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03/06/2012: Three Questions Patients Should Ask To Improve the Information They Receive

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Evidence-based Information & Decision Aid Examples for Health Care Professionals & Patients—Putting Everyone on the Same Page

Patient-centered Resources: Doctor-Patient Communications

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Not all clinical recommendations from other sources have been reviewed for validity and ours may or may not be uptodate, so selections below should be viewed as representing examples of approaches and formats for communications, etc. Feel free to contact us for details. Read our Health Care Information Source Cautions at Notices.

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Physician Communications with Patients — Information & Engagement: The Evidence
Observational studies show associations between physician behaviors and patient outcomes –

  • Health outcomes
  • Emotional well-being
  • Symptom resolution (e.g., pain control, well-being)
  • Improved functioning
  • Physiologic measures (e.g., glucose control, BP control)
  • Health care outcomes (e.g., adherence, comprehension, rapport, patient recall)
  • Satisfaction

The strongest association for improved patient outcomes with physician behavior is for providing information to patients.  Numerous studies have showed a statistically significant association between providing information and satisfaction, symptom improvement,  trust, comprehension, adherence.

We especially like these studies:

Stewart MA. Effective Physician-Patient Communication and Health Outcomes: A Review Abstract

Hall JA; Roter DL; Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Medical Care;1988, 26:657-675. PMID: 3292851. Abstract.

Beck RS, Daughtridge R, Sloane PD. Physician-Patient Communication in the Primary Care Office: A Systematic Review. JABFP 2002. 15:25-38. The Journal of the American Board of Family Practice. PMID: 11841136. Abstract.

Here's our critical appraisal of their review: Beck

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Communications with Patients — A Clinician-centered "Map" for Information & Engagement
Patient Information & Engagement Encounter Map — communication tool. Direct help for physicians and others who directly engage with patients to provide information, decision and action-oriented information, especially during clinical encounters. [WORD]

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Discussing Information and Decisions with Patients
Say and Thomson do a nice job summarizing challenges doctors may face moving toward greater involvement of patients in treatment decisions. These challenges include —

  • Doctors' perceptions that they do not have enough time to involve the patient and elicit values and preferences — yet research suggests there may be no significant effect on time, plus time might be saved ultimately.
  • Doctors often misperceive what patients want, underestimating the desire for information and overestimating the desire to be involved in decision making. When in doubt, give more information.
  • People do not retain information — this is true! Studies show huge variation in recall. One study showed that 38% of patients who were verbally counseled could not recall their diagnosis. (Ellis DA, Hopkin JM, Leitch AG, et al. "Doctors' orders": controlled trial of supplementary, written information for patients. BMJ 1979;1:456.) Clearly written communications can help patients. Communications customized to their individual circumstances are preferable.
  • There is a lack of helpful information — often this is true. Collect useful information and ways to communicate that information as you come across it.
  • Physician lack of understanding that they can present information in ways that will influence treatment choice. True! Plus doctors often do not understand measures of outcome sufficiently, which research shows can influence their treatment choices as well. (See here to see more information on measures of outcomes and why Relative Risk Reduction is so misleading. Relative Risk Reduction always overestimates benefit!)

    We advocate a balanced presentation. Examples: For patients at risk — baseline risk information + ARR + NNT converted to a rate + NNH. For patients facing treatment choices — ARR + NNT converted to a rate + NNH. Convey relative risk only with this kind of more absolute information. Communicate both sides of the coin — survival + mortality, as examples, for glass half-empty and half-full perspective. Avoid language such as "rare," "sometimes," or "frequently" as these terms will be interpreted differently by different people.

    NNT converted to a rate is more understandable to patients who may misperceive the larger number of NNT as better when it is not. To learn how to convert NNT to a rate, see how to quantify information at our Delfini
    Rx Messaging Scripts TM page by clicking here.
  • Physician difficulty dealing with unreasonable expectations of patients. We suggest that, after counseling a patient, ask them to express their hopes and expectations for what might happen for different choices to learn about their expectations and understandings.
  • And more. Link to the full article is below.

Say R, Thomson R.
The importance of patient preferences in treatment decisions — challenges for doctors.

BMJ. 2003 Sep 6;327(7414):542-5 Full text.

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Three Questions Patients Should Ask To Improve the Information They Receive


According to Shepherd  et al [1], the following questions appear to be powerful catalysts for good information exchanges between clinicians and patients:


1. “What are my options?”

2. “What are the benefits and harms of each?”

3. “How likely are the benefits and harms?"


Let’s start with Shepherd’s cross-over trial using the three questions above.[1]  In order to make informed decisions and improve outcomes, patients need reliable information about benefits and risks of the various options.  In this randomized cross-over trial, Shepherd et al. used two standardized patients with identical symptoms— one patient asked the three questions (and also about doing nothing if the physician did not mention this option), the other did not. The patient presented as an otherwise healthy divorced middle-aged female with one prior undiagnosed episode of depression and 3 months of worsening moderate symptoms of depression. Depression was chosen as the condition because evidence is available and patients express differences in preference for treatment. The authors found that the 3 questions were associated with greater provision of information and behavior supporting patient involvement without extending appointment time.


Stiggelbout et al. remind us that shared decision-making (SDM) should be routinely employed to ensure patient autonomy, beneficence (balancing risks and benefits), non-malfeasance (avoiding harm) and justice (patients frequently decline procedures when adequate information has been provided and this may result in improved sharing of limited resources).[2] Pamphlets, videos, tools of various sorts may be employed to facilitate SDM. Tactics and tools that appear to increase SDM include—

  • Creating awareness of equipoise (there is no best choice but a decision must be made—even if it is to do nothing);
  • Presenting or encouraging patients to ask about options and benefits and risks of each option;
  • Use of graphical displays to present risks;
  • Use absolute risk information such as the number of similar patients/100 or number/1000 who will benefit*;
  • Encouraging patients to pay attention to their preferences;
  • Provide appropriate support to help patients make decisions—respect the patient’s preference about his or her role—independent, shared or delegated decision-making role.

*We would add that this information is only useful when also providing information  that provides a more complete picture.  To hear that one’s chance of benefiting from an intervention is 5 out of a hundred has a very different meaning depending upon the specific context:

  • Scenario 1: Out of 100 patients, 10 taking drug A improved as compared to 5 taking placebo, versus—
  • Scenario 2: Out of 100 patients, 90 taking drug A improved as compared to 95 taking placebo.

Examples of decision-aids are available from the following:



Delfini Comment: “Patient demand,”  i.e., activating patients to voice their information needs, has been proposed as a method of improving healthcare consultations for several decades. In our experience, educational programs aimed at increasing the use of evidence-based information sharing with patients has been hampered by clinicians frequently not possessing accurate answers to the three questions studied here. The two studies discussed above [3,4] indicate  that patient-mediated approaches may be at least part of the answer to improved clinical decision-making. 



1. Shepherd HL et al. Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial. Patient Educ Couns. 2011 Sep;84(3):379-85. Epub 2011 Aug 9.PubMed PMID: 21831558.


2. Stiggelbout AM et al.  Shared decision making: really putting patients at the centre of healthcare. BMJ. 2012 Jan 27;344:e256. doi: 10.1136/bmj.e256. PubMed PMID:22286508.


3. Bell RA et al. Encouraging patients with depressive symptoms to seek care: a mixed methods approach to message development. Patient Educ Couns. 2010 Feb;78(2):198-205. Epub 2009 Aug 11. PubMed PMID: 19674862.


4. Kravitz RL et al. Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005 Apr 27;293(16):1995-2002. Erratum in: JAMA. 2005 Nov 16;294(19):2436. PubMed PMID: 15855433; PubMed Central PMCID: PMC3155410.


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Effects of Decision Aids for Menorrhagia on Treatment Choices, Health Outcomes, and Costs
A major goal of evidence-based medicine is to inform decisions. Patient decision aids are one way to “package” valid and useable evidence to help patients — 

  • Clarify values
  • Clarify preferences
  • Understand outcomes they can expect with various choices
  • Make treatment choices

This RCT (JAMA. 2002;288:2701-2708) reports that information alone did not affect treatment choices for menorrhagia when compared to usual care, but that adding the engagement of a physician did. Also, costs were reduced when decision-aids and a clinician interview were utilized. Enter PMID number in search window at www.pubmed.gov to read the abstract.

Kennedy AD, Sculpher MJ, Coulter A, Dwyer N, Rees M, Abrams KR, Horsley S, Cowley D, Kidson C, Kirwin C, Naish C, Stirrat G. Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: a randomized controlled trial. JAMA. 2002 Dec 4;288(21):2701-8. Erratum in: JAMA. 2003 Feb
12;289(6):703.. PubMed PMID: 12460093.

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Potential Value of Patient Decision Aids
From a Cochrane review of 34 RCTs on use of decision aids:

  • Impact was “…remarkable…” and consistent among private vs public health systems
  • Rates of most invasive surgical procedures (hysterectomy, mastectomy, prostatectomy, discectomy, CABG) declined by 23% (95%CI 10% - 30%) “in favour of more conservative surgical or medical options, without adversely affecting patients’ health outcomes, satisfaction, or anxiety.”

O’Connor A et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2003;(2):CD001431

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Messaging Scripts for Implementing Clinical Practice Change: Osteoporosis Example

For several years we have suggested that QI staff consider the use of messaging scripts — targeted treatment messaging & decision support tools for specific clinical topics. In brief, messaging scripts can be used for a variety of purposes.

Some examples —
1. Information and decision aids for clinicians, pharmacists and nurses;
2. Scripts for academic detailing;
3. Customized chart-based advisements from pharmacists to clinicians;
4. Information, decision & action aids for patients.

Although their approach differs from ours by including endorsements from opinion leaders rather than evidence statements with references, a Canadian group from Alberta has reported in CMAJ impressive results in creating clinical change using “messages,” also referred to as “guidelines” as part of a multifaceted intervention to improve care.

The study was a double-blind, randomized clinical trial of patients older than 50 seen in the emergency room with an acute wrist fracture. 137 patients were randomized to the control group and 135 patients to the intervention group with concealed allocation, blinded assessment and ITT analysis.

The control group received a copy of the Osteoporosis Canada pamphlet with encouragement to read it and discuss it with their respective primary care physicians.
Physicians of control patients were routinely notified that their patients had been treated for a wrist fracture in the emergency department and were informed of follow-up plans and appointments.

In the intervention arm, messages were mailed or faxed to physicians and written along with verbal messages, and “printed materials” were delivered to patients by an experienced registered nurse. The messages sent to physicians were endorsed by 5 local opinion leaders.

The messages and guidelines are available at http://www.cmaj.ca/cgi/content/full/178/5/569/DC2.

The primary outcome was starting treatment with a bisphosphonate within 6 months after the fracture. This outcome was determined by patient self-report and was confirmed through dispensing records of local community pharmacies. There was 100% agreement between self-reporting and dispensing records.

Secondary outcomes included bone mineral density testing, “appropriate care” (consisting of bone mineral density testing with treatment if bone mass was low) and quality of life.

Six months after the fracture, 30 (22%) of the 137 intervention patients, as compared with 10 (7%) of the 135 controls, had achieved the primary study outcome of bisphosphonate treatment for osteoporosis (unadjusted RR 3.0; adjusted RR 2.6, 95% CI 1.3–5.1, p = 0.008). Absolute increase in bisphosphonate treatment was 15%, NNT=7. The authors state that, “overall, the intervention led to a 27% absolute increase in the delivery of guideline-concordant (“appropriate”) care, which translates into an NNT of 4 patients.”

This study was well-designed and conducted (Grade B to B-U evidence). The intervention utilized opinion leaders, counseling of patients by a nurse and concise decision support for physicians and patients. The intervention was not costly.

To summarize our preferences for messaging scripts — they are —

  • Concise, text table-based;
  • Patient-centered and customizable to individual patient, caretaker or clinician;
  • Evidence-based with short evidence statements plus key references;
  • Informative and quantitative
    • Present quantified information on baseline risk, benefits and harms in natural language and in ways research suggests may be most easily understood
    • Inform about the benefits and harms of relevant choices, including no treatment;
  • Flexible – can add dosing info, cost info, patient preferences, value considerations, action steps, etc. to customize to topic and need;
  • Utility oriented
    • Help prepare for academic detailing and for preparation of information, decision and action aids.

More details and templates ( Delfini Rx Messaging Scripts ™) can be found on the Delfini website at http://www.delfini.org/page_SamePage_RxMessagingScripts.htm

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Screening and Decision Aids
Cochrane has done a nice systematic review of decision aids. A useful addition to this information appears in the BMJ (BMJ 2004;329:507-510.). The article points out that:

  • Both public (and professional) understanding of the drawbacks of screening is limited.
  • Public attitude is that early detection and/or prevention must be good if a test exists.
  • Screening leads to over-detection and over-treatment.
  • False positives: Decision aids dealing with screening need to include information on detection of inconsequential disease and about the risks of the full range of investigations and treatments (frequently invasive and risky) which may occur if results are abnormal.
  • Individual values and preferences are critical to screening decision making.
  • There may be strong financial and other incentives to get people to participate in screening.

Widespread uncritical support for screening is a major problem and this article provides valuable information and guidance.

Use of decision aids to support informed choices about screening.

BMJ. 2004 Aug 28;329(7464):507-10
Barratt A, Trevena L, Davey HM, McCaffery K.
Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, NSW 2006, Australia. alexb@health.usyd.edu.au

PMID: 15331483

Full text available at: http://bmj.bmjjournals.com/cgi/content/full/329/7464/507

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Strategies for Increasing Adherence
Many studies report that adherence rates for prescribed medications are about 50% (although the range is 0 to greater than 100%). If we believe that certain treatments improve health care outcomes, then it becomes worthwhile to monitor the evidence about which interventions are effective in improving adherence.

Unfortunately the evidence is weak, and the answer does not appear simple. More evidence is needed.

It does appear that about half the studied interventions are associated with statistically significant medication adherence and fewer are associated with improvements in treatment outcomes. For long-term care, adherence appears to be increased by utilizing a combination of strategies. This is in keeping with the evidence regarding successful implementation of clinical guidelines.

Strategies to keep in mind include:

  • Making care more convenient
  • Reminders
  • Reinforcement,
  • Engaging patients by stressing the importance of adherence and working with them to develop personalized strategies

This systematic review of this topic can be found in JAMA.

JAMA 2002 Dec 11;288(22):2868-79
Interventions to enhance patient adherence to medication prescriptions: scientific review.
McDonald HP, Garg AX, Haynes RB.
Health Research Methodology Program, McMaster University School of Graduate Studies, Hamilton, Ontario, Canada. PMID: 15139471. Abstract

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The Resourceful Patient
Both patient and physician roles are changing dramatically because of information. What are the patient and physician responsibilities for obtaining valid information? Where will we go in the future for valid, relevant information? How do the changes in information availability and information management relate to physician and patient decision-making? Here's a review we thought worth checking out.

The Review is available to subscribers of ACP Journal Club:

ACP Journal Club. The Resourceful Patient. 2002 Nov-Dec;137:A14.


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