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

Uncertainty Profiles and Treatment Preferences for Intraductal Papillary Mucinous Neoplasms

INTRODUCTION

Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic premalignant lesions frequently detected incidentally. Choosing between surgery and surveillance for IPMNs is rooted in uncertainty. We characterized patient preferences in IPMN management, and examined associations with patients' uncertainty profiles (risk perception, risk attitude, and uncertainty tolerance).

METHODS

We conducted a cross-sectional survey drawn from a national opt-in panel. We simulated an encounter following an incidental computed tomography scan finding of an IPMN with a 5% cancer risk. We elicited participants' preferred treatment (surgery versus surveillance). Participant cancer risk perception, risk attitude (risk seeking versus risk averse), and uncertainty tolerance (comfort with the unknown) were determined using validated measures. Multivariate regression models assessed for independent predictors of treatment preference and risk perception.

RESULTS

The sample included 520 participants, ages 40-70, racially representative of the US population. Participants preferred surveillance (n = 331, 64%) over surgery (n = 189, 36%). Patients were significantly more likely to prefer surgery as their cancer risk perception increased (absolute difference = 12% from 1.0 standard deviation below to 1.0 standard deviation above the mean, 95% CI 3.5-20.2). Treatment preference was not significantly associated with risk attitude (P = 0.068) or uncertainty tolerance (P = 0.755). However, initial cancer risk perception was significantly associated with both uncertainty tolerance (P = 0.013) and baseline cancer anxiety (risk perception 16.4% versus 65%, not worried at all versus extremely worried, P < 0.001).

CONCLUSIONS

Patient preference varies widely for IPMN and is significantly associated with cancer risk perception, which is, in turn, significantly associated with uncertainty tolerance and cancer anxiety. These findings argue for the preference-sensitive nature of IPMN treatment decisions.

Impact of gist intervention on automated system interpretability and user decision making

As they become more common, automated systems are also becoming increasingly opaque, challenging their users' abilities to explain and interpret their outputs. In this study, we test the predictions of fuzzy-trace theory-a leading theory of how people interpret quantitative information-on user decision making after interacting with an online decision aid. We recruited a sample of 205 online crowdworkers and asked them to use a system that was designed to detect URLs that were part of coordinated misinformation campaigns. We examined how user endorsements of system interpretability covaried with performance on this coordinated misinformation detection task and found that subjects who endorsed system interpretability displayed enhanced discernment. This interpretability was, in turn, associated with both objective mathematical ability and mathematical self-confidence. Beyond these individual differences, we evaluated the impact of a theoretically motivated intervention that was designed to promote sensemaking of system output. Participants provided with a "gist" version of system output, expressing the bottom-line meaning of that output, were better able to identify URLs that might have been part of a coordinated misinformation campaign, compared to users given the same information presented as verbatim quantitative metrics. This work highlights the importance of enabling users to grasp the essential, gist meaning of the information they receive from automated systems, which benefits users regardless of individual differences.

Presenting decision-relevant numerical information to Dutch women aged 50-70 with varying levels of health literacy: Case example of adjuvant systemic therapy for breast cancer

BACKGROUND

If communicated adequately, numerical decision-relevant information can support informed and shared decision making. Visual formats are recommended, but which format supports patients depending on their health literacy (HL) levels for specific decisions is unclear.

STUDY AIM

The aim of this study is to investigate: 1) the effect of survival rates and side-effects presentation formats on comprehension and 'feeling informed'; 2) differential effects among women with higher/lower HL, with adjuvant systemic breast cancer therapy as case example.

METHODS

Two online experiments among women from the Dutch population without a history of breast cancer were conducted. Experiment 1 had a 3 (survival rate format: text block-bar graph-icon array) x 2 (HL: low-high) between-subjects design. Experiment 2 had a 5 (side-effects format: no probability information-probability information in numbers with or without a visualisation-probability information in numbers with or without a visualisation accompanied by a description of the side-effects) x 2 (HL: low-high) design. Primary outcomes were comprehension and feeling informed (Experiment 2 only). Formats were previously designed in co-creation with patients.

RESULTS

In Experiment 1, presentation format did not affect gist or verbatim comprehension. Higher HL was associated with higher gist comprehension. Experiment 2 showed an interaction between presentation format and HL on 'feeling informed'. When provided with visualised probability information without a description of the side-effects, women with lower HL felt better informed than women with higher HL.

CONCLUSION

Visual formats did not enhance comprehension of survival rate information beyond a well-designed text block format. However, none of the formats could overcome HL differences. When designing decision-relevant information, visualisations might not necessarily provide an advantage over structured numerical information for both patients with lower and higher HL. However, a deeper understanding of presenting side-effect information is warranted.

A theory of oral healthcare decision-making in Appalachia

INTRODUCTION

People make oral healthcare decisions regardless of having partial information, misinformation, sources that deliberately mislead, or information that is culturally influenced. This is particularly true in the Appalachian culture where oral healthcare decision-making practices are not well understood by researchers and dental professionals. Despite efforts to improve dental care utilization, the Appalachia region remains low in oral healthcare utilization. There is a need for a theory to identify concepts in decision-making when seeking oral healthcare. The theory could be useful in creating oral health interventions. The study objective is to develop a theory to identify concepts that influence oral healthcare decision-making in Appalachia (OHDA).

METHODS

The researchers used a grounded theory qualitative study design to explain data for a theory of OHDA. Participants from Appalachia, in 20-minute interviews, provided insights into concepts that influence OHDA from August 22, 2017 to May 26, 2022. Notes/memos were written during and after the interviews and coding was conducted after the interviews. Open coding categories emerged through constant comparison of responses.

RESULTS

Five overarching concepts that embody OHDA were discovered: Affect (Level of Pain/Emotion/Stress involvement), Awareness, Trust/belief, Resources, and Risk Perception. All participants discussed the impact of social media toward these concepts.

CONCLUSION

To influence a person's OHDA, public health officials and researchers need to address the person's affect, level of awareness, trust/belief, available resources, and risk perception. Social media is very important in awareness concerning oral health information. These factors are important to consider for similar research in oral healthcare utilization at the population level.

Making decisions one drink at a time and the "just one drink" effect: A fuzzy-trace theory model of harmful drinking

BACKGROUND

Understanding the decision factors that drive harmful alcohol use among young adults is of practical and theoretical importance. We apply fuzzy-trace theory (FTT) to investigate a potential danger that may arise from the arguably correct notion that a single drink carries no meaningful risk. Decisions that are mentally represented as one drink at a time could contribute to excessive drinking.

METHODS

College students (N = 351) made a series of decisions to take or decline eight hypothetical drinks presented one at a time. Outcome measures included each decision, recent alcohol consumption (weekly drinks, peak blood alcohol content, and binges), and alcohol-related harms (scores on the Brief Young Adult Alcohol Consequences Questionnaire and Alcohol Use Disorders Identification Test). Linear regression models predicted each outcome from sex, perceived risk of a single drink, perceived risk of heavy drinking, perceived consequences of drinking, and general health-related risk sensitivity.

RESULTS

Consistent with FTT, decisions to have a first drink and up to four additional drinks in short succession were each associated with lower perceived risk of one drink-a "just-one drink" effect-independent of perceived risks of heavy drinking, perceived consequences of drinking, and general risk sensitivity. Similarly, all measures of recent alcohol consumption and consequent harms were associated with perceived risk of one drink. Participants reporting "zero risk" of a single drink had worse outcomes on all measures than those reporting at least "low risk."

CONCLUSIONS

Results are consistent with the theoretically informed premise that consumption decisions are typically made one drink at a time rather than by deciding the total number of drinks to be consumed in a sitting. When decisions about alcohol use proceed one drink at a time, a perception of zero risk in a single drink may contribute to heavy drinking.

Factors contributing to antibiotic misuse among parents of school-going children in Dhaka City, Bangladesh

Antimicrobial resistance (AMR) is a pressing global health concern, especially in resource-constrained countries, such as Bangladesh. This study aimed to identify the factors contributing to antibiotic misuse by assessing knowledge, attitude, and practice (KAP). A cross-sectional study was conducted from August 20 to August 30, 2022, among 704 parents of school-going children in Dhaka South City. Descriptive statistics were used to analyze the KAP, and multivariate models, including linear and ordinal logistic regression, were used to explore the associations between these factors. The findings revealed that approximately 22% of the participants were male and 78% were female. Most parents (58%) had completed higher secondary education. Approximately 45% of the respondents demonstrated moderate knowledge, 53% had uncertain attitudes, and 64% exhibited antibiotic misuse. Factors such as parental age, education level, employment status, income, child's age, and family type significantly influenced KAP. These findings emphasize the importance of targeted education and awareness initiatives to enhance knowledge and responsible antibiotic use among parents, contributing to global efforts against antibiotic resistance. The government should enforce laws and regulations regarding the misuse of antibiotics.

Optimization of an Information Leaflet to Influence Medication Beliefs in Women With Breast Cancer: A Randomized Factorial Experiment

BACKGROUND

Adherence to adjuvant endocrine therapy (AET) is low in women with breast cancer. Negative beliefs about the necessity of AET and high concerns are barriers to adherence.

PURPOSE

To use the multiphase optimization strategy to optimize the content of an information leaflet intervention, to change AET beliefs.

METHODS

We conducted an online screening experiment using a 25 factorial design to optimize the leaflet. The leaflet had five components, each with two levels: (i) diagrams about AET mechanisms (on/off); (ii) infographics displaying AET benefits (enhanced/basic); (iii) AET side effects (enhanced/basic); (iv) answers to AET concerns (on/off); (v) breast cancer survivor (patient) input: quotes and photographs (on/off). Healthy adult women (n = 1,604), recruited via a market research company, were randomized to 1 of 32 experimental conditions, which determined the levels of components received. Participants completed the Beliefs about Medicines Questionnaire before and after viewing the leaflet.

RESULTS

There was a significant main effect of patient input on beliefs about medication (β = 0.063, p < .001). There was one significant synergistic two-way interaction between diagrams and benefits (β = 0.047, p = .006), and one antagonistic two-way interaction between diagrams and side effects (β = -0.029, p = .093). There was a synergistic three-way interaction between diagrams, concerns, and patient input (β = 0.029, p = .085), and an antagonistic four-way interaction between diagrams, benefits, side effects, and concerns (β = -0.038, p = .024). In a stepped approach, we screened in four components and screened out the side effects component.

CONCLUSIONS

The optimized leaflet did not contain enhanced AET side effect information. Factorial experiments are efficient and effective for refining the content of information leaflet interventions.

Giving information strategically and transparently: A pilot trial of the Oncolo-GIST intervention to promote patients' prognostic understanding

PURPOSE

Most patients with cancer lack the prognostic understanding necessary to make informed decisions. We tested the feasibility and acceptability of the Oncolo-GIST ("Giving Information Strategically and Transparently, GIST") intervention and explored its associations with patients' improved prognostic understanding.

METHODS

The Oncolo-GIST intervention distills prognostic discussions into easy-to-understand talking points. Patients with metastatic cancers that progressed on ≥1 line of chemotherapy and not expected to survive 12 months (n = 31) were recruited from October 2020 through November 2022. We compared patients who discussed their progressive scans with an oncologist trained in the GIST technique or not (i.e., usual care). A primary outcome was prognostic understanding (e.g., patients reporting a life-expectancy of months) assessed within a week of the scan discussion visit.

RESULTS

Oncologists (n = 4) appeared receptive to the Oncolo-GIST intervention and scored nearly perfectly on post-training tests of material mastery after a < 2-h tutorial. Post-scan discussion visit, 100% of patients who met with an Oncolo-GIST-trained clinician understood that their cancer was considered incurable (a 31% improvement from pre-visit) compared with 91% of patients meeting with usual care oncologists (an 18% improvement); 33% of patients who met with an Oncolo-GIST-trained oncologist understood that they likely had months, not years, compared to 18% in the usual care group. No statistically significant differences emerged for these changes, nor for therapeutic alliance, anxiety, or depression scores between groups.

CONCLUSION

Oncolo-GIST appears to be an easily learned approach to improve prognostic understanding that neither undermines therapeutic alliances nor increases patients' anxiety or depressive symptoms. Efficacy testing in a larger trial is warranted.

Numeracy, gist, literal thinking and the value of nothing in decision making

The onus on the average person is greater than ever before to make sense of large amounts of readily accessible quantitative information, but the ability and confidence to do so are frequently lacking. Many people lack practical mathematical skills that are essential for evaluating risks, probabilities and numerical outcomes such as survival rates for medical treatments, income from retirement savings plans or monetary damages in civil trials. In this Review, we integrate research on objective and subjective numeracy, focusing on cognitive and metacognitive factors that distort human perceptions and foment systematic biases in judgement and decision making. Paradoxically, an important implication of this research is that a literal focus on objective numbers and mechanical number crunching is misguided. Numbers can be a matter of life and death but a person who uses rote strategies (verbatim representations) cannot take advantage of the information contained in the numbers because 'rote' strategies are, by definition, processing without meaning. Verbatim representations (verbatim is only surface form, not meaning) treat numbers as data as opposed to information. We highlight a contrasting approach of gist extraction: organizing numbers meaningfully, interpreting them qualitatively and making meaningful inferences about them. Efforts to improve numerical cognition and its practical applications can benefit from emphasizing the qualitative meaning of numbers in context - the gist - building on the strengths of humans as intuitive mathematicians. Thus, we conclude by reviewing evidence that gist training facilitates transfer to new contexts and, because it is more durable, longer-lasting improvements in decision making.

Social media: Why sharing interferes with telling true from false

Sharing on social media decreases true-false discrimination but focusing on accuracy helps people recognize what they already know. Process-oriented research offers hope in combatting misinformation.

Measuring the Impact of Quantitative Information on Patient Understanding: Approaches for Assessing the Adequacy of Patient Knowledge about Colorectal Cancer Screening

Background. Guidelines recommend that decision aids disclose quantitative information to patients considering colorectal cancer (CRC) screening, but the impact on patient knowledge and decision making is limited. An important challenge for assessing any disclosure involves determining when an individual has “adequate knowledge” to make a decision. Methods. We analyzed data from a trial that randomized 213 patients to view a decision aid about CRC screening that contained verbal information (qualitative arm) versus one containing verbal plus quantitative information (quantitative arm). We analyzed participants’ answers to 8 “qualitative knowledge” questions, which did not cover the quantitative information, at baseline (T0) and after viewing the decision aid (T1). We introduce a novel approach that defines adequate knowledge as correctly answering all of a subset of questions that are particularly relevant because of the participant’s test choice (“Choice-Based Knowledge Assessment”). Results. Participants in the quantitative arm answered a higher mean number of knowledge questions correctly at T1 than did participants in the qualitative arm (7.3 v. 6.9, P < 0.05), and they more frequently had adequate knowledge at T1 based on a cutoff of 6 or 7 correct out of 8 (94% v. 83%, P < 0.05, and 86% v. 71%, P < 0.05, respectively). Members of the quantitative group also more frequently had adequate knowledge at T1 when assessed by Choice-Based Knowledge Assessment (87% v. 76%, P < 0.05). Conclusions. Patients who viewed quantitative information in addition to verbal information had greater qualitative knowledge and more frequently had adequate knowledge compared with those who viewed verbal information alone, according to most ways of defining adequate knowledge. Quantitative information may have helped participants better understand qualitative or gist concepts.

Trial Registration: ClinicalTrials.gov ID# NCT01415479

Highlights

Patients who viewed quantitative information in a decision aid about colorectal cancer screening were more knowledgeable about nonquantitative information and were more likely to have adequate knowledge according to a variety of approaches for assessing that, compared with individuals who viewed only qualitative information. This result supports the inclusion of quantitative information in decision aids. Researchers assessing patient understanding should consider a variety of ways to define adequate knowledge when assessing decision quality.