Describing treatment effects to patients

OBJECTIVE: To examine the impact of different presentations of equivalent information (framing) on treatment decisions faced by patients.DESIGN: A systematic review of the published literature was conducted. English language publications allocating participants to different frames were retrieved using electronic and bibliographic searches. Two reviewers examined each article for inclusion, and assessed methodological quality. Study characteristics were tabulated and where possible, relative risks (RR; 95% confidence intervals) were calculated to estimate intervention effects.MEASUREMENTS AND MAIN RESULTS: Thirty-seven articles, yielding 40 experimental studies, were included. Studies examined treatment (N=24), immunization (N=5), or health behavior scenarios (N=11). Overall, active treatments were preferred when outcomes were described in terms of relative rather than absolute risk reductions or number needed to treat. Surgery was preferred to other treatments when treatment efficacy was presented in a positive frame (survival) rather than a negative frame (mortality) (relative risk [RR]=1.51, 95% confidence interval [CI], 1.39 to 1.64). Framing effects were less obvious for immunization and health behavior scenarios. Those with little interest in the behavior at baseline were influenced by framing, particularly when information was presented as gains. In studies judged to be of good methodological quality and/or examining actual decisions, the framing effect, although still evident, was less convincing compared to the results of all included studies.CONCLUSIONS: Framing effects varied with the type of scenario, responder characteristics, scenario manipulations, and study quality. When describing treatment effects to patients, expressing the information in more than one way may present a balanced view to patients and enable them to make informed decisions.

[1]  D. Henry,et al.  The effects of information framing on the practices of physicians , 1999, Journal of General Internal Medicine.

[2]  Kristine M. Kuhn Communicating Uncertainty: Framing Effects on Responses to Vague Probabilities☆ , 1997 .

[3]  Kenneth A. Wallston,et al.  Effects of Contract Framing, Motivation to Quit, and Self‐Efficacy on Smoking Reduction1 , 1990 .

[4]  R. W. Rogers,et al.  Beyond Fear Appeals: Negative and Positive Persuasive Appeals to Health and Self‐Esteem , 1988 .

[5]  J. Brug,et al.  Framing of nutrition education messages in persuading consumers of the advantages of a healthy diet. , 2001, Journal of human nutrition and dietetics : the official journal of the British Dietetic Association.

[6]  G. Elwyn,et al.  Presenting risk information--a review of the effects of "framing" and other manipulations on patient outcomes. , 2001, Journal of health communication.

[7]  A R Jadad,et al.  Assessing the quality of reports of randomized clinical trials: is blinding necessary? , 1996, Controlled clinical trials.

[8]  Tamera R. Schneider,et al.  Visual and Auditory Message Framing Effects on Tobacco Smoking1 , 2001 .

[9]  N. Boyd,et al.  Eliciting Preferences for Alternative Cancer Drug Treatments , 1985, Medical decision making : an international journal of the Society for Medical Decision Making.

[10]  Baruch Fischhoff,et al.  AIDS risk perceptions and decision biases. , 1993 .

[11]  Irwin P. Levin,et al.  Need for Cognition and Choice Framing Effects , 1996 .

[12]  A Coulter,et al.  Evidence based patient information , 1998, BMJ.

[13]  H. Gurm,et al.  Framing Procedural Risks to Patients: Is 99% Safe the Same as a Risk of 1 in 100? , 2000, Academic medicine : journal of the Association of American Medical Colleges.

[14]  S. Straus Individualizing Treatment Decisions , 2002, Evaluation & the health professions.

[15]  Alexander J. Rothman,et al.  Message framing and sunscreen use: gain-framed messages motivate beach-goers. , 1999, Health psychology : official journal of the Division of Health Psychology, American Psychological Association.

[16]  J. Hammitt,et al.  Using Life Expectancy to Communicate Benefits of Health Care Programs in Contingent Valuation Studies , 2001, Medical decision making : an international journal of the Society for Medical Decision Making.

[17]  Michael Siegrist,et al.  Communicating Low Risk Magnitudes: Incidence Rates Expressed as Frequency Versus Rates Expressed as Probability , 1997 .

[18]  E. Blair,et al.  Attribute Framing and Goal Framing Effects in Health Decisions. , 2001, Organizational behavior and human decision processes.

[19]  Carissa Wong,et al.  Framing communication: Communicating the antismoking message effectively to all smokers , 2002 .

[20]  Joan Meyers-Levy,et al.  The Influence of Message Framing and Issue Involvement , 1990 .

[21]  Irwin P. Levin,et al.  Information framing effects in social and personal decisions , 1988 .

[22]  Magnus Johannesson,et al.  Hypothetical versus real willingness to pay in the health care sector: results from a field experiment. , 2001 .

[23]  D. Armstrong,et al.  Patients' responses to risk information about the benefits of treating hypertension. , 2001, The British journal of general practice : the journal of the Royal College of General Practitioners.

[24]  R. Dales,et al.  Framing effects on expectations, decisions, and side effects experienced: the case of influenza immunization. , 1996, Journal of clinical epidemiology.

[25]  Peter Salovey,et al.  The Systematic Influence of Gain-and Loss-Framed Messages on Interest in and Use of Different Types of Health Behavior , 1999 .

[26]  M. Johannesson,et al.  An experimental test of question framing in health state utility assessment. , 1998, Health policy.

[27]  C. Zimmermann,et al.  Framing of outcome and probability of recurrence: Breast cancer patients' choice of adjuvant chemotherapy (ACT) in hypothetical patient scenarios , 2000, Breast Cancer Research and Treatment.

[28]  Peter Salovey,et al.  The Influence of Message Framing on Intentions to Perform Health Behaviors , 1993 .

[29]  G. Chapman,et al.  Framing Effects in Choices between Multioutcome Life-expectancy Lotteries , 1999, Medical decision making : an international journal of the Society for Medical Decision Making.

[30]  John A. Baron,et al.  The framing effect of relative and absolute risk , 1993, Journal of General Internal Medicine.

[31]  Vicki M. Bier,et al.  Ambiguity seeking in multi-attribute decisions: Effects of optimism and message framing , 1994 .

[32]  A. Tversky,et al.  The framing of decisions and the psychology of choice. , 1981, Science.

[33]  Amos Tversky,et al.  ON THE FRAMING OF MEDICAL DECISIONS , 1988 .

[34]  G. Koren,et al.  Effects of framing on teratogenic risk perception in pregnant women , 2001, The Lancet.

[35]  J. Rybash,et al.  The framing heuristic influences judgements about younger and older adults' decision to refuse medical treatment. , 1989, Applied cognitive psychology.

[36]  C D Naylor,et al.  Communicating the Benefits of Chronic Preventive Therapy , 1995, Medical decision making : an international journal of the Society for Medical Decision Making.

[37]  Josef Perner,et al.  Framing decisions: Hypothetical and real , 2002 .

[38]  K. Lowe,et al.  Confidence in the safety of blood for transfusion: the effect of message framing , 2001, Transfusion.

[39]  G. Baker,et al.  The impact of counselling with a practical statistical model on patients' decision-making about treatment for epilepsy: Findings from a pilot study , 1993, Epilepsy Research.

[40]  A. O'Connor,et al.  Effects of framing and level of probability on patients' preferences for cancer chemotherapy. , 1989, Journal of clinical epidemiology.

[41]  T. Marteau,et al.  Framing of information: its influence upon decisions of doctors and patients. , 1989, The British journal of social psychology.

[42]  A. Tversky,et al.  On the elicitation of preferences for alternative therapies. , 1982, The New England journal of medicine.

[43]  Alexander J. Rothman,et al.  Shaping perceptions to motivate healthy behavior: the role of message framing. , 1997, Psychological bulletin.

[44]  A. Tversky,et al.  Choices, Values, and Frames , 2000 .

[45]  A R Jadad,et al.  Assessing the quality of randomized controlled trials: an annotated bibliography of scales and checklists. , 1995, Controlled clinical trials.

[46]  K. Wallston,et al.  Compliance to health recommendations: a theoretical overview of message framing , 1988 .

[47]  R J Donovan,et al.  Positive versus Negative Framing of a Hypothetical Infant Immunization: The Influence of Involvement , 2000, Health education & behavior : the official publication of the Society for Public Health Education.

[48]  A Coulter,et al.  Sharing decisions with patients: is the information good enough? , 1999, BMJ.