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Communicating risk using absolute risk reduction or prolongation of life formats: cluster-randomised trial in general practice. Br J Gen Pract 2015; 64:e199-207. [PMID: 24686884 DOI: 10.3399/bjgp14x677824] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND It is important that patients are well-informed about risks and benefits of therapies to help them decide whether to accept medical therapy. Different numerical formats can be used in risk communication but It remains unclear how the different formats affect decisions made by real-life patients. AIM To compare the impact of using Prolongation Of Life (POL) and Absolute Risk Reduction (ARR) information formats to express effectiveness of cholesterol-lowering therapy on patients' redemptions of statin prescriptions, and on patients' confidence in their decision and satisfaction with the risk communication. DESIGN AND SETTING Cluster-randomised clinical trial in general practices. Thirty-four Danish GPs from 23 practices participated in a primary care-based clinical trial concerning use of quantitative effectiveness formats for risk communication in health prevention consultations. METHOD GPs were cluster-randomised (treating practices as clusters) to inform patients about cardiovascular mortality risk and the effectiveness of statin treatment using either POL or ARR formats. Patients' redemptions of statin prescriptions were obtained from a regional prescription database. The COMRADE questionnaire was used to measure patients' confidence in their decision and satisfaction with the risk communication. RESULTS Of the 240 patients included for analyses, 112 were allocated to POL information and 128 to ARR. Patients redeeming a statin prescription totalled six (5.4%) when informed using POL, and 32 (25.0%) when using ARR. The level of confidence in decision and satisfaction with risk communication did not differ between the risk formats. CONCLUSION Patients redeemed statin prescriptions less often when their GP communicated treatment effectiveness using POL compared with ARR.
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Bo NJ, Ejg JD, Dorte GH, Lind BBM, Veldt LP. Determinants for acceptance of preventive treatment against heart disease - a web-based population survey. BMC Public Health 2014; 14:783. [PMID: 25086654 PMCID: PMC4137069 DOI: 10.1186/1471-2458-14-783] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/22/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients' perception of risk and their lifestyle choices are of major importance in the treatment of common chronic diseases. This study reveals determinants for and knowledge about why people accept or reject preventive medical interventions against heart disease. METHODS A representative sample of 40-60-year-old Danish inhabitants was invited to participate in a web-based survey. The respondents were presented with a hypothetical scenario and asked to imagine that they were at an increased risk of heart disease, and subsequently presented with an offer of a preventive medical intervention. The aim was to elicit preference structures when potential patients are presented with different treatment conditions. RESULTS About one third of the respondents were willing to accept preventive medical treatment. Respondents with personal experience with heart disease were more likely to accept treatment than respondents with family members with heart disease or no prior experience with heart disease. The willingness to accept treatment was similar for both genders, and when adjusting for experience with heart disease, age was not associated with willingness to accept treatment. Socioeconomic status in terms of lower education was positively associated with acceptance. The price of treatment reduced willingness to accept for the lower income groups, whereas it had no effect in the highest income group. Some 57% of respondents who were willing to accept treatment changed their decision following information on potential side effects. CONCLUSIONS In accordance with our pre-study hypothesis, individuals with low income were more sensitive to price than individuals with high income. Thus, if the price of preventive medication increases above certain limits, a substantial proportion of the population may refrain from treatment. More than half of the respondents who were initially willing to accept treatment changed their decision when informed about the presence of potential side effects. This is an important observation in relation to risk communication, since most side effects occur very seldom, and a skewed assessment of treatment efficacy compared to risk of side effects may refrain some patients from treatment. Thus, more research is needed to better allow patients to compare treatment efficacy with risk of side effects in quantitative terms.
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Affiliation(s)
- Nielsen Jesper Bo
- />Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
| | - Jarbøl Dorte Ejg
- />Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
| | - Gyrd-Hansen Dorte
- />COHERE, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
| | - Barfoed Benedicte Marie Lind
- />Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
| | - Larsen Pia Veldt
- />Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, J.B.Winsløws Vej 9, DK-5000 Odense C, Denmark
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Harmsen CG, Jarbøl DE, Nexøe J, Støvring H, Gyrd-Hansen D, Nielsen JB, Edwards A, Kristiansen IS. Impact of effectiveness information format on patient choice of therapy and satisfaction with decisions about chronic disease medication: the "Influence of intervention Methodologies on Patient Choice of Therapy (IMPACT)" cluster-randomised trial in general practice. BMC Health Serv Res 2013; 13:76. [PMID: 23442351 PMCID: PMC3599428 DOI: 10.1186/1472-6963-13-76] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 02/14/2013] [Indexed: 01/22/2023] Open
Abstract
Background Risk communication is an integral part of shared decision-making in health care. In the context of interventions for chronic diseases it represents a particular challenge for all health practitioners. By using two different quantitative formats to communicate risk level and effectiveness of a cholesterol-lowering drug, we posed the research question: how does the format of risk information influence patients’ decisions concerning therapy, patients’ satisfaction with the communication as well as confidence in the decision. We hypothesise that patients are less prone to accept therapy when the benefits of long-term intervention are presented in terms of prolongation of life (POL) in months compared to the absolute risk reduction (ARR). We hypothesise that patients presented with POL will be more satisfied with the communication and confident in their decision, suggesting understanding of the time-related term. Methods/Design In 2009 a sample of 328 general practitioners (GPs) in the Region of Southern Denmark was invited to participate in a primary care-based clinical trial among patients making real-life clinical decisions together with their GP. Interested GPs were cluster-randomised to inform patients about cardiovascular disease (CVD) risk and the effectiveness of statin therapy using either POL or ARR. The GPs attended a training session before informing their patients. Before training and after the trial period they received a questionnaire about their attitudes to risk communication and the use of numerical information. Patients’ redemptions of statin prescriptions will be registered in a regional prescription database to evaluate a possible association between redemption rates and effectiveness format. The Combined Outcome Measure for Risk Communication And Treatment Decision Making Effectiveness (COMRADE) questionnaire will be used to measure patients’ confidence and satisfaction with the risk communication immediately after the conversation with their GPs. Discussion This randomised clinical trial compares the impact of two effectiveness formats on real-life risk communication between patients and GPs, including affective patient outcomes and actual choices about acceptance of therapy. Though we found difficulties in recruiting GPs, according to the study protocol we have succeeded in engaging sufficient GPs for the trial, enabling us to perform the planned analyses. Trial registration ClinicalTrials.gov Protocol Registration System
http://ww.clinicaltrials.gov/NCT01414751
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Affiliation(s)
- Charlotte Gry Harmsen
- Research Unit of General Practice, University of Southern Denmark, Southern Denmark, Denmark.
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Gyrd-Hansen D, Halvorsen P, Nexøe J, Nielsen J, Støvring H, Kristiansen I. Joint and Separate Evaluation of Risk Reduction. Med Decis Making 2010; 31:E1-10. [PMID: 21173438 DOI: 10.1177/0272989x10391268] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. When people make choices, they may have multiple options presented simultaneously or, alternatively, have options presented 1 at a time. It has been shown that if decision makers have little experience with or difficulties in understanding certain attributes, these attributes will have greater impact in joint evaluations than in separate evaluations. The authors investigated the impact of separate versus joint evaluations in a health care context in which laypeople were presented with the possibility of participating in risk-reducing drug therapies. Methods. In a randomized study comprising 895 subjects aged 40 to 59 y in Odense, Denmark, subjects were randomized to receive information in terms of absolute risk reduction (ARR), relative risk reduction (RRR), number needed to treat (NNT), or prolongation of life (POL), all with respect to heart attack, and they were asked whether they would be willing to receive a specified treatment. Respondents were randomly allocated to valuing the interventions separately (either great effect or small effect) or jointly (small effect and large effect). Results. Joint evaluation reduced the propensity to accept the intervention that offered the smallest effect. Respondents were more sensitive to scale when faced with a joint evaluation for information formats ARR, RRR, and POL but not for NNT. Evaluability bias appeared to be most pronounced for POL and ARR. Conclusion. Risk information appears to be prone to evaluability bias. This suggests that numeric information on health gains is difficult to evaluate in isolation. Consequently, such information may bear too little weight in separate evaluations of risk-reducing interventions.
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Affiliation(s)
- Dorte Gyrd-Hansen
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Peder Halvorsen
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Jørgen Nexøe
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Jesper Nielsen
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Henrik Støvring
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
| | - Ivar Kristiansen
- University of Southern Denmark, Institute of Public Health, Odense, Denmark (DG-H, J. Nielsen, HS)
- Health Economics Unit, Danish Institute for Health Services Research, Dampfaergvej, Denmark (DG-H)
- University of Tromsø, Institute of Community Medicine, Tromsø, Norway (PH)
- University of Southern Denmark, Research Unit for General Practice, Odense, Denmark (J. Nexøe)
- University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway (IK)
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Communicating effectiveness of intervention for chronic diseases: what single format can replace comprehensive information? BMC Med Inform Decis Mak 2008; 8:25. [PMID: 18565218 PMCID: PMC2467410 DOI: 10.1186/1472-6947-8-25] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2007] [Accepted: 06/19/2008] [Indexed: 11/10/2022] Open
Abstract
Background There is uncertainty about how GPs should convey information about treatment effectiveness to their patients in the context of cardiovascular disease. Hence we study the concordance of decisions based on one of four single information formats for treatment effectiveness with subsequent decisions based on all four formats combined with a pictorial representation. Methods A randomized study comprising 1,169 subjects aged 40–59 in Odense, Denmark. Subjects were randomized to receive information in terms of absolute risk reduction (ARR), relative risk reduction (RRR), number needed to treat (NNT), or prolongation of life (POL) without heart attack, and were asked whether they would consent to treatment. Subsequently the same information was conveyed with all four formats jointly accompanied by a pictorial presentation of treatment effectiveness. Again, subjects should consider consent to treatment. Results After being informed about all four formats, 52%–79% of the respondents consented to treatment, depending on level of effectiveness and initial information format. Overall, ARR gave highest concordance, 94% (95% confidence interval (91%; 97%)) between initial and final decision, but ARR was not statistically superior to the other formats. Conclusion Decisions based on ARR had the best concordance with decisions based on all four formats and pictorial representation, but the difference in concordance between the four formats was small, and it is unclear whether respondents fully understood the information they received.
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