Multilayered and digitally structured presentation formats of trustworthy recommendations: a combined survey and randomised trial

BMJ Open. 2017 Feb 10;7(2):e011569. doi: 10.1136/bmjopen-2016-011569.


Objectives: To investigate practicing physicians' preferences, perceived usefulness and understanding of a new multilayered guideline presentation format-compared to a standard format-as well as conceptual understanding of trustworthy guideline concepts.

Design: Participants attended a standardised lecture in which they were presented with a clinical scenario and randomised to view a guideline recommendation in a multilayered format or standard format after which they answered multiple-choice questions using clickers. Both groups were also presented and asked about guideline concepts.

Setting: Mandatory educational lectures in 7 non-academic and academic hospitals, and 2 settings involving primary care in Lebanon, Norway, Spain and the UK.

Participants: 181 practicing physicians in internal medicine (156) and general practice (25).

Interventions: A new digitally structured, multilayered guideline presentation format and a standard narrative presentation format currently in widespread use.

Primary and secondary outcome measures: Our primary outcome was preference for presentation format. Understanding, perceived usefulness and perception of absolute effects were secondary outcomes.

Results: 72% (95% CI 65 to 79) of participants preferred the multilayered format and 16% (95% CI 10 to 22) preferred the standard format. A majority agreed that recommendations (multilayered 86% vs standard 91%, p value=0.31) and evidence summaries (79% vs 77%, p value=0.76) were useful in the context of the clinical scenario. 72% of participants randomised to the multilayered format vs 58% for standard formats reported correct understanding of the recommendations (p value=0.06). Most participants elected an appropriate clinical action after viewing the recommendations (98% vs 92%, p value=0.10). 82% of the participants considered absolute effect estimates in evidence summaries helpful or crucial.

Conclusions: Clinicians clearly preferred a novel multilayered presentation format to the standard format. Whether the preferred format improves decision-making and has an impact on patient important outcomes merits further investigation.


Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Consumer Behavior*
  • Data Display*
  • General Practitioners
  • Humans
  • Internal Medicine
  • Lebanon
  • Norway
  • Physicians, Primary Care*
  • Practice Guidelines as Topic*
  • Spain
  • United Kingdom

Associated data

  • Dryad/10.5061/dryad.2qv30