Teaching About Risks Has Its Benefits

WHITE RIVER JUNCTION, Vt., Feb. 20 -- A slim primer that help patients weigh the subtleties of medical claims and the consequences of treatment decisions appears to have survived the rigors of a randomized controlled study.

To help patients better understand their medical risks hand the book to them, ask them to read it, and discuss it with them later, recommended Steven Woolskin, M.D., and colleagues of the Dartmouth Medical School in Hanover, N.J.

The book is designed to help patients weigh the effects of medical and lifestyle choices on overall health, and better understand the health messages they hear on the evening news.

In the randomized controlled study, the primer improved risk-interpretation skills in patients of both high and low socioeconomic status, and more than 90% of patients across the economic and educational spectrum rated it as "helpful" or "very helpful," the authors reported in the Feb. 20 issue of the Annals of Internal Medicine.

"We wrote the primer because, while people are bombarded with messages about health risks and treatment benefits, little is done to prepare them to understand these messages," said Dr. Woloshin.

He and colleagues tested the primer against a government issued booklet that discusses health and risks, but did not teach patients the skills needed to interpret information about risk.

The primer, in contrast, is specifically designed to get patients to think critically about health risks, and consider the relative benefits of interventions.

The Dartmouth booklet asks patients to consider the outcome for a specific risk is (e.g., lung cancer from cigarette smoking) and the magnitude of the risk, and to ask questions such as "does the risk information reasonably apply to you?"

The primer also contains self-tests such as the following:

"Imagine that you are a typical 70-year-old woman who has never smoked. Consider two drugs. Both drugs lower the chance of dying from a disease by 50%. However, one works on cervical cancer and the other works on heart attacks. Which drug is more likely to help you?"

"Because many people are intimidated by numbers and statistics," the authors wrote, "we worked hard to make the primer inviting and non-threatening by liberal use of cartoons and figures; by working through examples, separating the most technical material into optional 'learn-more boxes'; and by providing readers with quizzes (with answers) to assess their mastery of the material."

In the randomized, controlled, parallel group study, the authors recruited participants from two local populations: those with high socioeconomic status, which included people who attended a public lecture series at Dartmouth Medical School, and those with low socioeconomic status, including veterans and their families recruited from waiting areas at the VA Medical Center here.

Among the 334 high-status participants, 80% had at least a college degree. In the low-status group, half of the 221 participants had a high school degree or less formal education.

In both groups, the participants were randomized to receive the risk-interpretation primer, or a general health booklet of about the same length developed by the Agency for Health Care Research and Quality.

After they had read the assigned booklets, the participants were tested on their ability to interpret medical data with a validated 18-item interpretation test, also developed by the authors. The test is scored on a 100-point scale, of which 76 or more is passing.

Other outcomes included two other 100-point validated scores evaluating the participants' interest and confidence in interpreting medical statistics, and their subjective ratings of the assigned booklet's usefulness.

The authors found that 74% of the high-status participants who received the primer got a passing grade on the medical data interpretation test, compared with 56% of controls (P =0.001). The mean score in the primer group was 81 compared with 75 in the control group (P =0.0006).

Among participants with low socioeconomic status, 44% got passing grades, compared with 26% of controls (P =0.010). The mean score for the primer group was 69, for controls was 62 (P=0.008).

High-status and low-status participants also reported that the primer significantly increased their interest in medical statistics, but did not improve their confidence in being able to interpret medical statistics in either group.

In all, 91% of participants in the high-status trial rated the primer as "helpful" or "very helpful," as did 95% of participants in the low socioeconomic status trial.

"We don't know of any other generic educational interventions like this" Dr. Woloshin said. "It's simple, low tech, inexpensive, and we're happy to learn that it's also effective."

The authors noted that their study was limited by the fact that the low-socioeconomic status group was primarily male, and the high group was primarily female, making it difficult to generalize results to a larger population. They also noted that they did not assess whether better data interpretation skills translated into actual improvements in the participants' decision-making skills.