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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.


Fagerlin A.,usa practice management | Fagerlin A.,University of Michigan | Fagerlin A.,Center for Behavioral and Decision science in Medicine | Dillard A.J.,usa practice management | And 15 more authors.
Breast Cancer Research and Treatment | Year: 2011

Although tamoxifen can prevent primary breast cancer, few women use it as a preventive measure. A second option, raloxifene, has recently been approved. The objective of the study was to determine women's interest in tamoxifen and raloxifene after reading a decision aid (DA) describing the risks and benefits of each medication. Women with 5-year risk of breast cancer ≥ 1.66 from two large health maintenance organizations were randomized to receive a DA versus usual care. After reading an on-line DA that discussed the risks and benefits of tamoxifen and raloxifene, women completed measures of risk perception, decisional conflict, behavioral intentions, and actual behavior related to tamoxifen and raloxifene. 3 months following the intervention, 8.1% of participants had looked for additional information about breast cancer prevention drugs, and 1.8% had talked to their doctor about tamoxifen and/or raloxifene. The majority, 54.7%, had decided to not take either drug, 0.5% had started raloxifene, and none had started tamoxifen. Participants were not particularly worried about taking tamoxifen or raloxifene and did not perceive significant benefits from taking these drugs. Over 50% did not perceive a change in their risk of getting breast cancer if they took tamoxifen or raloxifene. After reading a DA about tamoxifen and raloxifene, few women were interested in taking either breast cancer prevention drug. © 2011 Springer Science+Business Media, LLC (outside the USA).


Couper M.P.,University of Michigan | Couper M.P.,Center for Behavioral and Decision science in Medicine | Singer E.,University of Michigan | Levin C.A.,Foundation for Informed Medical Decision Making | And 7 more authors.
Medical Decision Making | Year: 2010

Background. The rise in Internet use for seeking health information raises questions about the role the Internet may play in how patients make medical decisions. Objective. To examine Internet use and perceived importance of different sources of information by patients making 9 specific medical decisions covering prescription medication initiation, cancer screening, and elective surgery. Setting. National sample of US adults identified by random-digit dialing. Design. Cross-sectional survey conducted between November 2006 and May 2007. Participants. The final sample comprised 2575 English-speaking US adults aged 40 y and older who had either undergone 1 of 9 medical procedures or tests or talked with a health care provider about doing so during the previous 2 y. Measurements. Participants indicated if they or other family members used the Internet to seek information related to each of the specific medical decisions and rated how important the health care provider, the Internet (if used), family and friends, and the media (newspapers, magazines, and television) were in providing information to help make the medical decision. Results. Use of the Internet for information related to specific decisions among adults 40 y and older was generally low (28%) but varied across decisions, from 17% for breast cancer screening to 48% for hip/knee replacement. Internet use was higher at younger ages, rising from 14% among those aged 70 y and older to 38% for those aged 40 to 49 y. Internet users consistently rated health care providers as the most influential source of information for medical decisions, followed by the Internet, family and friends, and media. Limitations. Telephone surveys are limited by coverage and nonresponse. The authors excluded health-related Internet use not associated with the 9 target decisions. Conclusions. A minority of patients reported using the Internet to make specific common medical decisions, but use varied widely by type of decision. Perhaps reflecting perceived risk and uncertainty, use was lowest for screening decisions and highest for surgical decisions.


Ratanawongsa N.,San Francisco General Hospital | Zikmund-Fisher B.J.,VA Ann Arbor Healthcare System | Zikmund-Fisher B.J.,University of Michigan | Zikmund-Fisher B.J.,Center for Behavioral and Decision science in Medicine | And 4 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.


Fagerlin A.,VA Ann Arbor Healthcare System | Fagerlin A.,University of Michigan | Fagerlin A.,Center for Behavioral and Decision science in Medicine | Sepucha K.R.,Harvard University | And 8 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.


Sepucha K.R.,Harvard University | Sepucha K.R.,Massachusetts General Hospital | Fagerlin A.,VA Ann Arbor Healthcare System | Fagerlin A.,University of Michigan | And 8 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.


Dillard A.J.,VA Ann Arbor Healthcare System | 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 | And 3 more authors.
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.


Zikmund-Fisher B.J.,VA Health Services Research | Zikmund-Fisher B.J.,Center for Behavioral and Decision science in Medicine | Zikmund-Fisher B.J.,University of Michigan | Fagerlin A.,VA Health Services Research | And 5 more authors.
Medical Decision Making | Year: 2010

Background. Online tools such as Adjuvant! provide tailored estimates of the possible outcomes of adjuvant therapy options available to breast cancer patients. The graphical format typically displays 4 outcomes simultaneously: survival, mortality due to cancer, other-cause mortality, and incremental survival due to adjuvant treatment. Objective. To test whether simpler formats that present only baseline and incremental survival would improve comprehension of the relevant risk statistics and/or affect treatment intentions. Design. Randomized experimental manipulation of risk graphics shown included in Internet-administered survey vignettes about adjuvant therapy decisions for breast cancer patients with ER + tumors. Participants. Demographically diverse, stratified random samples of women ages 40 to 74 y recruited from an Internet research panel. Intervention. Participants were randomized to view either pictographs (icon arrays) that displayed all 4 possible outcomes or pictographs that showed only survival outcomes. Measurements. Comprehension of key statistics, task completion times, graph evaluation ratings, and perceived interest in adjuvant chemotherapy. Results. In the primary study (N = 832), participants who viewed survival-only pictographs had better accuracy when reporting the total chance of survival with both chemotherapy and hormonal therapy (63% v. 50%, P < 0.001), higher graph evaluation ratings (x = 7.98 v. 7.67, P = 0.04), and less interest in adding chemotherapy to hormonal therapy (43% v. 50%, P = 0.04; adjusted odds ratio [OR] = 0.68, P = 0.008). A replication study (N = 714) confirmed that participants who viewed survival-only graphs had higher graph evaluation ratings (x = 8.06 v. 7.72, P = 0.04) and reduced interest in chemotherapy (OR=0.67,P=0.03). Limitations. Studies used general public samples; actual patients may process risk information differently. Conclusions. Taking a "less is more" approach by omitting redundant mortality outcome statistics can be an effective method of risk communication and may be preferable when using visual formats such as pictographs.


Zikmund-Fisher B.J.,University of Michigan | Zikmund-Fisher B.J.,Center for Behavioral and Decision science in Medicine | Fagerlin A.,University of Michigan | Fagerlin A.,Center for Behavioral and Decision science in Medicine | And 4 more authors.
Patient Education and Counseling | Year: 2010

Objective: Emotion plays a strong role in the perception of risk information but is frequently underemphasized in the decision-making and communication literature. We sought to discuss and put into context several lines of research that have explored the links between emotion and risk perceptions. Methods: In this article, we provide a focused, " state of the science" review of research revealing the ways that emotion, or affect, influences people's cancer-related decisions. We identify illustrative experimental research studies that demonstrate the role of affect in people's estimates of cancer risk, their decisions between different cancer treatments, their perceptions of the chance of cancer recurrence, and their reactions to different methods of presenting risk information. Results: These studies show that people have strong affective reactions to cancer risk information and that the way risk information is presented often determines the emotional gist people take away from such communications. Conclusion: Cancer researchers, educators and oncologists need to be aware that emotions are often more influential in decision making about cancer treatments and prevention behaviors than factual knowledge is. Practice implications: Anticipating and assessing affective reactions is an essential step in the evaluation and improvement of cancer risk communications. © 2010 Elsevier Ireland Ltd.


Zikmund-Fisher B.J.,VA Ann Arbor Healthcare System | 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 13 more authors.
Medical Decision Making | Year: 2010

Background. Patient involvement is required before patients' preferences can be reflected in the medical care they receive. Furthermore, patients are a vital link between physicians' assessments of patients' needs and actual implementation of appropriate care. Yet no study has specifically examined how and when a representative sample of patients considered, discussed, and made medical decisions. Objective. To identify decision prevalence and decision-making processes regarding 1) initiation of prescription medications for hypertension, hypercholesterolemia, or depression; 2) screening tests for colorectal, breast, or prostate cancer; and 3) surgeries for knee or hip replacement, cataracts, or lower back pain. Design. Computer-assisted telephone interview survey. Setting. Nationally representative sample of US adults in households with telephones. Participants. 3010 English-speaking adults age 40 and older identified using a stratified random sample of telephone numbers. Measurements. Estimated prevalence of medical decisions, defined as the patient having initiated medications, been screened, or had surgery within the past 2 years or having discussed these actions with a health care provider during the same interval, as well as decision-specific data regarding patient knowledge, attitudes and patient-provider interactions. Results. 82.2% of the target population reported making at least 1 medical decision in the preceding 2 years. The proportion of decisions resulting in patient action varied dramatically both across decision type (medications [61%] v. screening [83%] v. surgery [44%]; P < 0.001), and within each category (e.g., blood pressure medications [76%] v. cholesterol medications [55%] vs. depression medications [48%]; P < 0.001). Respondents reported making more decisions if they had a primary care provider or poorer health status and fewer decisions if they had lower education, were male, or were under age 50. Limitations. Retrospective self-reports may incorporate recall biases. Conclusions. Medical decisions with significant life-saving, quality of life, and cost implications are a pervasive part of life for most US adults. The DECISIONS dataset provides a rich research environment for exploring factors influencing when and how patients make common medical decisions.

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