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Original Investigation
Less Is More
January 2016

A Comparative Effectiveness Trial of Alternate Formats for Presenting Benefits and Harms Information for Low-Value Screening ServicesA Randomized Clinical Trial

Author Affiliations
  • 1University of North Carolina Research Center for Excellence in Clinical Preventive Services, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
  • 2Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
  • 3Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
  • 4Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill
  • 5Community Programs, Napa County Office of Education, Napa, California
  • 6University of North Carolina Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill
  • 7Duke Clinical Research Institute and Department of Medicine, Duke University School of Medicine, Durham, Chapel Hill
  • 8Division of General Medicine, University of Colorado School of Medicine, Denver
  • 9Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
JAMA Intern Med. 2016;176(1):31-41. doi:10.1001/jamainternmed.2015.7339

Importance  Healthcare overuse, the delivery of low-value services, is increasingly recognized as a critical problem. However, little is known about the comparative effectiveness of alternate formats for presenting benefits and harms information to patients as a strategy to reduce overuse.

Objective  To examine the effect of different benefits and harms presentations on patients’ intentions to accept low-value or potentially low-value screening services (prostate cancer screening in men ages 50-69 years; osteoporosis screening in low-risk women ages 50-64 years; or colorectal cancer screening in men and women ages 76-85 years).

Design, Setting, and Participants  Randomized clinical trial of 775 individuals eligible to receive information about any 1 of the 3 screening services and scheduled for a visit with their clinician. Participants were randomized to 1 of 4 intervention arms that differed in terms of presentation format: words, numbers, numbers plus narrative, and numbers plus framed presentation. The trial was conducted from September 2012 to June 2014 at 2 family medicine and 2 internal medicine practices affiliated with the Duke Primary Care Research Consortium. The data were analyzed between May and September of 2015.

Interventions  One-page evidence-based decision support sheets on each of the 3 screening services, with benefits and harms information presented in 1 of 4 formats: words, numbers, numbers plus narratives, or numbers plus a framed presentation.

Main Outcomes and Measures  The primary outcome was change in intention to accept screening (on a response scale from 1 to 5). Our secondary outcomes included general and disease-specific knowledge, perceived risk and consequences of disease, screening attitudes, perceived net benefit of screening, values clarity, and self-efficacy for screening.

Results  We enrolled and randomly allocated 775 individuals, aged 50 to 85 years, to 1 of 4 intervention arms: 195 to words, 192 to numbers, 196 to narrative, and 192 to framed formats. Intentions to accept screening were high before the intervention and change in intentions did not differ across intervention arms (words, −0.07; numbers, −0.05; numbers plus narrative, −0.12; numbers plus framed presentation, −0.02; P = .57 for all comparisons). Change in other outcomes also showed no difference across intervention arms. Results were similar when stratified by screening service.

Conclusions and Relevance  Single, brief, written decision support interventions, such as the ones in this study, are unlikely to be sufficient to change intentions for screening. Alternate and additional interventions are needed to reduce overused screening services.

Trial Registration  clinicaltrials.gov Identifier: NCT01694784