Communicating Evidence for Participatory Decision Making
Epstein, Ronald M.
Alper, Brian S.
Quill, Timothy E.
JAMA: The Journal of the American Medical Association 2004 May 19; 291(19): 2359-2366
CONTEXT: Informed patients are more likely to actively participate in their care, make wiser decisions, come to a common understanding with their physicians, and adhere more fully to treatment; however, currently there are no evidence-based guidelines for discussing clinical evidence with patients in the process of making medical decisions. OBJECTIVE: To identify ways to communicate evidence that improve patient understanding, involvement in decisions, and outcomes. DATA SOURCES AND STUDY SELECTION: Systematic review of MEDLINE for the period 1966-2003 and review of reference lists of retrieved articles to identify original research dealing with communication between clinicians and patients and directly addressing methods of presenting clinical evidence to patients. DATA EXTRACTION: Two investigators and a research assistant screened 367 abstracts and 2 investigators reviewed 51 full-text articles, yielding 8 potentially relevant articles. DATA SYNTHESIS: Methods for communicating clinical evidence to patients include nonquantitative general terms, numerical translation of clinical evidence, graphical representations, and decision aids. Focus-group data suggest presenting options and/or equipoise before asking patients about preferred decision-making roles or formats for presenting details. Relative risk reductions may be misleading; absolute risk is preferred. Order of information presented and time-frame of outcomes can bias patient understanding. Limited evidence supports use of human stick figure graphics or faces for single probabilities and vertical bar graphs for comparative information. Less-educated and older patients preferred proportions to percentages and did not appreciate confidence intervals. Studies of decision aids rarely addressed patient-physician communication directly. No studies addressed clinical outcomes of discussions of clinical evidence. CONCLUSIONS: There is a paucity of evidence to guide how physicians can most effectively share clinical evidence with patients facing decisions; however, basing our recommendations largely on related studies and expert opinion, we describe means of accomplishing 5 communication tasks to address in framing and communicating clinical evidence: understanding the patient's (and family members') experience and expectations; building partnership; providing evidence, including a balanced discussion of uncertainties; presenting recommendations informed by clinical judgment and patient preferences; and checking for understanding and agreement.
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