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

Development of a decision aid with cost information for heart failure medication in Singapore

Objective

This study presents the development process of a heart failure (HF) medication decision aid (DA) specific to Singapore context, with the objective of promoting cost conversations.

Methods

Phase 1 was to create a DA prototype, where two HF clinicians were consulted on their input and needs. Phase 2 was pilot testing where the prototype was tested on HF patients and revised based on their feedback.

Results

The DA is a one-page poster that compares only two classes of HF medications. It encompasses seven attributes for comparison, including route of administration, treatment duration, frequency of use, hospitalization rate, survival rate, low blood pressure probability with personalized subsidized cost being the key attribute. A total of 48 patients participated in the pilot testing with only 2 patients (4.2 %) finding the DA difficult to understand. Almost all patients agreed that the DA provided greater clarity in the medication options.

Conclusion

By integrating the needs of both clinicians and patients and conducting user testing, we developed a novel HF medication DA. Patients found the tool easy to understand and acceptable.

Innovation

This innovative DA aims to improve cost conversations by providing tailored, concise, and locally relevant information for efficient use.

Evaluation of natural history communication and shared decision making for self-limiting conditions: Analysis of UK primary care consultations

OBJECTIVE

To analyse communication about the natural course of self-limiting illnesses, as part of shared decision-making (SDM), in general practice consultations.

METHODS

Natural history communication and SDM (using Observing Patient Involvement in Decision-Making (OPTION-12) and Assessing Communication about Evidence and Patient Preferences (ACEPP) items) were rated by two raters using transcripts from the UK 'One in a Million' database.

RESULTS

Of 55 eligible consultations, a 'wait and see' option was mentioned in 27 consultations (49 %), using varying terminology, with a general recovery timeframe provided in 21. Mean OPTION-12 score (of 100) was 25.2 (SD=7.4), indicating a low level of SDM. Mean ACEPP score (out of 5) was 1.2 (SD=0.5), indicating minimal communication about the options' benefits and harms. Recovery likelihood was quantified in only two consultations, while harms were quantified in none.

CONCLUSION

Communication about the natural history of self-limiting illnesses was generally limited. The 'wait and see' approach, along with its benefits and harms, was typically not explicitly presented as an option for patients to consider.

PRACTICE IMPLICATIONS

Improving clinicians' awareness of the importance of and skills for communicating the natural history of self-limiting illnesses, as part of SDM, may facilitate informed decision-making in managing these conditions.

Communicating Probabilities of Cervical Cancer Screening Results with Icon Arrays or Tree Diagrams: A Longitudinal Experiment

Simple graphical displays such as icon arrays and tree diagrams have been proposed for communicating health risks and supporting informed decisions. The UK's National Health Service (NHS) uses tree diagrams to communicate the chances of different cervical cancer screening results, but their effectiveness has not been compared to icon arrays. We conducted a well-powered longitudinal experiment involving 3,100 UK women eligible for cervical screening (25-64 years) to examine the effectiveness of icon arrays to communicate possible cervical screening results, relative to the UK NHS's tree diagram and to a numerical-only format. We also examined whether the presence (vs. absence) of explanatory text referring to different types of results (i.e. distinguishing between HPV positive results with vs. without abnormal cervical cells) moderated effects of presentation format. Presentation format did not affect verbatim or gist knowledge of probabilities at initial assessment (i.e. immediately after participants viewed the displays), but icon arrays were associated with better gist knowledge of absolute magnitudes than tree diagrams and numerical-only formats at 1-month follow-up. Participants exposed to icon arrays also perceived lower likelihood of adverse screening results and reported stronger screening intentions at initial assessment. For displays without explanatory text, icon arrays were also associated with more positive user evaluations and less negative affective reactions than tree diagrams at initial assessment. Overall, our findings suggest that icon arrays support enduring knowledge of approximate magnitudes of probabilities and are better suited than tree diagrams for communicating possible screening results.

Communicating Risk in Imaging: A Scoping Review of Risk Presentation in Patient Decision Aids

PURPOSE

Best practices exist for communicating medical information to patients, but there is less emphasis on methods to communicate risks, especially in medical imaging. The authors conducted a scoping review of patient decision aids in medical imaging and characterized the presentation methods of imaging risks.

METHODS

Embase, MEDLINE, CINAHL, and PsychINFO were searched to identify studies involving patient decision aids used in diagnostic imaging that communicated the risks. Study characteristics included the number and types of risks included, as well as the presentation type and how the probability of risks were communicated.

RESULTS

The final study included 46 articles encompassing 27 distinct patient decision aids. Mammography was the most common imaging scenario (22 of 46), followed by lung cancer screening (18 of 46), traumatic brain injury (5 of 46), and urolithiasis (1 of 46). All patient decision aids included risks associated with imaging, but the number of risk types varied from two to nine (mean, 4 ± 2). Twelve risks were identified across the 27 decision aids, but no single study included all risks. Overall, most risks (65%) were communicated with text, and the presentation mode varied by type of risk. False-positive risks were most commonly communicated using a visual format, whereas radiation risk was most commonly communicated using text format.

CONCLUSIONS

There was no consistent manner of communicating risk to patients, and visual methods such as icon arrays were not consistently used. The variability of both included risks and the risk presentation modes in the patient decision aids may affect decision making, especially among patients and caregivers with lower health literacy and numeracy.

Impact of graphical display on the intention to undergo risk-reducing salpingo-oophorectomy and mastectomy in individuals positive for BRCA pathogenic variant

The BRCA1/2 pathogenic variant (PV) increases the risk of breast and ovarian cancer; thus, risk-reducing salpingo-oophorectomy (RRSO) and mastectomy (RRM) are recommended. We evaluated the effects of the graphical display of cancer risk compared with those of numerical presentation on the decision-making for risk-reducing (RR) surgery. A total of 471 women representing the Korean population were recruited. The lifetime risk of breast/ovarian cancer were given numerically followed by graphically in hypothetical BRCA1/2 PV-positive cases. Subsequently, the study participants were asked for their willingness to undergo RRSO/RRM. When the ovarian cancer risk was shown as 44.0%, the percentage of study participants who chose RRSO was 41.0% after numerical presentation versus 39.9% after graphical display, of which the difference was not significant. When the breast cancer risk was presented as 72.0%, 30.4% of the participants opted for RRM under numerical presentation, whereas this increased to 38.6% under graphical display, of which the difference was significant (p < 0.0075). The average levels of the cancer risk which study participants consider RR surgery were 57.1% for ovarian cancer and 60.6% for breast cancer. This suggests that the impacts of different formats of risk communication on decision about RRSO or RRM may be different by the absolute levels of ovarian or breast cancer.

Impact of personalized risk scores on shared decision making in left ventricular assist device implantation: Findings from a qualitative study

OBJECTIVE

To assess stakeholders' perspectives on integrating personalized risk scores (PRS) into left ventricular assist device (LVAD) implantation decisions and how these perspectives might impact shared decision making (SDM).

METHODS

We conducted 40 in-depth interviews with physicians, nurse coordinators, patients, and caregivers about integrating PRS into LVAD implantation decisions. A codebook was developed to identify thematic patterns, and quotations were consolidated for analysis. We used Thematic Content Analysis in MAXQDA software to identify themes by abstracting relevant quotes.

RESULTS

Clinicians had varying preferences regarding PRS integration into LVAD decision making, while patients and caregivers preferred real-time discussions about PRS with their physicians. Physicians voiced concerns about time constraints and suggested delegating PRS discussions to advanced practice providers or nurse coordinators.

CONCLUSIONS

Integrating PRS information into LVAD decision aids presents both opportunities and challenges for SDM. Given variable preferences among clinicians and patients, clinicians should elicit patients' desired role in the decision-making process. Addressing time constraints and ensuring patient-centered care will be crucial for optimizing SDM. Practice implications Clinicians should elicit patient preferences for PRS information disclosure and address challenges, such as time constraints and delegation of PRS discussions to other team members.

Exploring the MAPPING application to facilitate risk communication and shared decision-making between physicians and patients with gynaecological cancer

This is an observational study in which we evaluated current levels of risk communication (RC) among gynaecological oncologists and their view on the Mapping All Patient Probabilities in Numerical Graphs (MAPPING) application as a possible tool to facilitate RC and shared decision-making (SDM). In part A, we audio-recorded 29 conversations between gynaecological oncologists and patients when discussing treatment options. In part B, interviews were performed with eight gynaecological oncologists.RC and SDM were measured using two observer-based measures, that is, the RC content (RCC) tool (scale 0-2) and the OPTION-5 instrument (scale 0-100). We used CollaboRATE questionnaire (scale 0-10) and a self-developed survey to assess patient-reported RC and SDM. In part B, we evaluated physicians' attitudes regarding the use of the MAPPING application to support RC. Patients were minimally involved in the decision-making process (OPTION-5 25.9%±13.4 RCC 0.21±0.18). Patient-reported SDM was high (mean collaboRATE score 9.19±1.79) and patients preferred receiving numeric information, whereas most physicians used qualitative risk terms rather than exact numbers. In part B, gynaecologists had a positive attitude towards the MAPPING application. However, they stated that the app was difficult to use improvement of layout and better implementations are needed.

Icon Arrays for Medical Risk Communication: Do Icon Type and Color Influence Cardiovascular Risk Perception and Recall?

BACKGROUND

Icon arrays have been shown to be an effective method for communicating medical risk information. However, in practice, icon arrays used to visualize personal risks often differ in the type and color of the icons. The aim of this study was to examine the influence of icon type and color on the perception and recall of cardiovascular risk, as little is known about how color affects the perception of icon arrays.

METHODS

A total of 866 participants aged 40 to 90 years representative of the German population in terms of gender and age completed an online experiment. Using a 2 × 2 between-subjects design, participants were randomly assigned to 1 of 4 experimental groups. They received their hypothetical 10-year cardiovascular risk using an icon array that varied by icon type (smiley v. person) and color (black/white v. red/yellow). We measured risk perception, emotional response, intentions of taking action to reduce the risk (e.g., increasing one's physical activity), risk recall, and graph evaluation/trustworthiness, as well as numeracy and graphical literacy.

RESULTS

Icon arrays using person icons were evaluated more positively. There was no effect of icons or color on risk perception, emotional response, intentions of taking action to reduce the risk, or trustworthiness of the graph. While more numerate/graphical literate participants were more likely to correctly recall the presented risk estimate, icon type and color did not influence the probability of correct recall.

CONCLUSIONS

Differences in the perception of the tested icon arrays were rather small, suggesting that they may be equally suitable for communicating medical risks. Further research on the robustness of these results across other colors, icons, and risk domains could add to guidelines on the design of visual aids.

HIGHLIGHTS

The use of different icons and colors did not influence the perception and the probability of recalling the 10-year cardiovascular risk, the emotional response, or the intentions to reduce the presented risk.Icon arrays with person icons were evaluated more positively.There was no evidence to suggest that the effectiveness of the studied icon arrays varied based on individuals' levels of numerical or graphical literacy, nor did it differ between people with or without a history of CVD or on medication for an increased CVD risk.

Using Separate Single-Outcome Risk Presentations Instead of Integrated Multioutcome Formats Improves Comprehension in Discrete Choice Experiments

INTRODUCTION

Despite decades of research on risk-communication approaches, questions remain about the optimal methods for conveying risks for different outcomes across multiple time points, which can be necessary in applications such as discrete choice experiments (DCEs). We sought to compare the effects of 3 design factors: 1) separated versus integrated presentations of the risks for different outcomes, 2) use or omission of icon arrays, and 3) vertical versus horizontal orientation of the time dimension.

METHODS

We conducted a randomized study among a demographically diverse sample of 2,242 US adults recruited from an online panel (mean age 59.8 y, s = 10.4 y; 21.9% African American) that compared risk-communication approaches that varied in the 3 factors noted above. The primary outcome was the number of correct responses to 12 multiple-choice questions asking survey respondents to identify specific numbers, contrast options to recognize dominance (larger v. smaller risks), and compute differences. We used linear regression to test the effects of the 3 design factors, controlling for health literacy, graph literacy, and numeracy. We also measured choice consistency in a subsequent DCE choice module.

RESULTS

Mean comprehension varied significantly across versions (P < 0.001), with higher comprehension in the 3 versions that provided separated risk information for each risk. In the multivariable regression, separated risk presentation was associated with 0.58 more correct responses (P < 0.001; 95% confidence interval: 0.39, 0.77) compared with integrated risk information. Neither providing icon arrays nor using vertical versus horizontal time formats affected comprehension rates, although participant understanding did correlate with DCE choice consistency.

CONCLUSIONS

In presentations of multiple risks over multiple time points, presenting risk information separately for each health outcome appears to increase understanding.

HIGHLIGHTS

When conveying information about risks of different outcomes at multiple time points, separate presentations of single-outcome risks resulted in higher comprehension than presentations that combined risk information for different outcomes.We also observed benefits of presenting single-outcome risks separately among respondents with lower numeracy and graph literacy.Study participants who scored higher on risk understanding were more internally consistent in their responses to a discrete choice experiment.

Development of Promising Interventions to Improve Human Papillomavirus Vaccination in a School-Based Program in Quebec, Canada: Results From a Formative Evaluation Using a Mixed Methods Design

BACKGROUND

Despite the availability of school-based human papillomavirus (HPV) vaccination programs, disparities in vaccine coverage persist. Barriers to HPV vaccine acceptance and uptake include parental attitudes, knowledge, beliefs, and system-level barriers. A total of 3 interventions were developed to address these barriers: an in-person presentation by school nurses, an email reminder with a web-based information and decision aid tool, and a telephone reminder using motivational interviewing (MI) techniques.

OBJECTIVE

Here we report on the development and formative evaluation of interventions to improve HPV vaccine acceptance and uptake among grade 4 students' parents in Quebec, Canada.

METHODS

In the summer of 2019, we conducted a formative evaluation of the interventions to assess the interventions' relevance, content, and format and to identify any unmet needs. We conducted 3 focus group discussions with parents of grade 3 students and nurses. Interviews were recorded, transcribed, and analyzed for thematic content using NVivo software (Lumivero). Nurses received training on MI techniques and we evaluated the effect on nurses' knowledge and skills using a pre-post questionnaire. Descriptive quantitative analyses were carried out on data from questionnaires relating to the training. Comparisons were made using the proportions of the results. Finally, we developed a patient decision aid using an iterative, user-centered design process. The iterative refinement process involved feedback from parents, nurses, and experts to ensure the tool's relevance and effectiveness. The evaluation protocol and data collection tools were approved by the CHU (Centre Hospitalier Universitaire) de Québec Research Ethics Committee (MP-20-2019-4655, May 16, 2019).

RESULTS

The data collection was conducted from April 2019 to March 2021. Following feedback (n=28) from the 3 focus group discussions in June 2019, several changes were made to the in-person presentation intervention. Experts (n=27) and school nurses (n=29) recruited for the project appreciated the visual and simplified information on vaccination in it. The results of the MI training for school nurses conducted in August 2019 demonstrated an increase in the skills and knowledge of nurses (n=29). School nurses who took the web-based course (n=24) filled out a pretest and posttest questionnaire to evaluate their learning. The rating increased by 19% between the pretest and posttest questionnaires. Several changes were made between the first draft of the web-based decision-aid tool and the final version during the summer of 2019 after an expert consultation of experts (n=3), focus group participants (n=28), and parents in the iterative process (n=5). More information about HPV and vaccines was added, and users could click if more detail is desired.

CONCLUSIONS

We developed and pilot-tested 3 interventions using an iterative process. The interventions were perceived as potentially effective to increase parents' knowledge and positive attitudes toward HPV vaccination, and ultimately, vaccine acceptance. Future research will assess the effectiveness of these interventions on a larger scale.

Development of the AMPDECIDE Decision Aid to Facilitate Shared Decision Making in Patients Facing Amputation Secondary to Chronic Limb Threatening Ischemia

INTRODUCTION

We developed a patient decision aid to enhance patient participation in amputation level decision making when there is a choice between a transmetatarsal or transtibial amputation.

METHODS

In accordance with International Patient Decision Aid Standards, we developed an amputation level patient decision aid for patients who are being considered for either a transmetatarsal or transtibial amputation, incorporating qualitative literature data, quantitative literature data, qualitative provider and patient interviews, expert panel input and iterative patient feedback.

RESULTS

The rapid qualitative literature review and qualitative interviews identified five domains outcome priority domains important to patients facing amputation secondary to chronic limb threatening ischemia: 1) the ability to walk, 2) healing and risk for reamputation, 3) rehabilitation program intensity, 4) ease of prosthetic use, and 5) limb length after amputation. The rapid quantitative review identified only two domains with adequate evidence comparing differences in outcomes between the two amputation levels: mobility and reamputation. Patient, surgeon, rehabilitation and decision aid expert feedback allowed us to integrate critical facets of the decision including addressing the emotional context of loss of limb, fear and anxiety as an obstacle to decision making, shaping the decision in the context of remaining life years, and how to facilitate patient knowledge of value tradeoffs.

CONCLUSIONS

Amputation level choice is associated with significant outcome trade-offs. The AMPDECIDE patient decision aid can facilitate acknowledgment of patient fears, enhance knowledge of amputation level outcomes, assist patients in determining their personal outcome priorities, and facilitate shared amputation level decision making.

Risk-Adapted Breast Screening for Women at Low Predicted Risk of Breast Cancer: An Online Discrete Choice Experiment

BACKGROUND

A risk-stratified breast screening program could offer low-risk women less screening than is currently offered by the National Health Service. The acceptability of this approach may be enhanced if it corresponds to UK women's screening preferences and values.

OBJECTIVES

To elicit and quantify preferences for low-risk screening options.

METHODS

Women aged 40 to 70 y with no history of breast cancer took part in an online discrete choice experiment. We generated 32 hypothetical low-risk screening programs defined by 5 attributes (start age, end age, screening interval, risk of dying from breast cancer, and risk of overdiagnosis), the levels of which were systematically varied between the programs. Respondents were presented with 8 choice sets and asked to choose between 2 screening alternatives or no screening. Preference data were analyzed using conditional logit regression models. The relative importance of attributes and the mean predicted probability of choosing each program were estimated.

RESULTS

Participants (N = 502) preferred all screening programs over no screening. An older starting age of screening, younger end age of screening, longer intervals between screening, and increased risk of dying had a negative impact on support for screening programs (P < 0.01). Although the risk of overdiagnosis was of low relative importance, a decreased risk of this harm had a small positive impact on screening choices. The mean predicted probabilities that risk-adapted screening programs would be supported relative to current guidelines were low (range, 0.18 to 0.52).

CONCLUSIONS

A deintensified screening pathway for women at low risk of breast cancer, especially one that recommends a later screening start age, would run counter to women's breast screening preferences. Further research is needed to enhance the acceptability of offering less screening to those at low risk of breast cancer.

HIGHLIGHTS

Risk-based breast screening may involve the deintensification of screening for women at low risk of breast cancer.Low-risk screening pathways run counter to women's screening preferences and values.Longer screening intervals may be preferable to a later start age.Work is needed to enhance the acceptability of a low-risk screening pathway.

A Decision Aid for Patients Considering Surgery for Sciatica: Codesign and User-Testing With Patients and Clinicians

BACKGROUND

Surgery can help patients with leg pain caused by sciatica recover faster, but by 12 months outcomes are similar to nonsurgical management. For many the decision to have surgery may require reflection, and patient decision aids are an evidence-based clinical tool that can help guide patients through this decision.

OBJECTIVE

The aim of this study was to develop and refine a decision aid for patients with sciatica who are deciding whether to have surgery or 'wait and see' (i.e., try nonsurgical management first).

DESIGN

Semistructured interviews with think-aloud user-testing protocol.

PARTICIPANTS

Twenty clinicians and 20 patients with lived experience of low back pain or sciatica.

OUTCOME MEASURES

Items from Technology Acceptance Model, Preparation for Decision Making Scale and Decision Quality Instrument for Herniated Disc 2.0 (knowledge instrument).

METHODS

The prototype integrated relevant research with working group perspectives, decision aid standards and health literacy guidelines. The research team refined the prototype through seven rounds of user-testing, which involved discussing user-testing feedback and implementing changes before progressing to the next round.

RESULTS

As a result of working group feedback, the decision aid was divided into sections: before, during and after a visit to the surgeon. Across all rounds of user-testing, clinicians rated the resource 5.9/7 (SD = 1.0) for perceived usefulness, and 6.0/7 for perceived ease of use (SD = 0.8). Patients reported the decision aid was easy to understand, on average correctly answering 3.4/5 knowledge questions (SD = 1.2) about surgery for sciatica. The grade reading score for the website was 9.0. Patients scored highly on preparation for decision-making (4.4/5, SD = 0.7), suggesting strong potential to empower patients. Interview feedback showed that patients and clinicians felt the decision aid would encourage question-asking and help patients reflect on personal values.

CONCLUSIONS

Clinicians found the decision aid acceptable, patients found it was easy to understand and both groups felt it would empower patients to actively engage in their care and come to an informed decision that aligned with personal values. Input from the working group and user-testing was crucial for ensuring that the decision aid met patient and clinician needs.

PATIENT OR PUBLIC CONTRIBUTION

Patients and clinicians contributed to prototype development via the working group.

Impact of screening participation on modelled mortality benefits of a multi-cancer early detection test by socioeconomic group in England

BACKGROUND

Cancer burden is higher and cancer screening participation is lower among individuals living in more socioeconomically deprived areas of England, contributing to worse health outcomes and shorter life expectancy. Owing to higher multi-cancer early detection (MCED) test sensitivity for poor-prognosis cancers and greater cancer burden in groups experiencing greater deprivation, MCED screening programmes may have greater relative benefits in these groups. We modelled potential differential benefits of MCED screening between deprivation groups in England at different levels of screening participation.

METHODS

We applied the interception multi-cancer screening model to cancer incidence and survival data made available by the National Cancer Registration and Analysis Service in England to estimate reductions in late-stage diagnoses and cancer mortality from an MCED screening programme by deprivation group across 24 cancer types. We assessed the impact of varying the proportion of people who participated in annual screening in each deprivation group on these estimates.

RESULTS

The modelled benefits of an MCED screening programme were substantial: reductions in late-stage diagnoses were 160 and 274 per 100 000 persons in the least and most deprived groups, respectively. Reductions in cancer mortality were 60 and 99 per 100 000 persons in the least and most deprived groups, respectively. Benefits were greatest in the most deprived group at every participation level and were attenuated with lower screening participation.

CONCLUSIONS

For the greatest possible population benefit and to decrease health inequalities, an MCED implementation strategy should focus on enhancing equitable, informed participation, enabling equal participation across all socioeconomic deprivation groups.

TRIAL REGISTRATION NUMBER

NCT05611632.

Patients' and physicians' beliefs and attitudes towards integrating personalized risk estimates into patient education about left ventricular assist device therapy

BACKGROUND

Personalized risk (PR) estimates may enhance clinical decision making and risk communication by providing individualized estimates of patient outcomes. We explored stakeholder attitudes toward the utility, acceptability, usefulness and best-practices for integrating PR estimates into patient education and decision making about Left Ventricular Assist Device (LVAD).

METHODS AND RESULTS

As part of a 5-year multi-institutional AHRQ project, we conducted 40 interviews with stakeholders (physicians, nurse coordinators, patients, and caregivers), analyzed using Thematic Content Analysis. All stakeholder groups voiced positive views towards integrating PR in decision making. Patients, caregivers and coordinators emphasized that PR can help to better understand a patient's condition and risks, prepare mentally and logistically for likely outcomes, and meaningfully engage in decision making. Physicians felt it can improve their decision making by enhancing insight into outcomes, enhance tailored pre-emptive care, increase confidence in decisions, and reduce bias and subjectivity. All stakeholder groups also raised concerns about accuracy, representativeness and relevance of algorithms; predictive uncertainty; utility in relation to physician's expertise; potential negative reactions among patients; and overreliance.

CONCLUSION

Stakeholders are optimistic about integrating PR into clinical decision making, but acceptability depends on prospectively demonstrating accuracy, relevance and evidence that benefits of PR outweigh potential negative impacts on decision making quality.

"R" you getting this? Factors contributing to the public's understanding, evaluation, and use of basic reproduction numbers for infectious diseases

BACKGROUND

We (1) examined the effects of evaluative labels and visual aids on people's understanding, evaluation, and use of the COVID-19 reproduction number (or "r-number"), (2) examined whether people's perceived susceptibility and (intended) adherence to preventive measures changed after being exposed to the r-number, and (3) explored whether these effects and changes depended on people's numeracy skills.

METHODS

In an online experiment, participants from a large Dutch representative sample (N = 1,168) received information about the COVID-19 r-number displayed on the corona dashboard of the Dutch Ministry of Health, Welfare and Sport. The r-number was either presented with or without a categorical line display (i.e., evaluative label) and with or without an icon-based tree diagram (i.e., visual aid) explaining how the number works. Regarding people's use of the statistic, we measured perceived susceptibility to COVID-19 and adherence (intention) to five preventive measures before and after exposure to the r-number. After exposure, we also measured participants' understanding, perceived usefulness, affective and cognitive evaluation, and objective numeracy.

RESULTS

About 56% of participants correctly interpreted the r-number, with highly numerate people having better understanding than less numerate people. Information about the r-number was perceived as more useful when presented with a visual aid. There were no differences across experimental conditions in people's understanding, affective, and cognitive evaluations. Finally, independent of experimental conditions, intention to adhere to preventive measures was higher after seeing the r-number, but only among highly numerate people.

CONCLUSIONS

Although evaluative labels and visual aids did not facilitate people's understanding and evaluation of the r-number, our results show that the statistic is perceived as useful and may be used to stimulate adherence to preventive measures. Policy makers and public health communicators are advised to clearly explain why they are giving these numbers to - especially - the less numerate people, but also how people could use them for behavior change to combat the spread of virus during a pandemic.

Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study

AIM

To develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction.

DESIGN

Mixed-methods study describing the development of a patient decision aid.

SETTING

A draft decision aid was developed by a multidisciplinary steering group (including various types of health professionals and researchers, and consumers) informed by the best available evidence and existing patient decision aids.

PARTICIPANTS

People who ruptured their ACL when they were under 18 years old (ie, adolescents), their parents, and health professionals who manage these patients. Participants were recruited through social media and the network outreach of the steering group.

PRIMARY AND SECONDARY OUTCOMES

Semistructured interviews and questionnaires were used to gather feedback on the decision aid. The feedback was used to refine the decision aid and assess acceptability. An iterative cycle of interviews, refining the aid according to feedback and further interviews, was used. Interviews were analysed using reflexive thematic analysis.

RESULTS

We conducted 32 interviews; 16 health professionals (12 physiotherapists, 4 orthopaedic surgeons) and 16 people who ruptured their ACL when they were under 18 years old (7 were adolescents and 9 were adults at the time of the interview). Parents participated in 8 interviews. Most health professionals, patients and parents rated the aid's acceptability as good-to-excellent. Health professionals and patients agreed on most aspects of the decision aid, but some health professionals had differing views on non-surgical management, risk of harms, treatment protocols and evidence on benefits and harms.

CONCLUSION

Our patient decision aid is an acceptable tool to help children and adolescents choose an appropriate management option following ACL rupture with their parents and health professionals. A clinical trial evaluating the potential benefit of this tool for children and adolescents considering ACL reconstruction is warranted.

Use of Persuasive Language in Communication of Risk during Prostate Cancer Treatment Consultations

BACKGROUND

Physician treatment preference may influence how risks are communicated in prostate cancer consultations. We identified persuasive language used when describing cancer prognosis, life expectancy, and side effects in relation to a physician's recommendation for aggressive (surgery/radiation) or nonaggressive (active surveillance/watchful waiting) treatment.

METHODS

A qualitative analysis was performed on transcribed treatment consultations of 40 men with low- and intermediate-risk prostate cancer across 10 multidisciplinary providers. Quotes pertaining to cancer prognosis, life expectancy, and side effects were randomized. Coders predicted physician treatment recommendations from isolated blinded quotes. Testing characteristics of consensus predictions against the physician's treatment recommendation were reported. Coders then identified persuasive strategies favoring aggressive/nonaggressive treatment for each quote. Frequencies of persuasive strategies favoring aggressive/nonaggressive treatment were reported. Logistic regression quantified associations between persuasive strategies and physician treatment recommendations.

RESULTS

A total of 496 quotes about cancer prognosis (n = 127), life expectancy (n = 51), and side effects (n = 318) were identified. The accuracy of predicting treatment recommendation based on individual quotes containing persuasive language (n = 256/496, 52%) was 91%. When favoring aggressive treatment, persuasive language downplayed side effect risks and amplified cancer risk (recurrence, progression, or mortality). Significant predictors (P < 0.05) of aggressive treatment recommendation included favorable side effect interpretation, downplaying side effects, and long time horizon for cancer risk due to longevity. When favoring nonaggressive treatment, persuasive language amplified side effect risks and downplayed cancer risk. Significant predictors of nonaggressive treatment recommendation included unfavorable side effect interpretation, favorable interpretation of cancer risk, and short time horizon for cancer risk due to longevity.

CONCLUSIONS

Physicians use persuasive language favoring their preferred treatment, regardless of whether their recommendation is appropriate.

IMPLICATIONS

Clinicians should quantify risk so patients can judge potential harm without solely relying on persuasive language.

HIGHLIGHTS

Physicians use persuasive language favoring their treatment recommendation when communicating risks of prostate cancer treatment, which may influence a patient's treatment choice.Coders predicted physician treatment recommendations based on isolated, randomized quotes about cancer prognosis, life expectancy, and side effects with 91% accuracy.Qualitative analysis revealed that when favoring nonaggressive treatment, physicians used persuasive language that amplified side effect risks and downplayed cancer risk. When favoring aggressive treatment, physicians did the opposite.Providers should be cognizant of using persuasive strategies and aim to provide quantified assessments of risk that are jointly interpreted with the patient so that patients can make evidence-based conclusions regarding risks without solely relying on persuasive language.

Merging machine learning and patient preference: a novel tool for risk prediction of percutaneous coronary interventions

BACKGROUND AND AIMS

Predicting personalized risk for adverse events following percutaneous coronary intervention (PCI) remains critical in weighing treatment options, employing risk mitigation strategies, and enhancing shared decision-making. This study aimed to employ machine learning models using pre-procedural variables to accurately predict common post-PCI complications.

METHODS

A group of 66 adults underwent a semiquantitative survey assessing a preferred list of outcomes and model display. The machine learning cohort included 107 793 patients undergoing PCI procedures performed at 48 hospitals in Michigan between 1 April 2018 and 31 December 2021 in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry separated into training and validation cohorts. External validation was conducted in the Cardiac Care Outcomes Assessment Program database of 56 583 procedures in 33 hospitals in Washington.

RESULTS

Overall rate of in-hospital mortality was 1.85% (n = 1999), acute kidney injury 2.51% (n = 2519), new-onset dialysis 0.44% (n = 462), stroke 0.41% (n = 447), major bleeding 0.89% (n = 942), and transfusion 2.41% (n = 2592). The model demonstrated robust discrimination and calibration for mortality {area under the receiver-operating characteristic curve [AUC]: 0.930 [95% confidence interval (CI) 0.920-0.940]}, acute kidney injury [AUC: 0.893 (95% CI 0.883-0.903)], dialysis [AUC: 0.951 (95% CI 0.939-0.964)], stroke [AUC: 0.751 (95%CI 0.714-0.787)], transfusion [AUC: 0.917 (95% CI 0.907-0.925)], and major bleeding [AUC: 0.887 (95% CI 0.870-0.905)]. Similar discrimination was noted in the external validation population. Survey subjects preferred a comprehensive list of individually reported post-procedure outcomes.

CONCLUSIONS

Using common pre-procedural risk factors, the BMC2 machine learning models accurately predict post-PCI outcomes. Utilizing patient feedback, the BMC2 models employ a patient-centred tool to clearly display risks to patients and providers (https://shiny.bmc2.org/pci-prediction/). Enhanced risk prediction prior to PCI could help inform treatment selection and shared decision-making discussions.

Participant-guided development of bilingual genomic educational infographics for Electronic Medical Records and Genomics Phase IV study

OBJECTIVE

Developing targeted, culturally competent educational materials is critical for participant understanding of engagement in a large genomic study that uses computational pipelines to produce genome-informed risk assessments.

MATERIALS AND METHODS

Guided by the Smerecnik framework that theorizes understanding of multifactorial genetic disease through 3 knowledge types, we developed English and Spanish infographics for individuals enrolled in the Electronic Medical Records and Genomics Network. Infographics were developed to explain concepts in lay language and visualizations. We conducted iterative sessions using a modified "think-aloud" process with 10 participants (6 English, 4 Spanish-speaking) to explore comprehension of and attitudes towards the infographics.

RESULTS

We found that all but one participant had "awareness knowledge" of genetic disease risk factors upon viewing the infographics. Many participants had difficulty with "how-to" knowledge of applying genetic risk factors to specific monogenic and polygenic risks. Participant attitudes towards the iteratively-refined infographics indicated that design saturation was reached.

DISCUSSION

There were several elements that contributed to the participants' comprehension (or misunderstanding) of the infographics. Visualization and iconography techniques best resonated with those who could draw on prior experiences or knowledge and were absent in those without. Limited graphicacy interfered with the understanding of absolute and relative risks when presented in graph format. Notably, narrative and storytelling theory that informed the creation of a vignette infographic was most accessible to all participants.

CONCLUSION

Engagement with the intended audience who can identify strengths and points for improvement of the intervention is necessary to the development of effective infographics.

Visualizing machine learning-based predictions of postpartum depression risk for lay audiences

OBJECTIVES

To determine if different formats for conveying machine learning (ML)-derived postpartum depression risks impact patient classification of recommended actions (primary outcome) and intention to seek care, perceived risk, trust, and preferences (secondary outcomes).

MATERIALS AND METHODS

We recruited English-speaking females of childbearing age (18-45 years) using an online survey platform. We created 2 exposure variables (presentation format and risk severity), each with 4 levels, manipulated within-subject. Presentation formats consisted of text only, numeric only, gradient number line, and segmented number line. For each format viewed, participants answered questions regarding each outcome.

RESULTS

Five hundred four participants (mean age 31 years) completed the survey. For the risk classification question, performance was high (93%) with no significant differences between presentation formats. There were main effects of risk level (all P < .001) such that participants perceived higher risk, were more likely to agree to treatment, and more trusting in their obstetrics team as the risk level increased, but we found inconsistencies in which presentation format corresponded to the highest perceived risk, trust, or behavioral intention. The gradient number line was the most preferred format (43%).

DISCUSSION AND CONCLUSION

All formats resulted high accuracy related to the classification outcome (primary), but there were nuanced differences in risk perceptions, behavioral intentions, and trust. Investigators should choose health data visualizations based on the primary goal they want lay audiences to accomplish with the ML risk score.

Involving patients and the public In sTatistIcal Analysis pLans (INITIAL): A delphi survey

BACKGROUND

Patient and public involvement (PPI) in trials aims to enhance research by improving its relevance and transparency. Planning for statistical analysis begins at the design stage of a trial within the protocol and is refined and detailed in a Statistical Analysis Plan (SAP). While PPI is common in design and protocol development it is less common within SAPs. This study aimed to reach consensus on the most important and relevant statistical analysis items within an SAP to involve patients and the public.

METHODS

We developed a UK-based, two-round Delphi survey through an iterative consultation with public partners, statisticians, and trialists. The consultation process started with 55 items from international guidance for statistical analysis plans. We aimed to recruit at least 20 participants per key stakeholder group for inclusion in the final analysis of the Delphi survey. Participants were asked to vote on each item using a Likert scale from 1 to 9, where a rating of 1 to 3 was labelled as having 'limited importance'; 4 to 6 as 'important but not critical' and 7 to 9 as 'critical' to involve patients and the public. Results from the second round determined consensus on critical items for PPI.

RESULTS

The consultation exercise led to the inclusion of 15 statistical items in the Delphi survey. We recruited 179 participants, of whom 72% (129: 36 statisticians, 29 patients or public partners, 25 clinical researchers or methodologists, 27 trial managers, and 12 PPI coordinators) completed both rounds. Participants were on average 48 years old, 60% were female, 84% were White, 64% were based in England and 84% had at least five years' experience in trials. Four items reached consensus regarding critical importance for patient and public involvement: presentation of results to trial participants; summary and presentation of harms; interpretation and presentation of findings in an academic setting; factors impacting how well a treatment works. No consensus was reached for the remaining 11 items. In general, the results were consistent across stakeholder groups.

DISCUSSION

We identified four critical items to involve patients and the public in statistical analysis plans. The remaining 11 items did not reach consensus and need to be considered in a case-by-case basis with most responders considering patient and public involvement important (but not critical). Our research provides a platform to enable focused future efforts to improve patient and public involvement in trials and enhance the relevance of statistical analyses to patients and the public.

Implementation costs of sugary drink policies in the United States

To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.

Using Patient Decision Aids for Cardiology Care in Diverse Populations

PURPOSE OF REVIEW

Patient decision aids (PDAs) are tools that help guide treatment decisions and support shared decision-making when there is equipoise between treatment options. This review focuses on decision aids that are available to support cardiac treatment options for underrepresented groups.

RECENT FINDINGS

PDAs have been developed to support multiple treatment decisions in cardiology related to coronary artery disease, valvular heart disease, cardiac arrhythmias, heart failure, and cholesterol management. By considering the unique needs and preferences of diverse populations, PDAs can enhance patient engagement and promote equitable healthcare delivery in cardiology. In this review, we examine the benefits, challenges, and current trends in implementing PDAs, with a focus on improving decision-making processes and outcomes for patients from underrepresented racial and ethnic groups. In addition, the article highlights key considerations when implementing PDAs and potential future directions in the field.

How Do People Process Different Representations of Statistical Information? Insights into Cognitive Effort, Representational Inconsistencies, and Individual Differences

BACKGROUND

Graphical representation formats (e.g., icon arrays) have been shown to lead to better understanding of the benefits and risks of treatments compared to numbers. We investigate the cognitive processes underlying the effects of format on understanding: how much cognitive effort is required to process numerical and graphical representations, how people process inconsistent representations, and how numeracy and graph literacy affect information processing.

METHODS

In a preregistered between-participants experiment, 665 participants answered questions about the relative frequencies of benefits and side effects of 6 medications. First, we manipulated whether the medical information was represented numerically, graphically (as icon arrays), or inconsistently (numerically for 3 medications and graphically for the other 3). Second, to examine cognitive effort, we manipulated whether there was time pressure or not. In an additional intervention condition, participants translated graphical information into numerical information before answering questions. We also assessed numeracy and graph literacy.

RESULTS

Processing icon arrays was more strongly affected by time pressure than processing numbers, suggesting that graphical formats required more cognitive effort. Understanding was lower when information was represented inconsistently (v. consistently) but not if there was a preceding intervention. Decisions based on inconsistent representations were biased toward graphically represented options. People with higher numeracy processed quantitative information more efficiently than people with lower numeracy did. Graph literacy was not related to processing efficiency.

LIMITATIONS

Our study was conducted with a nonpatient sample, and the medical information was hypothetical.

CONCLUSIONS

Although graphical (v. numerical) formats have previously been found to lead to better understanding, they may require more cognitive effort. Therefore, the goal of risk communication may play an important role when choosing how to communicate medical information.

HIGHLIGHTS

This article investigates the cognitive processes underlying the effects of representation format on the understanding of statistical information and individual differences therein.Processing icon arrays required more cognitive effort than processing numbers did.When information was represented inconsistently (i.e., partly numerically and partly graphically), understanding was lower than with consistent representation, and decisions were biased toward the graphically represented options.People with higher numeracy processed quantitative information more efficiently than people with lower numeracy did.

The Lure of Beauty: People Select Representations of Statistical Information Largely Based on Attractiveness, Not Comprehensibility

OBJECTIVE

People differ in whether they understand graphical or numerical representations of statistical information better. However, assessing these skills is often not feasible when deciding which representation to select or use. This study investigates whether people choose the representation they understand better, whether this choice can improve risk comprehension, and whether results are influenced by participants' skills (graph literacy and numeracy).

METHODS

In an experiment, 160 participants received information about the benefits and side effects of painkillers using either a numerical or a graphical representation. In the "no choice" condition, the representation was randomly assigned to each participant. In the "choice" condition, participants could select the representation they would like to receive. The study assessed gist and verbatim knowledge (immediate comprehension and recall), accessibility of the information, attractiveness of the representation, as well as graph literacy and numeracy.

RESULTS

In the "choice" condition, most (62.5%) chose the graphical format, yet there was no difference in graph literacy or numeracy (nor age or gender) between people who chose the graphical or the numerical format. Whereas choice slightly increased verbatim knowledge, it did not improve gist or overall knowledge compared with random assignment. However, participants who chose a representation rated the representation as more attractive, and those who chose graphs rated them as more accessible than those without a choice.

LIMITATIONS

The sample consisted of highly educated undergraduate students with higher graph literacy than the general population. The task was inconsequential for participants in terms of their health.

CONCLUSIONS

When people can choose between representations, they fail to identify what they comprehend better but largely base that choice on how attractive the representation is for them.

HIGHLIGHTS

People differ systematically in whether they understand graphical or numerical representations of statistical information better. However, assessing these underlying skills to get the right representation to the right people is not feasible in practice. A simple and efficient method to achieve this could be to let people choose among representations themselves.However, our study showed that allowing participants to choose a representation (numerical v. graphical) did not improve overall or gist knowledge compared with determining the representation randomly, even though it did slightly improve verbatim knowledge.Rather, participants largely chose the representation they found more attractive. Most preferred the graphical representation, including those with low graph literacy.It would therefore be important to develop graphical representations that are not only attractive but also comprehensible even for people with low graph literacy.

Decision aids to assist patients and professionals in choosing the right treatment for kidney failure

Background

Kidney services vary in the way they involve people with kidney failure (PwKF) in treatment decisions as management needs change. We discuss how decision-science applications support proactively PwKF to make informed decisions between treatment options with kidney professionals.

Methods

A conceptual review of findings about decision making and use of decision aids in kidney services, synthesized with reference to: the Making Informed Decisions-Individually and Together (MIND-IT) multiple stakeholder decision makers framework; and the Medical Research Council-Complex Intervention Development and Evaluation research framework.

Results

This schema represents the different types of decision aids that support PwKF and professional reasoning as they manage kidney disease individually and together; adjustments at micro, meso and macro levels supports integration in practice.

Conclusion

Innovating services to meet clinical guidelines on enhancing shared decision making processes means enabling all stakeholders to use decision aids to meet their goals within kidney pathways at individual, service and organizational levels.

Decision Making About Disease-Modifying Treatments for Relapsing-Remitting Multiple Sclerosis: Stated Preferences and Real-World Choices

BACKGROUND

People with relapsing-remitting multiple sclerosis can benefit from disease-modifying treatments (DMTs). Several DMTs are available that vary in their efficacy, side-effect profile and mode of administration.

OBJECTIVE

We aimed to measure the preferences of people with relapsing-remitting multiple sclerosis for DMTs using a discrete choice experiment and to assess which stated preference attributes correlate with the attributes of the DMTs they take in the real world.

METHODS

Discrete choice experiment attributes were developed from literature reviews, interviews and focus groups. In a discrete choice experiment, participants were shown two hypothetical DMTs, then chose whether they preferred one of the DMTs or no treatment. A mixed logit model was estimated from responses and individual-level estimates of participants' preferences conditional on their discrete choice experiment choices calculated. Logit models were estimated with stated preferences predicting current real-world on-treatment status, DMT mode of administration and current DMT.

RESULTS

A stated intrinsic preference for taking a DMT was correlated with currently taking a DMT, and stated preferences for mode of administration were correlated with the modes of administration of the DMTs participants were currently taking. Stated preferences for treatment effectiveness and adverse effects were not correlated with real-world behaviour.

CONCLUSIONS

There was variation in which discrete choice experiment attributes correlated with participants' real-world DMT choices. This may indicate patient preferences for treatment efficacy/risk are not adequately taken account of in prescribing. Treatment guidelines must ensure they take into consideration patients' preferences and improve communication around treatment efficacy/risk.

A systematic review of the effects of positive versus negative framing on cancer treatment decision making

OBJECTIVE

Presenting treatment outcomes positively or negatively may differently influence treatment preferences and lead to sub-optimal decision in a medical context. This review systematically organised how positive versus negative framing of treatment outcomes influenced cancer treatment decisions of cancer patients and individuals without a cancer diagnosis.

DESIGN

Three databases (PubMed, PsycInfo and Scopus) were searched for studies reporting the effects of positive versus negative framing on cancer treatment decision-making from 1981 to December 2020.

MAIN OUTCOME MEASURE

The effects of positive versus negative framing on cancer treatment preferences and the elimination of framing effect were evaluated.

RESULTS

A total of 12 studies that met inclusion criteria were reviewed. Framing effect was consistently observed in individuals without a cancer diagnosis. There was not enough evidence to suggest a robust framing effect in cancer patients. Surgery was preferred in positive framing, whereas adjuvant therapy was preferred in negative framing. Justification intervention significantly eliminated framing effect. Mixed framing failed to eliminate framing effect.

CONCLUSION

Current recommendations for presenting treatment options are based on research in cancer-screening decision-making. Knowledge of how positive versus negative framing affect cancer patients' treatment decisions is still limited. Our review highlighted the need for continued research in this area.

Patients' Perspectives Regarding Generator Exchanges of Implantable Cardioverter Defibrillators

BACKGROUND

Shared decision-making is mandated for patients receiving primary prevention implantable cardioverter defibrillators (ICDs). Less attention has been paid to generator exchange decisions, although at the time of generator exchange, patients' risk of sudden cardiac death, risk of procedural complications, quality of life, or prognosis may have changed. This study was designed to explore how patients make ICD generator exchange decisions.

METHODS

Emory Healthcare patients with primary prevention ICDs implanted from 2013 to 2021 were recruited to complete in-depth interviews exploring perspectives regarding generator exchanges. Interviews were conducted in 2021. Transcribed interviews were qualitatively coded using multilevel template analytic methods. To investigate benefit thresholds for pursuing generator exchanges, patients were presented standard-gamble type hypothetical scenarios where their ICD battery was depleted but their 5-year risk of sudden cardiac death at that time varied (10%, 5%, and 1%).

RESULTS

Fifty patients were interviewed; 18 had a prior generator exchange, 16 had received ICD therapy, and 17 had improved left ventricular ejection fraction. As sudden cardiac death risk decreased from 10% to 5% to 1%, the number of participants willing to undergo a generator exchange decreased from 48 to 42 to 33, respectively. Responses suggest that doctor's recommendations are likely to substantially impact patients' decision-making. Other drivers of decision-making included past experiences with ICD therapy and device implantation, as well as risk aversion. Therapeutic inertia and misconceptions about ICD therapy were common and represent substantive barriers to effective shared decision-making in this context.

CONCLUSIONS

Strong defaults may exist to continue therapy and exchange ICD generators. Updated risk stratification may facilitate shared decision-making and reduce generator exchanges in very low-risk patients, especially if these interventions are directed toward clinicians. Interventions targeting phenomena such as therapeutic inertia may be more impactful and warrant exploration in randomized trials.

Effect of different visual presentations on the public's comprehension of prognostic information using acute and chronic condition scenarios: two online randomised controlled trials

OBJECTIVES

To assess the effectiveness of bar graph, pictograph and line graph compared with text-only, and to each other, for communicating prognosis to the public.

DESIGN

Two online four-arm parallel-group randomised controlled trials. Statistical significance was set at p<0.016 to allow for three-primary comparisons.

PARTICIPANTS AND SETTING

Two Australian samples were recruited from members registered at Dynata online survey company. In trial A: 470 participants were randomised to one of the four arms, 417 were included in the analysis. In trial B: 499 were randomised and 433 were analysed.

INTERVENTIONS

In each trial four visual presentations were tested: bar graph, pictograph, line graph and text-only. Trial A communicated prognostic information about an acute condition (acute otitis media) and trial B about a chronic condition (lateral epicondylitis). Both conditions are typically managed in primary care where 'wait and see' is a legitimate option.

MAIN OUTCOME

Comprehension of information (scored 0-6).

SECONDARY OUTCOMES

Decision intention, presentation satisfaction and preferences.

RESULTS

In both trials, the mean comprehension score was 3.7 for the text-only group. None of the visual presentations were superior to text-only. In trial A, the adjusted mean difference (MD) compared with text-only was: 0.19 (95% CI -0.16 to 0.55) for bar graph, 0.4 (0.04 to 0.76) for pictograph and 0.06 (-0.32 to 0.44) for line graph. In trial B, the adjusted MD was: 0.1 (-0.27 to 0.47) for bar graph), 0.38 (0.01 to 0.74) for pictograph and 0.1 (-0.27 to 0.48) for line graph. Pairwise comparisons between the three graphs showed all were clinically equivalent (95% CIs between -1.0 and 1.0). In both trials, bar graph was the most preferred presentation (chosen by 32.9% of trial A participants and 35.6% in trial B).

CONCLUSIONS

Any of the four visual presentations tested may be suitable to use when discussing quantitative prognostic information.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12621001305819).

Developing an Educational and Decision Support Tool for Stage I Lung Cancer Using Decision Science

BACKGROUND

Guidelines recommend shared decision-making about treatment options for high-risk, operable stage I lung cancer. Patient decision aids can facilitate shared decision-making; however, their development, implementation, and evaluation in routine clinical practice presents numerous challenges and opportunities.

METHODS

The purpose of this review is to reflect on the process of tool development; identify the challenges associated with meeting the needs of patients, clinicians from multiple disciplines, and institutional workflow during implementation; and propose recommendations for future clinicians who wish to develop, refine, or implement similar tools into routine care.

RESULTS

In this review, we: (1) discuss guidelines for decision aid development; (2) describe how we applied those to create an education and decision support tool for patients with clinical stage I lung cancer deciding between radiation therapy and surgical resection; and (3) highlight challenges in implementing and evaluating the tool.

CONCLUSIONS

We provide recommendations for those seeking to develop, refine, or implement similar tools into routine care.

Leveraging Math Cognition to Combat Health Innumeracy

Rational numbers (i.e., fractions, percentages, decimals, and whole-number frequencies) are notoriously difficult mathematical constructs. Yet correctly interpreting rational numbers is imperative for understanding health statistics, such as gauging the likelihood of side effects from a medication. Several pernicious biases affect health decision-making involving rational numbers. In our novel developmental framework, the natural-number bias-a tendency to misapply knowledge about natural numbers to all numbers-is the mechanism underlying other biases that shape health decision-making. Natural-number bias occurs when people automatically process natural-number magnitudes and disregard ratio magnitudes. Math-cognition researchers have identified individual differences and environmental factors underlying natural-number bias and devised ways to teach people how to avoid these biases. Although effective interventions from other areas of research can help adults evaluate numerical health information, they circumvent the core issue: people's penchant to automatically process natural-number magnitudes and disregard ratio magnitudes. We describe the origins of natural-number bias and how researchers may harness the bias to improve rational-number understanding and ameliorate innumeracy in real-world contexts, including health. We recommend modifications to formal math education to help children learn the connections among natural and rational numbers. We also call on researchers to consider individual differences people bring to health decision-making contexts and how measures from math cognition might identify those who would benefit most from support when interpreting health statistics. Investigating innumeracy with an interdisciplinary lens could advance understanding of innumeracy in theoretically meaningful and practical ways.

Vitruvian plot: a visualisation tool for multiple outcomes in network meta-analysis

OBJECTIVE

A network meta-analysis (NMA) usually assesses multiple outcomes across several treatment comparisons. The Vitruvian plot aims to facilitate communication of multiple outcomes from NMAs to patients and clinicians.

METHODS

We developed this tool following the recommendations on the communication of benefit-risk information from the available literature. We collected and implemented feedback from researchers, statisticians, methodologists, clinicians and people with lived experience of physical and mental health issues.

RESULTS

We present the Vitruvian plot, which graphically presents absolute estimates and relative performance of competing interventions against a common comparator for several outcomes of interest. We use two alternative colour schemes to highlight either the strength of statistical evidence or the confidence in the evidence. Confidence in the evidence is evaluated across six domains (within-study bias, reporting bias, indirectness, imprecision, heterogeneity and incoherence) using the Confidence in Network Meta-Analysis (CINeMA) system.

CONCLUSIONS

The Vitruvian plot allows reporting of multiple outcomes from NMAs, with colourings appropriate to inform credibility of the presented evidence.

Person-based co-design of a decision aid template for people with a genetic predisposition to cancer

Background

People with genetic predispositions to cancer are faced with complex health decisions about managing their risk. Decision aids can support informed, values-based decisions, alongside shared decision-making with a clinician. Whilst diagnoses of genetic predispositions to cancer are increasing, there is no scalable decision aid to support these people. This paper presents an accessible, relevant decision aid template which can be adapted for different predispositions to cancer.

Methods

The decision aid template was co-developed with 12 patients affected by cancer and informed by empirical and theoretical literature. In addition, consultations were conducted with a further 19 people with Lynch syndrome; a specific genetic predisposition to cancer. Clinical stakeholders were consulted regularly. Coulter's framework for decision aid development guided the process, and these activities were complemented by the International Patient Decision Aid Standards, and the latest evidence on communicating risk in decision aids. Programme theory was developed to hypothesise how the decision aid would support decision-making and contextual factors which could influence the process. Guiding principles co-developed with the patient panel described how the decision aid could effectively engage people.

Results

The in-depth co-design process led to the identification of five core components of an accessible decision aid template for people with a genetic predisposition to cancer: defining the decision; option grid showing implications of each option; optional further details such as icon arrays to show tailored risk and personal narratives; values clarification activity; and a summary to facilitate discussion with a clinician. Specific guidance was produced describing how to develop each component. The guiding principles identified that the decision aid template needed to promote trust, reduce distress, and be comprehensive, personally relevant and accessible in order to engage people.

Conclusion

Adopting a co-design process helped ensure that the decision aid components were relevant and accessible to the target population. The template could have widespread application through being adapted for different genetic predispositions. The exact content should be co-designed with people from diverse backgrounds with lived experience of the specific predisposition to ensure it is as useful, engaging and relevant as possible.

Shared decision-making in patients with multiple sclerosis

Multiple sclerosis (MS) is a chronic and progressive neurological disorder impacting physical, cognitive, and psychosocial health. The disease course, severity, and presence of symptoms differ within and between persons over time and are unpredictable. Given the preference-sensitive nature of many key decisions to be made, and the increasing numbers of disease-modifying therapies, shared decision-making (SDM) with patients seems to be key in offering optimum care and outcomes for people suffering from MS. In this paper, we describe our perspective on how to achieve SDM in patients with MS, following key SDM-elements from established SDM-frameworks. As for deliberation in the clinical encounter, SDM communication training of professionals and feedback on their current performance are key aspects, as well as encouraging patients to participate. Concerning information for patients, it is important to provide balanced, evidence-based information about the benefits and the harms of different treatment options, including the option of surveillance only. At the same time, attention is needed for the optimal dosage of that information, given the symptoms of cognitive dysfunction and fatigue among MS-patients, and the uncertainties they have to cope with. Finally, for broader communication, a system is required that assures patient preferences are actually implemented by multidisciplinary MS-teams. As SDM is also being implemented in many countries within the context of value-based health care, we consider the systematic use of outcome information, such as patient-reported outcome measures (PROMs) and Patient Decision Aids, as an opportunity to achieve SDM.

Are you prepared for the next storm? Developing social norms messages to motivate community members to perform disaster risk mitigation behaviors

Preparing for natural disasters and adapting to climate change can save lives. Yet, minimal research has examined how governments can motivate community members to prepare for disasters (e.g., purchasing flood insurance or installing water barriers in homes for floods and hurricanes). Instead, studies have focused on how to communicate actions individuals should take during disasters, rather than before disasters. This study develops messages targeting social norms, which are promising approaches to motivate community members to adopt disaster risk preparedness and mitigation behaviors. Specifically, we developed a variety of messages integrating descriptive norms (i.e., what others do), injunctive norms (i.e., what others believe should be done), and a social norms-based fear appeal, or social disapproval rationale (i.e., a negative social result of [not] taking behaviors). Then, we tested these messages through two between-subject factorial online experiments in flood- and hurricane-prone U.S. states with adult samples (N = 2,286). In experiment 1 (i.e., purchasing flood insurance), the injunctive norms message using weather forecasters and the social disapproval rationale message significantly increased social norms perceptions, which in turn influenced behavioral intentions. In experiment 2 (i.e., installing water barriers), the injunctive norms message using weather forecasters, the injunctive norms message using neighbors, and the social disapproval rationale message significantly increased social norms perceptions, which in turn influenced mitigation intentions. However, the descriptive social norms message was not effective in increasing social norms perceptions. We provide some of the first empirical evidence on how organizations' risk communication can empower community members to prepare and mitigate the impact of disasters.

Need for numbers: assessing cancer survivors' needs for personalized and generic statistical information

Background

Statistical information (e.g., on long-term survival or side effects) may be valuable for healthcare providers to share with their patients to facilitate shared decision making on treatment options. In this pre-registered study, we assessed cancer survivors’ need for generic (population-based) versus personalized (tailored towards patient/tumor characteristics) statistical information after their diagnosis. We examined how information coping style, subjective numeracy, and anxiety levels of survivors relate to these needs and identified statistical need profiles. Additionally, we qualitatively explored survivors’ considerations for (not) wanting statistical information.

Methods

Cancer survivors’ need for statistics regarding incidence, survival, recurrence, side effects and quality of life were assessed with an online questionnaire. For each of these topics, survivors were asked to think back to their first cancer diagnosis and to indicate their need for generic and personalized statistics on a 4-point scale (‘not at all’- ‘very much’). Associations between information coping style, subjective numeracy, and anxiety with need for generic and personalized statistics were examined with Pearson’s correlations. Statistical need profiles were identified using latent class analysis. Considerations for (not) wanting statistics were analyzed qualitatively.

Results

Overall, cancer survivors (n = 174) had a higher need for personalized than for generic statistics (p < .001, d = 0.74). Need for personalized statistics was associated with higher subjective numeracy (r = .29) and an information-seeking coping style (r = .41). Three statistical need profiles were identified (1) a strong need for both generic and personalized statistics (34%), (2) a stronger need for personalized than for generic statistics (55%), and (3) a little need for both generic and personalized statistics (11%). Considerations for wanting personalized cancer statistics ranged from feelings of being in control to making better informed decisions about treatment. Considerations for not wanting statistics related to negative experience with statistics and to the unpredictability of future events for individual patients.

Conclusions

In light of the increased possibilities for using personalized statistics in clinical practice and decision aids, it appears that most cancer survivors want personalized statistical information during treatment decision-making. Subjective numeracy and information coping style seem important factors influencing this need. We encourage further development and implementation of data-driven personalized decision support technologies in oncological care to support patients in treatment decision making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-02005-2.

Decision Support Tools for Low-Dose CT Lung Cancer Screening: A Scoping Review of Information Content, Format, and Presentation Methods

Several countries mandate informed or shared decision-making for low-dose CT (LDCT) lung cancer screening, but knowledge is limited about the type of information and presentation techniques used to support decision-making in practice. This review aimed to characterize the content, format, mode, and presentation methods of decision support tools (DSTs) for LDCT lung cancer screening. DSTs reported within peer-reviewed articles (January 2000-April 2021) were identified systematically from PubMed, PsycInfo, EMBASE, and CINAHL Plus. Inclusion criteria revolved around the development or evaluation of a resource or tool intended to support individual or shared decision-making for LDCT lung cancer screening. The data-charting and extraction framework was based on the International Patient Decision Aids Standards instrument and Template for Intervention Description and Reporting. Extracted data were organized within two categories: (1) study characteristics and context, format, and mode of DST use and (2) DST content and presentation methods. This review identified 22 DSTs in paper, video, or electronic formats across 26 articles. Most DSTs (n = 13) focused on knowledge exchange, whereas seven used interactive techniques to support values clarification (eg, Likert scales) and nine DSTs guided deliberation (eg, suggested discussion topics). The DSTs addressed similar topics, but the detail, quantification of probability, and presentation methods varied considerably. None described all the potential screening harms and results. The heterogeneity in DST design may affect the quality of decision-making, particularly for participants with lower literacy and numeracy. Evidence-based consensus guidelines for DST content and presentation methods should be developed collaboratively with screening-eligible adults.

The impact of a patient decision aid on intention to undergo surgery for subacromial pain syndrome: An online randomised controlled trial

OBJECTIVE

To evaluate the effects of a patient decision aid for people considering shoulder surgery.

METHODS

Participants with shoulder pain considering shoulder surgery (n = 425) were recruited online and randomised to (i) a decision aid outlining the benefits and harms of shoulder surgery and non-surgical options (then randomised to a side-by-side vs. top-and-bottom display of options); and (ii) general information about shoulder pain from the NHS. Outcomes included treatment intention (primary), knowledge, attitudes, informed choice, and decisional conflict. Linear and logistic regression models were used to evaluate between-groups differences in outcomes.

RESULTS

409 participants (96%) had post-intervention data. Mean age was 41.3 years, 44.2% were female. There was no between-group difference in post-intervention treatment intention (MD -0.2, 95% CI: -3.3 to 2.8) and likelihood of intending to have shoulder surgery (OR 0.7, 95% CI: 0.3-1.5). The decision aid slightly improved knowledge (MD 4.4, 95% CI: 0.2-8.6), but not any other secondary outcomes. The display of options did not influence any outcome.

CONCLUSIONS

In this online trial, a co-designed patient decision aid had no effect on treatment intention, attitudes, informed choice, and decisional conflict, but a small effect on improving knowledge.

PRACTICE IMPLICATIONS

Research is needed to understand reasons for the lack of anticipated effects.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ACTRN12621000992808).

Supporting Health and Medical Decision Making: Findings and Insights from Fuzzy-Trace Theory

HIGHLIGHTS

Fuzzy-trace theory (FTT) supports practical approaches to improving health and medicine.FTT differs in important respects from other theories of decision making, which has implications for how to help patients, providers, and health communicators.Gist mental representations emphasize categorical distinctions, reflect understanding in context, and help cue values relevant to health and patient care.Understanding the science behind theory is crucial for evidence-based medicine.

Cocreation with Dutch patients of decision-relevant information to support shared decision-making about adjuvant treatment in breast cancer care

BACKGROUND

To support patients in shared decision-making about treatment options, patient decision aids (PtDAs) usually provide benefit/harm information and value clarification methods (VCMs). Recently, personalized risk information from prediction models is also being integrated into PtDAs. This study aimed to design decision-relevant information (i.e., personalized survival rates, harm information and VCMs) about adjuvant breast cancer treatment in cocreation with patients, in a way that suits their needs and is easily understandable.

METHODS

Three cocreation sessions with breast cancer patients (N = 7-10; of whom N = 5 low health literate) were performed. Participants completed creative assignments and evaluated prototypes of benefit/harm information and VCMs. Prototypes were further explored through user testing with patients (N = 10) and healthcare providers (N = 10). The researchers interpreted the collected data, for example, creative and homework assignments, and participants' presentations, to identify key themes. User tests were transcribed and analysed using ATLAS.ti to assess the understanding of the prototypes.

RESULTS

Important information needs were: (a) need for overview/structure of information directly after diagnosis and; (b) need for transparent benefit/harm information for all treatment options, including detailed harm information. Regarding VCMs, patients stressed the importance of a summary/conclusion. A bar graph seemed the most appropriate way of displaying personalized survival rates; the impact of most other formats was perceived as too distressful. The concept of 'personalization' was not understood by multiple patients.

CONCLUSIONS

A PtDA about adjuvant breast cancer treatment should provide patients with an overview of the steps and treatment options, with layers for detailed information. Transparent information about the likelihood of benefits and harm should be provided. Given the current lack of information on the likelihood of side effects/late effects, efforts should be made to collect and share these data with patients. Further quantitative studies are needed to validate the results and to investigate how the concept of 'personalization' can be communicated.

PATIENT OR PUBLIC CONTRIBUTION

Ten breast cancer patients participated in three cocreation sessions to develop decision-relevant information. Subsequent user testing included 10 patients. The Dutch Breast Cancer Association (BVN) was involved as an advisor in the general study design.

Medical decision-making with tables and graphs: The role of cognition, emotions, and analytic thinking

The shift from one-way to two-way communication in healthcare decision-making has heightened the need to understand the role of display formats including tables and graphs as decision aids. In this paper, we investigate cognitive and affective influences on decision-making involving display formats. We find that a display format's impact on decision quality is mediated by two distinct components of cognition (verbatim and gist knowledge), and that tables compared to bar graphs improve decision quality. We also find evidence that analytic thinking and lower negative affect can improve decision quality. Implications for marketers, better engaging patients, and encouraging improved decision-making are discussed.

Implementing shared decision-making in Australia

Person-centred care (PCC) and shared decision-making (SDM) are part of national clinical standards for an increasing number of areas of health care delivery. In addition to existing standards for accrediting hospitals, day surgery facilities, public dental services and medical education in Australia, new standards governing primary health care and digital mental health services have been added. Implementation and measurement of PCC and SDM to comply with standards, and training of health professionals, remain challenges for the Australian health sector. Consumer involvement in health research, policy and clinical service governance continues to increase and the National Health and Medical Research Council has begun to encourage consumer and community involvement in health and medical research. This increased consumer engagement and moves towards more PCC provision is reflected in a focus on encouraging patients to ask questions during their clinical care and supports improvements in consumer health literacy. SDM support tools are now being culturally adapted whilst a need for more systemic approaches to their development and implementation persists. With increasing resources and tools for all aspects of PCC and SDM challenges to find sustainable solutions to ensure tools are kept up to date with the best available evidence remain.

Development and user-testing of a digital patient decision aid to facilitate shared decision-making for people with stable angina

Background

Research shows that people with stable angina need decision support when considering elective treatments. Initial treatment is with medicines but patients may gain further benefit with invasive percutaneous coronary intervention (PCI). Choosing between these treatments can be challenging for patients because both confer similar benefits but have different risks. Patient decision aids (PtDAs) are evidence-based interventions that support shared decision-making (SDM) when making healthcare decisions. This study aimed to develop and user-test a digital patient decision aid (CONNECT) to facilitate SDM for people with stable angina considering invasive treatment with elective PCI.

Methods

A multi-phase study was conducted to develop and test CONNECT (COroNary aNgioplasty dECision Tool) using approaches recommended by the International Patient Decision Aid Standards Collaboration: (i) Steering Group assembled, (ii) review of clinical guidance, (iii) co-design workshops with patients and cardiology health professionals, (iv) first prototype developed and ‘alpha’ tested (semi-structured cognitive interviews and 12-item acceptability questionnaire) with patients, cardiologists and cardiac nurses, recruited from two hospitals in Northern England, and (v) final PtDA refined following iterative user-feedback. Quantitative data were analysed descriptively and qualitative data from the interviews analysed using deductive content analysis.

Results

CONNECT was developed and user-tested with 34 patients and 29 cardiology health professionals. Findings showed that CONNECT was generally acceptable, usable, comprehensible, and desirable. Participants suggested that CONNECT had the potential to improve care quality by personalising consultations and facilitating SDM and informed consent. Patient safety may be improved as CONNECT includes questions about symptom burden which can identify asymptomatic patients unlikely to benefit from PCI, as well as those who may need to be fast tracked because of worsening symptoms.

Conclusions

CONNECT is the first digital PtDA for people with stable angina considering elective PCI, developed in the UK using recommended processes and fulfilling international quality criteria. CONNECT shows promise as an approach to facilitate SDM and should be evaluated in a clinical trial. Further work is required to standardise the provision of probabilistic risk information for people considering elective PCI and to understand how CONNECT can be accessible to underserved communities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01882-x.

Numeracy and the Motivational Mind: The Power of Numeric Self-efficacy

BACKGROUND

Objective numeracy appears to support better medical decisions and health outcomes. The more numerate generally understand and use numbers more and make better medical decisions, including more informed medical choices. Numeric self-efficacy-an aspect of subjective numeracy that is also known as numeric confidence-also relates to decision making via emotional reactions to and inferences from experienced difficulty with numbers and via persistence linked with numeric comprehension and healthier behaviors over time. Furthermore, it moderates the effects of objective numeracy on medical outcomes.

PURPOSE

We briefly review the numeracy and decision-making literature and then summarize more recent literature on 3 separable effects of numeric self-efficacy. Although dual-process theories can account for the generally superior decision making of the highly numerate, they have neglected effects of numeric self-efficacy. We discuss implications for medical decision-making (MDM) research and practice. Finally, we propose a modification to dual-process theories, adding a "motivational mind" to integrate the effects of numeric self-efficacy on decision-making processes (i.e., inferences from experienced difficulty with numbers, greater persistence, and greater use of objective-numeracy skills) important to high-quality MDM.

CONCLUSIONS

The power of numeric self-efficacy (confidence) has been little considered in MDM, but many medical decisions and behaviors require persistence to be successful over time (e.g., comprehension, medical-recommendation adherence). Including numeric self-efficacy in research and theorizing will increase understanding of MDM and promote development of better decision interventions.

HIGHLIGHTS

Research demonstrates that objective numeracy supports better medical decisions and health outcomes.The power of numeric self-efficacy (aka numeric confidence) has been little considered but appears critical to emotional reactions and inferences that patients and others make when encountering numeric information (e.g., in decision aids) and to greater persistence in medical decision-making tasks involving numbers.The present article proposes a novel modification to dual-process theory to account for newer findings and to describe how numeracy mechanisms can be better understood.Because being able to adapt interventions to improve medical decisions depends in part on having a good theory, future research should incorporate numeric self-efficacy into medical decision-making theories and interventions.