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Different Ways to Describe the Benefits of Risk-Reducing Treatments: A Randomized Trial

Peder A. Halvorsen, MD; Randi Selmer, PhD; and Ivar Sønbø Kristiansen, MD, PhD, MPH
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From the University of Southern Denmark, Odense, Denmark; University of Tromsø, Tromsø, Norway; and Norwegian Institute of Public Health and University of Oslo, Oslo, Norway.


Acknowledgments: The authors thank Arthur Elstein, Dorte Gyrd-Hansen, Jørgen Nexøe, and Henrik Støvring for comments on the paper. The authors also thank the residents of Finnmark, Norway, for their willingness to contribute to the study and the Norwegian Institute of Public Health for conducting the practical part of the data collection.

Grant Support: By governmental funds held by the University of Tromsø, Tromsø, Norway.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Peder A. Halvorsen, MD, Nordlys Legesenter, N-9509 Alta, Norway; e-mail, phalvor@online.no.

Current Author Addresses: Dr. Halvorsen: Nordlys Legesenter, N-9509 Alta, Norway.

Dr. Selmer: Division of Epidemiology, Norwegian Institute of Public Health, PO Box 4404, Nydalen, N-0403 Oslo, Norway.

Dr. Kristiansen: Institute of Health Management and Health Economics, University of Oslo, PO Box 1089, Blindern, N-0317 Oslo, Norway.

Author Contributions: Conception and design: P.A. Halvorsen, R. Selmer, I.S. Kristiansen.

Analysis and interpretation of the data: P.A. Halvorsen, I.S. Kristiansen.

Drafting of the article: P.A. Halvorsen, I.S. Kristiansen.

Critical revision of the article for important intellectual content: R. Selmer, I.S. Kristiansen.

Final approval of the article: P.A. Halvorsen, R. Selmer, I.S. Kristiansen.

Statistical expertise: R. Selmer.


Ann Intern Med. 2007;146(12):848-856. doi:10.7326/0003-4819-146-12-200706190-00006
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In this population-based survey, laypersons were more inclined to accept therapy to reduce the risk for heart attack or hip fracture when the benefit was presented as the NNT to prevent 1 adverse outcome than when presented as postponements of the outcome. The benefits described in all 3 scenarios were equivalent because we used the same clinical study to calculate them. Many respondents reported difficulty understanding the description of treatment benefit regardless of how we presented it, and such persons were less likely to consent to therapy. These findings are intriguing when placed in the context of informed consent, patient-directed choices, and shared decision making. Because assisting patients in decision making is a core element of the physician's work, knowing that decisions may be influenced by the words used to describe benefits, and perhaps harms, is important for clinical practice. The main body of empirical knowledge, however, stems from the field of experimental cognitive psychology.

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Figure 1.
Study flow diagram.

A total of 2754 attendees to a population-based health study were randomly assigned to hypothetical scenarios that presented the benefits of preventive drug therapies in terms of number needed to treat (NNT) or postponement of adverse events. Eligibility criteria were as follows: attended screening, consented to additional studies, were alive or did not emigrate between the time of the screening and the survey, and had a known address. Strategic allocation to the study groups by risk for cardiovascular disease (CVD) was done for other study purposes, and for similar reasons, the low-risk sample was selected so that the proportion of women was the same as that in the high-risk sample (14). We expected to enroll approximately 1000 persons in each risk group, but the number of high-risk persons was lower than expected.

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Figure 2.
The questionnaire for the heart attack group.

In each questionnaire, only 1 of the 3 versions of item Q1 (a, b, or c) was used. The respondents were randomly allocated to 1 version of the questionnaire only. We used similar scenarios with different numbers for the hip fracture questionnaire.

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Summary for Patients

Different Ways to Describe the Benefits of Risk-Reducing Treatments

The summary below is from the full report titled “Different Ways to Describe the Benefits of Risk-Reducing Treatments. A Randomized Trial.” It is in the 19 June 2007 issue of Annals of Internal Medicine (volume 146, pages 848-856). The authors are P.A. Halvorsen, R. Selmer, and I.S. Kristiansen.

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