Abukmail et al. BMC Med Inform Decis Mak (2021) 21:249 https://doi.org/10.1186/s12911-021-01612-9 RESEARCH Open Access Efect of diferent visual presentations on the comprehension of prognostic information: a systematic review Eman Abukmail*, Mina Bakhit, Chris Del Mar and Tammy Hofmann Abstract Background: Understanding prognostic information can help patients know what may happen to their health over time and make informed decisions. However, communicating prognostic information well can be challenging. Purpose: To conduct a systematic review to identify and synthesize research that has evaluated visual presentations that communicate quantitative prognostic information to patients or the public. Data sources: MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC and the Cochrane Central Register of Controlled Trials (CENTRAL) (from inception to December 2020), and forward and backward citation search. Study selection: Two authors independently screened search results and assessed eligibility. To be eligible, studies required a quantitative design and comparison of at least one visual presentation with another presentation of quan- titative prognostic information. The primary outcome was comprehension of the presented information. Secondary outcomes were preferences for or satisfaction with the presentations viewed, and behavioral intentions. Data extraction: Two authors independently assessed risk of bias and extracted data. Data synthesis: Eleven studies (all randomized trials) were identifed. We grouped studies according to the presenta- tion type evaluated. Bar graph versus pictograph (3 studies): no diference in comprehension between the groups. Survival vs mortality curves (2 studies): no diference in one study; higher comprehension in survival curve group in another study. Tabular format versus pictograph (4 studies): 2 studies reported similar comprehension between groups; 2 found higher comprehension in pictograph groups. Tabular versus free text (3 studies): 2 studies found no diference between groups; 1 found higher comprehension in a tabular group. Limitations: Heterogeneity in the visual presentations and outcome measures, precluding meta-analysis. Conclusions: No visual presentation appears to be consistently superior to communicate quantitative prognostic information. Keywords: Prognosis, Natural history, Health communication, Decision support techniques Introduction Shared decision making is a bidirectional communica- tion process in which clinicians and patients collaborate on making a health decision and discuss the available options (based on the best available evidence), the ben- *Correspondence: [email protected] efts and harms of each option, and the patient’s values, Faculty of Health Sciences and Medicine, Institute for Evidence-Based preferences, and circumstances [1, 2]. As part of making Healthcare, Bond University, 14 University Dr, Robina, QLD 4229, Australia © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Abukmail et al. BMC Med Inform Decis Mak (2021) 21:249 Page 2 of 10 decisions about the prevention or management of a Eligibility criteria health condition, patients need to know about more than Study types and participants just treatment options; they also need to know about the We included only studies with a quantitative design prognosis of the condition, with and without treatment. that looked at the prognosis of any health condition Communication of prognostic information is essential (real condition, hypothetical scenario, or fctitious as it helps patients to know what may happen to their condition). Te only participation restriction was the health over time, to make appropriate preparations, and exclusion of health professionals or health professional to make informed decisions about whether to intervene students. Studies of mixed populations (e.g. health and if so, how. If prognostic information is not communi- professionals and patients) were eligible if data were cated adequately, patients may have inaccurate expecta- reported separately for the eligible group. Tere was no tions about the likely course of their illness [3–5]. Poor limitation on study setting or publication language. communication of prognostic information can also make patients anxious, confused, and damage the relationship Interventions between clinician and patient [6, 7]. Studies were eligible if they compared a visual presen- Prognosis communication can be complex and chal- tation (e.g. a graph, words and numbers displayed in lenging for clinicians and patients. Clinicians sometimes tabular format) with at least one another type of pres- try to avoid or delay this kind of communication, while entation (e.g. another type of graph, or free text) to dis- patients often wait for their clinicians to initiate the pro- play quantitative prognostic information and included cess [8]. As with the communication of treatment infor- a specifed time frame (e.g. over the next 5 years) or mation, a contributor to the challenge of communicating time point (e.g. at 1 year). Prognostic information was prognostic information well is the difculty that clini- defned as information about the likelihood of any cians and patients can have understanding relevant quan- future outcome in patients with a given health condi- titative information [9–11]. tion including those who received no treatment (natu- To facilitate discussion about prognosis, clinicians may ral history) or those who did. use visual means (such as a graph) to present the quan- titative information. Although there is a large body of Outcomes synthesized evidence on how to communicate the quan- Our primary outcome was comprehension of the pre- titative benefts and harms of treatments, we are unaware sented information that was assessed using questions of any synthesis about the various visual presentations that required a quantitative answer (e.g. likelihood or that can be used to communicate quantitative prognostic duration of the outcome). For this reason, only some information. of the questions asked were eligible. Studies/data that assessed comprehension with questions requiring qual- Methods itative responses were ineligible. Secondary outcomes included: preferences for any of the presentations eval- Te protocol of this systematic review is registered at uated; satisfaction with the presentation; and behav- (CRD42020192564) and can be found in the Open Sci- ioral intentions relevant to the information presented ence Framework osf.io/ze26g. (e.g. intention to be screened). Objective Study selection Tis systematic review aimed to identify and synthesize Two authors (EA and MB) independently screened the research that has evaluated visual presentations that titles and abstracts, and then the full text of potentially communicate quantitative prognostic information to included studies. Discrepancies were resolved through patients or the public. consultation with the other two senior authors (CDM and TH). Information sources Data extraction and risk of bias assessment We searched for studies in six databases: MEDLINE, Data were extracted into a custom-designed spread- EMBASE, CINAHL, ERIC, PsycINFO, and the Cochrane sheet. Te studies’ characteristics (e.g., study settings, Central Register of Controlled Trials (CENTRAL), each sampling methods, study design) and participants’ from date of inception till December 2020. We used a tai- characteristics (e.g., age, sex, educational level, health lored search strategy for each database (see Additional literacy level, numeracy level, and the health condi- fle 1). Forward and backward citation analysis of the tion studied). Intervention details (including type of included studies was performed using Web of Science. Abukmail et al. BMC Med Inform Decis Mak (2021) 21:249 Page 3 of 10 presentation (e.g., bar graph), the presented informa- Results tion, who delivered the information, how, where and Study selection when the information was delivered), outcome details Our search identifed 5648 articles across the databases (including the eligible outcomes, how they were meas- and 614 articles identifed through forward and back- ured and at what timepoints) and result details (includ- ward citation analysis of the included studies (6262 in ing number of responses analysed, follow up rate, total), 5133 remained after duplicates were removed. results of eligible studies) are tabulated in the Addi- After the full-text screening, we identifed 9 articles: in tional fle 1 and show the data extracted. Two authors 2 of these,