Carling and colleagues carry out a trial evaluating different methods of communicating information to people regarding the risks and benefits of taking statins. They suggest that natural frequencies are likely to be the most appropriate summary statistic for presenting the effects of treatment.
While different ways of presenting treatment effects can affect health care decisions, little is known about which presentations best help people make decisions consistent with their own values. We compared six summary statistics for communicating coronary heart disease (CHD) risk reduction with statins: relative risk reduction and five absolute summary measures—absolute risk reduction, number needed to treat, event rates, tablets needed to take, and natural frequencies.
Methods and Findings
We conducted a randomized trial to determine which presentation resulted in choices most consistent with participants' values. We recruited adult volunteers who participated through an interactive Web site. Participants rated the relative importance of outcomes using visual analogue scales (VAS). We then randomized participants to one of the six summary statistics and asked them to choose whether to take statins based on this information. We calculated a relative importance score (RIS) by subtracting the VAS scores for the downsides of taking statins from the VAS score for CHD. We used logistic regression to determine the association between participants' RIS and their choice. 2,978 participants completed the study. Relative risk reduction resulted in a 21% higher probability of choosing to take statins over all values of RIS compared to the absolute summary statistics. This corresponds to a number needed to treat (NNT) of 5; i.e., for every five participants shown the relative risk reduction one additional participant chose to take statins, compared to the other summary statistics. There were no significant differences among the absolute summary statistics in the association between RIS and participants' decisions whether to take statins. Natural frequencies were best understood (86% reported they understood them well or very well), and participants were most satisfied with this information.
Presenting the benefits of taking statins as a relative risk reduction increases the likelihood of people accepting treatment compared to presenting absolute summary statistics, independent of the relative importance they attach to the consequences. Natural frequencies may be the most suitable summary statistic for presenting treatment effects, based on self-reported preference, understanding of and satisfaction with the information, and confidence in the decision.
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Please see later in the article for the Editors' Summary
People often have to make decisions about their health care. Ideally, all the health care decisions that a person makes should be those best suited to his or her personal circumstances and expectations. Take, for example, someone with a high amount of cholesterol (a type of fat) in his or her blood. Because this condition increases the chances of developing potentially fatal coronary heart disease (CHD), such a person will often be advised by his or her doctor to take statins to reduce blood cholesterol levels. However, the person needs to consider both the benefits and downsides of this course of action. Can he or she afford to pay for statins, if their health care system requires him or her to? Does the person want to take a pill every day that might cause some side effects? That is, the person has to consider his or her “values”—the relative desirability of all the possible outcomes of taking statins—before deciding whether to follow his or her doctor's advice.
Why Was This Study Done?
It is well known that how information is presented to patients about treatment options and their consequences affects the choices that they make. For example, patients who are told that a drug will halve their chances of developing a disease (a 50% relative risk reduction) are more likely to decide to take that drug than those who are told it will reduce their absolute (actual) risk of developing the disease from 4% to 2%. Less is known, however, about which presentations of treatment effects best help people to make decisions that are consistent with their own values. In 2002, therefore, a series of internet-based randomized trials (studies in which participants are randomly allocated to different “treatment” groups) called the Health Information Project: Presentation Online (HIPPO) was initiated. Here, the researchers describe HIPPO 2, a trial that investigates how alternative summary statistics for communicating the reduction of CHD risk with statins affect people's decisions to take statins.
What Did the Researchers Do and Find?
Nearly 3,000 adults in Norway and North America rated the relative importance to them of CHD risk reduction, the cost of statins, and the need to take a daily pill through an interactive Web site. The researchers used these data to calculate a “relative importance score” (RIS), an indicator of each participant's values. Each participant then decided whether or not to take statins after being shown one of six summary statistics about the effect of statins on CHD risk (relative risk reduction and five indicators of absolute risk reduction). The presentation of the effect of statins as a relative risk reduction resulted in more people deciding to take statins over the whole RIS range than any of the absolute summary statistics. For every five participants shown the relative risk reduction statistic, an extra participant chose to take statins compared to the other summary statistics. When asked to compare the six summary statistics, the statistic that most people preferred and understood best was the “natural frequency,” an absolute summary statistic that gave the number of people likely to develop CHD with and without statin treatment.
What Do These Findings Mean?
Although these findings may not be generalizable to other populations or to other medical decisions, they provide new insights into how the presentation of information can affect the choices people make about health care. Specifically, these findings indicate that the presentation of the reduced risk of getting CHD as a result of taking stains as a relative amount is more likely to persuade people to take statins than several absolute summary statistics. They also suggest that the persuasive effect of the relative risk reduction summary statistic is not affected by the relative importance attached to the consequences of taking statins by individuals. That is, people shown the relative risk reduction statistic may be more likely to start statins to reduce their CHD risk (or a drug that reduces the risk of developing another disease) whatever their personal values than people shown absolute summary statistics. Finally, the findings on participant preferences suggest that natural frequencies may be the best summary statistic to include in tools designed to help people make decisions about their healthcare.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000134.
A PLoS Medicine Editorial discusses this trial and the results of another HIPPO trial that are presented in a separate PLoS Medicine Research Article by Carling and colleagues; details of a pilot HIPPO trial are also available
The Foundation for Informed Medical Decision Making (a US-based non-profit organization) provides information on many aspects of medical decision making
The Dartmouth-Hitchcock Medical Center provides information to help people make health care decisions through its Center for Shared Decision Making
The Ottawa Hospital Research Institute provides also information on patient decision aids, including an inventory of decision aids available on the Web (in English and French)
MedlinePlus provides links to information and advice about statins and about coronary heart disease (in English and Spanish)