Educating physicians on strong opioids by descriptive versus simulated-experience formats: a randomized controlled trial

Background: Long-term prescriptions of strong opioids for chronic noncancer pain-which are not supported by scientific evidence-suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Because risk perceptions and behaviors can differ depending on whether people learn about risks through description or experience, we investigated the effects of descriptive versus simulated-experience educative formats on physicians' risk perceptions of strong opioids and their prescription behavior for managing chronic noncancer pain. Methods: Three hundred general practitioners and 300 pain specialists in Germany-enrolled separately in two independent exploratory randomized controlled online trials-were randomly assigned to either a descriptive format (fact box) or a simulated-experience format (interactive simulation). Primary endpoints: Objective risk perception (numerical estimates of opioids' benefits and harms), actual prescriptions of seven therapy options for managing chronic pain. Secondary endpoint: Implementation of intended prescriptions of seven therapy options for managing chronic pain. Results: Both formats improved the proportion of correct numerical estimates of strong opioids' benefits and harms immediately after intervention, with no notable differences between formats. Compared to description, simulated experience led to significantly lower reported actual prescription rates for strong and/or weak opioids, and was more effective at increasing prescription rates for non-drug-based therapies (e.g., means of opioid reduction) from baseline to follow-up for both general practitioners and pain specialists. Simulated experience also resulted in a higher implementation of intended behavior for some drug-based and non-drug-based therapies. Conclusions: The two formats, which recruit different cognitive processes, may serve different risk-communication goals: If the goal is to improve exact risk perception, descriptive and simulated-experience formats are likely to be equally suitable. If, however, the goal is to boost less risky prescription habits, simulated experience may be the better choice

Patients’ self‐reported physical and psychological effects of opioid use in chronic noncancer pain—A retrospective cross‐sectional analysis

Background: Strong opioids can have unintended effects. Clinical studies of strong opioids mainly report physical side effects, psychiatric or opioid use disorders. To date, too little attention has been paid to the psychological effects of opioids to treat patients with chronic noncancer pain (CNCP). This study aims to identify and measure (i) the nature and frequency of physical and psychological effects and (ii) the degree of physician counseling of patients with CNCP taking strong opioids. Methods: Within a cross-sectional survey-conducted as part of a randomised controlled online intervention trial (ERONA [Experiencing the risk of overusing opioids among patients with chronic non-cancer pain in ambulatory care])-300 German CNCP patients were surveyed via patient-reported outcome measures regarding on both the side effects from their use of strong opioids as well as their counselling experience. Results: Among the patients' reported effects, the psychological outcomes of the opioids in CNCP were: feeling relaxed (84%), fatigue (76%), dizziness (57%), listlessness (37%), difficulty with mental activities (23%), dulled emotions (17%) and poor memory (17%). Ninety-two per cent of the patients reported having received information about opioid effects, and 46% had discussed cessation of the opioid medication with their physicians before commencing the prescription. Conclusions: In addition to the well-known physical side effects, patients with CNCP taking strong opioids experience significant psychological effects. In view of these effects, discontinuation of opioid therapy should be discussed early to ensure their benefits do not outweigh their harm. Significance: In this study, patients with non-cancer pain notice that opioids they have taken do not only cause physical side effects but also may have an impact on their psyche and their emotions and, thus, may also affect quality of life substantially. Clinical trial number: DRKS00020358

Health-related preferences of older patients with multimorbidity: the protocol for an evidence map

Introduction: Interaction of conditions and treatments, complicated care needs and substantial treatment burden make patient–physician encounters involving multimorbid older patients highly complex. To optimally integrate patients’ preferences, define and prioritise realistic treatment goals and individualise care, a patient-centred approach is recommended. However, the preferences of older patients, who are especially vulnerable and frequently multimorbid, have not been systematically investigated with regard to their health status. The purpose of this evidence map is to explore current research addressing health-related preferences of older patients with multimorbidity, and to identify the knowledge clusters and research gaps. Methods and analysis: To identify relevant research, we will conduct searches in the electronic databases MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL, Social Science Citation Index, Social Science Citation Index Expanded and the Cochrane library from their inception. We will check reference lists of relevant articles and carry out cited reference research (forward citation tracking). Two independent reviewers will screen titles and abstracts, check full texts for eligibility and extract the data. Any disagreement will be resolved and consensus reached with the help of a third reviewer. We will include both qualitative and quantitative studies, and address preferences from the patients’ perspectives in a multimorbid population of 60 years or older. There will be no restrictions on the publication language. Data extraction tables will present study and patient characteristics, aim of study, methods used to identify preferences and outcomes (ie, type of preferences). We will summarise the data using tables and figures (ie, bubble plot) to present the research landscape and to describe clusters and gaps. Ethics and dissemination: Due to the nature of the proposed evidence map, ethics approval will not be required. Results from our research will be disseminated by means of specifically prepared materials for patients, at relevant (inter)national conferences and via publication in peer-reviewed journals

What do European women know about their female cancer risks and cancer screening? A cross-sectional online intervention survey in five European countries.

OBJECTIVES: Informed decisions about cancer screening require accurate knowledge regarding cancer risks and screening. This study investigates: (1) European women's knowledge of their risk of developing breast, ovarian, cervical or endometrial cancer, (2) their knowledge about mammography screening and (3) whether an evidence-based leaflet improves their knowledge. DESIGN: Cross-sectional online intervention survey. SETTING: National samples from five European countries (Czech Republic, Germany, UK, Italy and Sweden)-drawn from the Harris Interactive and the Toluna panel, respectively, in January 2017-were queried on their knowledge of age-specific risks of developing breast, cervical, ovarian or endometrial cancer within the next 10 years and of mammography screening before and after intervention. PARTICIPANTS: Of 3629 women (inclusion criteria: age 40-75 years) invited, 2092 responded and 1675 completed the survey (response rate: 61.4%). INTERVENTION: Evidence-based leaflet summarising information on age-adjusted female cancer risks, mammography and aspects of cancer prevention. PRIMARY OUTCOME MEASURES: Proportion of women (1) accurately estimating their risk of four female cancers, (2) holding correct assumptions of mammography screening and (3) changing their estimations and assumptions after exposure to leaflet. FINDINGS: Across countries, 59.2% (95% CI 56.8% to 61.6%) to 91.8% (95% CI 90.3% to 93.0%) overestimated their female cancer risks 7-33 fold (mediansacross tumours: 50.0 to 200.0). 26.5% (95% CI 24.4% to 28.7%) were aware that mammography screening has both benefits and harms. Women who accurately estimated their breast cancer risk were less likely to believe that mammography prevents cancer (p<0.001). After leaflet intervention, knowledge of cancer risks improved by 27.0 (95% CI 24.9 to 29.2) to 37.1 (95% CI 34.8 to 39.4) percentage points and of mammography by 23.0 (95% CI 21.0 to 25.1) percentage points. CONCLUSION: A considerable number of women in five European countries may not possess the prerequisites for an informed choice on cancer screening. Evidence-based information in patient leaflets can improve this situation

How do family physicians communicate about cardiovascular risk? Frequencies and determinants of different communication formats

Background: Patients understand information about risk better if it is communicated in numerical or visual formats (e.g. graphs) compared to verbal qualifiers only. How frequently different communication formats are used in clinical primary care settings is unknown. Methods: We collected socioeconomic and patient understanding data using questionnaires and audio-recorded consultations about cardiovascular disease risk. The frequencies of the communication formats were calculated and multivariate regression analysis of associations between communication formats, patient and general practitioner characteristics, and patient subjective understanding was performed. Results: In 73% of 70 consultations, verbal qualifiers were used exclusively to communicate cardiovascular risk, compared to numerical (11%) and visual (16%) formats. Female GPs and female patient's gender were significantly associated with a higher use of verbal formats compared to visual formats (p = 0.001 and p = 0.039, respectively). Patient subjective understanding was significantly higher in visual counseling compared to verbal counseling (p = 0.001). Conclusions: Verbal qualifiers are the most often used communication format, though recommendations favor numerical and visual formats, with visual formats resulting in better understanding than others. Also, gender is associated with the choice of communication format. Barriers against numerical and visual communication formats among GPs and patients should be studied, including gender aspects. Adequate risk communication should be integrated into physicians' education

Personalized early detection and prevention of breast cancer: ENVISION consensus statement

Abstract: The European Collaborative on Personalized Early Detection and Prevention of Breast Cancer (ENVISION) brings together several international research consortia working on different aspects of the personalized early detection and prevention of breast cancer. In a consensus conference held in 2019, the members of this network identified research areas requiring development to enable evidence-based personalized interventions that might improve the benefits and reduce the harms of existing breast cancer screening and prevention programmes. The priority areas identified were: 1) breast cancer subtype-specific risk assessment tools applicable to women of all ancestries; 2) intermediate surrogate markers of response to preventive measures; 3) novel non-surgical preventive measures to reduce the incidence of breast cancer of poor prognosis; and 4) hybrid effectiveness–implementation research combined with modelling studies to evaluate the long-term population outcomes of risk-based early detection strategies. The implementation of such programmes would require health-care systems to be open to learning and adapting, the engagement of a diverse range of stakeholders and tailoring to societal norms and values, while also addressing the ethical and legal issues. In this Consensus Statement, we discuss the current state of breast cancer risk prediction, risk-stratified prevention and early detection strategies, and their implementation. Throughout, we highlight priorities for advancing each of these areas

Measuring the burden of infodemics : summary of the methods and results of the fifth WHO infodemic management conference

Background: An infodemic is excess information, including false or misleading information, that spreads in digital and physical environments during a public health emergency. The COVID-19 pandemic has been accompanied by an unprecedented global infodemic that has led to confusion about the benefits of medical and public health interventions, with substantial impact on risk-taking and health-seeking behaviors, eroding trust in health authorities and compromising the effectiveness of public health responses and policies. Standardized measures are needed to quantify the harmful impacts of the infodemic in a systematic and methodologically robust manner, as well as harmonizing highly divergent approaches currently explored for this purpose. This can serve as a foundation for a systematic, evidence-based approach to monitoring, identifying, and mitigating future infodemic harms in emergency preparedness and prevention. Objective: In this paper, we summarize the Fifth World Health Organization (WHO) Infodemic Management Conference structure, proceedings, outcomes, and proposed actions seeking to identify the interdisciplinary approaches and frameworks needed to enable the measurement of the burden of infodemics. Methods: An iterative human-centered design (HCD) approach and concept mapping were used to facilitate focused discussions and allow for the generation of actionable outcomes and recommendations. The discussions included 86 participants representing diverse scientific disciplines and health authorities from 28 countries across all WHO regions, along with observers from civil society and global public health–implementing partners. A thematic map capturing the concepts matching the key contributing factors to the public health burden of infodemics was used throughout the conference to frame and contextualize discussions. Five key areas for immediate action were identified. Results: The 5 key areas for the development of metrics to assess the burden of infodemics and associated interventions included (1) developing standardized definitions and ensuring the adoption thereof; (2) improving the map of concepts influencing the burden of infodemics; (3) conducting a review of evidence, tools, and data sources; (4) setting up a technical working group; and (5) addressing immediate priorities for postpandemic recovery and resilience building. The summary report consolidated group input toward a common vocabulary with standardized terms, concepts, study designs, measures, and tools to estimate the burden of infodemics and the effectiveness of infodemic management interventions. Conclusions: Standardizing measurement is the basis for documenting the burden of infodemics on health systems and population health during emergencies. Investment is needed into the development of practical, affordable, evidence-based, and systematic methods that are legally and ethically balanced for monitoring infodemics; generating diagnostics, infodemic insights, and recommendations; and developing interventions, action-oriented guidance, policies, support options, mechanisms, and tools for infodemic managers and emergency program managers.peer-reviewe

das Verständnis medizinischer Statistik zu Krebsfrüherkennung und Prävention von Ärzten und Patienten

Efficient health care requires both informed doctors and patients. Our health care system falls short on both counts. Four of the five studies summarized in this Habilitation illustrate the extent of the problem: Not a single German gynecologist out of a group of 20 provided a patient with all of the relevant information on the benefit and harms of mammography that patients need in order to make an informed decision for or against the screening. Of 65 German internal medicine physicians, only 14 knew that the 5-year survival rate is an invalid statistic in the context of screening and only two were able to explain the lead-time bias. Among a national sample of 412 US primary care physicians, 47% wrongly thought that if more cancers are detected by a screening test, this proves that the test saves lives, and 76% mistakenly believed that if screen-detected cancers have better 5-year-survival rates than cancers detected by symptoms, this would prove that a test saves lives. Given the number of uninformed physicians, it is no surprise that 91% of 317 US citizens at screening age had never been told about the most impacting harms of cancer screening—overdiagnosis (diagnosis of cancers never destined to do harm) and overtreatment (unnecessary cancer treatment)—by their physicians, although nearly all regularly attended one or more screening tests. These examples demonstrate that in the context of cancer screening, both physicians and patients are uninformed about the most important means of screening—benefit and harms. Physicians’ misunderstanding of health statistics can not only stimulate enthusiasm for unproven tests but also make them conclude that a test is worth doing when in fact it may only lead to harm, such as by overdiagnosis. What can be done against this collective illiteracy in medicine? Evidence suggests that the provision of transparent health information on benefit and harms (e.g., absolute risk instead of relative risk, mortality rates instead of 5-year survival rates, age-related prevalence instead of life-time incidence) might serve as a solution. The fifth study of the Habilitation showed that complete and transparent reporting about the benefit and harms of the HPV vaccination increased people’s correct understanding about the effectiveness of the vaccine, reduces their unrealistic beliefs about the basic risk of getting cervical cancer, and induced an vaccination intention that reliably predicted their actual HPV vaccination uptake. What can be done beyond? Every medical school should teach their students how to understand evidence in general and health statistics in particular, and statistical literacy should be assessed in continuing medical education (CME). To cultivate informed patients, elementary and high schools need to start teaching the mathematics of uncertainty—statistical thinking—rather than only the mathematics of certainty. Guidelines about complete and transparent reporting in journals, brochures, and the media need to be better enforced. A critical mass of informed physicians and citizens will not resolve all health care problems, but can constitute a major triggering factor for a better and more efficient health care.Ein effizientes Gesundheitswesen braucht informierte Ärzte und Patienten. Unserem Gesundheitswesen mangelt es an beidem. Vier der fünf in der Habilitation vorgestellten Studien illustrieren das Ausmaß des Problems: Nicht ein einziger deutscher Gynäkologe von 20 befragten war in der Lage, die Patientin mit all jenen Informationen zu Nutzen und Schaden der Mammographie zu versorgen, die es bedürfte, um eine informierte Entscheidung für oder gegen die Früherkennung zu treffen. Von 65 deutschen Ärzten der Inneren Medizin wussten lediglich 14, dass die 5-Jahres-Überlebensrate eine invalide Statistik zur Beurteilung des Nutzens von Früherkennungen ist und nur zwei konnten den dafür ursächlichen Lead-time bias richtig erklären. In einer nationalen Stichprobe von 412 amerikanischen Primärversorgungs-Ärzten nahmen 47% fälschlicherweise an, dass mehr detektierte Tumore in der Früherkennungsgruppe meine, dass die Früherkennung mehr Leben rette und 76% glaubten irrtümlicherweise, dass eine höhere 5-Jahres-Überlebensrate in der Früherkennungsgruppe im Vergleich zur Nicht-Früherkennungsgruppe diesen Beweis liefere. In Anbetracht der Anzahl uninformierter Ärzte ist es nicht überraschend, dass 91% von 317 U.S. Bürgern im anspruchsberechtigten Alter für Früherkennung von ihrem Arzt noch nie etwas über die tiefgreifendsten Schäden der Früherkennung – Überdiagnose und Überbehandlung – gehört hatten, obwohl die große Mehrzahl regelmäßig an einer oder mehreren Früherkennungen teilnahm. Was kann gegen diese kollektive Risikounmündigkeit getan werden? Die gegenwärtige Evidenz im Bereich der medizinischen Risikokommunikation legt nah, dass die Nutzung transparenter Gesundheitsstatistiken zu Nutzen und Schaden (z.B. absolute Risiken anstatt relativer Risiken/odds ratio; Mortalitätsraten anstatt 5-Jahres-Überlebensraten im Früherkennungskontext, altersadjustierte Prävalenz anstatt Lebenszeitinzidenz) eine tragfähige Lösung des Problems bietet. Die fünfte Studie der Habilitation zeigt, dass vollständiges und transparentes Berichten von Nutzen und Schaden zur HPV- Impfung das korrekte Verständnis zur Impfung erhöht, unrealistische Ängste bezogen auf das Erkrankungsrisiko zum Zervix-Karzinom senkt und zu eine Impfintention führt, welche zuverlässig die spätere, tatsächliche Impfung- Teilnahme vorhersagt. Was kann darüber hinaus getan werden? Jede medizinische Fakultät sollte ihre Studenten das Verständnis medizinischer Evidenz im Allgemeinen und praktisch-relevanter Gesundheitsstatistik im Speziellen lehren und darüber hinaus statistische Risikokompetenz zum Gegenstand von Prüfungen im Studium und der späteren ärztlichen Weiterbildung machen. Um informierte Patienten „aufzubauen“, bedarf es eines frühzeitigen Beginns der Vermittlung von Risikokompetenz bereits in Grundschulen und der weiterführenden schulischen Ausbildung. Auch muss die Entwicklung von verbindlichen Leitlinien zum vollständigen und transparenten Berichten von Gesundheitsstatistiken in medizinischen Fachzeitschriften, Patientenbroschüren und den Medien verstärkt vorangetrieben werden. Eine kritische Masse an informierten Ärzten und Patienten wird nicht alle Probleme eines Gesundheitssystems lösen, aber sie kann der entscheidende Faktor für eine bessere und effizientere Gesundheitsversorgung sein

Smart strategies for doctors and doctors-in-training : heuristics in medicine

CONTEXT How do doctors make sound deci- sions when confronted with probabilistic data, time pressures and a heavy workload? One theory that has been embraced by many researchers is based on optimisation, which emphasises the need to integrate all informa- tion in order to arrive at sound decisions. This notion makes heuristics, which use less than complete information, appear as second-best strategies. In this article, we challenge this pessimistic view of heuristics.METHODS We introduce two medical problems that involve decision making to the reader: one concerns coronary care issues and the other macrolide prescriptions. In both settings, decision-making tools grounded in the principles of optimisation and heuristics, respectively, have been developed to assist doctors in making decisions. We explain the structure of each of these tools and compare their performance in terms of their facilitation of correct predictions.RESULTS For decisions concerning both the coronary care unit and the prescribing of macrolides, we demonstrate that sacrificing information does not necessarily imply a forfeiting of predictive accuracy, but can sometimes even lead to better decisions. Sub- sequently, we discuss common misconceptions about heuristics and explain when and why ignoring parts of the available information can lead to the making of more robust predictions.CONCLUSIONS Heuristics are neither good nor bad per se, but, if applied in situations to which they have been adapted, can be helpful companions for doctors and doctors-in-training. This, however, requires that heuristics in medicine be openly discussed, criticised, refined and then taught to doctors-in-training rather than being simply dismissed as harmful or irrelevant. A more uniform use of explicit and accepted heuristics has the potential to reduce variations in diagnoses and to improve medical care for patients