Patients Respond Well to Visual, Numerical Risk Indicators, Study Finds

Family physicians may be able to better communicate the risk of cardiovascular disease, or CVD, to their patients by using pie charts, bar graphs, histograms, absolute risk percentages, relative risk percentages and naturally occurring frequencies, according to recent research. However, many physicians instead rely on verbal communications alone.

The findings are from the study "How Do Family Physicians Communicate About Cardiovascular Risk? Frequencies and Determinants of Different Communication Formats" (9-page PDF; About PDFs) in BioMed Central's open-access journal BMC Family Practice.

According to the study authors, there's no clear evidence that points to the best format for communicating risk most effectively, but recent research has allowed a ranking of the different communication formats in terms of effectiveness and patient understanding. Research shows that using information on natural frequencies; graphics, such as bar charts; or combinations of these items leads to greater comprehension than using percentages or verbal qualifiers.

Moreover, patients prefer these types of formats to the use of percentages, said the study, which involved 22 Swedish primary care physicians audiotaping their counseling sessions with a total of 77 patients who had at least one risk factor for CVD, such as a lipid disorder, high blood pressure or smoking.

After the sessions, both the physicians and the patients answered a questionnaire. Patients rated how well they understood the information they received and their awareness of the risk of developing CVD.

Then, when the audiotapes were transcribed, the researchers classified the communication formats into verbal, numerical, visual or combined.

According to the study, most physicians communicated CVD risk to their patients through verbal qualifiers alone. A few combined verbal qualifiers with numerical information. Only one consultation used graphics alone; 10 other physicians combined graphics with numerical information.

Most of the visual format tools used were tables with a color-coding system indicating low, medium and high risk, and study authors noting that the colors seemed to be "powerful and familiar" to patients.

Although the study authors acknowledged that their sample was small and, therefore, not representative, the study was the first to provide data from a real clinical setting targeting the use of different formats in communicating cardiovascular risk factors.

"Our findings demonstrate a gap between the recommendations of medical associations, which favor numerical and visual formats for communicating risk, and the reality in clinical practice," the study authors said.

Family physician Alan Schwartzstein, M.D., of Oregon, Wis., a member of the AAFP Commission on Health of the Public and Science, told AAFP News Now he uses a number of formats -- verbal, numerical and visual -- to convey CVD risk to patients, making good use of the computer terminals that populate his practice's exam rooms and the practice's electronic health record, or EHR, system.

For example, he accesses the Framingham cardiovascular risk calculator (so named for its origination as part of the Framingham Heart Study), enters a patient's data and shows it to the patient. The application computes cardiac risk based on different variables and health behaviors.

"I say, 'OK, your blood pressure is up, you're smoking. Let's see how much we can change your risk of a heart attack if you stop smoking.' "

Schwartzstein enters blood pressure and lipid numbers, as well as other data, and the program computes that the patient has, for example, a 12 percent risk of a heart attack in the next 10 years. This approach is effective, he said.

"I've seen patients being extremely impressed by seeing it on the computer -- more than if I had talked to them about stopping smoking."

Schwartzstein said he also has a number of images that he uses as part of patient education materials on a variety of diseases. If a child has frequent ear infections, for example, he explains the cause with a pictorial representation of the head and ear.

"My experience is that patients respond incredibly well to both the pictures and the graphs," Schwartzstein said.

According to Wendy Biggs, M.D., assistant director of the AAFP Division of Medical Education, and formerly an associate professor of family medicine at Michigan State University College of Human Medicine in East Lansing, the Internet and EHRs have made patient education materials -- both written and graphical -- easily accessible.

However, she told AAFP News Now, the quality of information on the Internet, whether text or visual, can vary widely, and physicians can help patients sort it all out by pointing them to the most reliable sites.

What's more, according to Biggs, information about such communication issues is being inculcated into medical training in the United States.

"U.S. medical schools have recognized the importance of doctor-patient communication, and many now train medical students how to discuss medical risks and health screening tests with patients," she said.