Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles

Co-creation of a health literate-sensitive training and conversation aid to support shared decision-making in maternity care

Background

Maternity care increasingly aims to achieve Shared Decision-making (SDM), yet seemingly not to the benefit of clients with low health literacy (HL). We developed an SDM training for healthcare professionals (HCPs) and a conversation aid to support HL-sensitive SDM in maternity care.

Methods

The training and conversation aid were based on previous needs assessments and expert consultation, and were developed in co-creation with clients (n = 15) and HCPs (n = 7). Usability, acceptability and comprehension of the conversation aid were tested among new clients (n = 14) and HCPs (n = 6). Acceptability of the training was tested among midwifery students (n = 5).

Results

In the co-creation sessions, clients reported to expect that their midwife becomes acquainted with their general values, priorities and daily context. Clients also emphasized wanting to be supported in their preferred decisional role. User test interviews showed that clients and HCPs were positive towards using the conversation aid, but also apprehensive about the time it required. The user test of the training showed that more attention was needed for recognizing and adapting information provision to clients' HL level.

Conclusion and innovation

The newly developed conversation aid and training have potential to support HCPs and clients in HL-sensitive SDM.

Understanding random resampling techniques for class imbalance correction and their consequences on calibration and discrimination of clinical risk prediction models

OBJECTIVE

Class imbalance is sometimes considered a problem when developing clinical prediction models and assessing their performance. To address it, correction strategies involving manipulations of the training dataset, such as random undersampling or oversampling, are frequently used. The aim of this article is to illustrate the consequences of these class imbalance correction strategies on clinical prediction models' internal validity in terms of calibration and discrimination performances.

METHODS

We used both heuristic intuition and formal mathematical reasoning to characterize the relations between conditional probabilities of interest and probabilities targeted when using random undersampling or oversampling. We propose a plug-in estimator that represents a natural correction for predictions obtained from models that have been trained on artificially balanced datasets ("naïve" models). We conducted a Monte Carlo simulation with two different data generation processes and present a real-world example using data from the International Stroke Trial database to empirically demonstrate the consequences of applying random resampling techniques for class imbalance correction on calibration and discrimination (in terms of Area Under the ROC, AUC) for logistic regression and tree-based prediction models.

RESULTS

Across our simulations and in the real-world example, calibration of the naïve models was very poor. The models using the plug-in estimator generally outperformed the models relying on class imbalance correction in terms of calibration while achieving the same discrimination performance.

CONCLUSION

Random resampling techniques for class imbalance correction do not generally improve discrimination performance (i.e., AUC), and their use is hard to justify when aiming at providing calibrated predictions. Improper use of such class imbalance correction techniques can lead to suboptimal data usage and less valid risk prediction models.

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.

Prognostication in Neurocritical Care

OBJECTIVE

This article synthesizes the current literature on prognostication in neurocritical care, identifies existing challenges, and proposes future research directions to reduce variability and enhance scientific and patient-centered approaches to neuroprognostication.

LATEST DEVELOPMENTS

Patients with severe acute brain injury often lack the capacity to make their own medical decisions, leaving surrogate decision makers responsible for life-or-death choices. These decisions heavily rely on clinicians' prognostication, which is still considered an art because of the previous lack of specific guidelines. Consequently, there is significant variability in neuroprognostication practices. This article examines various aspects of neuroprognostication. It explores the cognitive approach to prognostication, highlights the use of statistical modeling such as Bayesian models and machine learning, emphasizes the importance of clinician-family communication during prognostic disclosures, and proposes shared decision making for more patient-centered care.

ESSENTIAL POINTS

This article identifies ongoing challenges in the field and emphasizes the need for future research to ameliorate variability in neuroprognostication. By focusing on scientific methodologies and patient-centered approaches, this research aims to provide guidance and tools that may enhance neuroprognostication in neurocritical care.

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.

It is, uh, very likely? The impact of prosodic uncertainty cues on the perception and interpretation of spoken verbal probability phrases

People typically use verbal probability phrases when discussing risks ("It is likely that this treatment will work"), both in written and spoken communication. When speakers are uncertain about risks, they can nonverbally signal this uncertainty by using prosodic cues, such as a rising, question-like intonation or a filled pause ("uh"). We experimentally studied the effects of these two prosodic cues on the listener's perceived speaker certainty and numerical interpretation of spoken verbal probability phrases. Participants (N = 115) listened to various verbal probability phrases that were uttered with a rising or falling global intonation and with or without a filled pause before the probability phrase. For each phrase, they gave a point estimate of their numerical interpretation in percentages and indicated how certain they thought the speaker was about the correctness of the probability phrase. Speakers were perceived as least certain when the verbal probability phrases were spoken with both prosodic uncertainty cues. Interpretation of verbal probability phrases varied widely across participants, especially when rising intonation was produced by the speaker. Overall, high probability phrases (e.g., "very likely") were estimated as lower (and low probability phrases, such as "unlikely," as higher) when they were uttered with a rising intonation. The effects of filled pauses were less pronounced, as were the uncertainty effects for medium probability phrases (e.g., "probable"). These results stress the importance of nonverbal communication when verbally communicating risks and probabilities to people, for example, in the context of doctor-patient communication.

Communicating the Imperfect Diagnostic Accuracy of COVID-19 Rapid Antigen Self-Tests: An Online Randomized Experiment

OBJECTIVE

To investigate the potential impacts of optimizing coronavirus disease 2019 (COVID-19) rapid antigen test (RAT) self-testing diagnostic accuracy information.

DESIGN

Online randomized experiment using hypothetical scenarios: in scenarios 1 to 3 (RAT result positive), the posttest probability was considered to be very high (likely true positives), and in scenarios 4 and 5 (RAT result negative), the posttest probability was considered to be moderately high (likely false negatives).

SETTING

December 12 to 22, 2022, during the mixed-variant Omicron wave in Australia.

PARTICIPANTS

Australian adults. Intervention: diagnostic accuracy of a COVID-19 self-RAT presented in a health literacy-sensitive way; usual care: diagnostic accuracy information provided by the manufacturer; control: no diagnostic accuracy information.

MAIN OUTCOME MEASURE

Intention to self-isolate.

RESULTS

A total of 226 participants were randomized (control n = 75, usual care n = 76, intervention n = 75). More participants in the intervention group correctly interpreted the meaning of the diagnostic accuracy information (P = 0.08 for understanding sensitivity, P < 0.001 for understanding specificity). The proportion who would self-isolate was similar across scenarios 1 to 3 (likely true positives). The proportion was higher in the intervention group than in the control for scenarios 4 and 5 (likely false negatives). These differences were not statistically significant. The largest potential effect was seen in scenario 5 (dinner party with confirmed cases, the person has symptoms, negative self-RAT result), with 63% of the intervention group and 49% of the control group indicating they would self-isolate (absolute difference 13.3%, 95% confidence interval: -2% to 30%, P = 0.10).

CONCLUSION

Health literacy sensitive formatting supported participant understanding and recall of diagnostic accuracy information. This may increase community intentions to self-isolate when there is a likely false-negative self-RAT result. Trial registration: Australia New Zealand Clinical Trial Registry (ACTRN12622001517763).

HIGHLIGHTS

Community-based diagnostic accuracy studies of COVID-19 self-RATs indicate substantially lower sensitivity (and higher risk of false-negative results) than the manufacturer-supplied information on most government public Web sites.This online randomized study found that a health literacy-sensitive presentation of the imperfect diagnostic accuracy COVID-19 self-RATs supported participant understanding and recall of diagnostic accuracy information.Health literacy-sensitive presentation may increase community intentions to self-isolate after a negative test result where the posttest probability is still moderately high (i.e., likely false-negative result).To prevent the onward spread of infection, efforts to improve communication about the high risk of false-negative results from COVID-19 self-RATs are urgently needed.

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.

Patient listening on social media for patient-focused drug development: a synthesis of considerations from patients, industry and regulators

Patients, life science industry and regulatory authorities are united in their goal to reduce the disease burden of patients by closing remaining unmet needs. Patients have, however, not always been systematically and consistently involved in the drug development process. Recognizing this gap, regulatory bodies worldwide have initiated patient-focused drug development (PFDD) initiatives to foster a more systematic involvement of patients in the drug development process and to ensure that outcomes measured in clinical trials are truly relevant to patients and represent significant improvements to their quality of life. As a source of real-world evidence (RWE), social media has been consistently shown to capture the first-hand, spontaneous and unfiltered disease and treatment experience of patients and is acknowledged as a valid method for generating patient experience data by the Food and Drug Administration (FDA). While social media listening (SML) methods are increasingly applied to many diseases and use cases, a significant piece of uncertainty remains on how evidence derived from social media can be used in the drug development process and how it can impact regulatory decision making, including legal and ethical aspects. In this policy paper, we review the perspectives of three key stakeholder groups on the role of SML in drug development, namely patients, life science companies and regulators. We also carry out a systematic review of current practices and use cases for SML and, in particular, highlight benefits and drawbacks for the use of SML as a way to identify unmet needs of patients. While we find that the stakeholders are strongly aligned regarding the potential of social media for PFDD, we identify key areas in which regulatory guidance is needed to reduce uncertainty regarding the impact of SML as a source of patient experience data that has impact on regulatory decision making.

The future of allergic rhinitis management: A partnership between healthcare professionals and patients

Allergic rhinitis (AR) is a chronic respiratory condition that internationally continues to be burdensome and impacts quality of life. Despite availability of medicines and guidelines for healthcare providers for the optimal management of AR, optimisation of its management in the community continues to be elusive. The reasons for this are multi-faceted and include both environmental and healthcare related factors. One factor that we can no longer ignore is that AR management is no longer limited to the domain of healthcare provider and that people with AR make their own choices when choosing how to manage their condition, without seeking advice from a health care provider. We must build a bridge between healthcare provider knowledge and guidelines and patient decision-making. With this commentary, we propose that a shared decision-making approach between healthcare professionals and people with AR be developed and promoted, with a focus on patient health literacy. As custodians of AR knowledge, we have a responsibility to ensure it is accessible to those that matter most-the people with AR.

Stated-Preference Survey Design and Testing in Health Applications

Following the conceptualization of a well-formulated and relevant research question, selection of an appropriate stated-preference method, and related methodological issues, researchers are tasked with developing a survey instrument. A major goal of designing a stated-preference survey for health applications is to elicit high-quality data that reflect thoughtful responses from well-informed respondents. Achieving this goal requires researchers to design engaging surveys that maximize response rates, minimize hypothetical bias, and collect all the necessary information needed to answer the research question. Designing such a survey requires researchers to make numerous interrelated decisions that build upon the decision context, selection of attributes, and experimental design. Such decisions include considering the setting(s) and study population in which the survey will be administered, the format and mode of administration, and types of contextual information to collect. Development of a survey is an interactive process in which feedback from respondents should be collected and documented through qualitative pre-test interviews and pilot testing. This paper describes important issues to consider across all major steps required to design and test a stated-choice survey to elicit patient preferences for health preference research.

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.

Multiclass risk models for ovarian malignancy: an illustration of prediction uncertainty due to the choice of algorithm

BACKGROUND

Assessing malignancy risk is important to choose appropriate management of ovarian tumors. We compared six algorithms to estimate the probabilities that an ovarian tumor is benign, borderline malignant, stage I primary invasive, stage II-IV primary invasive, or secondary metastatic.

METHODS

This retrospective cohort study used 5909 patients recruited from 1999 to 2012 for model development, and 3199 patients recruited from 2012 to 2015 for model validation. Patients were recruited at oncology referral or general centers and underwent an ultrasound examination and surgery ≤ 120 days later. We developed models using standard multinomial logistic regression (MLR), Ridge MLR, random forest (RF), XGBoost, neural networks (NN), and support vector machines (SVM). We used nine clinical and ultrasound predictors but developed models with or without CA125.

RESULTS

Most tumors were benign (3980 in development and 1688 in validation data), secondary metastatic tumors were least common (246 and 172). The c-statistic (AUROC) to discriminate benign from any type of malignant tumor ranged from 0.89 to 0.92 for models with CA125, from 0.89 to 0.91 for models without. The multiclass c-statistic ranged from 0.41 (SVM) to 0.55 (XGBoost) for models with CA125, and from 0.42 (SVM) to 0.51 (standard MLR) for models without. Multiclass calibration was best for RF and XGBoost. Estimated probabilities for a benign tumor in the same patient often differed by more than 0.2 (20% points) depending on the model. Net Benefit for diagnosing malignancy was similar for algorithms at the commonly used 10% risk threshold, but was slightly higher for RF at higher thresholds. Comparing models, between 3% (XGBoost vs. NN, with CA125) and 30% (NN vs. SVM, without CA125) of patients fell on opposite sides of the 10% threshold.

CONCLUSION

Although several models had similarly good performance, individual probability estimates varied substantially.

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.

Communication of benefits and harms in shared decision making with patients with limited health literacy: A systematic review of risk communication strategies

OBJECTIVES

Risk communication (RC), as part of shared decision making, is challenging with people with limited health literacy (LHL). We aim to provide an overview of strategies to communicate benefits and harms of diagnostic and treatment options to this group.

METHODS

We systematically searched PubMed, Embase, Cinahl and PsycInfo. We included 28 studies on RC in informed/shared decision making without restriction to a health setting or condition and using a broad conceptualization of health literacy. Two researchers independently selected studies and one researcher performed data extraction. We descriptively compared findings for people with LHL towards recommendations for RC.

RESULTS

Health literacy levels varied in the included studies. Most studies used experimental designs, primarily on visual RC. Findings show verbal RC alone should be avoided. Framing of risk information influences risk perception (less risky when positively framed, riskier when negatively framed). Most studies recommended the use of icon arrays. Graph literacy should be considered when using visual RC.

CONCLUSIONS

The limited available evidence suggests that recommended RC strategies seem mainly to be valid for people with LHL, but more research is required.

PRACTICE IMPLICATIONS

More qualitative research involving people with LHL is needed to gain further in-depth insights into optimal RC strategies.

PROTOCOL REGISTRATION

PROSPERO ID 275022.

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.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Health literate-sensitive shared decision-making in maternity care: needs for support among maternity care professionals in the Netherlands

BACKGROUND

Shared decision-making (SDM) in maternity care is challenging when clients have insufficient health literacy (HL) skills. This study gained insight in how professionals apply HL-sensitive SDM in Dutch maternity care and their needs for support therein.

METHODS

Maternity care professionals (n = 30) completed a survey on SDM and the role of HL. Midwives (n = 13) were observed during simulated conversations discussing pain relief options and interviewed afterwards. The client-actors were instructed to portrait specific inadequate HL skills. Observation items focused on adapting communication to HL, and SDM (OPTION-5).

RESULTS

In the survey, professionals indicated experiencing most challenges when estimating clients' information comprehension. Observations showed that most midwives created choice awareness and informed clients about options, whereas exploring preferences and actual decision-making together with clients were observed less frequently. Their perceived HL-related obstacles and needs for support related to clients' information comprehension. In the interviews, midwives reported putting much effort into explaining available options in maternity care, but also that decisions about pain relief are often postponed until the moment of labour.

CONCLUSION

Professionals' self-reported needs focus on clients' information comprehension. However, observations indicate that it is not the stage of informing, but rather value clarification and actual decision-making that need improvement in HL-sensitive SDM.

Thyroid Cancer Risk Communication in Patients with Thyroid Nodules

The objective of this study is to evaluate thyroid cancer risk clinician-patient communication among patients receiving usual counseling and counseling enhanced by a conversation aid. A secondary analysis of clinical visit recordings and post-visit surveys obtained during a trial assessing the impact of a conversation aid for patients with thyroid nodules was conducted. We assessed how thyroid cancer risk was communicated, different risk communication strategies between groups, and predictors of accurate cancer risk perception. Fifty-nine patients were analyzed. Most were women (90%) and middle-aged (median 57 years). A verbal description of thyroid cancer risk was present most frequently (83%) and was more frequent in the conversation aid than the usual care group (100% vs. 63%, p < 0.001). A numerical description using percentages was present in 41% of visits and was more frequent in the conversation aid group (59% vs. 19%, p = 0.012). Natural frequencies (7%) and positive/negative framing (10%) were utilized less commonly. Uncertainty about risks was not discussed. No predictors of accurate risk perception were identified. Clinicians most commonly present a verbal description of thyroid cancer risk. Less commonly, natural frequencies, negative/positive framing, or uncertainty is discussed. Clinicians caring for patients with thyroid nodules should be aware of different strategies for communicating thyroid cancer risk.

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.

Predicting 30-day readmission following total knee arthroplasty using machine learning and clinical expertise applied to clinical administrative and research registry data in an Australian cohort

BACKGROUND

Thirty-day readmission is an increasingly important problem for total knee arthroplasty (TKA) patients. The aim of this study was to develop a risk prediction model using machine learning and clinical insight for 30-day readmission in primary TKA patients.

METHOD

Data used to train and internally validate a multivariable predictive model were obtained from a single tertiary referral centre for TKA located in Victoria, Australia. Hospital administrative data and clinical registry data were utilised, and predictors were selected through systematic review and subsequent consultation with clinicians caring for TKA patients. Logistic regression and random forest models were compared to one another. Calibration was evaluated by visual inspection of calibration curves and calculation of the integrated calibration index (ICI). Discriminative performance was evaluated using the area under the receiver operating characteristic curve (AUC-ROC).

RESULTS

The models developed in this study demonstrated adequate calibration for use in the clinical setting, despite having poor discriminative performance. The best-calibrated readmission prediction model was a logistic regression model trained on administrative data using risk factors identified from systematic review and meta-analysis, which are available at the initial consultation (ICI = 0.012, AUC-ROC = 0.589). Models developed to predict complications associated with readmission also had reasonable calibration (ICI = 0.012, AUC-ROC = 0.658).

CONCLUSION

Discriminative performance of the prediction models was poor, although machine learning provided a slight improvement. The models were reasonably well calibrated, meaning they provide accurate patient-specific probabilities of these outcomes. This information can be used in shared clinical decision-making for discharge planning and post-discharge follow up.

Verbal Descriptions of the Probability of Treatment Complications Lead to High Variability in Risk Perceptions: A Survey Study

OBJECTIVE

To assess whether different methods for communicating the probability of treatment complications for operative and nonoperative appendicitis treatments result in differences in risk perception.

BACKGROUND

Surgeons must communicate the probability of treatment complications to patients, and how risks are communicated may impact the accuracy and variability in patient risk perceptions and ultimately their decision making.

METHODS

A series of online surveys of American adults communicated the probability of complications associated with surgical or antibiotic treatment of acute appendicitis. Probability was communicated with verbal descriptors (eg, "uncommon"), point estimates (eg, "3% risk"), or risk ranges (eg, "1% to 5%"). Respondents then estimated the probability of a complication for a "typical patient with appendicitis." The Fligner-Killeen test of homogeneity of variance was used to compare the variability in respondent risk estimates based on the method of probability communication.

RESULTS

Among 296 respondents, variance in probability estimates was significantly higher when verbal descriptions were used compared to point estimates ( P < 0.001) or risk ranges ( P < 0.001). Identical verbal descriptors produced meaningfully different risk estimates depending on the complication being described. For example, "common" was perceived as a 45.6% for surgical site infection but 61.7% for antibiotic-associated diarrhea.

CONCLUSION

Verbal probability descriptors are associated with widely varying and inaccurate perceptions about treatment risks. Surgeons should consider alternative ways to communicate probability during informed consent and shared decision-making discussions.

Measuring feelings about choices and risks: The Berlin Emotional Responses to Risk Instrument (BERRI)

We introduce a brief instrument specifically validated for measuring positive and negative feelings about risks-the Berlin Emotional Responses to Risk Instrument (BERRI). Based on seven studies involving diverse adults from three countries (n = 2120), the BERRI was found to robustly estimate anticipatory affective reactions derived from subjective evaluations of positive (i.e., assured, hopeful, and relieved) and negative emotions (i.e., anxious, afraid, and worried). The brief BERRI outperformed a 14-item assessment, uniquely tracking costs/benefits associated with cancer screening among men and women (Studies 1 and 2). Predictive validity was further documented in paradigmatic risky choice studies wherein options varied over probabilities and severities across six contexts (health, social, financial, technological, ethical, and environmental; Study 3). Studies 4-6, conducted during the Ebola epidemic and COVID-19 pandemic, indicated BERRI responses were sensitive to subtle effects caused by emotion-related framing manipulations presented in different cultures and languages (the United States, Spain, and Poland). Study 7 indicated BERRI responses remained stable for 2 weeks. Although the BERRI can provide an estimate of overall affect, choices were generally better explained by the unique influences of positive and negative affect. Overall, results suggest the novel, brief instrument can be an efficient tool for high-stakes research on decision making and risk communication.

Multiple Automated Health Literacy Assessments of Written Health Information: Development of the SHeLL (Sydney Health Literacy Lab) Health Literacy Editor v1

Producing health information that people can easily understand is challenging and time-consuming. Existing guidance is often subjective and lacks specificity. With advances in software that reads and analyzes text, there is an opportunity to develop tools that provide objective, specific, and automated guidance on the complexity of health information. This paper outlines the development of the SHeLL (Sydney Health Literacy Lab) Health Literacy Editor, an automated tool to facilitate the implementation of health literacy guidelines for the production of easy-to-read written health information. Target users were any person or organization that develops consumer-facing education materials, with or without prior experience with health literacy concepts. Anticipated users included health professionals, staff, and government and nongovernment agencies. To develop this tool, existing health literacy and relevant writing guidelines were collated. Items amenable to programmable automated assessment were incorporated into the Editor. A set of natural language processing methods were also adapted for use in the SHeLL Editor, though the approach was primarily procedural (rule-based). As a result of this process, the Editor comprises 6 assessments: readability (school grade reading score calculated using the Simple Measure of Gobbledygook (SMOG)), complex language (percentage of the text that contains public health thesaurus entries, words that are uncommon in English, or acronyms), passive voice, text structure (eg, use of long paragraphs), lexical density and diversity, and person-centered language. These are presented as global scores, with additional, more specific feedback flagged in the text itself. Feedback is provided in real-time so that users can iteratively revise and improve the text. The design also includes a "text preparation" mode, which allows users to quickly make adjustments to ensure accurate calculation of readability. A hierarchy of assessments also helps users prioritize the most important feedback. Lastly, the Editor has a function that exports the analysis and revised text. The SHeLL Health Literacy Editor is a new tool that can help improve the quality and safety of written health information. It provides objective, immediate feedback on a range of factors, complementing readability with other less widely used but important objective assessments such as complex and person-centered language. It can be used as a scalable intervention to support the uptake of health literacy guidelines by health services and providers of health information. This early prototype can be further refined by expanding the thesaurus and leveraging new machine learning methods for assessing the complexity of the written text. User-testing with health professionals is needed before evaluating the Editor's ability to improve the health literacy of written health information and evaluating its implementation into existing Australian health services.

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.

Association between Risk Communication Format and Perceived Risk of Adverse Events after COVID-19 Vaccination among US Adults

The format used to communicate probability-verbal versus numerical descriptors-can impact risk perceptions and behaviors. This issue is salient for the Coronavirus disease 2019 (COVID-19), where concerns about vaccine-related risks may reduce uptake and verbal descriptors have been widely used by public health, news organizations and on social media, to convey risk. Because the effect of risk-communication format on perceived COVID-19 vaccine-related risks remains unknown, we conducted an online randomized survey among 939 US adults. Participants were given risk information, using verbal or numerical descriptors and were asked to report their perceived risk of experiencing headache, fever, fatigue or myocarditis from COVID-19 vaccine. Associations between risk communication format and perceived risk were assessed using multivariable regression. Compared to numerical estimates, verbal descriptors were associated with higher perceived risk of headache (β = 5.0 percentage points, 95% CI = 2.0-8.1), fever (β = 27 percentage points, 95% CI = 23-30), fatigue (β = 4.9 percentage points, 95% = CI 1.8-8.0) and myocarditis (β = 4.6 percentage points, 95% CI = 2.1-7.2), as well as greater variability in risk perceptions. Social media influence was associated with differences in risk perceptions for myocarditis, but not side effects. Verbal descriptors may lead to greater, more inaccurate and variable vaccine-related risk perceptions compared to numerical descriptors.

Discussing Cost and Value in Patient Decision Aids and Shared Decision Making: A Call to Action

Direct and indirect costs of care influence patients' health choices and the ability to implement those choices. Despite the significant impact of care costs on patients' health and daily lives, patient decision aid (PtDA) and shared decision-making (SDM) guidelines almost never mention a discussion of costs of treatment options as part of minimum standards or quality criteria. Given the growing study of the impact of costs in health decisions and the rising costs of care more broadly, in fall 2021 we organized a symposium at the Society for Medical Decision Making's annual meeting. The focus was on the role of cost information in PtDAs and SDM. Panelists gave an overview of work in this space at this virtual meeting, and attendees engaged in rich discussion with the panelists about the state of the problem as well as ideas and challenges in incorporating cost-related issues into routine care. This article summarizes and extends our discussion based on the literature in this area and calls for action. We recommend that PtDA and SDM guidelines routinely include a discussion of direct and indirect care costs and that researchers measure the frequency, quality, and response to this information.

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.

Investigating the presentation of uncertainty in an icon array: A randomized trial

BACKGROUND

Clinicians are often advised to use pictographs to communicate risk, but whether they offer benefits when communicating risk imprecision (e.g., 65%-79%) is unknown.

PURPOSE

To test whether any of three approaches to visualizing imprecision would more effectively communicate breast and ovarian cancer risk for BRCA1 pathogenic variant carriers.

METHODS

1,300 UK residents were presented with a genetic report with information about BRCA1-related risks, with random assignment to one of four formats: no visualization (text alone), or a pictograph using shaded icons, a gradient, or arrows marking range endpoints. We also tested pictographs in two layouts. Analysis of variance (ANOVA) and regression was employed.

RESULTS

There was no effect of format. Participants shown pictographs vs. text alone had better uptake of breast cancer risk messages (p < .05, η ² = 0.003). Pictographs facilitated memory for the specific amount of risk (p < 0.001, η ² = 0.019), as did the tabular layout. Individuals not having completed upper secondary education may benefit most.

CONCLUSIONS

We found weak evidence in favor of using simple pictographs with ranges to communicate BRCA risk (versus text alone), and of the tabular layout.

INNOVATION

Testing different ways of communicating imprecision within pictographs is a novel and promising line of research.

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.

Extended‐duration thromboprophylaxis for abdominopelvic surgery: Development and evaluation of a risk‐stratified patient decision aid to facilitate shared decision making

Background

Extended-duration thromboprophylaxis is used to decrease risk of venous thromboembolism (VTE) after surgery but may increase the risk of bleeding. The decision to complete a course of extended-duration thromboprophylaxis can be challenging.

Objective

The objective of this study was to develop an acceptable patient decision aid (PtDA) to facilitate shared decision making for the use of extended-duration thromboprophylaxis following major abdominal surgery.

Methods

An evidence-based, risk-stratified PtDA was created. The evidence on benefits and harms of a 28-day postoperative course of low-molecular-weight heparin (LMWH) versus in-hospital prophylaxis only were synthesized. Outcomes included minor bleeding, major bleeding, clinically significant VTE, and fatal VTE. Risks were calculated and reported by Caprini score. Alpha testing of the PtDA draft with various stakeholders was performed using a 10-question survey to assess acceptability of the PtDA with patients, thrombosis experts, and surgeons. The primary outcome was the acceptability of the PtDA.

Results

Acceptability testing was performed with 11 patients, 11 thrombosis experts, and 11 surgeons. Most responders felt the language on the PtDA was easy to follow (28/33, 85%), and that the information was well balanced between management options (9/11 [82%] patients; 17/21 [80%] clinicians). Most patients (9/11, 82%) and clinicians (18/22, 82%) believed it would be a useful clinical tool, and were satisfied with the overall quality of the PtDA (27/33, 82%).

Conclusions

A risk-stratified, evidence-based PtDA was created to facilitate shared decision making for the use of extended-duration LMWH following major abdominal surgery. This clinical tool was acceptable with patients and physicians and is available at https://decisionaid.ohri.ca/decaids.html.

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.

Decision Support Tools for Coronary Artery Calcium Scoring in the Primary Prevention of Cardiovascular Disease Do Not Meet Health Literacy Needs: A Systematic Environmental Scan and Evaluation

A shared decision-making approach is considered optimal in primary cardiovascular disease (CVD) prevention. Evidence-based patient decision aids can facilitate this but do not always meet patients' health literacy needs. Coronary artery calcium (CAC) scans are increasingly used in addition to traditional cardiovascular risk scores, but the availability of high-quality decision aids to support shared decision-making is unknown. We used an environmental scan methodology to review decision support for CAC scans and assess their suitability for patients with varying health literacy. We systematically searched for freely available web-based decision support tools that included information about CAC scans for primary CVD prevention and were aimed at the public. Eligible materials were independently evaluated using validated tools to assess qualification as a decision aid, understandability, actionability, and readability. We identified 13 eligible materials. Of those, only one qualified as a decision aid, and one item presented quantitative information about the potential harms of CAC scans. None presented quantitative information about both benefits and harms of CAC scans. Mean understandability was 68%, and actionability was 48%. Mean readability (12.8) was much higher than the recommended grade 8 level. Terms used for CAC scans were highly variable. Current materials available to people considering a CAC scan do not meet the criteria to enable informed decision-making, nor do they meet the health literacy needs of the general population. Clinical guidelines, including CAC scans for primary prevention, must be supported by best practice decision aids to support decision-making.

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).

Effects of side-effect risk framing strategies on COVID-19 vaccine intentions: a randomized controlled trial

Background:

Fear over side-effects is one of the main drivers of COVID-19 vaccine hesitancy. A large literature in the behavioral and communication sciences finds that how risks are framed and presented to individuals affects their judgments of its severity. However, it remains unknown whether such framing changes can affect COVID-19 vaccine behavior and be deployed as policy solutions to reduce hesitancy.

Methods:

We conducted a pre-registered randomized controlled trial among 8998 participants in the United States and the United Kingdom to examine the effects of different ways of framing and presenting vaccine side-effects on individuals’ willingness to get vaccinated and their perceptions of vaccine safety.

Results:

Adding a descriptive risk label (‘very low risk’) next to the numerical side-effect and providing a comparison to motor-vehicle mortality increased participants’ willingness to take the COVID-19 vaccine by 3.0 percentage points (p=0.003) and 2.4 percentage points (p=0.049), respectively. These effects were independent and additive and combining both framing strategies increased willingness to receive the vaccine by 6.1 percentage points (p<0.001). Mechanistically, we find evidence that these framing effects operate by increasing individuals’ perceptions of how safe the vaccine is.

Conclusions:

Low-cost side-effect framing strategies can meaningfully affect vaccine intentions at a population level.

Funding:

Heidelberg Institute of Global Health.

Clinical trial number:

German Clinical Trials Registry (#DRKS00025551).

Vaccination is one of the main strategies for controlling the COVID-19 pandemic. But vaccination rates have slowed and are below target levels in countries like the United States and the United Kingdom. While there are many causes of vaccine hesitancy, several studies have found that fear of side effects is the one of the most important.

Although COVID-19 vaccine side-effects are rare, how the media presents these risks may amplify concerns. Addressing public concerns over vaccine side effects is key to improving the uptake of vaccines and booster doses, which has been even lower than primary vaccine series uptake.

Studies show that how risk is presented affects people’s risk perceptions and behavior. To learn more about how COVID-19 vaccine risk framing affects risk perception, Sudharsanan et al. enrolled 8,998 people from the United States and the United Kingdom in an online randomized controlled trial. Participants received information about a hypothetical new COVID-19 vaccine, including its side effect rate, and reported their perception of safety and whether they would take the vaccine.

The experiments showed that adding the label “very low risk” when describing vaccine side effect rates increased the number of people who said they would take the vaccine by three percentage points. Comparing the risks of the hypothetical vaccine to the much higher chances of motor vehicle deaths increased an individual’s willingness to take the vaccine by 2.4 percentage points. Combining both framing strategies increased people’s desire to get vaccinated by 6.1 percentage points.

Deploying these two strategies in vaccine risk communications may help increase primary and booster vaccinations against COVID-19. A next step would be to measure both vaccination intentions and vaccination rates to confirm these strategies.

Acceptability of a standalone written leaflet for the National Health Service for England Targeted Lung Health Check Programme: A concurrent, think-aloud study

BACKGROUND

Many countries are introducing low-dose computed tomography screening programmes for people at high risk of lung cancer. Effective communication strategies that convey risks and benefits, including unfamiliar concepts and outcome probabilities based on population risk, are critical to achieving informed choice and mitigating inequalities in uptake.

METHODS

This study investigated the acceptability of an aspect of NHS England's communication strategy in the form of a leaflet that was used to invite and inform eligible adults about the Targeted Lung Health Check (TLHC) programme. Acceptability was assessed in terms of how individuals engaged with, comprehended and responded to the leaflet. Semi-structured, 'think aloud' interviews were conducted remotely with 40 UK screening-naïve current and former smokers (aged 55-73). The verbatim transcripts were analysed thematically using a coding framework based on the Dual Process Theory of cognition.

RESULTS

The leaflet helped participants understand the principles and procedures of screening and fostered cautiously favourable intentions. Three themes captured the main results of the data analysis: (1) Response-participants experienced anxiety about screening results and further investigations, but the involvement of specialist healthcare professionals was reassuring; (2) Engagement-participants were rapidly drawn to information about lung cancer prevalence, and benefits of screening, but deliberated slowly about early diagnosis, risks of screening and less familiar symptoms of lung cancer; (3) Comprehension-participants understood the main principles of the TLHC programme, but some were confused by its rationale and eligibility criteria. Radiation risks, abnormal screening results and numerical probabilities of screening outcomes were hard to understand.

CONCLUSION

The TLHC information leaflet appeared to be acceptable to the target population. There is scope to improve aspects of comprehension and engagement in ways that would support informed choice as a distributed process in lung cancer screening.

PATIENT OR PUBLIC CONTRIBUTION

The insight and perspectives of patient representatives directly informed and improved the design and conduct of this study.

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.

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.

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.

Decision aids linked to the recommendations in clinical practice guidelines: results of the acceptability of a decision aid for patients with generalized anxiety disorder

Background

Generalized anxiety disorder (GAD) is one of the most prevalent mental health problems. Patients with GAD have unmet needs related to the information received about their disorder, its treatments and their participation in the decision-making process. The aim of this study is to develop and assess the acceptability of a patient decision aid (PtDA) for patients with GAD.

Method

The PtDA was developed following the International Patient Decision Aid Standards. The recommendations of the Spanish clinical practice guideline (CPG) for patients with GAD were used as the basis. The first prototype was developed by an expert committee, further improvements were made with patients (n = 2), clinical experts (n = 13) and the project management group (n = 7). The acceptability of this second draft was assessed by patients non-involved in the previous phases (n = 11).

Results

The final PtDA version included a brief description of GAD and its treatments. Most participants agreed that the PtDA was easy to use, visually appealing and useful. At least half of the participants learned new things about treatments and adverse effects.

Conclusions

A PtDA was developed for patients with GAD based on recommendations from the Spanish CPG. It was improved and accepted by patients and clinical experts involved. An evaluation of its effectiveness on the shared decision-making process during the clinical encounter is planned.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01899-2.