Comparing the standard rating scale and the magnifier scale for assessing risk perceptions.

OBJECTIVE: A new risk perception rating scale ("magnifier scale") was recently developed to reduce elevated perceptions of low-probability health events, but little is known about its performance. The authors tested whether the magnifier scale lowers risk perceptions for low-probability (in 0%-1% magnifying glass section of scale) but not high-probability (>1%) events compared to a standard rating scale (SRS). METHOD: In studies 1 (n = 463) and 2 (n = 105), undergraduates completed a survey assessing risk perceptions of high- and low-probability events in a randomized 2 x 2 design: in study 1 using the magnifier scale or SRS, numeric risk information provided or not, and in study 2 using the magnifier scale or SRS, high- or low-probability event. In study 3, hypertension patients at the Philadelphia Veterans Affairs hospital completed a similar survey (n = 222) assessing risk perceptions of 2 self-relevant high-probability events-heart attack and stroke-with the magnifier scale or the SRS. RESULTS: In study 1, when no risk information was provided, risk perceptions for both high- and low-probability events were significantly lower (P < 0.0001) when using the magnifier scale compared to the SRS, but risk perceptions were no different by scale when risk information was provided (interaction term: P = 0.003). In studies 2 and 3, risk perceptions for the high-probability events were significantly lower using the magnifier scale than the SRS (P = 0.015 and P = 0.014, respectively). CONCLUSIONS: The magnifier scale lowered risk perceptions but did so for low- and high-probability events, suggesting that the magnifier scale should not be used for assessments of risk perceptions for high-probability events.

Patients' resistance to risk information in genetic counseling for BRCA1/2.

BACKGROUND: Risk information from health care providers is relevant to and used in nearly all medical decisions. Patients often misunderstand their risks, yet little is known about the risk perception that patients derive from risk communications with health care providers. This study examines patients' risk perceptions following communication with health care providers during genetic counseling about the risks of breast cancer and BRCA1/2 mutations. METHODS: A prospective, longitudinal study was conducted from October 2002 to February 2004 of women who received genetic counseling. The women completed a survey before their counseling and a telephone interview in the week after the counseling. Main outcome measures included change from precounseling in risk perception and accuracy of postcounseling risk perception (relative to actual risk information communicated). RESULTS: A total of 108 women agreed to participate in the study. The women's postcounseling risk perceptions were significantly lower than their precounseling risk perceptions (breast cancer: 17%, P<.001; mutation: 13%, P<.001) but were significantly higher than the actual risk information communicated (breast cancer: 19%, P<.001; mutation: 24%, P<.001). Accuracy of breast cancer risk perception but not mutation risk perception was associated with precounseling worry (P = .04), even after adjusting for trait anxiety (P = .01). CONCLUSIONS: This research demonstrates patients' resistance to risk information. Inappropriately high risk perception derived from a risk communication with a health care provider can lead patients to make different, and potentially worse, medical decisions than they would with an accurate risk perception and to be unnecessarily distressed about their risk.

Screening practices and beliefs of assisted reproductive technology programs.

OBJECTIVE: To explore assisted reproductive technology (ART) programs' beliefs about and practices for screening program candidates for the use of ART services. DESIGN: An anonymous, self-administered, mailed questionnaire. SETTING: U.S. ART programs. PARTICIPANT(S): Directors of U.S. ART programs. MAIN OUTCOME MEASURE(S): Screening practices and beliefs, agreement with statements about screening rights and responsibility, information collected about candidates, and likelihood of turning away hypothetical candidates. RESULT(S): The majority of programs do not have a formal policy for screening candidates. The majority of program directors agree that they have a right and responsibility to screen candidates. On average, programs turn away 4% of candidates each year. The majority of programs report being very to extremely likely to deny treatment to the couples described in various scenarios, such as physical abuse, positive HIV status, and single parenthood. Significant variation was seen across programs in their likelihood of turning away various hypothetical candidates. CONCLUSION(S): There is substantial variation in ART programs' screening practices. These results highlight the need for increased debate over what constitutes inappropriate denial of access to services, and what are prudent, social, ethical, and medical judgments.

Accounting for apparent "reverse" racial disparities in Department of Veterans Affairs (VA)-based medical care: influence of out-of-VA care.

Conclusions regarding racial differences in care following a newly elevated prostate-specific antigen (PSA) test at the Department of Veterans Affairs (VA) may differ depending on whether follow-up care outside the VA is considered. Consecutive Philadelphia, Pa, VA patients with newly elevated PSA tests (n = 183) were interviewed 1 year after baseline. Among exclusive VA users, Blacks had higher rates of urology referrals and prostate biopsies compared with Whites. However, these racial differences were attenuated when care obtained outside the VA also was considered.

Intended message versus message received in hypothetical physician risk communications: exploring the gap.

We examined the risk perception that is derived from hypothetical physician risk communications. Subjects (n= 217) completed a questionnaire on the Web for $3. Subjects were presented with four hypothetical cancer risk scenarios that included a physician risk communication in one of three risk communication formats: verbal only, verbal plus numeric probability as a percent, and verbal plus numeric probability as a fraction. In each scenario, subjects were asked to imagine themselves as the patient described and to state their perceived personal susceptibility to the cancer (i.e., risk perception) on a 0 to 100 scale, as well as responses to other measures. Subjects' risk perceptions were highly variable, spanning nearly the entire probability scale for each scenario, and the degree of variation was only slightly less in the risk communication formats in which a numeric statement of risk was provided. Subjects were more likely to overestimate than underestimate their risk relative to the stated risk in the numeric versions, and overestimation was associated with the belief that the physician minimized the risk so they wouldn't worry, innumeracy, and worry, as well as decisions about testing for the cancer. These results demonstrate significant gaps between the intended message and the message received in physician risk communications. Implications for medical decisions, patient distress, and future research are discussed.

The effect of numerical statements of risk on trust and comfort with hypothetical physician risk communication.

OBJECTIVE: To contribute to the debate about whether numeric statements of risk ought to be included in risk communications. DESIGN: Subjects (n = 115) completed a questionnaire involving a physician risk communication and 4 scenarios, each of which described a patient with symptoms and signs potentially suggestive of cancer. Each scenario was presented in 3 risk communication versions (a verbal version and 2 numeric versions) in a within-subject 4 x 3 design. Subjects rated their trust in and comfort with the information and their belief that the physician distorted their risk level. RESULTS: Subjects were significantly more trusting of (t =4.0, P < 0.001) and comfortable with (t =3.4, P = 0.001) the risk information, less likely to believe that the physician minimized the risk in the numeric versions than verbal versions (t =4.3, P < 0.0001), and just as likely to believe that the physician exaggerated the risk in the 2 versions (P = 0.588). CONCLUSIONS: Including a numeric statement of risk in a risk communication can increase trust and belief in and comfort with the risk information.

Differential willingness to undergo smallpox vaccination among African-American and white individuals.

OBJECTIVE: To examine potential disparities in willingness to be vaccinated against smallpox among different U.S. racial/ethnic groups. DESIGN: Cross-sectional survey using an experimental design to assess willingness to be vaccinated among African Americans compared to whites according to 2 strategies: a post-exposure "ring vaccination" method and a pre-exposure national vaccination program. SETTING: Philadelphia County district courthouse. PARTICIPANTS: Individuals awaiting jury duty. MEASUREMENTS: We included 2 scenarios representing these strategies in 2 otherwise identical questionnaires and randomly assigned them to participants. We compared responses by African Americans and whites. MAIN RESULTS: In the pre-exposure scenario, 66% of 190 participants were willing to get vaccinated against smallpox. In contrast, 84% of 200 participants were willing to get vaccinated in the post-exposure scenario (P =.0001). African Americans were less willing than whites to get vaccinated in the pre-exposure scenario (54% vs 77%; P =.004), but not in the post-exposure scenario (84% vs 88%; P =.56). In multivariate analyses, overall willingness to undergo vaccination was associated with vaccination strategy (odds ratio, 3.29; 95% confidence interval, 1.8 to 6.1). CONCLUSIONS: Racial disparity in willingness to get vaccinated varies by the characteristics of the vaccination program. Overall willingness was highest in the context of a post-exposure scenario. These results highlight the importance of considering social issues when constructing bioterror attack response plans that adequately address the needs of all of society's members.

Embryo disposal practices in IVF clinics in the United States.

BACKGROUND: The moral status of the human embryo is particularly controversial in the United States, where one debate has centered on embryos created in excess at in vitro fertilization (IVF) clinics. Little has been known about the disposal of these embryos. METHODS: We mailed anonymous, self-administered questionnaires to directors of 341 American IVF clinics. RESULTS: 217 of 341 clinics (64 percent) responded. Nearly all (97 percent) were willing to create and cryopreserve extra embryos. Fewer, but still a majority (59 percent), were explicitly willing to avoid creating extras. When embryos did remain in excess, clinics offered various options: continual cryopreservation for a charge (96 percent) or for no charge (4 percent), donation for reproductive use by other couples (76 percent), disposal prior to (60 percent) or following (54 percent) cryopreservation, and donation for research (60 percent) or embryologist training (19 percent). Qualifications varied widely among those personnel responsible for securing couples' consent for disposal and for conducting disposal itself. Some clinics performed a religious or quasi-religious disposal ceremony. Some clinics required a couple's participation in disposal; some allowed but did not require it; some others discouraged or disallowed it. CONCLUSIONS: The disposal of human embryos created in excess at American IVF clinics varies in ways suggesting both moral sensitivity and ethical divergence.

The role of physicians' recommendations in medical treatment decisions.

BACKGROUND: A shift away from the medical paternalism of the past has occurred, and today, the law and ethics advocate that physicians share decision-making responsibility with their patients. It is unclear, however, what the appropriate role of physicians' recommendations ought to be in this new shared decision-making paradigm. One way to approach this question is to assess the influence of physicians' recommendations. OBJECTIVE: In this study, the authors examine the influence of physicians' recommendations on hypothetical treatment decisions. Do physicians' recommendations influence treatment decisions in scenarios where the decision that maximizes health is obvious and apparent to subjects? Do recommendations pull subjects away from the treatment choice that they otherwise prefer (based on their decision when unaware of the physicians' recommendation)? DESIGN: An experimental web questionnaire presented hypothetical medical treatment scenarios in which the treatment choice that maximized health was obvious. Across scenarios, the authors varied physicians' recommendations in 3 ways: (1) physicians' recommendations supporting what maximized health, (2) physicians' recommendations that went against what maximized health, and (3) no physicians' recommendation. The participants were 102 volunteers. RESULTS: Hypothetical treatment decisions were significantly influenced by physicians'recommendations (P < 0.0001), and physicians'recommendations against the decision that maximized health pulled subjects away from the treatment decision that they made when no recommendation was given (P < 0.0001). CONCLUSION: Physicians' recommendations can lead people to make decisions that go against what is best and against what they would otherwise prefer. Physicians must take care in making recommendations and should incorporate patient preferences into their recommendations.