Decision Aids: The Effect of Labeling Options on Patient Choices and Decision Making

Abstract

Background: Conscious and unconscious biases can influence how people interpret new information and make decisions. Current standards for creating decision aids, however, do not address this issue.

Method: Using a 2×2 factorial design, we developed surveys that contained a decision scenario (involving a choice between aspirin or a statin drug to lower risk of heart attack) and a decision aid. Each aid presented identical information about reduction in heart attack risk and likelihood of a major side effect. They differed in whether the options were labeled and the amount of decisional guidance: information only (a balance sheet) versus information plus values clarification (a multicriteria decision analysis). We sent the surveys to members of 2 Internet survey panels. After using the decision aid, participants indicated their preferred medication. Those using a multicriteria decision aid also judged differences in the comparative outcome data provided for the 2 options and the relative importance of achieving benefits versus avoiding risks in making the decision.

Results: The study sample size was 536. Participants using decision aids with unlabeled options were more likely to choose a statin: 56% versus 25% (P < 0.001). The type of decision aid made no difference. This effect persisted after adjustment for differences in survey company, age, gender, education level, health literacy, and numeracy. Participants using unlabeled decision aids were also more likely to interpret the data presented as favoring a statin with regard to both treatment benefits and risk of side effects (P ≤ 0.01). There were no significant differences in decision priorities (P = 0.21).

Conclusion: Identifying the options in patient decision aids can influence patient preferences and change how they interpret comparative outcome data.

Keywords: cognitive biases; patient decision aids; shared decision making.

Figure 1

Blinded decision aid example. The upper panel shows the balance sheet decision aid. The AHP-based decision aid included all of the elements shown in the figure. The balance sheet was used to present the comparative outcome information. Pairwise comparison judgments regarding differences between the options’ benefits and risks were entered using the interactive sliders shown in the middle of the figure. Sliders were also used to compare the priorities of benefits versus risks in making the decision. Results of the analysis are summarized in the chart and table shown below. The unblinded decision aids were identical except that aspirin was denoted as Medication A and statin was denoted as Medication B.

Figure 2

Preferred medications. This figure illustrates the overall differences in preferred medications between decision aids with labeled versus unlabeled options and differences within each type of decision aid. All differences are statistically significant, p < 0.01.