The framing effect of relative and absolute risk

Abstract

Objective: To test whether a patient’s perception of benefit is influenced by whether the benefit is presented in relative or absolute terms.

Design: Questionnaire-based study.

Setting: A general medicine outpatient clinic at a rural tertiary care center associated with a medical school.

Patients: 470 of 511 consecutive patients who agreed to answer a questionnaire while waiting for their clinic visit. Mean age was 49.1 years, 62.1% were female, and 51.9% had at least one year of education beyond high school.

Main outcome measures: Patient response to the choice of two equally efficacious medications for the management of a hypothetical serious disease. The benefit of one medication was stated in relative terms, the other in absolute terms. Patients could choose either medication alone, indicate indifference to the choice of medication, or choose not to answer.

Main results: 56.8% of the patients chose the medication whose benefit was in relative terms.14.7% chose the medication whose benefit was in absolute terms. Only 15.5% were indifferent to the choice of medication. The patients preferred the medication whose benefit was in relative terms across a wide range of ages and educational levels. Further questioning suggested that the patients thought benefit was greater when expressed in relative terms because they ignored the underlying risk of disease and assumed it was one.

Conclusions: The “framing” of benefit (or risk) in relative versus absolute terms may have a major influence on patient preference.

Key words: framing; risk; patient preferences; benefit; decision making.

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References

  1. 1.

    Nisbett R, Ross L. Human Inference: Strategies and Shortcomings of Social Judgment. Englewood Cliffs, NJ: Prentice-Hall, 1980.

    Google Scholar 

  2. 2.

    Kong A, Barnett GO, Mosteller F, Youtz C. How medical professionals evaluate expressions of probability. N Engl J Med. 1986;315:740–4.

    PubMed  CAS  Article  Google Scholar 

  3. 3.

    Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science. 1981;211:453–8.

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    McNeil BJ, Pauker SG, Sox HC Jr, Tversky A. On the elicitation of preferences for alternative therapies. N Engl J Med. 1982;306:1259–62.

    PubMed  CAS  Article  Google Scholar 

  5. 5.

    Eraker SA, Sox HC Jr. Assessment of patients’ preferences for therapeutic outcomes. Med Decis Making 1981;1:29–39.

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    O’Connor AMC, Boyd NF, Warde P, Stolbach WL, Till JE. Eliciting preferences for alternative drug therapies in oncology: influence of treatment outcome description, elicitation technique and treatment experience on preferences. J Chron Dis. 1987;40:811–8.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Siminoff LA, Fetting JH. Effects of outcome framing on treatment decisions in the real world: impact of framing on adjuvant breast cancer decisions. Med Decis Making. 1989;9:262–71.

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Malenka DJ, Baron JA. Cholesterol and coronary heart disease; the importance of patient-specific attributable risk. Arch Intern Med. 1989;148:2247–52.

    Article  Google Scholar 

  9. 9.

    Laupacis A, Sackett DL, Roberts RS. An assessment of clinically useful measures of the consequences of treatment. N Engl J Med. 1988;318:1728–33.

    PubMed  CAS  Article  Google Scholar 

  10. 10.

    Browner WS, Hulley SB. Effect of risk status on treatment criteria; implications of hypertension trials. Hypertension. 1988; 13(suppl I):I51-I56.

    Google Scholar 

  11. 11.

    Benichou J, Gail MH. Estimates of absolute cause-specific risk in cohort studies. Biometrics. 1990;46:813–26.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Tversky A, Kahneman D. Judgement under uncertainty; heuristics and biases. Science. 1974;185:1124–31.

    Article  CAS  PubMed  Google Scholar 

  13. 13.

    Elstein AS. Clinical judgment: psychological research and medical practice. Science. 1976;194:696–700.

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Sox HC Jr, Blatt MA, Higgins MC, Marton KI. Medical Decision Making, 1st ed. Stoneham, MA: Butterworths, 1988;213–6.

    Google Scholar 

  15. 15.

    Hosmer DW Jr, Lemeshow S. Applied Logistic Regression. New York: John Wiley & Sons, 1989;38–63.

    Google Scholar 

  16. 16.

    SAS Institute Inc. SUGI Supplemental Library User’s Guide, Version 5 Edition. Cary, NO SAS Institute Inc. 1986;269–94.

  17. 17.

    Forrow L, Taylor WC, Arnold RM. Absolutely relative: how research results are summarized can effect treatment decisions. Am J Med. 1992;92:121–4.

    PubMed  Article  CAS  Google Scholar 

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Correspondence to Dr. David J. Malenka MD.

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Malenka, D.J., Baron, J.A., Johansen, S. et al. The framing effect of relative and absolute risk. J Gen Intern Med 8, 543–548 (1993). https://doi.org/10.1007/BF02599636

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Keywords

  • Absolute Term
  • Relative Term
  • General Internal Medicine
  • Relative Benefit
  • Absolute Risk Reduction