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

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.