Different Measures, Different Outcomes? A Systematic Review of Performance-Based versus Self-Reported Measures of Health Literacy and Numeracy.

BACKGROUND: Health literacy (HL) and numeracy are measured by one of two methods: performance on objective tests or self-report of one's skills. Whether results from these methods differ in their relationship to health outcomes or use of health services is unknown. METHODS: We performed a systematic review to identify and evaluate articles that measured both performance-based and self-reported HL or numeracy and examined their relationship to health outcomes or health service use. To identify studies, we started with an AHRQ-funded systematic review of HL and health outcomes. We then looked for newer studies by searching MEDLINE from 1 February 2010 to 9 December 2014. We included English language studies meeting pre-specified criteria. Two reviewers independently assessed abstracts and studies for inclusion and graded study quality. One reviewer abstracted information from included studies while a second checked content for accuracy. RESULTS: We identified four "fair" quality studies that met inclusion criteria for our review. Two studies measuring HL found no differences between performance-based and self-reported HL for association with self-reported outcomes (including diabetes, stroke, hypertension) or a physician-completed rheumatoid arthritis disease activity score. However, HL measures were differentially related to a patient-completed health assessment questionnaire and to a patient's ability to interpret their prescription medication name and dose from a medication bottle. Only one study measured numeracy and found no difference between performance-based and self-reported measures of numeracy and colorectal cancer (CRC) screening utilization. However, in a moderator analysis from the same study, performance-based and self-reported numeracy were differentially related to CRC screening utilization when stratified by certain patient-provider communication behaviors (e.g., the chance to always ask questions and get the support that is needed). DISCUSSION: Most studies found no difference in the relationship between results of performance-based and self-reported measures and outcomes. However, we identified few studies using multiple instruments and/or objective outcomes.

Adult Patients' Perspectives on the Benefits and Harms of Overused Screening Tests: a Qualitative Study.

BACKGROUND: In recent years, there has been a growing interest in reducing the overuse of healthcare services. However, little is known about how patients conceptualize the benefits and harms of overused screening tests or how patients make decisions regarding these tests. OBJECTIVE: To determine how patients think about the harms and benefits of overused screening tests and how they consider these and other factors when making decisions. DESIGN: Semi-structured, qualitative interviews. PARTICIPANTS: The study comprised 50 patients, ages 50-84, who had previously received or not received any of four overused screening services: 1) prostate cancer screening (men ages 50-69), 2) colon cancer screening (men and women ages 76-85), 3) osteoporosis screening (low-risk women ages 50-64), or 4) cardiovascular disease screening (low-risk men and women ages 50-85). APPROACH: We conducted a thematic analysis, using a hybrid inductive-deductive approach. Two independent coders analyzed interview transcriptions to identify themes and exemplifying quotes. KEY RESULTS: Many patients could not name a harm of screening. When they did name harms, patients often focused on only the harms of the screening test itself and rarely mentioned harms further along the screening cascade (e.g., from follow-up testing and treatment). In contrast, patients could easily name benefits of screening, although many seemed to misunderstand or overestimate the magnitude of the benefits. Furthermore, patients described many additional factors they considered when making screening decisions, including their clinicians' recommendations, their age, family or friends' experiences with disease, and insurance coverage. CONCLUSIONS: This study highlights the need to help adults recognize and understand the benefits and harms of screening and make appropriate decisions about overused screening tests.

Have screening harms become newsworthy? News coverage of prostate and colorectal cancer screening since the 2008 USPSTF recommendation changes.

In 2008, the US Preventive Services Task Force updated its recommendations to discourage screening for prostate cancer in men over 75 and for colorectal cancer in adults over 85. We aimed to determine whether newspapers portrayed these screenings differently after these recommendation changes. A quantitative content analysis included articles on prostate-specific antigen (PSA) testing or colonoscopy in US newspapers from 2005 to 2012. Outcomes included the number of benefits and harms mentioned and the gist expert and lay readers might get from articles. Benefits in PSA articles (n = 222) and harms and benefits in colonoscopy articles (n = 65) did not change over time. Mentions of PSA harms increased after 2008 (p < .01). Expected expert gist of PSA articles became more negative after 2008 (p < .01). Expected lay gist was positive and did not change. News coverage of PSA testing harms increased without a decrease in the discussion of benefits. Consumers, especially lay consumers, are receiving unbalanced information on cancer screening.

The effect of a decision aid intervention on decision making about coronary heart disease risk reduction: secondary analyses of a randomized trial.

BACKGROUND: Decision aids offer promise as a practical solution to improve patient decision making about coronary heart disease (CHD) prevention medications and help patients choose medications to which they are likely to adhere. However, little data is available on decision aids designed to promote adherence. METHODS: In this paper, we report on secondary analyses of a randomized trial of a CHD adherence intervention (second generation decision aid plus tailored messages) versus usual care in an effort to understand how the decision aid facilitates adherence. We focus on data collected from the primary study visit, when intervention participants presented 45 minutes early to a previously scheduled provider visit; viewed the decision aid, indicating their intent for CHD risk reduction after each decision aid component (individualized risk assessment and education, values clarification, and coaching); and filled out a post-decision aid survey assessing their knowledge, perceived risk, decisional conflict, and intent for CHD risk reduction. Control participants did not present early and received usual care from their provider. Following the provider visit, participants in both groups completed post-visit surveys assessing the number and quality of CHD discussions with their provider, their intent for CHD risk reduction, and their feelings about the decision aid. RESULTS: We enrolled 160 patients into our study (81 intervention, 79 control). Within the decision aid group, the decision aid significantly increased knowledge of effective CHD prevention strategies (+21 percentage points; adjusted p<.0001) and the accuracy of perceived CHD risk (+33 percentage points; adjusted p<.0001), and significantly decreased decisional conflict (-0.63; adjusted p<.0001). Comparing between study groups, the decision aid also significantly increased CHD prevention discussions with providers (+31 percentage points; adjusted p<.0001) and improved perceptions of some features of patient-provider interactions. Further, it increased participants' intentions for any effective CHD risk reducing strategies (+21 percentage points; 95% CI 5 to 37 percentage points), with a majority of the effect from the educational component of the decision aid. Ninety-nine percent of participants found the decision aid easy to understand and 93% felt it easy to use. CONCLUSIONS: Decision aids can play an important role in improving decisions about CHD prevention and increasing patient-provider discussions and intent to reduce CHD risk.

Kappa statistic for clustered dichotomous responses from physicians and patients.

The bootstrap method for estimating the standard error of the kappa statistic in the presence of clustered data is evaluated. Such data arise, for example, in assessing agreement between physicians and their patients regarding their understanding of the physician-patient interaction and discussions. We propose a computationally efficient procedure for generating correlated dichotomous responses for physicians and assigned patients for simulation studies. The simulation result demonstrates that the proposed bootstrap method produces better estimate of the standard error and better coverage performance compared with the asymptotic standard error estimate that ignores dependence among patients within physicians with at least a moderately large number of clusters. We present an example of an application to a coronary heart disease prevention study.

Addressing health literacy in patient decision aids.

BACKGROUND: Effective use of a patient decision aid (PtDA) can be affected by the user's health literacy and the PtDA's characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess: METHODS: We reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews. RESULTS: Aim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed. CONCLUSION: Lower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients.

From guidelines to decision aids and adherence supports: Insights from the process of evidence translation.

OBJECTIVE: To explore the evidence-translator's experience of the expert-recommended process of translating guidelines into tools for decision making, action, and adherence with the goal of improvement. METHODS: A single reviewer dual reviewed the content, quality, certainty, and applicability of primary atherosclerotic cardiovascular prevention guidelines from the U.S. Preventive Services Task Force at the time of this work and used targeted searches of Medline to define the ideal structure and outcomes of tools; fill in gaps in guidelines; identify end-user needs; and choose and optimize existing tools in preparation for testing. RESULTS: Guidelines addressed screening, treatments, and/or supports, but never the combination of all three. None provided all of the information needed for evidence translation. Searches in Medline filled in some evidence gaps and provided key insights into end-user needs and effective tools. However, evidence translators are left with complicated decisions about how to use and align evidence. CONCLUSION: Guidelines provide some, but not all, of the evidence needed for evidence translation, requiring additional intensive work. Evidence gaps result in complicated decisions about how to use and align evidence and balance feasibility and rigor. PRACTICE IMPLICATIONS: Guidelines, standards groups, and researchers should work to better support the process of evidence translation.

Conjoint analysis versus rating and ranking for values elicitation and clarification in colorectal cancer screening.

PURPOSE: To compare two techniques for eliciting and clarifying patient values for decision making about colorectal cancer (CRC) screening: choice-based conjoint analysis and a rating and ranking task. METHODS: Using our decision lab registry and university e-mail lists, we recruited average risk adults ages 48-75 for a written, mailed survey. Eligible participants were given basic information about CRC screening and six attributes of CRC screening tests, then randomized to complete either a choice-based conjoint analysis with 16 discrete choice tasks or a rating and ranking task. The main outcome was the most important attribute, as determined from conjoint analysis or participant ranking. Conjoint analysis-based most important attribute was determined from individual patient-level utilities generated using multinomial logistic regression and hierarchical Bayesian modeling. RESULTS: Of the 114 eligible participants, 104 completed and returned questionnaires. Mean age was 57 (range 48-73), 70% were female, 88% were white, 71% were college graduates, and 62% were up to date with CRC screening. Ability to reduce CRC incidence and mortality was the most frequent most important attribute for both the conjoint analysis (56% of respondents) and rating/ranking (76% of respondents) groups, and these proportions differed significantly between groups (absolute difference 20%, 95% CI 3%, 37%, p =0.03). There were no significant differences between groups in proportion with clear values (p = 0.352), intent to be screened (p = 0.226) or unlabelled test preference (p = 0.521) CONCLUSIONS: Choice-based conjoint analysis produced somewhat different patterns of attribute importance than a rating and ranking task, but had little effect on other outcomes.

Use of global coronary heart disease risk assessment in practice: a cross-sectional survey of a sample of U.S. physicians.

BACKGROUND: Global coronary heart disease (CHD) risk assessment is recommended to guide primary preventive pharmacotherapy. However, little is known about physicians' understanding and use of global CHD risk assessment. Our objective was to examine US physicians' awareness, use, and attitudes regarding global CHD risk assessment in clinical practice, and how these vary by provider specialty. METHODS: Using a web-based survey of US family physicians, general internists, and cardiologists, we examined awareness of tools available to calculate CHD risk, method and use of CHD risk assessment, attitudes towards CHD risk assessment, and frequency of using CHD risk assessment to guide recommendations of aspirin, lipid-lowering and blood pressure (BP) lowering therapies for primary prevention. Characteristics of physicians indicating they use CHD risk assessments were compared in unadjusted and adjusted analyses. RESULTS: A total of 952 physicians completed the questionnaire, with 92% reporting awareness of tools available to calculate CHD global risk. Among those aware of such tools, over 80% agreed that CHD risk calculation is useful, improves patient care, and leads to better decisions about recommending preventive therapies. However, only 41% use CHD risk assessment in practice. The most commonly reported barrier to CHD risk assessment is that it is too time consuming. Among respondents who calculate global CHD risk, 69% indicated they use it to guide lipid lowering therapy recommendations; 54% use it to guide aspirin therapy recommendations; and 48% use it to guide BP lowering therapy. Only 40% of respondents who use global CHD risk routinely tell patients their risk. Use of a personal digital assistant or smart phone was associated with reported use of CHD risk assessment (adjusted OR 1.58; 95% CI 1.17-2.12). CONCLUSIONS: Reported awareness of tools to calculate global CHD risk appears high, but the majority of physicians in this sample do not use CHD risk assessments in practice. A minority of physicians in this sample use global CHD risk to guide prescription decisions or to motivate patients. Educational interventions and system improvements to improve physicians' effective use of global CHD risk assessment should be developed and tested.

Low health literacy and health outcomes: an updated systematic review.

BACKGROUND: Approximately 80 million Americans have limited health literacy, which puts them at greater risk for poorer access to care and poorer health outcomes. PURPOSE: To update a 2004 systematic review and determine whether low health literacy is related to poorer use of health care, outcomes, costs, and disparities in health outcomes among persons of all ages. DATA SOURCES: English-language articles identified through MEDLINE, CINAHL, PsycINFO, ERIC, and Cochrane Library databases and hand-searching (search dates for articles on health literacy, 2003 to 22 February 2011; for articles on numeracy, 1966 to 22 February 2011). STUDY SELECTION: Two reviewers independently selected studies that compared outcomes by differences in directly measured health literacy or numeracy levels. DATA EXTRACTION: One reviewer abstracted article information into evidence tables; a second reviewer checked information for accuracy. Two reviewers independently rated study quality by using predefined criteria, and the investigative team jointly graded the overall strength of evidence. DATA SYNTHESIS: 96 relevant good- or fair-quality studies in 111 articles were identified: 98 articles on health literacy, 22 on numeracy, and 9 on both. Low health literacy was consistently associated with more hospitalizations; greater use of emergency care; lower receipt of mammography screening and influenza vaccine; poorer ability to demonstrate taking medications appropriately; poorer ability to interpret labels and health messages; and, among elderly persons, poorer overall health status and higher mortality rates. Poor health literacy partially explains racial disparities in some outcomes. Reviewers could not reach firm conclusions about the relationship between numeracy and health outcomes because of few studies or inconsistent results among studies. LIMITATIONS: Searches were limited to articles published in English. No Medical Subject Heading terms exist for identifying relevant studies. No evidence concerning oral health literacy (speaking and listening skills) and outcomes was found. CONCLUSION: Low health literacy is associated with poorer health outcomes and poorer use of health care services. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Shared decision making for prostate cancer screening: the results of a combined analysis of two practice-based randomized controlled trials.

BACKGROUND: Professional societies recommend shared decision making (SDM) for prostate cancer screening, however, most efforts have promoted informed rather than shared decision making. The objective of this study is to 1) examine the effects of a prostate cancer screening intervention to promote SDM and 2) determine whether framing prostate information in the context of other clearly beneficial men's health services affects decisions. METHODS: We conducted two separate randomized controlled trials of the same prostate cancer intervention (with or without additional information on more clearly beneficial men's health services). For each trial, we enrolled a convenience sample of 2 internal medicine practices, and their interested physicians and male patients with no prior history of prostate cancer (for a total of 4 practices, 28 physicians, and 128 men across trials). Within each practice site, we randomized men to either 1) a video-based decision aid and researcher-led coaching session or 2) a highway safety video. Physicians at each site received a 1-hour educational session on prostate cancer and SDM. To assess intervention effects, we measured key components of SDM, intent to be screened, and actual screening. After finding that results did not vary by trial, we combined data across sites, adjusting for the random effects of both practice and physician. RESULTS: Compared to an attention control, our prostate cancer screening intervention increased men's perceptions that screening is a decision (absolute difference +41%; 95% CI 25 to 57%) and men's knowledge about prostate cancer screening (absolute difference +34%; 95% CI 19% to 50%), but had no effect on men's self-reported participation in shared decisions or their participation at their preferred level. Overall, the intervention decreased screening intent (absolute difference -34%; 95% CI -50% to -18%) and actual screening rates (absolute difference -22%; 95% CI -38 to -7%) with no difference in effect by frame. CONCLUSIONS: SDM interventions can increase men's knowledge, alter their perceptions of prostate cancer screening, and reduce actual screening. However, they may not guarantee an increase in shared decisions. TRIAL REGISTRATION: #NCT00630188.

Acceptance of a Polypill approach to prevent cardiovascular disease among a sample of U.S. physicians.

OBJECTIVE: To examine US physicians' self-reported knowledge about the Polypill, factors considered in deciding whether to prescribe it, and acceptance of prescribing it for cardiovascular disease (CVD) prevention. METHODS: Numerical scales of 0 (lowest) to 5 (highest) were used to assess self-reported knowledge and importance of factors relevant to making a decision to prescribe a Polypill. Characteristics of physicians indicating they would prescribe a Polypill were compared. RESULTS: Among 952 physicians surveyed February through March 2010, mean self-rated knowledge about the Polypill was 2.0±1.5. Importance of degree of CVD event reduction, cost, and side effects were rated with means of 4.4, 4.3, and 4.3, respectively. 83% of respondents indicated they would "definitely" or "probably" prescribe it for high-risk patients; 62% would do so for moderate risk patients. Physicians with self-rated knowledge at ≥75th percentile were more likely to indicate they would prescribe a Polypill for moderate risk (adjusted OR 2.16; 95% CI 1.60-2.93) and high-risk (adjusted OR 1.57; 95% CI 1.07-2.32) patients. CONCLUSION: Among this sample of physicians, there is relatively high acceptance of prescribing a Polypill for CVD prevention despite relatively modest knowledge about it.

Patient-physician agreement on the content of CHD prevention discussions.

BACKGROUND: Little is known about agreement between patients and physicians on content and outcomes of clinical discussions. A common perception of content and outcomes may be desirable to optimize decision making and clinical care. OBJECTIVE: To determine patient-physician agreement on content and outcomes of coronary heart disease (CHD) prevention discussions. DESIGN: Cross-sectional survey nested within a randomized CHD prevention study. SETTING AND PARTICIPANTS: University internal medicine clinic; 24 physicians and 157 patients. METHODS: Following one clinic visit, we surveyed patients and physicians on discussion content, decision making and final decisions about CHD prevention. For comparison, we audio-recorded, transcribed and coded 20 patient-physician visits. We calculated percent agreement between patient/physician reports, patient/transcription reports and physician/transcription reports. We calculated Cohen's kappas to compare patient/physician perspectives. RESULTS: Patients and physicians agreed on whether CHD was discussed in 130 visits (83%; kappa = 0.55; 95% CI 0.40-0.70). When discussions occurred, they agreed about discussion content (pros versus cons) in 53% of visits (kappa = 0.15; 95% CI -0.01-0.30) and physicians' recommendations in 73% (kappa = 0.44; 95% CI 0.28-0.66). Patients and physicians agreed on final decisions to take medication in 78% (kappa = 0.58; 95% CI 0.45-0.71) and change lifestyle in 69% (kappa = 0.38; 95% CI 0.24-0.53). They agreed less often, 43% (kappa = 0.13; 95% CI -0.11-0.37) about degree of involvement in decision making. Audio-recorded results were similar, but showed very low agreement between transcripts and patients' and physicians' self-report on discussion content and decision making. CONCLUSIONS: Disagreements about clinical discussions and decision making may be common. Future work is needed to determine: how widespread such agreements are; whether they impact clinical outcomes; and the relative importance of the subjective experience versus objective steps of shared decision making.

A randomized trial of an intervention to improve use and adherence to effective coronary heart disease prevention strategies.

BACKGROUND: Efficacious strategies for the primary prevention of coronary heart disease (CHD) are underused, and, when used, have low adherence. Existing efforts to improve use and adherence to these efficacious strategies have been so intensive that they are impractical for clinical practice. METHODS: We conducted a randomized trial of a CHD prevention intervention (including a computerized decision aid and automated tailored adherence messages) at one university general internal medicine practice. After obtaining informed consent and collecting baseline data, we randomized patients (men and women age 40-79 with no prior history of cardiovascular disease) to either the intervention or usual care. We then saw them for two additional study visits over 3 months. For intervention participants, we administered the decision aid at the primary study visit (1 week after baseline visit) and then mailed 3 tailored adherence reminders at 2, 4, and 6 weeks. We assessed our outcomes (including the predicted likelihood of angina, myocardial infarction, and CHD death over 10 years (CHD risk) and self-reported adherence) between groups at 3 month follow-up. Data collection occurred from June 2007 through December 2009. All study procedures were IRB approved. RESULTS: We randomized 160 eligible patients (81 intervention; 79 control) and followed 96% to study conclusion. Mean predicted CHD risk at baseline was 11.3%. The intervention increased self-reported adherence to chosen risk reducing strategies by 25 percentage points (95% CI 8% to 42%), with the biggest effect for aspirin. It also changed predicted CHD risk by -1.1% (95% CI -0.16% to -2%), with a larger effect in a pre-specified subgroup of high risk patients. CONCLUSION: A computerized intervention that involves patients in CHD decision making and supports adherence to effective prevention strategies can improve adherence and reduce predicted CHD risk.

Interventions for individuals with low health literacy: a systematic review.

The U.S. Department of Health and Human Services recently called for action on health literacy. An important first step is defining the current state of the literature about interventions designed to mitigate the effects of low health literacy. We performed an updated systematic review examining the effects of interventions that authors reported were specifically designed to mitigate the effects of low health literacy. We searched MEDLINE®, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Educational Resources Information Center (ERIC), and the Cochrane Library databases (2003 forward for health literacy; 1966 forward for numeracy). Two reviewers independently reviewed titles, abstracts, and full-text articles for inclusion and included studies that examined outcomes by health literacy level and met other pre-specified criteria. One reviewer abstracted article information into evidence tables; a second checked accuracy. Two reviewers independently rated study quality using predefined criteria. Among 38 included studies, we found multiple discrete design features that improved comprehension in one or a few studies (e.g., presenting essential information by itself or first, presenting information so that the higher number is better, adding icon arrays to numerical information, adding video to verbal narratives). In a few studies, we also found consistent, direct, fair or good-quality evidence that intensive self-management interventions reduced emergency department visits and hospitalizations; and intensive self- and disease-management interventions reduced disease severity. Evidence for the effects of interventions on other outcomes was either limited or mixed. Multiple interventions show promise for mitigating the effects of low health literacy and could be considered for use in clinical practice.

Global risk of coronary heart disease: assessment and application.

Coronary heart disease is the most common cause of death in the United States. The conventional risk factor approach to primary prevention excludes many patients who could benefit from preventive therapies. A global risk approach allows more accurate estimates of risk to guide clinical primary prevention efforts. Global risk of coronary heart disease is a calculation of the absolute risk of having a coronary heart disease event (e.g., death, myocardial infarction) over a specified period. It is based on an empiric equation that combines major risk factors, such as blood pressure and cholesterol levels. When physicians know a patient's global risk of coronary heart disease, they are more likely to prescribe risk-reducing therapies such as antihypertensives, statins, and aspirin. In addition, patients who know their risk level are more likely to initiate risk-reducing therapies. Many tools are available to estimate global risk, including several Web-based calculators. In the United States, tools based on the Framingham Heart Study are recommended.

Randomized trial of presenting absolute v. relative risk reduction in the elicitation of patient values for heart disease prevention with conjoint analysis.

BACKGROUND: The authors performed a randomized controlled trial to test the effect of 2 different formats of risk reduction information when using conjoint analysis to elicit values about heart disease prevention. METHODS: Participants ages 30 to 75 were enrolled and presented the same hypothetical scenario: a person with a 13% ten-year risk of heart disease. Participants then worked through a values elicitation exercise using conjoint analysis, making pairwise comparisons of hypothetical treatments that differed on 5 attributes. For the attribute "ability to reduce heart attacks," participants were randomized to receive either absolute risk reduction (ARR) or relative risk reduction (RRR) information. Participants selected which attribute they felt was most important. Participants' responses to the pairwise comparisons were then used to generate their most important attribute using ordinary least squares regression. Outcomes included differences between groups in the proportion choosing and generating ability to reduce heart attacks as the most important attribute. RESULTS: In total, 113 participants completed the study: mean age was 51, 29% were male, 52% were white, and 42% were African American. The proportion who selected the ability to reduce heart attacks as the most important treatment attribute did not differ significantly (64% RRR; 53% ARR, Fisher's P=0.26). For the conjoint-generated most important attribute, those receiving the RRR version were significantly more likely to generate ability to reduce heart attacks as the most important attribute (59% RRR; 35% ARR, Fisher's P=0.01). DISCUSSION: Risk presentation format appears to affect the perceived value of different treatment attributes generated from conjoint analysis.

Communication message strategies for increasing knowledge about prostate cancer screening.

BACKGROUND: This community-based intervention study examined the effects of 2 different message strategies for presenting information about the prostate specific antigen (PSA) test. METHODS: A quasi-experimental longitudinal design with 2 intervention and 1 control group. RESULTS: Knowledge increased significantly among participants who received either version of the intervention message and remained elevated at 12 months. Presenting information in the context of other men's health issues was associated with greater increases in knowledge relative to PSA only. CONCLUSIONS: Community-based interventions can increase knowledge about prostate cancer screening. Clinicians need to take careful account of what their patients understand and correct misperceptions.

Beginning with high value care in mind: A scoping review and toolkit to support the content, delivery, measurement, and sustainment of high value care.

OBJECTIVE: To create a shared vision for the content, delivery, measurement, and sustainment of patient-centered high value care. METHODS: We performed a scoping review and translated findings into toolkit for system leaders. For our scoping review, we searched Medline, 2005-November 2015, for literature on patient-centered care (PCC) and its relationship to a high value care change model. We supplemented searches with key author, Google Scholar, and key website searches. One author reviewed all titles, abstracts, and articles for inclusion; another reviewed a random 20%. To develop our toolkit, we translated evidence into simple, actionable briefs on key topics and added resources. We then iteratively circulated briefs and the overall toolkit to potential users, making updates as needed. RESULTS: In our scoping review, we found multiple interventions and measures to support the components of PCC and our change model. We found little on the overall effects of PCC or how PCC creates value. Potential users reported our toolkit was simple, understandable, thorough, timely, and likely to be globally useful. CONCLUSIONS: Considerable evidence supports patient-centered high value care and a toolkit garnered enthusiasm. PRACTICE IMPLICATIONS: The toolkit is ready for use, but needs comparison to other approaches.

Promoting prostate-specific antigen informed decision-making. Evaluating two community-level interventions.

BACKGROUND: Most medical associations recommend that patients make informed decisions about whether to be screened for prostate cancer with the prostate-specific antigen (PSA) test. Studies assessing how to promote PSA informed decision-making (IDM) have been conducted almost exclusively in healthcare settings; there is a need for similar research in community settings. METHODS: This paper describes the results of a 5-year study (2002--2007) in which two community-level interventions were developed, implemented, and evaluated in matched upper- and lower-SES comparison communities in Greensboro and Wilmington, North Carolina. Both interventions promoted PSA informed decision-making. One intervention (PSA-Only) consisted of educational information about prostate cancer and the PSA test, and the other (Men's Health) included additional information about recognizing and preventing heart attack, stroke, and colon cancer. Structured survey, semistructured interview, and structured observational data were combined to compare participating community residents' pre/post changes in knowledge, intentions, and behaviors related to PSA IDM. RESULTS: The community-level interventions successfully engaged community participants in discussions, educated individuals, encouraged deliberation of information, and facilitated PSA test discussions with physicians. Men who participated in the PSA-Only educational sessions were more likely than those who attended the Men's Health educational sessions to discuss the PSA test with their physician (p=0.037). CONCLUSIONS: When prospective SES-related confounding factors are matched across comparison communities, PSA IDM interventions can be shown to promote IDM. Framing the PSA test decision relative to less-ambiguous screening decisions does not appear to increase the likelihood of PSA IDM.