Physician colorectal cancer screening recommendations: an examination based on informed decision making

Opportunities and Challenges When Using the Electronic Health Record for Practice-Integrated Patient-Facing Interventions: The e-Assist Colon Health Randomized Trial

Background

Even after a physician recommendation, many people remain unscreened for colorectal cancer (CRC). The proliferation of electronic health records (EHRs) and tethered online portals may afford new opportunities to embed patient-facing interventions within clinic workflows and engage patients following a physician recommendation for care. We evaluated the effectiveness of a patient-facing intervention designed to complement physician office-based recommendations for CRC screening.

Design

Using a 2-arm pragmatic, randomized clinical trial, we evaluated the intervention’s effect on CRC screening use as documented in the EHR (primary outcome) and the extent to which the intervention reached the target population. Trial participants were insured, aged 50 to 75 y, with a physician recommendation for CRC screening. Typical EHR functionalities, including patient registries, health maintenance flags, best practice alerts, and secure messaging, were used to support research-related activities and deliver the intervention to enrolled patients.

Results

A total of 1,825 adults consented to trial participation, of whom 78% completed a baseline survey and were exposed to the intervention. Most trial participants (>80%) indicated an intent to be screened on the baseline survey, and 65% were screened at follow-up, with no significant differences by study arm. One-third of eligible patients were sent a secure message. Among those, more than three-quarters accessed study material.

Conclusions

By leveraging common EHR functionalities, we integrated a patient-facing intervention within clinic workflows. Despite practice integration, the intervention did not improve screening use, likely in part due to portal-based interventions not reaching those for whom the intervention may be most effective.

Implications

Embedding patient-facing interventions within the EHR enabled practice integration but may minimize program effectiveness by missing important segments of the patient population.

Highlights

The communication of uncertainty in health: A scoping review

OBJECTIVE

To conduct a scoping review of existing studies that examine communication strategies that address uncertainty in health and categorize them using the taxonomy of uncertainty.

METHODS

Relevant articles retrieved from ten databases were categorized according to the dimensions of the taxonomy of uncertainty, and study characteristics were extracted from each article.

RESULTS

All articles (n = 63) explored uncertainty in the context of probabilistic risk and related to scientific issues (n = 63; 100%). The majority focused on complexity (n = 24; 38.1%) and uncertainty experienced by patients (n = 52; 82.5%). Most utilized quantitative methods (n = 46; 73.0%), hypothetical scenarios (n = 49; 77.8%), and focused on cancer (n = 20; 31.7%). Theory guided messages and study design in fewer than half (n = 27; 42.9%).

CONCLUSIONS

Heterogeneity in terminology used to refer to different types of uncertainties preclude a unified research agenda on uncertainty communication. Research predominately focuses on probability as the source of uncertainty, uncertainties related to scientific issues, and uncertainty experienced by patients.

PRACTICE IMPLICATIONS

Additional efforts are needed to understand providers' experience of uncertainty, and to identify strategies to address ambiguity. Future studies should use consistent terminology to allow for coherence and advancement of uncertainty communication scholarship. Continued efforts to refine the existing taxonomy should be undertaken.

Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol

Background

Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation’s most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation.

Methods

This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase.

Discussion

There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study.

Trial registration

This protocol is registered at clinicaltrials.gov (NCT04514341) on 14 August 2020.

Lower Adherence: A Description of Colorectal Cancer Screening Barrier Talk

Understanding how patients and physicians discuss screening barriers may illuminate reasons for non-adherence to recommended colorectal cancer (CRC) screening. The goal of the present study was to describe patients' reporting of and physicians' responses to CRC screening barriers and examine their associations with patients' CRC screening behaviors. Audio-recorded primary care consultations (N = 413) with patients due for CRC screening were used to identify CRC screening-related barrier talk and physician responses. Presence of barrier talk was associated with less patient adherence to CRC screening (OR = 0.568, p = 0.007). Neither CRC screening talk (n = 413) nor physician responses (n = 151) were associated with patients' CRC screening. Among the consultations in which barrier talk occurred (n = 151), patients most often reported test-related (28.9%) and psychological (26.1%) barriers. Barriers were most often reported in the context of CRC screening discussions (45.7%) or in direct response to a physician's question about CRC screening (48.6%). Results indicated that patients rarely raised CRC screening barriers unprompted and that presence of barrier talk was predictive of CRC screening behavior. These findings may help improve future clinical practice by highlighting that patients may benefit from physicians initiating and facilitating discussions of CRC screening barriers and directly helping patients overcome known barriers to CRC screening.

[Cancer prevention and screening: What french GPs could do?]

An effective health system is based on effective primary care, at the center of which is family medicine. Cancer prevention and screening are integral aspects of general practitioners skills. Prevention is linked with the notion of risk. The relationship between the general practitioner and his or her patient reinforces the prevention of the development of preventable risk factors. It also strengthens information on intrinsic risk factors for patients. The protective factors highlighted by the general practitioner can thus reduce the risk a little more. Screening strategies differs across cancers and countries. In France, general practitioner's involvement is important for colorectal cancer screening. The active participation of their general practitioner, strengths patient's adherence and participation. Their role is to inform and collect data for breast cancer screening. Recently organized cervical cancer screening requires greater involvement of general practitioners who can act as both actors and informants. Family medicine is at the heart of cancer prevention and screening. It is a central hub for improving the health of patients in our healthcare system. The general practitioner knows the patient, which gives him an important advantage to accompany him in the prevention and screening of his risk factors.

Individualized Colorectal Cancer Screening Discussions Between Older Adults and Their Primary Care Providers: A Cross-Sectional Study

Introduction. Discussions of colorectal cancer (CRC) screening with older adults should be individualized to maximize appropriate screening. Our aim was to describe CRC screening discussions and explore their associations with patient characteristics and screening intentions. Methods. Cross-sectional survey of 422 primary care patients aged ≥70 years and eligible for CRC screening, including open-ended questions about CRC screening discussions. Primary outcomes were the frequency with which CRC screening discussions occurred, who had those discussions, and the domains that emerged from thematic analysis of participants' brief reports of their discussions. We also examined the associations between 1) patient characteristics and whether a screening discussion occurred and 2) the domains discussed and what screening decisions were made. Results. Of 422 participants, 209 reported having discussions and 201 responded to open-ended questions about CRC discussions. In a regression analysis, several factors were associated with increased odds of having a discussion: participants' preference to pursue screening (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3, 3.9), good health (OR 2.9, 95% CI 1.7, 4.8), and receipt of the decision aid (OR 2.1, 95% CI 1.4, 3.2). Our thematic analysis identified five domains related to discussion content and three related to discussion process. The CRC screening-related information domain was the most commonly discussed content domain, and the timing/frequency domain was associated with increased odds of intent to pursue screening. Decision-making role, the most commonly discussed process domain, was associated with increased odds of the intent to forgo CRC screening. Conclusions and Relevance. CRC screening discussions varied by type of participant and content. Future work is needed to determine if interventions focused on specific domains alters the appropriateness of participants' colorectal cancer screening intentions.

Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening

Background

Primary-care providers may contribute to the use of low-value cancer screening.

Objective

We sought to examine circumstances under which primary-care providers would discuss and recommend two types of cancer screening services across a spectrum of net benefit and other factors known to influence screening.

Patients and methods

This was a cross sectional survey of 126 primary-care providers in 24 primary-care clinics in the US. Participants completed surveys with two hypothetical screening scenarios for prostate or colorectal cancer (CRC). Patients in the scenarios varied by age and screening-request status. For each scenario, providers indicated whether they would discuss and recommend screening. Providers also reported on their screening attitudes and the influence of other factors known to affect screening (short patient visits, worry about lawsuits, clinical reminders/performance measures, and screening guidelines). We examined associations between providers’ attitudes and their screening recommendations for hypothetical 90-year-olds (the lowest-value screening).

Results

Providers reported they would discuss cancer screening more often than they would recommend it (P<0.001). More providers would discuss and recommend screening for CRC than prostate cancer (P<0.001), for younger than older patients (P<0.001), and when the patient requested it than when not (P<0.001). For a 90-year-old patient, every point increase in cancer-specific screening attitude increased the likelihood of a screening recommendation (30% for prostate cancer and 30% for CRC).

Discussion

While most providers’ reported practice patterns aligned with net benefit, some providers would discuss and recommend low-value cancer screening, particularly when faced with a patient request.

Conclusion

More work appears to be needed to help providers to discuss and recommend screening that aligns with value.

Ethical issues with colorectal cancer screening-a systematic review

RATIONALE, AIMS, AND OBJECTIVES

Colorectal cancer (CRC) screening is widely recommended and implemented. However, sometimes CRC screening is not implemented despite good evidence, and some types of CRC screening are implemented despite lack of evidence. The objective of this article is to expose and elucidate relevant ethical issues in the literature on CRC screening that are important for open and transparent deliberation on CRC screening.

METHODS

An axiological question-based method is used for exposing and elucidating ethical issues relevant in HTA. A literature search in MEDLINE, Embase, PsycINFO, PubMed Bioethics subset, ISI Web of Knowledge, Bioethics Literature Database (BELIT), Ethics in Medicine (ETHMED), SIBIL Base dati di bioetica, LEWI Bibliographic Database on Ethics in the Sciences and Humanities, and EUROETHICS identified 870 references of which 114 were found relevant according to title and abstract. The content of the included papers were subject to ethical analysis to highlight the ethical issues, concerns, and arguments.

RESULTS

A wide range of important ethical issues were identified. The main benefits are reduced relative CRC mortality rate, and potentially incidence rate, but there is no evidence of reduced absolute mortality rate. Potential harms are bleeding, perforation, false test results, overdetection, overdiagnosis, overtreatment (including unnecessary removal of polyps), and (rarely) death. Other important issues are related to autonomy and informed choice equity, justice, medicalization, and expanding disease.

CONCLUSION

A series of important ethical issues have been identified and need to be addressed in open and transparent deliberation on CRC screening.

Eliciting women's cervical screening preferences: a mixed methods systematic review protocol

BACKGROUND

With the accumulation of evidence regarding potential harms of cancer screening in recent years, researchers, policy-makers, and the public are becoming more critical of population-based cancer screening. Consequently, a high-quality cancer screening program should consider individuals' values and preferences when determining recommendations. In cervical cancer screening, offering women autonomy is considered a "person-centered" approach to health care services; however, it may impact the effectiveness of the program should women choose to not participate. As part of a larger project to investigate women's cervical screening preferences and correlates of these preferences, this systematic review will capture quantitative and qualitative investigations of women's cervical screening preferences and the methods used to elicit them.

DESIGN AND METHODS

This mixed methods synthesis will use a thematic analysis approach to synthesize qualitative, quantitative, and mixed methods evidence. This protocol describes the methods that will be used in this investigation. A search strategy has been developed with a health librarian and peer reviewed using PRESS. Based on this strategy, five databases and the gray literature will be searched for studies that meet the inclusion criteria. The quality of the included individual studies will be examined using the Mixed Methods Appraisal Tool. Three reviewers will extract data from the primary studies on the tools or instruments used to elicit women's preferences regarding cervical cancer screening, theoretical frameworks used, outcomes measured, the outstanding themes from quantitative and qualitative evidence, and the identified preferences for cervical cancer screening. We will describe the relationships between study results and the study population, "intervention" (e.g., tool or instrument), and context. We will follow the PRISMA reporting guideline. We will compare findings across studies and between study methods (e.g., qualitative versus quantitative study designs). The strength of the synthesized findings will be assessed using the validated GRADE and CERQual tool.

DISCUSSION

This review will inform the development of a tool to elicit women's cervical screening preferences. Understanding the methods used to elicit women's preferences and what is known about women's cervical screening preferences will be useful for guideline developers who wish to incorporate a woman-centered approach specifically for cervical screening guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016035737.

Knowledge and values for cancer screening decisions: Results from a national survey

BACKGROUND

Guidelines recommend shared decision making (SDM) for cancer screening decisions. SDM requires providers to ensure that patients are informed about screening issues and to support decisions that are concordant with patient values. We evaluated decision-quality factors for breast, colorectal, and prostate cancer screening decisions.

METHODS

We conducted a national, population-based Internet survey of adults aged 40+ to characterize perceptions about about cancer screening, the importance of information sources, cancer screening knowledge, values and preferences for screening, and the most influential drivers of decisions.

RESULTS

Among 1452 participants who completed the survey, the mean age was 60, and 94% were insured. Most participants reported feeling well informed about cancer screening, though only 21% reported feeling extremely well informed. Most participants correctly answered about 50% of the knowledge questions, with the majority markedly overestimating lifetime risk of cancer diagnoses and mortality. Participants rated health care providers as the most important source of information.

CONCLUSION

Although respondents considered themselves well informed about cancer they performed poorly on knowledge questions. This discordance suggests the potential for poor-quality decision making.

PRACTICE IMPLICATIONS

To improve the quality of decision making, providers need training to utilize decision support tools and time to carry out SDM.

The Effectiveness of a Physician-Only and Physician-Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician-patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician-patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician-patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.

Validity, reliability, and generalizability in qualitative research

In general practice, qualitative research contributes as significantly as quantitative research, in particular regarding psycho-social aspects of patient-care, health services provision, policy setting, and health administrations. In contrast to quantitative research, qualitative research as a whole has been constantly critiqued, if not disparaged, by the lack of consensus for assessing its quality and robustness. This article illustrates with five published studies how qualitative research can impact and reshape the discipline of primary care, spiraling out from clinic-based health screening to community-based disease monitoring, evaluation of out-of-hours triage services to provincial psychiatric care pathways model and finally, national legislation of core measures for children's healthcare insurance. Fundamental concepts of validity, reliability, and generalizability as applicable to qualitative research are then addressed with an update on the current views and controversies.

Validity, reliability, and generalizability in qualitative research

In general practice, qualitative research contributes as significantly as quantitative research, in particular regarding psycho-social aspects of patient-care, health services provision, policy setting, and health administrations. In contrast to quantitative research, qualitative research as a whole has been constantly critiqued, if not disparaged, by the lack of consensus for assessing its quality and robustness. This article illustrates with five published studies how qualitative research can impact and reshape the discipline of primary care, spiraling out from clinic-based health screening to community-based disease monitoring, evaluation of out-of-hours triage services to provincial psychiatric care pathways model and finally, national legislation of core measures for children's healthcare insurance. Fundamental concepts of validity, reliability, and generalizability as applicable to qualitative research are then addressed with an update on the current views and controversies.

Physician use of persuasion and colorectal cancer screening

The impact of patient-physician communication on subsequent patient behavior has rarely been evaluated in the context of colorectal cancer (CRC) screening discussions. We describe physicians' use of persuasive techniques when recommending CRC screening and evaluate its association with patients' subsequent adherence to screening. Audio recordings of N = 414 periodic health examinations were joined with screening use data from electronic medical records and pre-/post-visit patient surveys. The association between persuasion and screening was assessed using generalized estimating equations. According to observer ratings, primary care physicians frequently use persuasive techniques (63 %) when recommending CRC screening, most commonly argument or refutation. However, physician persuasion was not associated with subsequent screening adherence. Physician use of persuasion may be a common vehicle for information provision during CRC screening discussions; however, our results do not support the sole reliance on persuasive techniques if the goal is to improve adherence to recommended screening.

Intention to undergo colonoscopy screening among relatives of colorectal cancer cases: a theory-based model

BACKGROUND

It is recommended that persons having familial risk of colorectal cancer begin regular colonoscopy screening at an earlier age than those in the general population. However, many individuals at increased risk do not adhere to these screening recommendations.

PURPOSE

The goal of this study was to examine cognitive, affective, social, and behavioral motivators of colonoscopy intention among individuals at increased risk of familial colorectal cancer.

METHODS

Relatives of colorectal cancer cases (N = 481) eligible for colonoscopy screening completed a survey assessing constructs from several theoretical frameworks including fear appeal theories.

RESULTS

Structural equation modeling indicated that perceived colorectal cancer risk, past colonoscopy, fear of colorectal cancer, support from family and friends, and health-care provider recommendation were determinants of colonoscopy intention.

CONCLUSIONS

Future interventions to promote colonoscopy in this increased risk population should target the factors we identified as motivators. (ClinicalTrials.gov number NCT01274143).

Effectiveness of a primary care practice intervention for increasing colorectal cancer screening in Appalachian Kentucky

OBJECTIVE

This report describes findings from a randomized controlled trial of an intervention to increase colorectal cancer (CRC) screening in primary care practices in Appalachian Kentucky.

METHODS

Sixty-six primary care practices were randomized to early or delayed intervention groups. The intervention was provided at practices using academic detailing, a method of education where providers receive information on a specific topic through personal contact. Data were collected in cross-sectional surveys of medical records at baseline and six months post-intervention.

RESULTS

A total of 3844 medical records were reviewed at baseline and 3751 at the six-month follow-up. At baselines, colonoscopy was recommended more frequently (43.4%) than any other screening modality, followed by fecal occult blood testing (18.0%), flexible sigmoidoscopy (0.4%), and double-contrast barium enema (0.3%). Rates of documented screening results were higher for all practices at the six-month follow-up for colonoscopy (31.8% vs 29.6%) and fecal occult blood testing (12.2% vs 11.2%). For early intervention practices that recommended screening, colonoscopy rates increased by 15.7% at six months compared to an increase of 2.4% in the delayed intervention practices (p=.01).

CONCLUSIONS

Using academic detailing to reach rural primary care providers with a CRC screening intervention was associated with an increase in colonoscopy.

Patient-physician colorectal cancer screening discussion content and patients' use of colorectal cancer screening

OBJECTIVE

The US Preventive Services Task Force recommends using the 5As (i.e., Assess, Advise, Agree, Assist and Arrange) when discussing preventive services. We evaluate the association of the 5As discussion during primary care office visits with patients' subsequent colorectal cancer (CRC) screening use.

METHODS

Audio-recordings of n=443 periodic health exams among insured patients aged 50-80 years and due for CRC screening were joined with pre-visit patient surveys and screening use data from an electronic medical record. Association of the 5As with CRC screening was assessed using generalized estimating equations.

RESULTS

93% of patients received a recommendation for screening (Advise) and 53% were screened in the following year. The likelihood of screening increased as the number of 5A steps increased: compared to patients whose visit contained no 5A step, those whose visit contained 1-2 steps (OR=2.96 [95% CI 1.16, 7.53]) and 3 or more steps (4.98 [95% CI 1.84, 13.44]) were significantly more likely to use screening.

CONCLUSIONS

Physician CRC screening recommendations that include recommended 5A steps are associated with increased patient adherence.

PRACTICE IMPLICATIONS

A CRC screening recommendation (Advise) that also describes patient eligibility (Assess) and provides help to obtain screening (Assist) may lead to improved adherence to CRC screening.

From qualitative data to GP training on CRC screening

Colorectal cancer (CRC) is the third most common cancer worldwide. In France, although mass screening has been performed using the guaiac fecal occult blood test since 2008, the participation rate remains too low. Previous studies have explored the perspectives of doctors and patients as well as the performance of general practitioners (GPs) by recording and analyzing consultations in which patients came and asked for fecal occult blood test. Results indicated that improvement was needed in patient-centered communication. This research aims to develop educational material and training programs for GPs in order to enhance their communication with patients on CRC screening, based on data from two qualitative studies. Triangulation of all qualitative data was performed and discussed with communication experts in order to develop educational material and training programs based on the patient-centered clinical method. Two different scenarios were developed to improve communication with patients: one for a compliant patient and another for a noncompliant patient. Two videos were made featuring a doctor and a simulated patient. A two-sequence training program was built, including role-playing and presentation of the video followed by a discussion. The qualitative data helped us to produce a useful, relevant training program for GPs on CRC screening.

Risk assessment and clinical decision making for colorectal cancer screening

BACKGROUND

Shared decision making (SDM) related to test preference has been advocated as a potentially effective strategy for increasing adherence to colorectal cancer (CRC) screening, yet primary care providers (PCPs) are often reluctant to comply with patient preferences if they differ from their own. Risk stratification advanced colorectal neoplasia (ACN) provides a rational strategy for reconciling these differences.

OBJECTIVE

To assess the importance of risk stratification in PCP decision making related to test preference for average-risk patients and receptivity to use of an electronic risk assessment tool for ACN to facilitate SDM.

DESIGN

Mixed methods, including qualitative key informant interviews and a cross-sectional survey.

PARTICIPANTS

PCPs at an urban, academic safety-net institution.

MAIN MEASURES

Screening preferences, factors influencing patient recommendations and receptivity to use of a risk stratification tool.

KEY RESULTS

Nine PCPs participated in interviews and 57 completed the survey. Despite an overwhelming preference for colonoscopy by 95% of respondents, patient risk (67%) and patient preferences (63%) were more influential in their decision making than patient comorbidities (31%; P < 0.001). Age was the single most influential risk factor (excluding family history), with <20% of respondents choosing factors other than age. Most respondents reported that they would be likely to use a risk stratification tool in their practice either 'often' (43%) or sometimes (53%).

CONCLUSIONS

Risk stratification was perceived to be important in clinical decision making, yet few providers considered risk factors other than age for average-risk patients. Providers were receptive to the use of a risk assessment tool for ACN when recommending an appropriate screening test for select patients.

Shared decision-making about colorectal cancer screening: a conceptual framework to guide research

OBJECTIVE

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

METHODS

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

RESULTS

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

CONCLUSION

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

PRACTICE IMPLICATIONS

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.

Factors explaining racial/ethnic disparities in rates of physician recommendation for colorectal cancer screening

OBJECTIVES

Physician recommendation plays a crucial role in receiving endoscopic screening for colorectal cancer (CRC). This study explored factors associated with racial/ethnic differences in rates of screening recommendation.

METHODS

Data on 5900 adults eligible for endoscopic screening were obtained from the National Health Interview Survey. Odds ratios of receiving an endoscopy recommendation were calculated for selected variables. Planned, sequenced logistic regressions were conducted to examine the extent to which socioeconomic and health care variables account for racial/ethnic disparities in recommendation rates.

RESULTS

Differential rates were observed for CRC screening and screening recommendations among racial/ethnic groups. Compared with Whites, Hispanics were 34% less likely (P < .01) and Blacks were 26% less likely (P < .05) to receive this recommendation. The main predictors that emerged in sequenced analysis were education for Hispanics and Blacks and income for Blacks. After accounting for the effects of usual source of care, insurance coverage, and education, the disparity reduced and became statistically insignificant.

CONCLUSIONS

Socioeconomic status and access to health care may explain major racial/ethnic disparities in CRC screening recommendation rates.

Patient-provider discussions about colorectal cancer screening: who initiates elements of informed decision making?

BACKGROUND

Colorectal cancer (CRC) screening rates remain low among low-income minority populations.

OBJECTIVE

To evaluate informed decision making (IDM) elements about CRC screening among low-income minority patients.

DESIGN

Observational data were collected as part of a patient-level randomized controlled trial to improve CRC screening rates. Medical visits (November 2007 to May 2010) were audio-taped and coded for IDM elements about CRC screening. Near the end of the study one provider refused recording of patients' visits (33 of 270 patients). Among all patients in the trial, agreement to be audio taped was 43.5 % (103/237). Evaluable patient (n = 100) visits were assessed for CRC screening discussion occurrence, IDM elements, and who initiated discussion of each IDM element.

PARTICIPANTS

Patients were African American (72.2 %), female (63.7 %), with annual household incomes <$20,000 (60.7 %), without health insurance (57.0 %), and limited health literacy (53.7 %).

KEY RESULTS

Although CRC screening was mentioned during 48 (48 %) visits, no further discussion about screening occurred in 23 visits (19 times mentioned by the participant with no response from providers). During any visit, the maximum number of IDM elements was five; however, only two visits included five elements. The most common IDM element discussed in addition to the nature of the decision was the assessment of the patient's understanding in 16 (33.3 %) of the visits that included a CRC discussion.

CONCLUSIONS

A patient activation intervention initiated CRC screening discussions with health care providers; however, limited IDM occurred about CRC screening during medical visits of minority and low-income patients.

Fecal occult blood testing instructions and impact on patient adherence

INTRODUCTION

Although the physician's role with patients is crucial in encouraging FOBT screening, the nature and content of physician-patient discussions about FOBT screening is unclear. As part of a larger study, this paper reports on our analyses of physician beliefs about fecal occult blood testing (FOBT) and strategies they employed to enhance patient adherence. The second aim of this paper is to report on the perceptions of individuals at average risk for colorectal cancer (CRC) in regard to their awareness of the FOBT and their responses to physician recommendations about FOBT screening.

METHODS

The larger study was conducted in urban and rural Manitoba, Canada between 2008 and 2010. We used a qualitative design and conducted semi-structured, audio-recorded interviews with 15 physicians and 27 individuals at average risk for CRC. We included data from 11 family members or friends on their perspectives of FOBT instructions as individuals who were also at average risk for CRC and had their own experiences with CRC screening recommendations.

RESULTS

Despite widespread knowledge of The Canadian Task Force on Preventive Health Care CRC screening guidelines, physician attitudes, behaviors, and instructions were not uniform in promoting patient adherence to FOBT screening. Individuals at average-risk for CRC identified that FOBT instructions were confusing and burdensome, which in turn served as a barrier in their adherence to FOBT screening.

CONCLUSIONS

Variation in FOBT instruction counseling in relation to the recommended age of individuals at average risk for CRC, as well as adequate patient preparation affected patient adherence. We recommend uniform or standardized instructions and counseling by health care providers who administer the FOBT kit to patients to promote adherence to recommended CRC screening.

Primary care colorectal cancer screening recommendation patterns: associated factors and screening outcomes

BACKGROUND

The relationship of a primary care provider's (PCP's) colorectal cancer (CRC) screening strategies to completion of screening is poorly understood.

OBJECTIVE

To describe PCP test recommendation patterns and associated factors and their relationship to patient test completion.

DESIGN

This cross-sectional study used a PCP survey, in-depth PCP interviews, and electronic medical records.

SETTING

Kaiser Permanente Northwest health maintenance organization.

PARTICIPANTS

Participants included 132 PCPs and 49,259 eligible patients aged 51 to 75.

MEASUREMENTS

The authors grouped PCPs by patterns of CRC screening recommendations based on reported frequency of recommending fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), and colonoscopy. They then compared PCP demographics, reported CRC screening test influences, concerns, decision-making and counseling processes, and actual rates of patient CRC screening completion by PCP group.

RESULTS

The authors identified 4 CRC screening recommendation groups: a "balanced" group (n = 54; 40.9%) that recommended the tests nearly equally, an FOBT group (n = 31; 23.5%) that largely recommended FOBT, an FOBT + FS group (n = 25; 18.9%), and a colonoscopy + FOBT group (n = 22; 16.7%) that recommended these tests nearly equally. Internal medicine (v. family medicine) PCPs were more common in groups more frequently recommending endoscopy. The FOBT and FOBT + FS groups were most influenced by clinical guidelines. Groups recommending more endoscopy were most concerned that FOBT generates a relatively high number of false positives and FOBT can miss cancers. The FOBT and FOBT + FS groups were more likely to recommend a specific screening strategy compared to the colonoscopy + FOBT and balanced groups, which were more likely to let the patient decide. CRC screening rates were 63.9% balanced, 62.9% FOBT, 61.7% FOBT + FS, and 62.2% colonoscopy + FOBT; rates did not differ significantly by group.

LIMITATIONS

Small numbers within PCP groups.

CONCLUSIONS

Specialty, the influence of guidelines, test concerns, and the "jointness" of the test selection decision distinguished CRC screening recommendation patterns. All patterns were associated with similar overall screening rates.

The impact of a novel computer-based decision aid on shared decision making for colorectal cancer screening: a randomized trial

BACKGROUND

Eliciting patients' preferences within a framework of shared decision making (SDM) has been advocated as a strategy for increasing colorectal cancer (CRC) screening adherence. Our objective was to assess the effectiveness of a novel decision aid on SDM in the primary care setting.

METHODS

An interactive, computer-based decision aid for CRC screening was developed and evaluated within the context of a randomized controlled trial. A total of 665 average-risk patients (mean age, 57 years; 60% female; 63% black, 6% Hispanic) were allocated to 1 of 2 intervention arms (decision aid alone, decision aid plus personalized risk assessment) or a control arm. The interventions were delivered just prior to a scheduled primary care visit. Outcome measures (patient preferences, knowledge, satisfaction with the decision-making process [SDMP], concordance between patient preference and test ordered, and intentions) were evaluated using prestudy/poststudy visit questionnaires and electronic scheduling.

RESULTS

Overall, 95% of patients in the intervention arms identified a preferred screening option based on values placed on individual test features. Mean cumulative knowledge, SDMP, and intention scores were significantly higher for both intervention groups compared with the control group. Concordance between patient preference and test ordered was 59%. Patients who preferred colonoscopy were more likely to have a test ordered than those who preferred an alternative option (83% v. 70%; P < 0.01). Intention scores were significantly higher when the test ordered reflected patient preferences.

CONCLUSIONS

Our interactive computer-based decision aid facilitates SDM, but overall effectiveness is determined by the extent to which providers comply with patient preferences.

Patients' perception of quality of pre-operative informed consent in athens, Greece: a pilot study

BACKGROUND

We sought to perform a study to record and evaluate patients' views of the way surgeons communicate informed consent (IC) in Greece.

METHODOLOGY/PRINCIPAL FINDINGS

A prospective pilot study was carried out in Athens from 9/2007 to 4/2008. The study sample was extracted from patients, operated by eight different surgeons, who volunteered to fill in a post-surgery self-report questionnaire on IC. A composite delivered information index and a patient-physician relationship index were constructed for the purposes of the analysis. In total, 77 patients (42 males) volunteered to respond to the questionnaire. The delivered information index scores ranged from 3 to 10, the mean score was 8, and the standard deviation (SD) was 1.9. All patients were aware of their underlying diagnosis and reason for surgery. However, a considerable proportion of the respondents (14.3%) achieved a score below or equal to 5. The patient-physician relationship scores ranged from 0 to 20, the mean score was 16 and the standard deviation (SD) was 4.3. The better the patient-physician relationship, the more information was finally delivered to the patient from the physician (Spearman's rank-order correlation coefficient was 0.4 and p<0.001). Delivered information index was significantly higher among participants who comprehended the right to informed consent, compared to participants who did not (p<0.001), and among participants who were given information regarding other possible therapeutic options (p = 0.001). 43% of the respondents answered that less than 10 minutes were spent on the consent process, 58.4% of patients stated that they had not been informed about other possible therapeutic choices and 28.6% did not really comprehend their legal rights to IC.

CONCLUSIONS

Despite the inherent limitations and the small sample size that do not permit to draw any firm conclusions, results indicate that a successful IC process may be associated with specific elements such as the patient-physician relationship, the time spent by the physician to inform the patient, a participant's comprehension of the right to IC and the provision of information regarding other possible therapeutic options.

Behind closed doors: physician-patient discussions about colorectal cancer screening

BACKGROUND

Despite the availability of multiple effective screening tests for colorectal cancer, screening rates remain suboptimal. The literature documents patient preferences for different test types and recommends a shared decision-making approach for physician-patient colorectal cancer screening (CRCS) discussions, but it is unknown whether such communication about CRCS preferences and options actually occurs in busy primary-care settings.

OBJECTIVE

Describe physician-patient CRCS discussions during a wellness visit.

DESIGN

Cross-sectional; patients audio-recorded with physicians.

PARTICIPANTS

A subset of patients (N = 64) participating in a behavioral intervention trial designed to increase CRCS who completed a wellness visit during the trial with a participating physician (N = 8).

APPROACH

Transcripts were analyzed using qualitative methods.

RESULTS

Physicians in this sample consistently recommended CRCS, but focused on colonoscopy. Physicians did not offer a fecal occult blood test alone as a screening choice, which may have created missed opportunities for some patients to get screened. In this single visit, physicians' communication processes generally precluded discussion of patients' test preferences and did not facilitate shared decision-making. Patients' questions indicated their interest in different CRCS test types and appeared to elicit more information from physicians. Some patients remained resistant to CRCS after discussing it with a physician.

CONCLUSION

If a preference for colonoscopy is widespread among primary-care physicians, the implications for intervention are either to prepare patients for this preference or to train physicians to offer options when recommending screening to patients.

Predictors of colorectal cancer knowledge and screening among church-attending African Americans and Whites in the Deep South

This study examined colorectal cancer (CRC) knowledge and the relationship between knowledge, risk factors and screening behaviors among African Americans and Whites in the Deep South. One hundred and twenty three African Americans and Whites age-eligible for CRC screening were interviewed by telephone survey as part of a church-based CRC educational intervention. CRC knowledge was lower among those with less education, unemployed, Medicaid, Medicare, and less family income. Generally, participants who had more CRC knowledge were more likely to have engaged in screening behaviors. Participants who had a family history of CRC were more likely to have had a fecal occult blood test (OR = 2.55, 0.99-6.60) or barium enema (OR = 3.84, 1.44-10.24) than those without. Whites were more likely to have had a flexible sigmoidoscopy (OR = 4.17, 1.09-16.67), colonoscopy (OR = 7.14, 1.72-25) or barium enema (OR = 6.25, 1.67-25) than African Americans. Church-based CRC screening intervention programs should target African Americans, those with no family history of CRC, and those with less education.

Informed decision-making and colorectal cancer screening: is it occurring in primary care?

BACKGROUND

Current recommendations advise patients to participate in the decision-making for selecting a colorectal cancer (CRC) screening option. The degree to which providers communicate the information necessary to prepare patients for participation in this process is not known.

OBJECTIVE

To assess the level of informed decision-making occurring during actual patient-provider communications on CRC screening and test for the association between informed decision-making and screening behavior.

RESEARCH DESIGN

Observational study of audiotaped clinic visits between patients and their providers in the primary care clinic at a Veterans Administration Medical Center.

SUBJECTS

Male patients, age 50-74 years, presenting to a primary care visit at the study site.

MEASURES

The Informed Decision-Making (IDM) Model was used to code the audiotapes for 9 elements of communication that should occur to prepare patients for participation in decision-making. The primary outcome is completion of CRC screening during the study period.

RESULTS

The analytic cohort consisted of 91 patients due for CRC screening who had a test ordered at the visit. Six of the 9 IDM elements occurred in < or =20% of the visits with none addressed in > or =50%. CRC screening occurred less frequently for those discussing "pros and cons" (12% vs. 46%, P = 0.01) and "patient preferences" (6% vs. 47%, P = 0.001) compared with those who did not.

CONCLUSIONS

We found that a lack of informed decision-making occurred during CRC screening discussions and that particular elements of the process were negatively associated with screening. Further research is needed to better understand the effects of informed decision-making on screening behavior.

Community-based preferences for stool cards versus colonoscopy in colorectal cancer screening

BACKGROUND

In the United States, compliance with colorectal cancer (CRC) screening recommendations remains suboptimal. Professional organizations advocate use of shared decision making in screening test discussions, but strategies to facilitate informed choice in CRC screening have not been well elucidated.

OBJECTIVE

The objectives of the study were to determine screening test preference among colonoscopy-naïve adults after considering a detailed, written presentation of fecal occult blood testing (FOBT) and colonoscopy and to assess whether their preferences are associated with demographic characteristics, attitudes, and knowledge.

DESIGN

The design of the study was a cross-sectional survey.

PARTICIPANTS

Colonoscopy-naïve supermarket shoppers age 40-79 in low- and middle-income, multiethnic neighborhoods in Denver, CO, reviewed a detailed, side-by-side description of FOBT and colonoscopy and answered questions about test preference, strength of preference, influence of physician recommendation, basic knowledge of CRC, and demographic characteristics.

MEASUREMENTS AND MAIN RESULTS

Descriptive statistics characterized the sample, and bivariate and multivariable logistic regression analyses identified correlates of screening test preference. In a diverse sample of 323 colonoscopy-naïve adults, 53% preferred FOBT, and 47% preferred colonoscopy for CRC screening. Individuals of Latino ethnicity and those with lower educational attainment were more likely to prefer FOBT than non-Latino whites and those with at least some college. Almost half of the respondents felt "very strongly" about their preferences, and one third said they would adhere to their choice regardless of physician recommendation.

CONCLUSION

After considering a detailed, side-by-side comparison of the FOBT and colonoscopy, a large proportion of community-dwelling, colonoscopy-naïve adults prefer FOBT over colonoscopy for CRC screening. In light of professional guidelines and time-limited primary care visits, it is important to develop improved ways of facilitating informed patient decision making for CRC screening.

Using decision tree models to depict primary care physicians CRC screening decision heuristics

OBJECTIVE

The purpose of this study was to identify decision heuristics utilized by primary care physicians in formulating colorectal cancer screening recommendations.

DESIGN

Qualitative research using in-depth semi-structured interviews.

PARTICIPANTS

We interviewed 66 primary care internists and family physicians evenly drawn from academic and community practices. A majority of physicians were male, and almost all were white, non-Hispanic.

APPROACH

Three researchers independently reviewed each transcript to determine the physician's decision criteria and developed decision trees. Final trees were developed by consensus. The constant comparative methodology was used to define the categories.

RESULTS

Physicians were found to use 1 of 4 heuristics ("age 50," "age 50, if family history, then earlier," "age 50, if family history, then screen at age 40," or "age 50, if family history, then adjust relative to reference case") for the timing recommendation and 5 heuristics ["fecal occult blood test" (FOBT), "colonoscopy," "if not colonoscopy, then...," "FOBT and another test," and "a choice between options"] for the type decision. No connection was found between timing and screening type heuristics.

CONCLUSIONS

We found evidence of heuristic use. Further research is needed to determine the potential impact on quality of care.