A Randomized Trial of Decision-Making in Asymptomatic Carotid StenosisSilver B, Zaman IF, Ashraf K, et al. Neurology 2012;78:315-21. Conclusion: Presentation format (information framing) has a strong influence on patient decision making with regard to management of asymptomatic carotid stenosis.Summary: Randomized trials of asymptomatic carotid stenosis have shown a modest reduction in stroke risk when surgery is added to best medical therapy. One can express, when discussing with patients, this difference in multiple ways. The difference can be expressed as overall absolute risk reduction (11% vs 5% over 5 years), relative risk reduction (50% over 5 years), annualized absolute risk reduction (2% vs 1% per year over 5 years), absolute disease free survival (89% vs 95% over 5 years), or qualitative description of benefit, such as significantly less strokes with surgery vs medical therapy alone. There are also variables that may determine how patients respond to proposed alternative treatments, including patient age, sex, or race, as well as presenter age, sex, or race and how the information is presented (so-called information framing, Nikolajevic-Sarunac J et al, J Gen Intern Med 1999;14:591-8). This study sought to evaluate whether different presentation formats, presenter factors, and patient factors affected decision making regarding management of asymptomatic carotid stenosis. Subjects were recruited through a neurology clinic. All subjects were aged Ͼ18 years, without known carotid stenosis. Once recruited, subjects were randomized to a 30-second video with one of five presentation formats (absolute risk, absolute event-free survival, annualized absolute risk, relative risk, and qualitative description). Presentations were delivered by one of four presenter physicians (black women, white women, black men, and white men). After the presentation, subjects completed a 1-page form regarding background demographics and their decision regarding treatment choice. The video was watched and the survey completed by 409 subjects; overall, 48.4% chose surgery. The format of presentation strongly predicted choice of surgery (qualitative [64%], relative risk [63%], absolute risk [43%], absolute event-free survival [37%], and annualized absolute risk [35%]; P Ͻ .001). There was a trend for younger age (mean age 52 vs 55 years; P ϭ .054), male sex (53% vs 45%; P ϭ .08), and advanced education (42% for high school education or less vs 52% for more than high school education; P ϭ .052) to predict a choice for surgery. Sex and race of presenter and race of subject had no influence of the choice of treatment.Comment: The basic message is that it matters how you talk to patients. There are, however, multiple limitations to this study. The authors point out that the participants were only given information for 30 seconds and were not given the opportunity to ask questions to clarify information. It is therefore unclear whether the participants actually understood the message transmitted. Also, the subjects were not actual pat...