Evaluation of risk communication in a mammography patient decision aid

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

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 Online Interactive Decision Tools on Women's Decision-Making Regarding Breast Cancer Screening: Systematic Review and Meta-Analysis

BACKGROUND

The online nature of decision aids (DAs) and related e-tools supporting women's decision-making regarding breast cancer screening (BCS) through mammography may facilitate broader access, making them a valuable addition to BCS programs.

OBJECTIVE

This systematic review and meta-analysis aims to evaluate the scientific evidence on the impacts of these e-tools and to provide a comprehensive assessment of the factors associated with their increased utility and efficacy.

METHODS

We followed the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and conducted a search of MEDLINE, PsycINFO, Embase, CINAHL, and Web of Science databases from August 2010 to April 2023. We included studies reporting on populations at average risk of breast cancer, which utilized DAs or related e-tools, and assessed women's participation in BCS by mammography or other key cognitive determinants of decision-making as primary or secondary outcomes. We conducted meta-analyses on the identified randomized controlled trials, which were assessed using the revised Cochrane Risk of Bias 2 (RoB 2) tool. We further explored intermediate and high heterogeneity between studies to enhance the validity of our results.

RESULTS

In total, 22 different e-tools were identified across 31 papers. The degree of tailoring in the e-tools, specifically whether the tool was fully tailored or featured with tailoring, was the most influential factor in women's decision-making regarding BCS. Compared with control groups, tailored e-tools significantly increased women's long-term participation in BCS (risk ratio 1.14, 95% CI 1.07-1.23, P<.001, I2=0%). Tailored-to-breast-cancer-risk e-tools increased women's level of worry (mean difference 0.31, 95% CI 0.13-0.48, P<.001, I2=0%). E-tools also improved women's adequate knowledge of BCS, with features-with-tailoring e-tools designed and tested with the general population being more effective than tailored e-tools designed for or tested with non-BCS participants (χ21=5.1, P=.02). Features-with-tailoring e-tools increased both the rate of women who intended not to undergo BCS (risk ratio 1.88, 95% CI 1.43-2.48, P<.001, I2=0%) and the rate of women who had made an informed choice regarding their intention to undergo BCS (risk ratio 1.60, 95% CI 1.09-2.33, P=.02, I2=91%). Additionally, these tools decreased the proportion of women with decision conflict (risk ratio 0.77, 95% CI 0.65-0.91, P=.002, I2=0%). Shared decision-making was not formally evaluated. This review is limited by small sample sizes, including only a few studies in the meta-analysis, some with a high risk of bias, and high heterogeneity between the studies and e-tools.

CONCLUSIONS

Features-with-tailoring e-tools could potentially negatively impact BCS programs by fostering negative intentions and attitudes toward BCS participation. Conversely, tailored e-tools may increase women's participation in BCS but, when tailored to risk, they may elevate their levels of worry. To maximize the effectiveness of e-tools while minimizing potential negative impacts, we advocate for an "on-demand" layered approach to their design.

A Scoping Review of Personalized, Interactive, Web-Based Clinical Decision Tools Available for Breast Cancer Prevention and Screening in the United States

Introduction. Personalized web-based clinical decision tools for breast cancer prevention and screening could address knowledge gaps, enhance patient autonomy in shared decision-making, and promote equitable care. The purpose of this review was to present evidence on the availability, usability, feasibility, acceptability, quality, and uptake of breast cancer prevention and screening tools to support their integration into clinical care. Methods. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to conduct this review. We searched 6 databases to identify literature on the development, validation, usability, feasibility, acceptability testing, and uptake of the tools into practice settings. Quality assessment for each tool was conducted using the International Patient Decision Aid Standard instrument, with quality scores ranging from 0 to 63 (lowest-highest). Results. We identified 10 tools for breast cancer prevention and 9 tools for screening. The tools included individual (e.g., age), clinical (e.g., genomic risk factors), and health behavior (e.g., alcohol use) characteristics. Fourteen tools included race/ethnicity, but no tool incorporated contextual factors (e.g., insurance, access) associated with breast cancer. All tools were internally or externally validated. Six tools had undergone usability testing in samples including White (median, 71%; range, 9%-96%), insured (99%; 97%-100%) women, with college education or higher (60%; 27%-100%). All of the tools were developed and tested in academic settings. Seven (37%) tools showed potential evidence of uptake in clinical practice. The tools had an average quality assessment score of 21 (range, 9-39). Conclusions. There is limited evidence on testing and uptake of breast cancer prevention and screening tools in diverse clinical settings. The development, testing, and integration of tools in academic and nonacademic settings could potentially improve uptake and equitable access to these tools.

Highlights

There were 19 personalized, interactive, Web-based decision tools for breast cancer prevention and screening.Breast cancer outcomes were personalized based on individual clinical characteristics (e.g., age, medical history), genomic risk factors (e.g., BRCA1/2), race and ethnicity, and health behaviors (e.g., smoking). The tools did not include contextual factors (e.g., insurance status, access to screening facilities) that could potentially contribute to breast cancer outcomes.Validation, usability, acceptability, and feasibility testing were conducted mostly among White and/or insured patients with some college education (or higher) in academic settings. There was limited evidence on testing and uptake of the tools in nonacademic clinical settings.

Identifying best practices for disclosure of amyloid imaging results: A randomized controlled trial

INTRODUCTION

Empirical studies on effective communication for amyloid disclosure in mild cognitive impairment (MCI) are lacking. We aimed to study the impact of six communication strategies.

METHOD

We performed a randomized controlled trial with seven randomly assigned, video-vignette conditions: six emphasizing a communication strategy and one basic condition. All showed a scripted consultation of a neurologist disclosing positive amyloid positron emission tomography (PET) scan results to an MCI patient. Healthy individuals (N = 1017; mean age ± SD 64 ± 8, 808 (79%) female) were instructed to imagine themselves in the video, answered questionnaires assessing information recall, emotional state, and behavioral intentions, and evaluate the physician/information.

RESULTS

"Risk best practice" resulted in highest free recall compared to other strategies (P < .05), except "emotional support". Recall in "emotional support" was better compared to "basic-' and elaborate information"(P < .05). "Risk best practice" resulted in the highest uncertainty (P < .001). "Teach-back" and "emotional support" contributed to the highest evaluations (P -values < .01).

CONCLUSION

Risk communication best practices, attending to emotions, and teach-back techniques enhance information recall of amyloid-PET results, and could contribute to positive care evaluations.

Rapid review of virus risk communication interventions: Directions for COVID-19

OBJECTIVE

In response to COVID-19, we conducted a rapid review of risk communication interventions to mitigate risk from viruses to determine if such interventions are efficacious.

METHODS

We searched for risk communication interventions in four databases: Medline, PsycInfo, the ProQuest Coronavirus Research Database, and CENTRAL. The search produced 1572 articles. Thirty-one articles were included in the final review.

RESULTS

Results showed risk communication interventions can produce cognitive and behavior changes around viruses. Results were more consistently positive for interventions focused on HIV/AIDS as compared to influenza. There was no consistent best intervention approach when comparing peer health, audio/visual, and intensive multi-media interventions. Tailoring risk communication toward a target population, in comparison to not tailoring, was related to better outcomes.

CONCLUSION

The results suggest that risk communication interventions can be efficacious at reducing risk from viruses. They also highlight the complexity of risk communication interventions. Additional research is needed to understand the mechanisms that lead risk communication to reduce risk from viruses.

PRACTICAL VALUE

Results support risk communication interventions to reduce risk from viruses.

The communication of uncertainty in health: A scoping review

OBJECTIVE

To conduct a scoping review of existing studies that examine communication strategies that address uncertainty in health and categorize them using the taxonomy of uncertainty.

METHODS

Relevant articles retrieved from ten databases were categorized according to the dimensions of the taxonomy of uncertainty, and study characteristics were extracted from each article.

RESULTS

All articles (n = 63) explored uncertainty in the context of probabilistic risk and related to scientific issues (n = 63; 100%). The majority focused on complexity (n = 24; 38.1%) and uncertainty experienced by patients (n = 52; 82.5%). Most utilized quantitative methods (n = 46; 73.0%), hypothetical scenarios (n = 49; 77.8%), and focused on cancer (n = 20; 31.7%). Theory guided messages and study design in fewer than half (n = 27; 42.9%).

CONCLUSIONS

Heterogeneity in terminology used to refer to different types of uncertainties preclude a unified research agenda on uncertainty communication. Research predominately focuses on probability as the source of uncertainty, uncertainties related to scientific issues, and uncertainty experienced by patients.

PRACTICE IMPLICATIONS

Additional efforts are needed to understand providers' experience of uncertainty, and to identify strategies to address ambiguity. Future studies should use consistent terminology to allow for coherence and advancement of uncertainty communication scholarship. Continued efforts to refine the existing taxonomy should be undertaken.

Testing a best practices risk result format to communicate genetic risks

OBJECTIVE

To investigate the effect of a genetic report format using risk communication "best-practices" on risk perceptions, in part to reduce risk overestimates.

METHODS

Adults (N = 470) from the Coriell Personalized Medicine Collaborative (CPMC) were randomized to a 2 × 2 experimental design to receive a hypothetical "personalized" genetic risk result for leukemia (relative risk = 1.5 or 2.5) through either the standard CPMC report (N = 232) or an enriched report informed by best practices (N = 238). A one-time, online survey assessed numeracy and risk perceptions including "feelings of risk" and a numerical estimate.

RESULTS

Regardless of numeracy, participants who received the enriched report had fewer overestimates of their lifetime risk estimate (LRE; odds ratio = 0.19, p < .001) and lower feelings of risk on two of three measures (p < .001). Participants with higher numeracy scores had fewer overestimates of LRE (OR = 0.66, p < .001) and lower feelings of risk on two out of three measures (p ≤ .01); the interaction between numeracy and report format was non-significant.

CONCLUSION

The enriched report produced more accurate LRE and lower risk perceptions regardless of numeracy level, suggesting the enriched format was helpful to individuals irrespective of numeracy ability.

PRACTICE IMPLICATIONS

Best practice elements in risk reports may help individuals form more accurate risk perceptions.

Risk communication in a patient decision aid for radiotherapy in breast cancer: How to deal with uncertainty?

Background and aim

Patient decision aids for oncological treatment options, provide information on the effect on recurrence rates and/or survival benefit, and on side-effects and/or burden of different treatment options. However, often uncertainty exists around the probability estimates for recurrence/survival and side-effects which is too relevant to be ignored. Evidence is lacking on the best way to communicate these uncertainties. The aim of this study is to develop a method to incorporate uncertainties in a patient decision aid for breast cancer patients to support their decision on radiotherapy.

Methods

Firstly, qualitative interviews were held with patients and health care professionals. Secondly, in the development phase, thinking aloud sessions were organized with four patients and 12 health care professionals, individual and group-wise.

Results

Consensus was reached on a pictograph illustrating the whole range of uncertainty for local recurrence risks, in combination with textual explanation that a more exact personalized risk would be given by their own physician. The pictograph consisted of 100 female icons in a 10 x 10 array. Icons with a stepwise gradient color indicated the uncertainty margin. The prevalence and severity of possible side-effects were explained using verbal labels.

Conclusions

We developed a novel way of visualizing uncertainties in recurrence rates in a patient decision aid. The effect of this way of communicating risk uncertainty is currently being tested in the BRASA study (NCT03375801).

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There exists uncertainty around local recurrence risks for breast cancer patients.

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Little is known on how to communicate uncertainty to patients.

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Patient decision aids can help communicating risks and uncertainty.

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We developed pictographs to communicate numerical uncertainty in recurrence risks.

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The effect of the pictographs is currently being tested in the BRASA study.

Use of an Online Breast Cancer Risk Assessment and Patient Decision Aid in Primary Care Practices

Background: U.S. Preventive Services Task Force (USPSTF) recommendations for mammography screening, genetic counseling and testing for pathogenic BRCA1/2 mutations, and use of risk-reducing medications require assessment of breast cancer risk for clinical decision-making, but efficient methods for risk assessment in clinical practice are lacking. Materials and Methods: A cross-sectional study evaluating a web-based breast cancer risk assessment and decision aid (MammoScreen) was conducted in an academic general internal medicine clinic. All eligible women, 40-74 years of age without previous diagnosis of breast or ovarian cancer and who were enrolled in the Epic MyChart patient portal were invited. MammoScreen uptake and completion rates and consistency between breast cancer risk determined by MammoScreen and existing risk information in the Epic record were measured. Patient and physician experiences were summarized from interviews. Results: Of 448 invited participants, 339 (75.7%) read their MyChart invitation and 125 (36.9%) who read invitations enrolled in the study; 118 (94.4% of enrolled) completed MammoScreen. Twenty-one women were categorized as above-average risk from either MammoScreen data or the chart review and 7 (33.3%) were identified by both sources. Physicians and patients believed MammoScreen was easy to use and was helpful in identifying risks and facilitating shared decision-making. Conclusions: Breast cancer risk assessment and mammography screening decision support were efficiently implemented through a web-based tool for patients sent through an electronic patient portal. Integration of patient decision aids with risk algorithms in clinical practice may help support the implementation of USPSTF recommendations that include risk assessment and shared decision-making.

The Influence of Social Capital on Protective Action Perceptions Towards Hazardous Chemicals

The stigmatized character of hazardous chemicals has caused individuals in hazards to take excessive protective actions. Here, social capital is introduced to discuss its influence on the protective action decision model (PADM), considering this variable has a relatively high individual trust level in regards to information on hazardous chemicals. A model was constructed by taking protective action perceptions as the dependent variable, social capital as the independent variable, the pre-decision process as the mediating variable, and socioeconomic status as the moderating variables. Data were collected with a neighborhood sampling method, and a total of 457 questionnaires were obtained from neighboring residents near a large cold ammonia storage house in Haidian District, Beijing. Results: While the family and friendship networks produced a larger positive influence, the kinship network produced a smaller positive influence; furthermore, the influence of social capital must be brought through the pre-decision process; finally, socioeconomic status has a directional moderation on the friendship network, an enhancing moderation on the kinship network, and a weakening moderation on the family network.

What do patients and health care professionals view as important attributes in radiotherapy decisions? Input for a breast cancer patient decision aid

Background and aim

There is increased attention for shared decision making (SDM) when deciding on radiotherapy for selected patients with Stage 0–2 breast cancer. This study aimed to explore patients' and health care professionals’ experiences, decisional attributes and needs as input for the development of a patient decision aid to facilitate SDM.

Methods

Qualitative semi-structured interviews were held with fifteen breast cancer patients, being confronted with a radiotherapy decision one month to eight years earlier. Another fifteen interviews were held with professionals specialized in breast cancer care. Interviews were transcribed verbatim and independently coded by two researchers, who agreed upon relevant issues.

Results

Most patients made their decision by weighing the advantages of radiotherapy, i.e. comparing the decrease in recurrence risk with and without radiotherapy, and disadvantages, i.e. possible side effects. Patients and professionals agreed that recurrence risks should be communicated, but not on how to deal with uncertainty. There was wide variation in which, and how, side effects were explained by professionals. The most common side effects mentioned by both patients and professionals were skin toxicity, fatigue and breast deformity.

Conclusion

Patients and professionals appeared to agree on what type of attributes should be communicated during SDM on radiotherapy, but how this should be done is up for discussion. To ensure the patient's voice these attributes and needs need to be incorporated in the risk communication and value elicitation part of the patient decision aid. The format in which the attributes are communicated should be critically evaluated.

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Patients and professionals agree on most important attributes.

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These attributes need to be used in a patient decision aid.

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There is unwarranted inter doctor variation in informing about side effects.

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Professionals differ in opinion how to inform patients about epistemic uncertainties.

Key Elements of Mammography Shared Decision-Making: a Scoping Review of the Literature

BACKGROUND

New guidelines recommend shared decision-making (SDM) for women and their clinician in consideration of breast cancer screening, particularly for women ages 35-50 where guidelines for routine mammography are controversial. A number of models offer general guidelines for SDM across clinical practice, yet they do not offer specific guidance about conducting SDM in mammography. We conducted a scoping review of the literature to identify the key elements of breast cancer screening SDM and synthesize these key elements for utilization by primary care clinicians.

METHODS

The Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus); PsycInfo, PubMed (MEDLINE), Scopus, and SocIndex databases were searched. Inclusion criteria were original studies from peer-reviewed publications (from 2009 or later) reporting breast cancer screening (mammography), medical decision-making, and patient-centered care. Study populations needed to include female patients 18+ years of age facing a real-life breast cancer screening decision. Article findings were specific to shared decision-making and/or use of a decision aid. Data extracted includes study design, population, setting, intervention, and critical findings related to breast cancer screening SDM elements. Scoping analysis includes descriptive analysis of study features and content analysis to identify the SDM key elements.

RESULTS

Twenty-four articles were retained. Three thematic categories of key elements emerged from the extracted elements: information delivery/patient education (specific content and delivery modes), interpersonal clinician-patient communication (aspects of interpersonal relationship impacting SDM), and framework of the decision (sociocultural factors beyond direct SDM deliberation). A number of specific breast cancer screening SDM elements relevant to primary care clinical practice are delineated.

DISCUSSION

The findings underscore the importance of the relationship between the patient and clinician and the necessity of spelling out each step in the SDM process. The clinician needs to be explicit in telling a woman that she has a choice about whether to get a mammogram and the benefits and harms of screening mammography. Finally, clinicians need to be aware of sociocultural factors that can influence their relationships and their patients' decision-making processes and attempt to identify and address these factors.

Explanation and elaboration of the Standards for UNiversal reporting of patient Decision Aid Evaluations (SUNDAE) guidelines: examples of reporting SUNDAE items from patient decision aid evaluation literature

This Explanation and Elaboration (E&E) article expands on the 26 items in the Standards for UNiversal reporting of Decision Aid Evaluations guidelines. The E&E provides a rationale for each item and includes examples for how each item has been reported in published papers evaluating patient decision aids. The E&E focuses on items key to reporting studies evaluating patient decision aids and is intended to be illustrative rather than restrictive. Authors and reviewers may wish to use the E&E broadly to inform structuring of patient decision aid evaluation reports, or use it as a reference to obtain details about how to report individual checklist items.

Dumping the information bucket: A qualitative study of clinicians caring for patients with early stage non-small cell lung cancer

OBJECTIVE

To evaluate the quality of patient-clinician communication and shared decision making (SDM) when two disparate treatments for early stage non-small cell lung cancer (NSCLC) are discussed.

METHODS

We conducted a qualitative study to evaluate the experiences of 20 clinicians caring for patients with clinical Stage I NSCLC prior to treatment, focusing on communication practices. We used directed content analysis and a patient-centered communication theoretical model to guide understanding of communication strategies.

RESULTS

All clinicians expressed the importance of providing information, especially for mitigating patient worry, despite recognition that patients recall only a small amount of the information given. When patients expressed distress, clinicians exhibited empathy but preferred to provide more information in order to address patient concerns. Most clinicians reported practicing SDM, however, they also reported not clearly eliciting patient preferences and values, a key part of SDM.

CONCLUSION

Communication with patients about treatment options for early stage NSCLC primary includes information giving. We found that only a few communication domains associated with SDM occurred regularly, and SDM may not be necessary in this clinical context.

PRACTICE IMPLICATIONS

Clinicians may need to incorporate nurse navigators or more written materials for effectively discussing potentially equivalent treatment options with their patients.