Do Preferred Risk Formats Lead to Better Understanding? A Multicenter Controlled Trial on Communicating Familial Breast Cancer Risks Using Different Risk Formats

PURPOSE

Counselees' preferences are considered important for the choice of risk communication format and for improving patient-centered care. We here report on counselees' preferences for how risks are presented in familial breast cancer counseling and the impact of this preferred format on their understanding of risk.

PATIENTS AND METHODS

As part of a practice-based randomized controlled trial, 326 unaffected women with a family history of breast cancer received their lifetime risk in one of five presentation formats after standard genetic counseling in three Dutch familial cancer clinics: 1) in percentages, 2) in frequencies ("X out of 100"), 3) in frequencies plus graphical format (10×10 human icons), 4) in frequencies and 10-year age-related risk and 5) in frequencies and 10-year age-related risk plus graphical format. Format preferences and risk understanding (accuracy) were assessed at 2-week follow-up by a questionnaire, completed by 279/326 women.

RESULTS

The most preferred risk communication formats were numbers combined with verbal descriptions (37%) and numbers only (26%). Of the numerical formats, most (55%) women preferred percentages. The majority (73%) preferred to be informed about both lifetime and 10-year age-related risk. Women who had received a graphical display were more likely to choose a graphical display as their preferred format. There was no significant effect between the intervention groups with regard to risk accuracy. Overall, women given risk estimates in their preferred format had a slightly better understanding of risk.

CONCLUSION

The results suggest that the accuracy of breast cancer risk estimation is slightly better for women who had received this information in their preferred format, but the risk format used had no effect on women's risk accuracy. To meet the most frequent preference, counselors should consider providing a time frame of reference (eg, risk in the next 10 years) in a numerical format, in addition to lifetime risk.

Symptom attribution and risk perception in individuals with idiopathic environmental intolerance to electromagnetic fields and in the general population

Aim:

To investigate differences in health perception and electromagnetic fields (EMF) between people within the general population reporting sensitivity or non-sensitivity to EMF, and people who registered themselves as sensitive to EMF at a non-governmental organisation (NGO).

Methods:

Correlations and regression analysis to compare a sample of the general population recruited via internet panel to individuals with idiopathic environmental intolerance to EMF (IEI-EMF) recruited via an interest group.

Results:

The general population sensitive group was more similar to the non-sensitive group in personal characteristics than to the NGO sensitive group. They experienced more – and more frequent – non-specific symptoms, reported higher perceived risk of EMF, and attributed their symptoms more to EMF than the non-sensitive group, but less than the NGO sensitive group. There was a positive association between attribution of symptoms to EMF and reported intensity of non-specific symptoms, which was stronger for the NGO sensitive subjects than for the general population.

Conclusions:

People sensitive to EMF and recruited via an internet panel differ from people sensitive to EMF and recruited via an NGO, who reported a higher frequency of non-specific symptoms. Attribution of symptoms to EMF is one of the predictors of the intensity of physical symptoms. Changing the perceived association between EMF and health problems in individuals with IEI-EMF might contribute to a better health experience.

Perception of health risks of electromagnetic fields by MRI radiographers and airport security officers compared to the general Dutch working population: a cross sectional analysis

BACKGROUND

The amount of exposure to electromagnetic fields (EMF) at work is mainly determined by an individual's occupation and may differ from exposure at home. It is, however, unknown how different occupational groups perceive possible adverse health effects of EMF.

METHODS

Three occupational groups, the general Dutch working population (n = 567), airport security officers who work with metal detectors (n = 106), and MRI radiographers who work with MRI (n = 193), were compared on perceived risk of and positive and negative feelings towards EMF in general and of different EMF sources, and health concerns by using analyses of variances. Data were collected via an internet survey.

RESULTS

Overall, MRI radiographers had a lower perceived risk, felt less negative, and more positive towards EMF and different sources of EMF than the general working population and the security officers. For security officers, feeling more positive about EMF was not significantly related to perceived risk of EMF in general or EMF of domestic sources. Feeling positive about a source did not generalize to a lower perceived risk, while negative feelings were stronger related to perceived risk. MRI radiographers had fewer health concerns regarding EMF than the other two groups, although they considered it more likely that EMF could cause physical complaints.

CONCLUSIONS

These data show that although differences in occupation appear to be reflected in different perceptions of EMF, the level of occupational exposure to EMF as such does not predict the perceived health risk of EMF.

Monitoring the level of government trust, risk perception and intention of the general public to adopt protective measures during the influenza A (H1N1) pandemic in The Netherlands

BACKGROUND

During the course of an influenza pandemic, governments know relatively little about the possibly changing influence of government trust, risk perception, and receipt of information on the public's intention to adopt protective measures or on the acceptance of vaccination. This study aims to identify and describe possible changes in and factors associated with public's intentions during the 2009 influenza A (H1N1) pandemic in the Netherlands.

METHODS

Sixteen cross-sectional telephone surveys were conducted (N = 8060) between April - November 2009. From these repeated measurements three consecutive periods were categorized based on crucial events during the influenza A (H1N1) pandemic. Time trends in government trust, risk perception, intention to adopt protective measures, and the acceptance of vaccination were analysed. Factors associated with an intention to adopt protective measures or vaccination were identified.

RESULTS

Trust in the government was high, but decreased over time. During the course of the pandemic, perceived vulnerability and an intention to adopt protective measures increased. Trust and vulnerability were associated with an intention to adopt protective measures in general only during period one. Higher levels of intention to receive vaccination were associated with increased government trust, fear/worry, and perceived vulnerability. In periods two and three receipt of information was positively associated with an intention to adopt protective measures. Most respondents wanted to receive information about infection prevention from municipal health services, health care providers, and the media.

CONCLUSIONS

The Dutch response to the H1N1 virus was relatively muted. Higher levels of trust in the government, fear/worry, and perceived vulnerability were all positively related to an intention to accept vaccination. Only fear/worry was positively linked to an intention to adopt protective measures during the entire pandemic. Risk and crisis communication by the government should focus on building and maintaining trust by providing information about preventing infection in close collaboration with municipal health services, health care providers, and the media.

'A low risk is still a risk': exploring women's attitudes towards genetic testing for breast cancer susceptibility in order to target disease prevention

BACKGROUND

Population breast cancer screening programs by mammography are offered to women based on age. It has been suggested that a screening program based on genetic risk profile could be more effective by targeting interventions at those at higher genetic risk. This study explores women's attitudes towards genetic testing for breast cancer susceptibility in order to target breast cancer prevention.

METHODS

A qualitative study was conducted using 4 focus groups with 26 women aged 42-73 years. Women were selected irrespective of personal or family history of breast cancer. Discussions were audiotaped and content analyzed.

RESULTS

The results show that in general women are positive towards a breast cancer screening program based on genetic risk profile, provided that in the low-risk group, though less frequent, women are still offered mammography screening (i.e. right to screening (a)). Other themes that women addressed were: (b) value of the genetic risk information (e.g. possibilities for cancer prevention at younger ages, less screening burden for low-risk women), (c) personal autonomy (e.g. free choice to undergo testing), (d) dealing with test results (e.g. burden of risk, motivation to reduce the risk), (e) discrimination, and (f) financial aspects and priority (e.g. with respect to other health care programs).

CONCLUSION

These results suggest that women currently offered breast cancer screening based on age have a positive attitude towards population susceptibility screening for breast cancer, but also identified issues that need to be discussed and studied further, especially if women in the low-risk group were no longer to be offered mammography screening.

What Clinicians Can Offer: Assessing and Communicating Probabilities for Individual Patient Decision Making

Accurate diagnostic and prognostic probabilities are important for physicians and their patients because of their impact on decisions. For individual patient decision making, physicians have to rely on their own judgement. Research has shown that physicians' probability assessments are often not of high quality and that a variety of factors have a detrimental influence on their judgements. Using a formula or a model may produce superior assessments. Most treatment decisions involve uncertainty and value conflict in the sense that there is a trade off between the possible harms of alternative treatments and their benefits. The communication of diagnostic and prognostic probabilities to patients occurs largely in verbal terms, which can lead to ambiguity in communication. The precise words and context chosen for communication are very important and can have a major effect on patients' decisions.

Analysis of the variety in surgeons' decision strategies for the management of left colonic emergencies

OBJECTIVES

The aim of this study is to analyze surgeons' decision strategies about the optimal treatment for acute sigmoid resection for different patients. In particular, the authors wished to determine the predominant accepted treatment choice among surgeons, to determine the importance of patient characteristics for surgeons' evaluations of the appropriateness of treatments, and to identify the variety in decision strategies.

METHODS

A survey was carried out among all surgical members of the Netherlands Society of Gastro Intestinal Surgery, who evaluated 16 patient cases. Approximately 70% of the members completed the survey.

RESULTS

Overall, the predominant accepted strategy is resection, delayed anastomosis, and colostomy (Hartmann procedure). Consensus in terms of preferred treatment, however, was low. The most important factors influencing surgeons' evaluations of the appropriateness of treatments were the age of a patient, the degree of peritonitis, and the degree of fecal contamination. Further analysis showed that the variety in surgeons' decision strategies could not be explained by differences in experience, but was shown to be related to the evaluation of the appropriateness of treatment for 60-year-old patients and patients with a local peritonitis. Except for these factors, surgeons did not differ fundamentally in the evaluation of the factors that make a treatment more appropriate. Surgeons agreed about the optimal treatment for older patients in poor condition, although there is no epidemiologic literature to support this consensus position.

CONCLUSIONS

This study showed that lack of consensus in surgeons' choice of treatment could be explained partly by disagreement of the appropriateness of treatments for some, rather than all, patients.

[Financial limits to care; a survey among physicians]

OBJECTIVE

To determine physicians' opinions about the role of cost considerations in treatment decisions.

DESIGN

Oral inquiry.

SETTING

Hospitals in the area of Leiden and Amsterdam, the Netherlands.

METHODS

82 medical specialists (41 surgeons and 41 internists) were interviewed and answered questions regarding cost considerations in medical care. They were also asked to determine the probability of success below which they considered an expensive medical treatment useless.

RESULTS

The respondents agreed that the government can set limits to care and incorporate cost considerations, but they also indicated that the role of physicians is to treat individual patients. About half the physicians would agree to discontinue treatment when it became too expensive. Decisions regarding the limitation of care should be made by politicians with or without the advice of physicians. The respondents would discontinue (an expensive) treatment (in a presented case) if the probability of success was on average below 12%, but half the physicians said they would accept a lower probability of success for individual patients than they would recommend as a policy.

CONCLUSION

Although physicians agreed about the necessity to set limits to medical care, their behaviour in clinical practice appeared to be not always in agreement with this.

The discrepancy between daily practice and the policy of a decision-analytic model: the management of fever of unknown origin

The optimal treatment of children with fever of unknown origin is controversial, in spite of two decision analyses that advise treatment with antibiotics for all such children. The aim of this study was to analyze the differences between pediatricians' diagnostic and therapeutic decisions and the outcomes of the decision-analytic models. Thirty-six pediatricians were asked to evaluate 30 patient cases and to give their diagnostic and therapeutic judgments. In addition, the pediatricians were asked questions about the epidemiology of fever of unknown origin. Analyses showed that the differences in policy between pediatricians and the models could not be explained by the reasons mentioned in the literature, i.e., 1) differences in epidemiologic data used, 2) differences in the weighting of clinical information, and 3) differences in the evaluation of outcomes. The differences in policy might be due to a difference between the objective of the models and pediatricians' aim. In a curative setting, pediatricians are not trying to prevent meningitis (or another serious disease) by treating possible occult bacteremia, but rather aim to detect meningitis in an early stage. A decision analysis determining the most cost-effective strategy for early detection of meningitis might therefore be more easily accepted by pediatricians.

[Surgical strategy in acute or elective sigmoid resection in The Netherlands; survey based on a marketing model]

OBJECTIVE

To gain insight into the operative strategies used by Dutch surgeons for complicated diverticulitis and sigmoid carcinoma, and into the influence of patient risk factors and surgeon's experience on the preferred operative strategy.

DESIGN

Descriptive.

METHOD

A questionnaire was sent to all 148 members of the Dutch Society of Gastrointestinal Surgery, concerning 32 fictitious patients with sigmoid pathology. It was based on conjoint-analysis, a model used in marketing research. This model analyses qualities that make a product preferable to another product of the same product group. The operative choices were: resection with Hartmann's procedure, resection with primary anastomosis after on-table lavage, or with primary anastomosis only, or no primary resection but diverting stoma only, or some personal technique. The survey focused on experience of the surgeons with the operative procedures, and on treatment choices in four fictitious cases frequently encountered in general surgery.

RESULTS

There was little agreement concerning the preferred surgical option for treatment of complicated diverticular disease or sigmoid carcinoma. With the exception of one fictitious young, electively operated 'ideal' patient (resection with primary anastomosis) there is hardly any consensus among the surgeons with respect to preferred treatment.

CONCLUSIONS

Reasons to depart from the conceptually optimal treatment (resection and anastomosis) in complicated cases (from the point of view of the surgeon or the patient), and absence of agreement on responsible other treatment could be differences in appraisal of the importance of several risk factors, or differences in acquired decision making strategies. The literature offers no answer to the question which techniques should be preferred under various circumstances.