Communicating Numbers Communicating Numbers to Ensure Patient-Provider to Ensure Patient-Provider

Partnership DecisionsPartnership Decisions

Health numeracy-Health numeracy-Communicating evidence to the patientCommunicating evidence to the patient

David L. Hahn, M.D., M.S. David L. Hahn, M.D., M.S.

Director, Wisconsin Research and Education Network (WREN)Director, Wisconsin Research and Education Network (WREN)

Department of Family MedicineDepartment of Family Medicine

University of Wisconsin School of Medicine and Public HealthUniversity of Wisconsin School of Medicine and Public Health

DFM Faculty Development 2015

DisclosuresDisclosures

I have no conflicts of interest to discloseI have no conflicts of interest to disclose

ObjectivesObjectives

Review concepts and processes of shared Review concepts and processes of shared decision making (SDM)decision making (SDM)

Discuss the fundamental importance of Discuss the fundamental importance of quantifiable information to the SDM quantifiable information to the SDM process, including its uses and abuses.process, including its uses and abuses.

Present examples from the cancer Present examples from the cancer screening and treatment environment.screening and treatment environment.

To clarifyTo clarify

Risk assessment TOOLSRisk assessment TOOLS Patient Decision AIDSPatient Decision AIDS Shared decision making PROCESSShared decision making PROCESS

Medical decision makingMedical decision makingThen and NowThen and Now

Carling et al. PLoS Medicine 2009 Carling et al. PLoS Medicine 2009

Shared decision making (SDM) Shared decision making (SDM) ProcessProcess

Légaré et al. Cochrane Database of Systematic Reviews 2014

A process by which a healthcare choice is made jointly by the practitioner and the patient, and is said to be the crux of patient-centered care.

SDM ProcessSDM Process

Légaré et al. Cochrane Database of Systematic Reviews 2014

AHRQ Approach to SDMAHRQ Approach to SDM

http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/

SDM exists within a continuum of SDM exists within a continuum of patient-doctor relationshipspatient-doctor relationships

The Paternalism <--> Autonomy spectrumThe Paternalism <--> Autonomy spectrum What is the patient expectation?What is the patient expectation? Communication approaches may change Communication approaches may change

over time (even within the same visit)over time (even within the same visit)

McNutt JAMA 2004 McNutt JAMA 2004

Shared decision-making Shared decision-making really does not pertain to really does not pertain to sharing choices, but sharing choices, but rather involves sharing rather involves sharing information.information.

McNutt JAMA 2004 McNutt JAMA 2004

… … physicians should ensure physicians should ensure that that the information that that the information used in the patientused in the patient’’s s decision-making is decision-making is reasonable for the reasonable for the individual patient and that individual patient and that the patient understands the the patient understands the ramifications of choice.ramifications of choice.

McNutt JAMA 2004 McNutt JAMA 2004

A choice is made after A choice is made after reflecting on the reflecting on the numericnumeric estimates of benefit and estimates of benefit and harm. harm. Numbers alone may Numbers alone may fall short of being a fall short of being a language for decision language for decision making, but are a making, but are a necessary place to startnecessary place to start..

Eleven key components of Eleven key components of numerical communicationnumerical communication

Presenting the chance an event will occurPresenting the chance an event will occur Presenting changes in numeric outcomesPresenting changes in numeric outcomes Outcome estimates for test and screening Outcome estimates for test and screening

decisionsdecisions Numeric estimates in context and with Numeric estimates in context and with

evaluative labelsevaluative labels Conveying uncertaintyConveying uncertainty Visual formatsVisual formats

Trevena et al. Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers. BMC Medical Informatics and Decision Making 2013, 13(Suppl 2) 57 http://www.biomedcentral.com/1472-6947/13/52/57

Eleven key components of Eleven key components of numerical communicationnumerical communication

Tailoring estimatesTailoring estimates Formats for understanding outcomes over Formats for understanding outcomes over

timetime Narrative methods for conveying the chance Narrative methods for conveying the chance

of an eventof an event Important skills for understanding Important skills for understanding

numerical estimatesnumerical estimates Interactive web-based formatsInteractive web-based formats

Trevena et al. Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers. BMC Medical Informatics and Decision Making 2013, 13(Suppl 2) 57 http://www.biomedcentral.com/1472-6947/13/52/57

Quantifiable information:Quantifiable information:Uses and abusesUses and abuses

The WHAT - Patient-oriented v The WHAT - Patient-oriented v Disease-oriented OutcomesDisease-oriented Outcomes

The HOW - Informative v The HOW - Informative v Persuasive CommunicationPersuasive Communication

Patient-oriented v Disease-oriented Patient-oriented v Disease-oriented OutcomesOutcomes

Patient-oriented outcomesPatient-oriented outcomes– Outcomes that matter to patientsOutcomes that matter to patients and help them live and help them live

longer and better lives, including reduced morbidity, longer and better lives, including reduced morbidity, reduced mortality, symptom improvement, improved reduced mortality, symptom improvement, improved quality of life, or reduced costquality of life, or reduced cost

Strength of Recommendation Taxonomy (SORT)Strength of Recommendation Taxonomy (SORT)JABFP, JFP, AFP 2004JABFP, JFP, AFP 2004

Patient-oriented v Disease-oriented Patient-oriented v Disease-oriented OutcomesOutcomes

Disease-oriented outcomesDisease-oriented outcomes– These outcomes include These outcomes include intermediateintermediate, ,

histopathologic, physiologic, or histopathologic, physiologic, or surrogate resultssurrogate results (e.g., blood sugar, blood pressure, flow rate, coronary (e.g., blood sugar, blood pressure, flow rate, coronary plaque thickness) that may or may not reflect plaque thickness) that may or may not reflect improvement in patient outcomes.improvement in patient outcomes.

Strength of Recommendation Taxonomy (SORT)Strength of Recommendation Taxonomy (SORT)JABFP, JFP, AFP 2004JABFP, JFP, AFP 2004

Persuasive v Informative Persuasive v Informative CommunicationCommunication

Persuasive communicationPersuasive communication– Designed to influence and manipulateDesigned to influence and manipulate

Informative communicationInformative communication– Designed to inform and enhance Designed to inform and enhance

autonomyautonomy

Schwartz & Woloshin Eff Clin Pract 2001;4:76-79Schwartz & Woloshin Eff Clin Pract 2001;4:76-79

Which correct statement is more Which correct statement is more informative? more persuasive?informative? more persuasive?

1 in 8 women will get breast cancer1 in 8 women will get breast cancer In the next 10 years a 40 year old woman In the next 10 years a 40 year old woman

has a 2 in 1,000 chance of dying from has a 2 in 1,000 chance of dying from breast cancerbreast cancer

Woloshin et al. JNCI 2008Woloshin et al. JNCI 2008

Informative numerical communicationInformative numerical communicationPearlsPearls

Use natural frequencies over a defined time periodUse natural frequencies over a defined time period– E.g., E.g., ““ N per 1,000 over 10 years N per 1,000 over 10 years””

Compare optionsCompare options– E.g., Side-by-side discrete choicesE.g., Side-by-side discrete choices

Informative numerical communicationInformative numerical communicationPearlsPearls

Present all relevant benefits and harmsPresent all relevant benefits and harms– Using patient-oriented outcomesUsing patient-oriented outcomes

Use multiple formatsUse multiple formats– E.g., Text, Table, Graphic, VideoE.g., Text, Table, Graphic, Video

Frame in both positive and negative formatsFrame in both positive and negative formats– E.g., Survival and DeathE.g., Survival and Death

Why multiple formats?Why multiple formats?

People have different preferencesPeople have different preferences Descriptions of the anticipated outcomes may Descriptions of the anticipated outcomes may

influence patient willingness to accept a influence patient willingness to accept a recommended interventionrecommended intervention– Halvorsen et al. Different ways to describe the benefits Halvorsen et al. Different ways to describe the benefits

of risk-reducing treatments. A randomized trial. Annals of risk-reducing treatments. A randomized trial. Annals of Internal Medicine 2007;146:848-856of Internal Medicine 2007;146:848-856

Use with caution:Use with caution:

Numbers needed to treat (NNT)Numbers needed to treat (NNT) Numbers needed to harm (NNH)Numbers needed to harm (NNH)

– The are more useful for clinicians than for The are more useful for clinicians than for patientspatients

– May be helpful as secondary or illustrative May be helpful as secondary or illustrative examplesexamples

Use with extreme caution:Use with extreme caution:

Relative measures (unlinked to baseline)Relative measures (unlinked to baseline)– Percentages, Relative Risks, Odds ratiosPercentages, Relative Risks, Odds ratios

Appropriate for testing statistical Appropriate for testing statistical significancesignificance

Pictographs can illustrate the true meaning Pictographs can illustrate the true meaning of relative riskof relative risk

Relative risk: exampleRelative risk: example

A Newspaper Headline reads: A Newspaper Headline reads: ““Azithromycin Doubles the Risk of Azithromycin Doubles the Risk of Sudden Cardiovascular DeathSudden Cardiovascular Death””

Ray 2012 New Engl J MedRay 2012 New Engl J Med

Natural Frequencies: exampleNatural Frequencies: example

From 1 in 20,000 to 1 in 10,000From 1 in 20,000 to 1 in 10,000– 1 in 4000 for those at highest heart disease risk1 in 4000 for those at highest heart disease risk– Subsequent studies indicatedSubsequent studies indicated

No increased risk for the average healthy personNo increased risk for the average healthy person

Ray 2012 New Engl J MedRay 2012 New Engl J Med

Provide Sufficient ContextProvide Sufficient Context

This risk was already known for other This risk was already known for other macrolides (and some quinolones)macrolides (and some quinolones)

Compare to other common risksCompare to other common risks– Fatal motor vehicle accidents in 2006Fatal motor vehicle accidents in 2006

1 in 7500 cars1 in 7500 cars 1 in 1400 motorcycles1 in 1400 motorcycles

ExamplesExamples

TablesTables TextText PictographsPictographs

Tabular format exampleTabular format example

Hahn DL. J Fam Pract 2007Hahn DL. J Fam Pract 2007

Some people Some people preferred this preferred this tabular formattabular format

Pictograph formatsPictograph formats

Adjuvant chemotherapy for breast cancerAdjuvant chemotherapy for breast cancer

adjuvantonline.comadjuvantonline.com

Adjuvant chemotherapy for breast cancerAdjuvant chemotherapy for breast cancer

cbssm.orgcbssm.org

“Two simple changes, displaying only risk information related to treatment options that included hormonal therapy...and using pictographs instead of horizontal bars, resulted in significant improvements in both comprehension accuracy and speed of use.....”

cbssm.orgcbssm.org

Pictograph format example:Pictograph format example:MammographyMammography

One-Page SummaryOne-Page Summary Express that virtually all interventions have benefits AND Express that virtually all interventions have benefits AND

risksrisks Use numbers, not just words, to quantify theseUse numbers, not just words, to quantify these Balance the frame (e.g. survival AND death)Balance the frame (e.g. survival AND death) Clear reference class (who does the risk refer to?)Clear reference class (who does the risk refer to?) Use natural frequencies and a consistent denominatorUse natural frequencies and a consistent denominator Use visual aidsUse visual aids Explore the significance of the risk(s) and benefit(s) to the Explore the significance of the risk(s) and benefit(s) to the

individualindividual Share uncertaintyShare uncertainty

Naik G et al. Communicating risk to patients and the public. Br J Gen Pract 2012; 62:213-6

Decision Aids - Where can I find them?Decision Aids - Where can I find them?

Informed Medical Decisions Foundation Informed Medical Decisions Foundation (IMDF)(IMDF)– http://informedmedicaldecisions.org/shared-decision-http://informedmedicaldecisions.org/shared-decision-

making-in-practice/decision-aids/making-in-practice/decision-aids/

Ottawa Hospital Research Institute (OHRI)Ottawa Hospital Research Institute (OHRI)– http://decisionaid.ohri.ca/index.htmlhttp://decisionaid.ohri.ca/index.html

Development ToolkitDevelopment Toolkit Decision Aid Library and StandardsDecision Aid Library and Standards

– International Decision Aids Standards (IPDAS) CollaborationInternational Decision Aids Standards (IPDAS) Collaboration Implementation ToolkitImplementation Toolkit Online TutorialOnline Tutorial

Questions?Questions?