Communicating Outcomes to Patients: Can Less Be More?

Pictographs -- simple graphic depictions of outcome ratios using an icon array that shows the number of patients receiving the outcome per 100 -- have been well established by research as an effective tool in communicating outcomes to patients. Now, a recent study has found that a ‘‘less is more’’ approach that omits redundant mortality outcome statistics may be more preferable when using visual formats such as pictographs.

A 2008 study by Zikmund-Fisher, Fagerlin, and Ubel published in Cancer found that pictographs were preferred to the four horizontal bars used to represent outcomes in the online decision tool Adjuvant! Version 8 (www.adjuvantonline.com ). Adjuvant! calculates tailored estimates of the mortality risks, recurrence risks, and potential benefits of adjuvant therapy options such as hormone therapy or chemotherapy for breast cancer patients.

More recently, the same group of researchers tested the Adjuvant! graphs using only survival rates to see if the simplified versions would also enhance decisionmaking. The simplified pictographs were viewed by 832 participants, who were tested for comprehension, cognitive effort, treatment intentions, and graph evaluation ratings. A replication study was also conducted with 714 participants to ensure reliability of the findings.

In both randomized experiments, women who viewed the pictographs that only communicated survival rates comprehended the information as well if not better than those who viewed graphs depicting both survival and mortality rates. The survival-only graphs also had significantly higher evaluation ratings than the multi-outcome graphs. Interestingly, women who saw the survival-only graphs indicated an increased intention to select hormone therapy alone over a combination of hormone therapy and chemotherapy, a finding that the researchers admitted might be due to a bias created by presenting only survival rates.

Several limitations of the study reinforce the need for additional investigation. The researchers did not use breast cancer patients, who might have different responses to the graphs given their personal experience, and no demographic information was collected to determine what role patient sub-group differences may have played into the findings.

The researchers conclude, “By using a ‘less is more’ approach and stripping the risk graphics shown to our participants down to the bare minimum (the chance of survival), we increased participants’ satisfaction with the materials while simultaneously supporting risk comprehension that was at least as good as that achieved with more complex graphics.”
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Source: Zikmund-Fisher BJ, Fagerlin A and Ubel PA. A demonstration of “less can be more” in risk graphics. Med Decis Making OnlineFirst, published on April 7, 2010 as doi:10.1177/0272989X10364244.