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Background: Many people display omission bias in medical decision making, accepting the risk of passive nonintervention rather than actively choosing interventions (such as vaccinations) that result in lower levels of risk., Objective: Testing whether people's preferences for active interventions would increase when deciding for others versus for themselves., Research Design: Survey participants imagined themselves in 1 of 4 roles: patient, physician treating a single patient, medical director creating treatment guidelines, or parent deciding for a child. All read 2 short scenarios about vaccinations for a deadly flu and treatments for a slow-growing cancer., Participants: Two thousand three hundred and ninety-nine people drawn from a demographically stratified internet sample., Measures: Chosen or recommended treatments. We also measured participants' emotional response to our task., Results: Preferences for risk-reducing active treatments were significantly stronger for participants imagining themselves as medical professionals than for those imagining themselves as patients (vaccination: 73% [physician] & 63% [medical director] vs 48% [patient], Ps<.001; chemotherapy: 68% & 68% vs 60%, Ps<.012). Similar results were observed for the parental role (vaccination: 57% vs 48%, P=.003; chemotherapy: 72% vs 60%, P<.001). Reported emotional reactions were stronger in the responsible medical professional and parental roles yet were also independently associated with treatment choice, with higher scores associated with reduced omission tendencies (OR=1.15 for both regressions, Ps<.01)., Conclusions: Treatment preferences may be substantially influenced by a decision-making role. As certain roles appear to reinforce "big picture" thinking about difficult risk tradeoffs, physicians and patients should consider re-framing treatment decisions to gain new, and hopefully beneficial, perspectives.

Purpose: When making medical decisions, people often care not only about what happens but also about whether the outcome was a result of actions voluntarily taken or a result of inaction. This study assessed the proportion of people choosing nonoptimal treatments (treatments which reduced survival chances) when presented with hypothetical cancer scenarios which varied by outcome cause., Methods: A randomized survey experiment tested preferences for curing an existent cancer with 2 possible treatments (medication or surgery) and 2 effects of treatment (beneficial or harmful). Participants were 112 prospective jurors in the Philadelphia County Courthouse and 218 visitors to the Detroit-Wayne County Metropolitan Airport., Results: When treatment was beneficial, 27% of participants rejected medication, whereas only 10% rejected surgery with identical outcomes ( 2 = 5.87, P < 0.02). When treatment was harmful, participants offered surgery were significantly more inclined to take action (65% v. 38%, chi(2) = 11.40, P = 0.001), even though doing so reduced overall survival chances., Conclusions: Faced with hypothetical cancer diagnoses, many people say they would pursue treatment even if doing so would increase their chance of death. This tendency toward active treatment is notably stronger when the treatment offered is surgery instead of medication. Our study suggests that few people can imagine standing by and doing nothing after being diagnosed with cancer, and it should serve to remind clinicians that, for many patients, the best treatment alternative may not only depend on the medical outcomes they can expect to experience but also on whether those outcomes are achieved actively or passively.

Patients with chronic health conditions often rate their quality of life (QoL) significantly higher than non-patients. One explanation for this discrepancy is that non-patients focus on the negative aspects of the onset of a condition, especially the early difficulties people face when they first experience a debilitating condition, without considering that patients can adapt to it over time. To test this hypothesis, we had 359 people perform person tradeoff (PTO) elicitations in an online survey, varying whether the treatment programs under consideration saved the lives of patients (a) with pre-existing paraplegia; or (b) who would experience new onset of paraplegia. Half of each group completed an "adaptation exercise" which encouraged them to consider their own ability to emotionally adapt to negative events in general and specifically to having paraplegia. The adaptation manipulation increased the value participants placed on pre-existing paraplegia (p=0.03) and on new onset paraplegia (p=0.05), relative to saving healthy lives. Moreover, the adaptation exercise dramatically reduced the differences between evaluations of pre-existing and new onset paraplegia to values within 2% of each other. Our findings suggest that asking non-patients to do an adaptation exercise before giving QoL ratings may help close the gap in ratings between patients and citizen non-patients.

Background: Recent proposals to reform cost-effectiveness analysis (CEA) by weighting health benefits [(Quality-adjusted life-years) QALYs] by recipients' age are based on studies examining age-related preferences in life-saving contexts. We investigated whether the perceived importance of age in resource allocation decisions differs among intervention-types., Methods: 160 individuals were recruited from a cafeteria of a university medical centre and asked to choose between hypothetical health care programmes. Scenario A described two programmes treating life-threatening conditions and Scenario B two programmes providing palliative care. Programmes were identical except in average patient age (35 versus 65). Respondents also directly rated the importance of age for allocating resources for six types of interventions., Results: Responses for the life-saving scenario favoured younger age groups while those for the palliative care scenario showed no age preference. The difference between scenarios was statistically significant. When directly rating the importance of age in allocating treatment resources, people placed greatest importance on age in treating infertility and life-saving, and least importance in treating depression., Discussion: The importance people place on age as a resource allocation criterion depends on the clinical context. As QALYs serve as a common measure of health benefits for all intervention types, age weighting of QALYs is premature.

Reports of randomized clinical trials often use survival curves to summarize clinical outcomes over time and graphically demonstrate evidence of treatment effectiveness. Survival curves can also be used in patient communications to display how health risks accumulate over time. In a randomized survey experiment, administered online, we tested whether people viewing survival curves appropriately adjust their risk perceptions to account for the duration shown. Internet users (N= 864) were recruited from a demographically balanced U.S. panel. Participants read about a hypothetical disease and then viewed one of four survival graphs that displayed mortality risks with and without treatment. Survival graphs showed either a visually large or visually small difference between treatments and were labeled to represent either 5-year or 15-year risk statistics. Participants then provided ratings of disease seriousness, as well as treatment effectiveness for each possible treatment. Variations in ratings corresponded more with visual dissimilarity than with changes in the statistical risk exhibited, with participants perceiving somewhat greater disease seriousness and significant differences in treatment effectiveness in large visual difference graphs. We conclude that when people interpret survival curves, they often fail to sufficiently account for the timeframe represented and perceive more risk and larger differences when identical risks are displayed over longer periods of time. We recommend that all presentations of survival graphics, whether to patients, physicians, or scientists, emphasize duration information (e.g., in the title) and remind readers that attending to graph axis labels is the only way to pierce these visual illusions.

Counseling women about breast cancer risks has been found to decrease screening compliance. We investigated whether women's reactions to risk information are an artifact of requiring women to estimate the risk of breast cancer prior to receiving risk information. Three hundred and fifty-six women were randomized to either make or not make a risk estimate prior to receiving risk information. Outcome measures were participants' estimates of the average woman's breast cancer risk and their emotional response to the risk information. Women overestimated the lifetime risk of breast cancer (M = 46%). Women who made risk estimates felt more relieved about the risk and perceived the risk as being lower than women who did not make estimates (p's < 0.001). Asking people to estimate risks influenced their subsequent perceptions of the risk of breast cancer.

Choices of health care providers can become inconsistent when people lack sufficient context to assess the value of available information. In a series of surveys, general population samples were randomized to read descriptions of either 2 possible health care providers or a single provider. Some information about providers was easy to consider (e.g., travel time), but some was difficult to interpret without additional context (e.g., success rates). Ratings of the described health care providers varied significantly by whether options were evaluated independently or concurrently. For example, one fertility clinic (33% success rate, 15 min away) was rated higher than a 2nd (40% success rate, 45 min away) when each clinic was considered separately (7.1 v. 6.2, P = 0.046), but preferences reversed in joint evaluation (5.9 v. 6.7, P = 0.051). The results suggest that clinicians and developers of patient information materials alike should consider information evaluability when deciding how to present health care options to patients.