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Zikmund-Fisher B.J.,University of Michigan | Zikmund-Fisher B.J.,Center for Behavioral and Decision science in Medicine | Angott A.M.,Duke University | Ubel P.A.,Duke University
Breast Cancer Research and Treatment | Year: 2011

Breast cancer patients must often decide between multiple adjuvant therapy options to prevent cancer recurrence. Standard practice, as implemented in current decision support tools, is to present information about all options simultaneously, but psychology research suggests that sequential decision processes might improve decision making. We tested whether asking women to consider hormonal therapy and chemotherapy separately would improve women's risk knowledge and/or affect treatment intentions. We conducted an Internet-administered experimental survey of a demographically diverse sample of 1,781 women ages 40-74. Participants were randomized to experience a standard, comprehensive decision process versus sequential (one at a time) decisions regarding adjuvant therapy options for a hypothetical breast cancer patient with an estrogen receptor-positive (ER+) tumor. We assessed comprehension of key statistics, perceptions of treatment effectiveness, and perceived interest in adjuvant chemotherapy, as well as participants' numeracy levels. When participants made sequential decisions, they demonstrated greater comprehension of decision-relevant risk statistics, as compared to when they made decisions all at once (all P's < 0.001). Among higher-numeracy participants, those making sequential decisions were less interested in chemotherapy (P < 0.001). Lower-numeracy participants who considered all options simultaneously were insensitive to the degree of risk reduction, but those who made sequential decisions were sensitive (P = 0.03). In conclusion, presenting adjuvant therapy options sequentially improves women's comprehension of incremental treatment benefit and increases less numerate women's sensitivity to the magnitude of the achievable risk reduction over standard, all at once approaches. Sequential approaches to adjuvant therapy decisions may reduce use of chemotherapy among those at low risk for recurrence. © 2010 Springer Science+Business Media, LLC. Source

Dillard A.J.,Center for Behavioral and Decision science in Medicine | Dillard A.J.,University of Michigan | Couper M.P.,Center for Behavioral and Decision science in Medicine | Couper M.P.,University of Michigan | Zikmund-Fisher B.J.,Center for Behavioral and Decision science in Medicine
Medical Decision Making | Year: 2010

Background. Health behavior theories suggest that high perceived risk for cancer will be associated with screening, but few studies have examined how perceived risk relates to the screening decision process. Objective. To examine relationships between perceived risk of cancer and behaviors during decision making for 3 screening tests. Design. Cross-sectional survey conducted between November 2006 and May 2007. Setting. Nationwide random-digit dial telephone survey. Participants. A total of 1729 English-speaking US adults aged 40 y and older who reported making a cancer screening decision (about breast, colon, or prostate tests) in the previous 2 y. Measurements. Participants completed measures of perceived risk, information seeking, and shared decision-making tendencies. Results. As perceived risk for cancer increased, patients were more likely to seek information about screening on their own (e.g., 35% of participants who perceived a high risk of cancer searched the Internet compared with 18% for those who perceived a low risk, P < 0.001) and in interactions with their physicians. As perceived risk increased, patients were also more likely to consult with more than 1 provider. Gender moderated the shared decision-making preference such that men with high perceived risks were more likely than women with high perceived risks to report they would have preferred more involvement in the decision (35% v. 9%, P = 0.001). Limitations. Cross-sectional data limit causal inferences. Conclusions. Higher perceived risk was associated with greater patient participation, as shown by more information seeking and greater desire for decisional involvement (moderated by gender). The results suggest that perceived risk of cancer could influence patient behavior when deciding about screening. Source

Ratanawongsa N.,San Francisco General Hospital | Zikmund-Fisher B.J.,University of Michigan | Zikmund-Fisher B.J.,Center for Behavioral and Decision science in Medicine | Couper M.P.,Center for Behavioral and Decision science in Medicine | And 3 more authors.
Medical Decision Making | Year: 2010

Background. Racial/ethnic differences in shared decision making about cardiovascular risk-reduction therapy could affect health disparities. Objective. To investigate whether patient race/ethnicity is associated with experiences discussing cardiovascular risk-reduction therapy with health care providers. Setting. National sample of US adults identified by random-digit dialing. Design. Cross-sectional survey conducted in November 2006 to May 2007. Participants. Among participants in the National Survey of Medical Decisions (DECISIONS), a nationally representative sample of English-speaking US adults aged 40 and older, the authors analyzed respondents who reported discussing hyperlipidemia or hypertension medications with a health care provider in the previous 2 years. Measurements. In multivariate linear and logistic regressions adjusting for age, gender, income, insurance status, perceived health, and current therapy, they assessed the relation between race/ethnicity (black/Hispanic v. white) and decision making: knowledge, discussion of pros and cons of therapy, discussion of patient preference, who made the final decision, preferred involvement, and confidence in the decision. Results. Of respondents who discussed high cholesterol (N = 738) or hypertension (N = 745) medications, 88% were white, 9% black, and 4% Hispanic. Minorities had lower knowledge scores than whites for hyperlipidemia (42% v. 52%, difference -10% [95% confidence interval (CI): 15, -5], P < 0.001), but not for hypertension. For hyperlipidemia, minorities were more likely than whites to report that the health care provider made the final decision for treatment (31.7% v. 12.3% whites, difference 19.4% [95% CI: 6.9, 33.1%], P < 0.01); this was not true for hypertension. Limitations. Possible limitations include the small percentage of minorities in the sample and potential recall bias. Conclusions. Minorities considering hyperlipidemia therapy may be less informed about and less involved in the final decision-making process. Source

Sepucha K.R.,Harvard University | Sepucha K.R.,Massachusetts General Hospital | Fagerlin A.,University of Michigan | Fagerlin A.,Center for Behavioral and Decision science in Medicine | And 6 more authors.
Medical Decision Making | Year: 2010

Background. An important part of delivering high-quality, patient-centered care is making sure patients are informed about decisions regarding their health care. The objective was to examine whether patients' perceptions about how informed they were about common medical decisions are related to their ability to answer various knowledge questions. Methods. A cross-sectional survey was conducted November 2006 to May 2007 of a national sample of US adults identified by random-digit dialing. Participants were 2575 English-speaking US adults aged 40 and older who had made 1 of 9 medication, cancer screening, or elective surgery decisions within the previous 2 years. Participants rated how informed they felt on a scale of 0 (not at all informed) to 10 (extremely well-informed), answered decision-specific knowledge questions, and completed standard demographic questions. Results. Overall, 36% felt extremely well informed (10), 30% felt well informed (8-9), and 33% felt not at all to somewhat informed (0-7). Multivariate logistic regression analyses showed no overall relationship between knowledge scores and perceptions of being extremely well informed (odds ratio [OR] = 0.94, 95% confidence interval [CI] 0.63-1.42, P = 0.78). Three patterns emerged for decision types: a negative relationship for cancer screening decisions (OR = 0.58, CI 0.33-1.02, P = 0.06), no relationship for medication decisions (OR = 0.99, CI 0.54-1.83, P = 0.98), and a positive relationship for surgery decisions (OR = 3.07, 95% CI 0.90-10.54, P = 0.07). Trust in the doctor was associated with feeling extremely well-informed for all 3 types of decisions. Lower education and lower income were also associated with feeling extremely well informed for medication and screening decisions. Retrospective survey data are subject to recall bias, and participants may have had different perspectives or more factual knowledge closer to the time of the decision. Conclusions. Patients facing common medical decisions are not able to accurately assess how well informed they are. Clinicians need to be proactive in providing adequate information to patients and testing patients' understanding to ensure informed decisions. Source

Fagerlin A.,University of Michigan | Fagerlin A.,Center for Behavioral and Decision science in Medicine | Sepucha K.R.,Harvard University | Sepucha K.R.,Massachusetts General Hospital | And 6 more authors.
Medical Decision Making | Year: 2010

Background. To make informed decisions, patients must have adequate knowledge of key decision-relevant facts. Objective. To determine adults' knowledge about information relevant to common types of medication, screening, or surgery decisions they recently made. Setting. National sample of US adults identified by random-digit dialing. Design. Cross-sectional survey conducted between November 2006 and May 2007. Participants. A total of 2575 English-speaking adults aged 40 y or older who reported having discussed the following medical decisions with a health care provider within the previous 2 y: prescription medications for hypertension, hypercholesterolemia, or depression; screening tests for colorectal, breast, or prostate cancer; or surgeries for knee/hip replacement, cataracts, or lower back pain. Measurements. Participants answered knowledge questions and rated the importance of their health care provider, family/friends, and the media as sources of information. Results. Accuracy rates varied widely across questions and decision contexts. For example, patients considering cataract surgery were more likely to correctly estimate recovery time than those patients considering lower back pain or knee/hip replacement (78% v. 29% and 39%, P < 0.001). Similarly, participants were more knowledgeable of facts about colorectal cancer screening than those who were asked about breast or prostate cancer. Finally, respondents were consistently more knowledgeable on comparable questions about blood pressure medication than cholesterol medication or antidepressants. The impact of demographic characteristics and sources of information also varied substantially. For example, blacks had lower knowledge than whites about cancer screening decisions (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.43, 0.75; P = 0.001) and medication (OR = 0.77; 95% CI = 0.60, 0.97; P = 0.03) even after we controlled for other demographic factors. The same was not true for surgical decisions. Limitations. The questions did not measure all knowledge relevant to informed decision making, were subject to recall biases, and may have assessed numeracy more than knowledge. Conclusions. Patient knowledge of key facts relevant to recently made medical decisions is often poor and varies systematically by decision type and patient characteristics. Improving patient knowledge about risks, benefits, and characteristics of medical procedures is essential to support informed decision making. Source

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