Daniella A. Zipkin, MD; Craig A. Umscheid, MD, MS; Nancy L. Keating, MD, MPH; Elizabeth Allen, MD; KoKo Aung, MD, MPH; Rebecca Beyth, MD, MSc; Scott Kaatz, DO, MSc; Devin M. Mann, MD, MS; Jeremy B. Sussman, MD, MS; Deborah Korenstein, MD; Connie Schardt, MLS; Avishek Nagi, MS; Richard Sloane, MPH; David A. Feldstein, MD
Note: This review was performed by the Society of General Internal Medicine's Evidence-Based Medicine Task Force to inform the development of the Bottom Line evidence summaries available in the Web-only section of the Journal of General Internal Medicine. The Bottom Line evidence summaries are single-page tools that distill current, high-effect research findings for health care providers to facilitate patient discussions. Each summary addresses new evidence relevant to general internal medicine that has been covered in the media and may affect patient care. Summaries visually present key information about the potential benefits and harms of a test or treatment along with a clinical “bottom line” recommendation. They are designed to foster clearer and more accurate communication between patients and their doctors while enhancing patient understanding and satisfaction. To learn more about the Bottom Line evidence summaries, visit www.sgim.org/web-only/bottom-line.
Acknowledgment: The authors thank John Williams, MD, and Eugene Oddone, MD, for conceptual and logistic support and Patricia Duren for assistance with graphic design.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0295.
Requests for Single Reprints: Daniella A. Zipkin, MD, Duke University Medical Center, Box 2992, Durham, NC 27710; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Zipkin: Duke University Medical Center, Box 2992, Durham, NC 27710.
Dr. Umscheid: Center for Evidence-based Practice, University of Pennsylvania, 3535 Market Street, Mezzanine, Suite 50, Philadelphia, PA 19104.
Dr. Keating: Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115.
Dr. Allen: Portland Veterans Affairs Medical Center, P3-Med, 3710 SW US Veterans Hospital Road, Portland, OR 97207.
Dr. Aung: University of Texas Health Science Center, 7703 Floyd Curl Drive, MC 7879, San Antonio, TX 78229.
Dr. Beyth: North Florida/South Georgia Veterans Health System Geriatric Research Education and Clinical Centers T2 (182), 1601 Southwest Archer Road, Gainesville, FL 32608.
Dr. Kaatz: Hurley Medical Center, One Hurley Plaza, Flint, MI 48503.
Dr. Mann: Boston University School of Medicine, 801 Massachusetts Avenue, Suite 470, Boston, MA 02118.
Dr. Sussman: Center for Clinical Management Research, North Campus Research Center, 2800 Plymouth Road, Building 16/343E, Ann Arbor, MI 48109-2800.
Dr. Korenstein: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Ms. Schardt: School of Library & Information Science, Manning Hall, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599.
Mr. Nagi: Veterans Affairs Medical Center, 508 Fulton Street, Durham, NC 27705.
Mr. Sloane: Center for the Study of Aging, Duke University Medical Center, Box 3003, Durham, NC 27710.
Dr. Feldstein: University of Wisconsin School of Medicine and Public Health, 310 North Midvale Boulevard, Suite 205, Madison, WI 53705.
Author Contributions: Conception and design: D.A. Zipkin, C.A. Umscheid, N.L. Keating, E. Allen, S. Kaatz, D.M. Mann, J.B. Sussman, D. Korenstein, D.A. Feldstein.
Analysis and interpretation of the data: D.A. Zipkin, C.A. Umscheid, N.L. Keating, E. Allen, K. Aung, R. Beyth, S. Kaatz, D.M. Mann, J.B. Sussman, R. Sloane, D.A. Feldstein.
Drafting of the article: D.A. Zipkin.
Critical revision of the article for important intellectual content: D.A. Zipkin, C.A. Umscheid, N.L. Keating, E. Allen, K. Aung, R. Beyth, S. Kaatz, D.M. Mann, J.B. Sussman, D. Korenstein, R. Sloane, D.A. Feldstein.
Final approval of the article: D.A. Zipkin, C.A. Umscheid, N.L. Keating, E. Allen, K. Aung, R. Beyth, S. Kaatz, D.M. Mann, J.B. Sussman, D. Korenstein.
Statistical expertise: J.B. Sussman, R. Sloane.
Administrative, technical, or logistic support: C. Schardt, A. Nagi.
Collection and assembly of data: D.A. Zipkin, C.A. Umscheid, N.L. Keating, E. Allen, K. Aung, R. Beyth, S. Kaatz, D.M. Mann, D. Korenstein, D.A. Feldstein.
Effective communication of risks and benefits to patients is critical for shared decision making.
To review the comparative effectiveness of methods of communicating probabilistic information to patients that maximize their cognitive and behavioral outcomes.
PubMed (1966 to March 2014) and CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials (1966 to December 2011) using several keywords and structured terms.
Prospective or cross-sectional studies that recruited patients or healthy volunteers and compared any method of communicating probabilistic information with another method.
Two independent reviewers extracted study characteristics and assessed risk of bias.
Eighty-four articles, representing 91 unique studies, evaluated various methods of numerical and visual risk display across several risk scenarios and with diverse outcome measures. Studies showed that visual aids (icon arrays and bar graphs) improved patients’ understanding and satisfaction. Presentations including absolute risk reductions were better than those including relative risk reductions for maximizing accuracy and seemed less likely than presentations with relative risk reductions to influence decisions to accept therapy. The presentation of numbers needed to treat reduced understanding. Comparative effects of presentations of frequencies (such as 1 in 5) versus event rates (percentages, such as 20%) were inconclusive.
Most studies were small and highly variable in terms of setting, context, and methods of administering interventions.
Visual aids and absolute risk formats can improve patients’ understanding of probabilistic information, whereas numbers needed to treat can lessen their understanding. Due to study heterogeneity, the superiority of any single method for conveying probabilistic information is not established, but there are several good options to help clinicians communicate with patients.
Zipkin DA, Umscheid CA, Keating NL, Allen E, Aung K, Beyth R, et al. Evidence-Based Risk Communication: A Systematic Review. Ann Intern Med. ;161:270–280. doi: 10.7326/M14-0295
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Published: Ann Intern Med. 2014;161(4):270-280.
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