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Bonner C, Trevena LJ, Gaissmaier W, Han PKJ, Okan Y, Ozanne E, Peters E, Timmermans D, Zikmund-Fisher BJ. Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles. Med Decis Making 2021; 41:821-833. [PMID: 33660551 DOI: 10.1177/0272989x21996328] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids. METHODS Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team. RESULTS Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy. DISCUSSION Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.
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Affiliation(s)
- Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,ASK-GP NHMRC Centre of Research Excellence, The University of Sydney, Australia
| | - Lyndal J Trevena
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia.,ASK-GP NHMRC Centre of Research Excellence, The University of Sydney, Australia
| | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA.,School of Medicine, Tufts University, USA
| | - Yasmina Okan
- Centre for Decision Research, University of Leeds, Leeds, UK
| | | | - Ellen Peters
- Center for Science Communication Research, University of Oregon, Eugene, OR, USA
| | - Daniëlle Timmermans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, North Holland, The Netherlands
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Abstract
Patients, clinicians, payers and policy makers face substantial uncertainties in their respective healthcare decisions as they attempt to achieve maximum value, or the greatest level of benefit possible at a given cost. Uncertainties largely come from incomplete information at the time that decisions must be made. This is true in all areas of medicine because evidence from clinical trials is often incongruent with real-world patient care. This article highlights key uncertainties around the (comparative) benefits and harms of medical technologies. Initiatives and strategies such as comparative effectiveness research and coverage with evidence development may help to generate reliable and relevant evidence for decisions on coverage and treatment. These efforts could result in better decisions that improve patient outcomes and better use of scarce medical resources.
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Affiliation(s)
- C Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
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Sorich MJ, Horowitz JD, Sorich W, Wiese MD, Pekarsky B, Karnon JD. Cost–effectiveness of using CYP2C19 genotype to guide selection of clopidogrel or ticagrelor in Australia. Pharmacogenomics 2013; 14:2013-21. [DOI: 10.2217/pgs.13.164] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aims: This study aims to assess the cost–effectiveness in Australia of screening CYP2C19 loss-of-function (LoF) alleles to guide selection of clopidogrel or ticagrelor for individuals with acute coronary syndrome who are likely to undergo coronary stenting. Methods: Three treatment strategies were compared: universal clopidogrel therapy, universal ticagrelor therapy and genotyping CYP2C19 with use of ticagrelor for individuals with a LoF allele and clopidogrel for individuals without a LoF allele. Lifetime costs and quality-adjusted life years for each treatment strategy were estimated using a Markov model. The risks of events were primarily derived from the genetic substudy of the pivotal randomized controlled trial. Results: CYP2C19 genotyping resulted in greater effectiveness and was cost-effective when compared with universal use of clopidogrel. However, universal use of ticagrelor was the most effective strategy overall and the incremental cost–effectiveness compared with the genotyping strategy was generally within what is considered acceptable. Conclusion: Ticagrelor is likely to be cost-effective even for individuals not carrying a CYP2C19 LoF allele. Original submitted 30 May 2013; Revision submitted 16 August 2013
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Affiliation(s)
- Michael J Sorich
- Department of Clinical Pharmacology, School of Medicine, Flinders University, Adelaide, Australia
| | - John D Horowitz
- Cardiology Unit, Queen Elizabeth Hospital, University of Adelaide, Adelaide, Australia
| | - Wassana Sorich
- Pharmacy Department, Repatriation General Hospital, Adelaide, Australia
| | - Michael D Wiese
- School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, Australia
| | - Brita Pekarsky
- Baker IDI Heart & Diabetes Institute, Adelaide, Australia
| | - Jonathan D Karnon
- School of Population Health, University of Adelaide, Adelaide, Australia
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Trevena LJ, Zikmund-Fisher BJ, Edwards A, Gaissmaier W, Galesic M, Han PKJ, King J, Lawson ML, Linder SK, Lipkus I, Ozanne E, Peters E, Timmermans D, Woloshin S. Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers. BMC Med Inform Decis Mak 2013; 13 Suppl 2:S7. [PMID: 24625237 PMCID: PMC4045391 DOI: 10.1186/1472-6947-13-s2-s7] [Citation(s) in RCA: 300] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Making evidence-based decisions often requires comparison of two or more options. Research-based evidence may exist which quantifies how likely the outcomes are for each option. Understanding these numeric estimates improves patients' risk perception and leads to better informed decision making. This paper summarises current "best practices" in communication of evidence-based numeric outcomes for developers of patient decision aids (PtDAs) and other health communication tools. METHOD An expert consensus group of fourteen researchers from North America, Europe, and Australasia identified eleven main issues in risk communication. Two experts for each issue wrote a "state of the art" summary of best evidence, drawing on the PtDA, health, psychological, and broader scientific literature. In addition, commonly used terms were defined and a set of guiding principles and key messages derived from the results. RESULTS The eleven key components of risk communication were: 1) Presenting the chance an event will occur; 2) Presenting changes in numeric outcomes; 3) Outcome estimates for test and screening decisions; 4) Numeric estimates in context and with evaluative labels; 5) Conveying uncertainty; 6) Visual formats; 7) Tailoring estimates; 8) Formats for understanding outcomes over time; 9) Narrative methods for conveying the chance of an event; 10) Important skills for understanding numerical estimates; and 11) Interactive web-based formats. Guiding principles from the evidence summaries advise that risk communication formats should reflect the task required of the user, should always define a relevant reference class (i.e., denominator) over time, should aim to use a consistent format throughout documents, should avoid "1 in x" formats and variable denominators, consider the magnitude of numbers used and the possibility of format bias, and should take into account the numeracy and graph literacy of the audience. CONCLUSION A substantial and rapidly expanding evidence base exists for risk communication. Developers of tools to facilitate evidence-based decision making should apply these principles to improve the quality of risk communication in practice.
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Affiliation(s)
- Lyndal J Trevena
- Primary Health Care, School of Public Health, Room 321b, Edward Ford Building (A27), University of Sydney, NSW 2006, Australia
| | - Brian J Zikmund-Fisher
- Department of Health Behavior & Health Education, School of Public Health, Department of Internal Medicine, School of Medicine, and Center for Bioethics and Social Sciences in Medicine, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, USA
| | - Adrian Edwards
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK
| | - Wolfgang Gaissmaier
- Harding Center for Risk Literacy, Max Planck Institute for Human Development, Lentzeallee 94, 14195 Berlin, Germany
| | - Mirta Galesic
- Center for Adaptive Behavior and Cognition, Max Planck Institute for Human Development, Lentzeallee 94, 14195 Berlin, Germany
| | - Paul KJ Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, 509 Forest Avenue, Portland, ME 04101, USA
| | - John King
- Department of Family Medicine, University of Vermont College of Medicine, 235 Rowell, 106 Carrigan Drive, University of Vermont, Burlington, Vermont 05405, USA
| | - Margaret L Lawson
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, Ontario, K1H 8L1, Canada
| | - Suzanne K Linder
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Isaac Lipkus
- Duke University School of Nursing, 307 Trent Drive, Durham, NC 27710, USA
| | - Elissa Ozanne
- Department of Surgery and Institute for Health Policy Studies, University of California, San Francisco, 3333 California St. Suite 265, San Francisco, CA 94143-0936, USA
| | - Ellen Peters
- Department of Psychology, Ohio State University, 235 Psychology Building, 1835 Neil Avenue, Columbus, OH 43210, USA
| | - Danielle Timmermans
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
| | - Steven Woloshin
- Departments of Medicine and of Community & Family Medicine and The Dartmouth Institute for Health Policy & Clinical Practice at the Geisel School of Medicine at Dartmouth and the VA Outcomes Group, VA Medical Center, 215 North Main Street, White River Junction, VT 05009-0001, USA
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Challenges and limitations in the interpretation of systematic reviews: making sense of clopidogrel and CYP2C19 pharmacogenetics. Clin Pharmacol Ther 2013; 94:376-82. [PMID: 23670120 DOI: 10.1038/clpt.2013.100] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 05/03/2013] [Indexed: 11/08/2022]
Abstract
From 2010 to 2012, nine systematic reviews reported highly variable conclusions regarding the association between carriage of a cytochrome P450 2C19 loss-of-function allele and the risk of adverse cardiovascular (CV) events in individuals using clopidogrel. Possible contributors to the variable findings include differences in patient populations, CV end points, and statistical models utilized by the systematic reviews, as well as unexplained heterogeneity, inconsistent/incomplete reporting, and risk of publication bias with respect to the primary studies.
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Mannix SM, O'Sullivan C, Kelly GA. Acupuncture for Managing Phantom-Limb Syndrome: A Systematic Review. Med Acupunct 2013. [DOI: 10.1089/acu.2012.0928] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Sharon M. Mannix
- Health Sciences Centre, University College Dublin, Belfield, Dublin, Ireland
| | - Cliona O'Sullivan
- Health Sciences Centre, University College Dublin, Belfield, Dublin, Ireland
| | - Gráinne A. Kelly
- Health Sciences Centre, University College Dublin, Belfield, Dublin, Ireland
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