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Visual aids may help patients better understand some USPSTF screening recommendations
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Previously unseen and persuasive vignettes helped study participants better understand the USPSTF’s 2012 recommendations on prostate cancer screening and 2009 recommendations on mammography screening, according to research recently published in Annals of Family Medicine.
“We have an obligation to help our patients make the best decisions for their health that we can. For preference-sensitive or controversial decisions, simply telling them what to do or even providing unbiased information, such as with many traditional decision aids, frequently fails to achieve that goal,” Barry G. Saver, MD, MPH, of the University of Massachusetts Medical School, Worchester, Mass., told Healio Family Medicine. “Everyone uses persuasive messages — look at some of the messages from advocacy groups — and persuasive approaches are needed to help de-bias patients and let them make less-biased, better informed decisions.”
Using principles formulated from preceding qualitative work and behavioral science literature as a guide, Saver and colleagues recorded videos and created slides of physician-patient discussions about prostate cancer screening and mammography. They then performed a randomized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years. All participants saw a video intervention and a more traditional, paper-based decision aid intervention in random order. At the beginning of the study and after seeing each intervention, participants were asked about screening intentions, perceptions of benefits and harm, and decisional conflict.
At baseline, 69% of men reported wanting screening and 31% were unsure; 86% of women reported wanting screening and 6% were unsure. Mean change on a 3-point, yes, unsure, no scale was –0.93 (P < .001) for men and –0.5 (P < .001) for women after seeing the video interventions vs. 0.0 and –0.06 (P = .75) after seeing the print interventions. When the study was completed, 33% of men and 49% of women wanted screening, and 11% of the men and 20% of the women were unsure.
“We feel our results show that we helped patients overcome their biases as screening preferences of substantial proportions of patients changed, with a majority of men not desiring screening and nearly half of women either unsure or not desiring screening. That is a substantial change in stated preferences that other cancer screening decision aids of which I am aware have not produced — typical is a modest increase in knowledge and little or no change in screening preferences,” Saver told Healio Family Medicine. “[Just] as important … by working iteratively with patients, grounding our work in behavioral science research about human decision-making rather than assuming as usual that just providing unbiased information would be sufficient, and paying attention to the processes that occurred in our focus groups as well as what people explicitly told us, we came up with an approach to helping patients overcome biases and preconceptions and consider evidence-based recommendations that might not agree with what they heretofore believed or intuitively seem like they must be true.”
The researchers wrote that any interventions should: Not confront a patient’s existing belief; outline harms and make it clear that benefits are smaller than most think; provide difficult information more than once with increasing details each time; and have the information come from a trusted professional to give the intervention credibility and encourage discussion. – by Janel Miller
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Otis W. Brawley, MD, MACP
The American public is exposed to many public messages supporting cancer screening. Many of these messages suggest that breast and prostate cancer screening is all good with no harm. In reality, screening has significant limitations and even some harms but there can be benefit. Weighing the benefits and harms can be complicated and made even more difficult by some substantial unknowns.
A principle of medical ethics is patient preference should be respected. Physicians have a responsibility to explain the pros and cons of these tests before they are performed. Informed decision-making has become the norm in cancer screening guidelines. This is difficult as there are time limitations in the physician-patient encounter. Saver and colleagues evaluate novel decision aids designed to help patients trust and accept the controversial, evidence-based, recommendations about prostate cancer and mammography screening.
This study shows that these aids do lead to some changing of opinion regarding consenting for screening. The study gives some insight into how one should inform and consent patients prior to screening. The observed change in patient opinion indicates that appropriate informed decision-making is vital to the practice of ethical evidence-based medicine.
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