trials compared to all the other formats (p < 0.001). Significant positive correlations were found between self-ratings of certainty and comprehension of verbal labels, percentages and pie charts. Older age was also associated with better performance on all formats except percentages. Overall comprehension was calculated by summing the scores for the individual trials and this was independently associated with older age and higher IQ.

CONCLUSION

The results suggest that 7-11 year olds can understand probability information, but that the format used will significantly affect the accuracy and confidence with which children in this age group make judgements about the likelihood of an event. Of the formats studied, pie charts appear to be the optimal method of presenting probabilistic information to children in this age group. Health professionals and designers of health messages should be cognisant of this when communicating medical information to children aged 7-11 years old.

The impact of social contexts in testing for alpha-1 antitrypsin deficiency: the roles of physicians and others

AIMS

To elucidate psychosocial and ethical issues faced by adults at risk for alpha-1 antitrypsin deficiency (AATD) that have received little attention.

METHODS

Eleven individuals with AATD were interviewed in detail for 2 hours each.

RESULTS

Several specific aspects of AATD created critical, socially dynamic issues that shaped the patients' responses. The disease being relatively newly discovered, physicians do not know much about it and thus often do not consider or recommend testing for it. Hence, patients who may benefit from diagnosis and treatment are not always diagnosed. General practitioners, when they do diagnose patients, often refer them to specialists and thus remain inexperienced in treating the disorder. As a result, many individuals, too, remain unaware of this disease in their families and thus do not consider mentioning its possibility to doctors or family members. Thus, intrafamilial disclosures by patients become critical. Patients may be shocked and upset at diagnosis, as they might possibly already have transmitted the mutation to offspring, which further impedes disclosure to family members.

CONCLUSIONS

These issues highlight how patients' interactions with doctors and others concerning genetics are critical, and need to be further explored and addressed. Several aspects of physician education and practice (e.g., regarding disclosures to at-risk family members) need to be improved.

Design of the BRISC study: a multicentre controlled clinical trial to optimize the communication of breast cancer risks in genetic counselling

BACKGROUND

Understanding risks is considered to be crucial for informed decision-making. Inaccurate risk perception is a common finding in women with a family history of breast cancer attending genetic counseling. As yet, it is unclear how risks should best be communicated in clinical practice. This study protocol describes the design and methods of the BRISC (Breast cancer RISk Communication) study evaluating the effect of different formats of risk communication on the counsellee's risk perception, psychological well-being and decision-making regarding preventive options for breast cancer.

METHODS AND DESIGN

The BRISC study is designed as a pre-post-test controlled group intervention trial with repeated measurements using questionnaires. The intervention-an additional risk consultation-consists of one of 5 conditions that differ in the way counsellee's breast cancer risk is communicated: 1) lifetime risk in numerical format (natural frequencies, i.e. X out of 100), 2) lifetime risk in both numerical format and graphical format (population figures), 3) lifetime risk and age-related risk in numerical format, 4) lifetime risk and age-related risk in both numerical format and graphical format, and 5) lifetime risk in percentages. Condition 6 is the control condition in which no intervention is given (usual care). Participants are unaffected women with a family history of breast cancer attending one of three participating clinical genetic centres in the Netherlands.

DISCUSSION

The BRISC study allows for an evaluation of the effects of different formats of communicating breast cancer risks to counsellees. The results can be used to optimize risk communication in order to improve informed decision-making among women with a family history of breast cancer. They may also be useful for risk communication in other health-related services.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14566836.

Clinical geneticists' and genetic counselors' views on the communication of genetic risks: a qualitative study

OBJECTIVE

In genetic counseling, counselees' understanding of risk information is considered crucial for informed decision-making. The counselors' task is to convey risks in a format that is understandable. It is therefore important to know how and why counselors say they communicate risks in different formats, and to identify any perceived training needs. By investigating counselors' perspectives, training can be more tailored to their needs.

METHODS

Interviews were held with 18 counselors in 4 of the 8 clinical genetic centres in The Netherlands.

RESULTS

Counselors reported using different formats, but seemed to prefer a numerical format (e.g. percentages). Methods varied between counselors and depended on their training, their own abilities, experiences they have had with counselees, but rarely because of information they have gathered from the literature on risk communication. Counselors reported assessing comprehension most often from counselees' non-verbal responses, and reported tailoring their approaches to their clients' needs. Although some counselors are eager to know if their way of risk communication is 'right', overall the counselors did not report a need to be trained in risk communication.

CONCLUSION

Counselors appear to have clear ideas about how to present risks, although evidence for their methods is often lacking.

PRACTICE IMPLICATIONS

Training in general communication skills and evidence-based risk communication could be of benefit to counselors and, consequently, to their counselees.

The risk of death by age, sex, and smoking status in the United States: putting health risks in context

BACKGROUND

To make sense of the disease risks they face, people need basic facts about the magnitude of a particular risk and how one risk compares with other risks. Unfortunately, this fundamental information is not readily available to patients or physicians. We created simple one-page charts that present the 10-year chance of dying from various causes according to age, sex, and smoking status.

METHODS

We used the National Center for Health Statistics Multiple Cause of Death Public Use File for 2004 and data from the 2004 US Census to calculate age- and sex-specific death rates for various causes of death. We then combined data on smoking prevalence (from the National Health Interview Survey) and the relative risks of death from various causes for smokers vs never smokers (from the American Cancer Society's Cancer Prevention Study-II) to determine age-, sex-, and smoking-specific death rates. Finally, we accumulated these risks for various starting ages in a series of 10-year life tables. The charts present the 10-year risks of dying from heart disease; stroke; lung, colon, breast, cervical, ovarian, and prostate cancer; pneumonia; influenza; AIDS; chronic obstructive pulmonary disease; accidents; and all causes.

RESULTS

At all ages, the 10-year risk of death from all causes combined is higher for men than women. The effect of smoking on the chance of dying is similar to the effect of adding 5 to 10 years of age: for example, a 55-year-old man who smokes has about the same 10-year risk of death from all causes as a 65-year-old man who never smoked (ie, 178 vs 176 of 1000 men, respectively). For men who never smoked, heart disease death represents the single largest cause of death from age 50 on and the chance of dying from heart disease exceeds the chances of dying from lung, colon, and prostate cancers combined at every age. For men who currently smoke, the chance of dying from lung cancer is of the same order of magnitude as the chance dying from heart disease and after age 50 it is about 10 times greater than the chance of dying from prostate or colon cancer. For women who have never smoked, the magnitudes of the 10-year risks of death from breast cancer and heart disease are similar until age 60; from this age on, heart disease represents the single largest cause of death. For women who currently smoke, the chance of dying from heart disease or lung cancer exceeds the chance of dying from breast cancer from age 40 on (and does so by at least a factor of 5 after age 55).

CONCLUSION

The availability of simple charts with consistent data presentations of important causes of death may facilitate discussion about disease risk between physicians and their patients and help highlight the dangers of smoking.

Does labeling prenatal screening test results as negative or positive affect a woman's responses?

OBJECTIVE

We tested whether adding interpretive labels (eg, "negative test") to prenatal genetic screening test results changes perceived risk and preferences for amniocentesis.

STUDY DESIGN

Women (N = 1688) completed a hypothetical pregnancy scenario on the Internet. We randomly assigned participants into 2 groups: high risk of fetal chromosomal problems (12.5/1000) or low risk (2/1000). After prenatal screening, estimated risk was identical (5/1000) for all participants, but results were provided either alone or with interpretive labels.

RESULTS

When receiving test results without labels, all participants react similarly. With labels, the participants who received "positive" or "abnormal" results reported a higher perceived risk (P < .001), greater worry (P < .001), and greater interest in amniocentesis (57% vs 37%; P < .001) than did the participants who received "negative" or "normal" results.

CONCLUSION

Interpretive labels for test results can induce larger changes to a woman's risk perception and behavioral intention than can numeric results alone, which create decision momentum. This finding has broad clinical implications for patient-provider communication.

Rethinking health numeracy: a multidisciplinary literature review

The purpose of this review is to organize various published conceptions of health numeracy and to discuss how health numeracy contributes to the productive use of quantitative information for health. We define health numeracy as the individual-level skills needed to understand and use quantitative health information, including basic computation skills, ability to use information in documents and non-text formats such as graphs, and ability to communicate orally. We also identify two other factors affecting whether a consumer can use quantitative health information: design of documents and other information artifacts, and health-care providers' communication skills. We draw upon the distributed cognition perspective to argue that essential ingredients for the productive use of quantitative health information include not only health numeracy but also good provider communication skills, as well as documents and devices that are designed to enhance comprehension and cognition.

Perception of risk in relation to ultrasound screening for Down's syndrome during pregnancy

OBJECTIVE

to explore how information about being at risk of carrying a fetus with Down's syndrome was understood, and whether the actual risk and the woman's perception of risk was associated with worry or depressive symptoms during and after pregnancy.

DESIGN AND SETTING

observational study. The sample was drawn from the intervention group of a Swedish randomised controlled trial of ultrasound screening for Down's syndrome by nuchal translucency measurement.

MEASUREMENTS

data were collected by three questionnaires. Questions were asked about recall of the risk score and perception of risk. The Cambridge Worry Scale and the Edinburgh Postnatal Depression Scale measured worry and depressive symptoms, respectively, on all three occasions.

FINDINGS

of the 796 women who provided data for this study, one in five was unaware that the risk score was noted in her case record. In total, 620 women stated that they had received a risk score, but only 64% of them recalled the figure exactly or approximately. The actual risk was associated with the perceived risk, but of the 31 women who perceived the risk to be high, only 14 were actually at high risk. A high-risk score was not associated with worry or depressive symptoms in mid-pregnancy, in contrast to a woman's own perception of being at high risk. Two months postpartum, no associations were found between maternal emotional well-being and actual or perceived risk.

CONCLUSIONS

information about fetal risk is complicated and women's perception of risk does not always reflect the actual risk, at least not when presented as a numerical risk score. The possibility that the information may cause unnecessary emotional problems cannot be excluded.

IMPLICATIONS FOR PRACTICE

caregivers should ascertain that information about fetal risk is interpreted correctly by pregnant women.

Views and approaches toward risks and benefits among doctors who become patients

OBJECTIVE

To understand how views and approaches concerning risks and benefits may be affected by dynamic contexts and processes related to clinical roles and relationships.

METHODS

We conducted two in-depth, semi-structured interviews with 50 doctors who became patients due to serious illnesses, concerning their experiences before and after diagnosis.

RESULTS

As patients, these doctors gained critical new insights into the processes and contexts of communication about risks and benefits. Doctors and patients often varied in how they viewed and weighed risks and benefits (e.g., as "good' or "bad"). These data suggest a model in which patients undergo several dynamic processes: seeking statistics, accepting doctors' framing of statistics, being influenced by media hype, seeing statistics as relevant or not, over-valuing risks, weighing the importance of risks and benefits, interpreting statistics as good or bad, accepting or denying statistics and odds, and making treatment decisions. These processes are affected by external factors (e.g., doctors ordering tests, framing statistics, and often over- versus under-valuing risks), and internal factors (e.g., depression, denial of illness, optimism versus pessimism, magical thinking--that doctors are immune to disease--and rationalizations).

CONCLUSIONS

Doctors and patients are engaged in complex, dynamic processes that shape patients' approaches toward risks and benefits.

PRACTICE IMPLICATIONS

These data highlight the need for increased attention toward these issues in medical educational and care.

Bringing prostate cancer quality of life research back to the bedside: translating numbers into a format that patients can understand

PURPOSE

Although measuring quality of life of patients with prostate cancer serves important research goals, its primary clinical purpose is informing patients. Sophisticated quality of life measures produce purely numerical results that patients have difficulty understanding. We present an approach that preserves the methodological strengths of validated multi-item measures but provides more accessible information for clinical use.

MATERIALS AND METHODS

Using validated indexes measuring urinary, bowel and sexual function we surveyed patients with clinically localized prostate cancer before treatment and at intervals thereafter. Based on patient responses to parallel distress measures we defined 3 levels of function, including normal-no abnormal symptom, intermediate-any abnormal symptom but none severely abnormal and poor-any severely abnormal symptom. We then translated patient survey results into these levels. To assess measurement properties we compared average symptom distress scores in patients at each symptom level.

RESULTS

Levels of function and patient distress scores correlated strongly. Large and approximately equal differences in distress scores separated patients at successive levels in all symptom indexes (effect size greater than 1.2, p < 0.0001). Using these categories we created tables showing 24-month outcomes in 417 previously reported patients by pretreatment symptom level and treatment, providing a tool for patients to determine posttreatment outcomes in similar patients.

CONCLUSIONS

Using symptom indexes to define levels of function produces a quality of life metric that is valid, defines quantitative intervals, is transparent and may be more useful to patients. This approach provides methodologically sound outcome information to patients attempting to choose a prostate cancer treatment.

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

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

Number-needed-to-treat (NNT)--needs treatment with care

The "number-needed-to-treat" (NNT) was introduced about 15 years ago and has gained widespread use. It has been claimed to be "easy to understand" and gives "intuitive meaning". When used to measure the effectiveness of interventions targeting chronic disease processes e.g. atherosclerosis and osteoporosis, NNT (as well as relative and absolute risk reduction) does not capture the crucial time component, a fact that has important consequences: NNT varies over time, it may not mean that adverse events (fractures, myocardial infarctions etc.) are avoided, but simply that they are postponed. Finally, empirical studies indicate that lay people and doctors misunderstand NNT. We recommend that NNT be used with considerable care. There is probably no single effect measure that is able to convey all necessary information.

Communication and risk presentation in genetic counseling. Development of a checklist

OBJECTIVE

Genetic counseling involves advising people about genetic disorders, genetic risks and preventive measures, and guiding them in the process of decision-making. It remains unclear what effect certain aspects of risk communication have on outcomes like risk perception and the decisions people take. In order to examine this relationship between process and outcomes, the present study aimed to develop a reliable checklist to assess aspects of risk communication in genetic counseling.

METHODS

A preliminary checklist was developed on base of literature and tested for manageability in a pilot study. The checklist was adapted and tested for inter-observer reliability in 14 and 56 genetic counseling sessions. Inter-observer reliability was measured by computing Kappa and proportions of agreement.

RESULTS

Most of the items of the last version of the checklist had Kappa values between 0.4 and 1, which means that the inter-observer reliability for most items was sufficient or good. On the majority of items, the observers showed more than 80% agreement.

CONCLUSION

The checklist we have developed has adequate inter-observer reliability and may be applied in future studies to assess risk communication aspects in genetic counseling.

PRACTICE IMPLICATIONS

This checklist could be a useful instrument to identify the relationship between aspects of risk communication in genetic counseling and outcomes. Showing which communication skills and risk presentations affect client's feelings and decisions may help to improve genetic counseling.

[Perception and communication of medical risk which implications for preoperative anaesthetic consultations?]

Informing patients about available treatments, their advantages and disadvantages, as well as the associated risks, is critical to obtain an informed consent and is the responsibility of physicians, including anaesthesiologists. However, risks issues are not systematically discussed during anaesthesia consultations or are addressed in a vague and incomplete way. In order to improve communication and the quality of the informed consent, it is therefore essential to scrutinize problems linked to communication about risks. This article is based on a review of French and English literature on perception and communication about medical risks. Its objectives are for the one hand to summarize the main difficulties concerning risk communication in medicine and, on the other hand, to offer tools that can foster quality communication with patients especially during anaesthesia consultations.

Patients' views of the consent process for adult cardiac surgery: questionnaire survey

OBJECTIVE

Consent for surgical procedures has assumed increasing importance in surgical practice in recent days especially following the public inquiry into paediatric cardiac surgery deaths at Bristol in the UK. This study examines patient perceptions and recollections following surgical consent as currently practised in a UK cardiac unit.

METHODS

One hundred consecutive patients who underwent cardiac surgery in a London teaching hospital from January to February 2003 were studied. Patients completed questionnaires a day before their discharge from the hospital.

RESULTS

The majority of patients (89/100) responded that the information given at consent had been adequate or more than adequate. The time spent on the consent process was thought to be adequate by 91 patients. Eleven patients felt the consent had been insensitive. Several patients (38/100) felt use of booklets in preference to verbal explanations would be less intimidating. For most patients (94/100) the operation and postoperative course met their expectations; although 12 patients experienced untold complications, only five felt that they should have been informed of the possibility of the complication. Although most patients were informed of the risk of death during consent, at time of discharge 43 had forgotten the figure that had been quoted. Regarding the influence of media and publicity, 19 patients said that media had influenced their expectations of the consent process, 59 would have liked to see hospital league tables while 26 would have liked to know the mortality figures for their surgeon prior to giving consent.

CONCLUSIONS

Our study shows that patients undergoing cardiac surgery are largely satisfied with our improved consent procedures in the post-Bristol era. Use of booklets may be a useful adjunct to verbal consent as currently practised.

Information given to patients about adverse effects of radiotherapy: a survey of patients' views

AIMS

In practice, clinicians vary markedly in the amount of information they give to patients before consent for investigation or treatment is obtained. We present a study to evaluate the amount of information patients feel that they should be given.

MATERIALS AND METHODS

Between October 2001 and February 2002, 82 adults were enrolled into the study before commencing treatment with radiotherapy. Participants were interviewed with the aid of a questionnaire, and responses were analysed to detect differences related to age, sex, disease site, treatment intent and social class.

RESULTS

The distribution of responses to the interview was large. For a mild side-effect, 23 patients (28%) wanted to be informed if the risk of the side-effect was as small as 0.1%, whereas 25 patients (31%) would only want to be informed if there was either a 50% or a 100% chance of it occurring. For severe side-effects, 36 (44%) wanted to be informed of a 0.1% risk, whereas 13 (16%) only wanted to be informed if the risk was either 50% or 100%. There was no association with sex, treatment intent (radical or palliative), social class or disease site. Information requirements tended to be greater in people under 60 years. This reached statistical significance (P = 0.007) for severe side-effects, where younger patients were more likely to want to be informed of a side-effect if there was a 10% or less chance of it occurring.

CONCLUSIONS

Information needs varied widely within our survey population. It is difficult to predict how much information patients feel they need before giving informed consent. Therefore, a patient-centred approach must involve tailoring information to individual patient requirements.

Research issues in genetic testing of adolescents for obesity

Obesity is often established in adolescence, and advances are being made in identifying its genetic underpinnings. We examine issues related to the eventual likelihood of genetic tests for obesity targeted to adolescents: family involvement; comprehension of the test's meaning; how knowledge of genetic status may affect psychological adaptation; minors' ability to control events; parental/child autonomy; ability to make informed medical decisions; self-esteem; unclear distinctions between early/late onset for this condition; and social stigmatization. The public health arena will be important in educating families about possible future genetic tests for obesity.

Agreement between scales in the measurement of breast cancer risk perceptions

The objective of this article is to compare the accuracy and numeric responses of breast cancer risk perception as measured by a frequency scale and percentage scale. A cross-sectional survey was conducted. Perceptions of five-year and lifetime breast cancer risk were measured using a frequency and a percentage scale. Estimation error was calculated as the absolute difference between actual breast cancer risk as determined by the Gail model and perceived risk. Agreement between scales was determined by calculating the mean and standard deviation of the difference between numeric responses. The study was conducted among women enrolled in two primary care clinics associated with an academic medical center. Two-hundred-fifty-four participants were recruited from one of the two participating internal medicine clinics. Inclusion criteria included female gender and age 40-84 years. Exclusion criteria included a history of breast cancer, dementia, or a life expectancy of less than two years. The frequency scale was more accurate than the percentage scale in estimating lifetime risk (p= 0.05), but less accurate in estimating five-year risk (p < 0.02). Only 79 participants (31%) were considered consistent scale users, providing identical responses when using the frequency and percentage scale for a given risk estimate. Although the mean difference (percentage-frequency scale) for estimates of breast cancer lifetime risk was only 2.4, the empirically determined 90% limits of agreement between the frequency and percentage scale for lifetime risk were wide, from -30 to 40. Higher numeracy was associated with consistent use of scales (OR 1.61, 95% CI; 1.09-2.37). We report disagreement in breast cancer risk perceptions when measured by a frequency and a percentage scale. The accuracy and direction of bias associated with each scale varies according to the time frame of risk being assessed.

A randomized comparison of patients' understanding of number needed to treat and other common risk reduction formats

BACKGROUND

Commentators have suggested that patients may understand quantitative information about treatment benefits better when they are presented as numbers needed to treat (NNT) rather than as absolute or relative risk reductions.

OBJECTIVE

To determine whether NNT helps patients interpret treatment benefits better than absolute risk reduction (ARR), relative risk reduction (RRR), or a combination of all three of these risk reduction presentations (COMBO).

DESIGN

Randomized cross-sectional survey.

SETTING

University internal medicine clinic.

PATIENTS

Three hundred fifty-seven men and women, ages 50 to 80, who presented for health care.

INTERVENTIONS

Subjects were given written information about the baseline risk of a hypothetical "disease Y" and were asked (1) to compare the benefits of two drug treatments for disease Y, stating which provided more benefit; and (2) to calculate the effect of one of those drug treatments on a given baseline risk of disease. Risk information was presented to each subject in one of four randomly allocated risk formats: NNT, ARR, RRR, or COMBO.

MAIN RESULTS

When asked to state which of two treatments provided more benefit, subjects who received the RRR format responded correctly most often (60% correct vs 43% for COMBO, 42% for ARR, and 30% for NNT, P =.001). Most subjects were unable to calculate the effect of drug treatment on the given baseline risk of disease, although subjects receiving the RRR and ARR formats responded correctly more often (21% and 17% compared to 7% for COMBO and 6% for NNT, P =.004).

CONCLUSION

Patients are best able to interpret the benefits of treatment when they are presented in an RRR format with a given baseline risk of disease. ARR also is easily interpreted. NNT is often misinterpreted by patients and should not be used alone to communicate risk to patients.

A randomized trial of three videos that differ in the framing of information about mammography in women 40 to 49 years old

OBJECTIVE

To assess the effect of providing structured information about the benefits and harms of mammography in differing frames on women's perceptions of screening.

DESIGN

Randomized control trial.

SETTING

General internal medicine academic practice.

PARTICIPANTS

One hundred seventy-nine women aged 35 through 49.

INTERVENTION

Women received 1 of 3 5-minute videos about the benefits and harms of screening mammography in women aged 40 to 49. These videos differed only in the way the probabilities of potential outcomes were framed (positive, neutral, or negative).

MEASUREMENTS AND MAIN RESULTS

We measured the change in accurate responses to questions about potential benefits and harms of mammography, and the change in the proportion of participants who perceived that the benefits of mammography were more important than the harms. Before seeing the videos, women's knowledge about the benefits and harms of mammography was inaccurate (82% responded incorrectly to all 3 knowledge questions). After seeing the videos, the proportion that answered correctly increased by 52%, 43%, and 30% for the 3 knowledge questions, respectively, but there were no differences between video frames. At baseline, most women thought the benefits of mammography outweighed the harms (79% positive frame, 80% neutral frame, and 85% negative frame). After the videos, these proportions were similar among the 3 groups (84%, 81%, 83%, P =.93).

CONCLUSIONS

Women improved the accuracy of their responses to questions about the benefits and harms of mammography after seeing the videos, but this change was not affected by the framing of information. Women strongly perceived that the benefits of mammography outweighed the harms, and providing accurate information had no effect on these perceptions, regardless of how it was framed.

Strategies to help patients understand risks

Explaining risks to patients in an effective way is an essential part of ensuring that consent is “informed.” A consultant in risk communication discusses the strategies that can help doctors to communicate risks clearly, and thereby also build closer relationships with their patients