The RISAP-study: a complex intervention in risk communication and shared decision-making in general practice

A qualitative exploration of clinicians' strategies to communicate risks to patients in the complex reality of clinical practice

BACKGROUND

Risk communication, situated in the model of shared decision making (SDM), is an essential element in daily clinical practice. The scientific literature makes a number of generic recommendations. Yet the application of risk communication remains a challenge in patient-clinician encounters. How clinicians actually communicate risk during consultations is not well understood. We aimed to explore the risk communication strategies used by clinicians and extract narratives and visualizations of those strategies to help inform medical education.

METHODS

In this qualitative descriptive study, we interviewed fifteen purposely sampled clinicians from several medical disciplines, who were familiar with the concept of SDM. Deductive and inductive content analysis was used during an iterative data collection and analyses process.

RESULTS

Our study identified various strategies reported to be used by clinicians to address the complexities of risk communication such as dealing with uncertainty. These included verbal, numerical and visual risk communication and framing. Clinicians were familiar with recommended risk formats such as natural frequencies and population pictograms. However, it became clear that clinicians' expertise and communication goals also play an important role in the risk talk. Clinicians try to lay a foundation for balanced decision-making and to incorporate patient preferences while faced with several challenges such as the dilemma of raising awareness but triggering anxiety or fan fear in patients. Consequently, they also use communication goals such as influencing mindset and reassuring patients. Additionally, clinicians frequently have to account for the illusion of certainty in the risk talk.

CONCLUSION

Risk communication is a multi-faceted construct that cannot be dealt with in isolation from the clinical context. For future research we recommend considering a more practical framework within the clinical setting and to take a goal-directed approach into account when investigating and teaching the topic. The patient perspective should also be addressed in further research.

Communicating risk using absolute risk reduction or prolongation of life formats: cluster-randomised trial in general practice

BACKGROUND

It is important that patients are well-informed about risks and benefits of therapies to help them decide whether to accept medical therapy. Different numerical formats can be used in risk communication but It remains unclear how the different formats affect decisions made by real-life patients.

AIM

To compare the impact of using Prolongation Of Life (POL) and Absolute Risk Reduction (ARR) information formats to express effectiveness of cholesterol-lowering therapy on patients' redemptions of statin prescriptions, and on patients' confidence in their decision and satisfaction with the risk communication.

DESIGN AND SETTING

Cluster-randomised clinical trial in general practices. Thirty-four Danish GPs from 23 practices participated in a primary care-based clinical trial concerning use of quantitative effectiveness formats for risk communication in health prevention consultations.

METHOD

GPs were cluster-randomised (treating practices as clusters) to inform patients about cardiovascular mortality risk and the effectiveness of statin treatment using either POL or ARR formats. Patients' redemptions of statin prescriptions were obtained from a regional prescription database. The COMRADE questionnaire was used to measure patients' confidence in their decision and satisfaction with the risk communication.

RESULTS

Of the 240 patients included for analyses, 112 were allocated to POL information and 128 to ARR. Patients redeeming a statin prescription totalled six (5.4%) when informed using POL, and 32 (25.0%) when using ARR. The level of confidence in decision and satisfaction with risk communication did not differ between the risk formats.

CONCLUSION

Patients redeemed statin prescriptions less often when their GP communicated treatment effectiveness using POL compared with ARR.

Barriers in using cardiometabolic risk information among consumers with low health literacy

OBJECTIVES

To identify the barriers from the perspective of consumers with low health literacy in using risk information as provided in cardiometabolic risk assessments.

DESIGN

A qualitative thematic approach using cognitive interviews was employed.

METHODS

We performed interviews with 23 people with low health literacy/health numeracy, who were recruited through (1) several organisations and snowball sampling and (2) an online access panel. Participants completed the risk test of the Dutch national cardiometabolic risk assessment and viewed the personalized information about their risk. They were asked to answer probing questions about different parts of the information. The qualitative data were analysed by identifying main themes related to barriers in using the information, using a descriptive thematic approach.

RESULTS

The four main themes identified were as follows: (1) People did not fully accept the risk message, partly because numerical information had ambiguous meaning; (2) people lacked an adequate framework for understanding their risk; (3) the purpose and setting of the risk assessment was unclear; and (4) current information tells nothing new: A need for more specific risk information.

CONCLUSIONS

The main barriers were that the current presentation seemed to provoke undervaluation of the risk number and that texts throughout the test, for example about cardiometabolic diseases, did not match people's existing knowledge, failing to provide an adequate framework for understanding cardiometabolic risk. Our findings have implications for the design of disease risk information, for example that alternative forms of communication should be explored that provide more intuitive meaning of the risk in terms of good versus bad.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Online disease risk assessments have become widely available internationally. People with low SES and health literacy tend to participate less in health screening. Risk information is difficult to understand, yet little research has been carried out among people with low health literacy. What does this study add? People with low health literacy do not optimally use risk information in an online cardiometabolic risk assessment. The texts provided in the cardiometabolic risk assessment do not suit to their existing knowledge. The typical risk communication (numbers, bar graph, verbal label) seems to provoke undervaluation of risk.

Risk of cardiovascular disease? A qualitative study of risk interpretation among patients with high cholesterol

Background

Previous studies have shown the importance of paying attention to lay peoples’ interpretations of risk of disease, in order to explain health-related behavior. However, risk interpretations interplay with social context in complex ways. The objective was to explore how asymptomatic patients with high cholesterol interpret risk of cardiovascular disease.

Methods

Fourteen patients with high cholesterol and risk of cardiovascular disease were interviewed, and patterns across patient accounts were identified and analysed from an ethnographic approach.

Results

Information from the general practitioner about high cholesterol and risk of cardiovascular disease was reinterpreted in everyday social life. The risk associated with fatty foods was weighed against the pleasures of social and cultural events in which this type of food was common and cherished.

A positive mindset was applied as a strategy to lower the risk of having high cholesterol, but knowledge about risk was viewed as a cause of anxiety and self-absorption, and this anxiety made the body susceptible to disease, hampering the chances for healthy life.

Conclusion

Interpretations of high cholesterol and risk of cardiovascular disease are embedded in social relations and everyday life concerns. This should be addressed in general practice in preference-sensitive cases about risk-reducing medication.

Trial registration

ClinicalTrials.gov: NCT01187056

Development of PRIDe: a tool to assess physicians' preference of role in clinical decision making

OBJECTIVE

To develop and evaluate items for inclusion in PRIDe (Preferred Role in Decision Making), a new tool to assess changes of role preference among professionals exposed to training in shared decision making (SDM).

METHODS

This study was part of a pilot trial to evaluate the effectiveness of SDM training on the doctors' prescription of antibiotics for acute respiratory infections. Thirty-nine family physicians were randomized to immediate exposure to training or to delayed exposure. Potential items for PRIDe and a questionnaire about physicians' intention to engage in SDM were administered at baseline and at follow-up.

RESULTS

Following analysis, we retained five items that captured a change in physicians' preference. The items' scores were pooled and the resulting tool showed limited internal consistency (Cronbach's alpha = 0.41) but significant test-retest reliability (immediate group: P = 0.03; delayed group: P = 0.008) and acceptable discriminant validity, with patients involved in decision making more actively after training than before (Fisher's test, P = .02).

CONCLUSION

This initial step to develop an evaluation tool to assess changes in doctors' preference of role in decision making following SDM training shows promising results. The next step is to develop more clinical vignettes followed by questions inspired from this analysis.

PRACTICE IMPLICATIONS

The PRIDe instrument can be used in the assessment of health professionals' attitude towards shared decision making after training in shared decision making. Additional research is needed to evaluate its validity before it can be recommended for use.