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Epstein RM, Alper BS, Quill TE. Communicating Evidence for Participatory Decision Making. JAMA. 2004;291(19):2359–2366. doi:10.1001/jama.291.19.2359
Author Affiliations: Rochester Center to Improve Communication in Health Care, Department of Family Medicine (Dr Epstein) and Departments of Internal Medicine (Dr Quill) and Psychiatry (Drs Quill and Epstein), University of Rochester Medical Center, Rochester, NY; Department of Family and Community Medicine, School of Medicine, University of Missouri-Columbia (Dr Alper); and Dynamic Medical Information Systems LLC, Columbia, Mo (Dr Alper).
The Patient-Physician Relationship Section Editor: Richard M. Glass, MD, Deputy Editor.
Context Informed patients are more likely to actively participate in their care,
make wiser decisions, come to a common understanding with their physicians,
and adhere more fully to treatment; however, currently there are no evidence-based
guidelines for discussing clinical evidence with patients in the process of
making medical decisions.
Objective To identify ways to communicate evidence that improve patient understanding,
involvement in decisions, and outcomes.
Data Sources and Study Selection Systematic review of MEDLINE for the period 1966-2003 and review of
reference lists of retrieved articles to identify original research dealing
with communication between clinicians and patients and directly addressing
methods of presenting clinical evidence to patients.
Data Extraction Two investigators and a research assistant screened 367 abstracts and
2 investigators reviewed 51 full-text articles, yielding 8 potentially relevant
Data Synthesis Methods for communicating clinical evidence to patients include nonquantitative
general terms, numerical translation of clinical evidence, graphical representations,
and decision aids. Focus-group data suggest presenting options and/or equipoise
before asking patients about preferred decision-making roles or formats for
presenting details. Relative risk reductions may be misleading; absolute risk
is preferred. Order of information presented and time-frame of outcomes can
bias patient understanding. Limited evidence supports use of human stick figure
graphics or faces for single probabilities and vertical bar graphs for comparative
information. Less-educated and older patients preferred proportions to percentages
and did not appreciate confidence intervals. Studies of decision aids rarely
addressed patient-physician communication directly. No studies addressed clinical
outcomes of discussions of clinical evidence.
Conclusions There is a paucity of evidence to guide how physicians can most effectively
share clinical evidence with patients facing decisions; however, basing our
recommendations largely on related studies and expert opinion, we describe
means of accomplishing 5 communication tasks to address in framing and communicating
clinical evidence: understanding the patient's (and family members') experience
and expectations; building partnership; providing evidence, including a balanced
discussion of uncertainties; presenting recommendations informed by clinical
judgment and patient preferences; and checking for understanding and agreement.
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