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

Talking, not training, increased the accuracy of physicians' diagnosis of their patients' preferences for colon cancer screening

OBJECTIVE

Identify if primary care physicians (PCPs) accurately understand patient preferences for colorectal cancer (CRC) testing, whether shared decision making (SDM) training improves understanding of patient preferences, and whether time spent discussing CRC testing improves understanding of patient preferences.

METHODS

Secondary analysis of a trial comparing SDM training plus a reminder arm to a reminder alone arm. PCPs and their patients completed surveys after visits assessing whether they discussed CRC testing, patient testing preference, and time spent discussing CRC testing. We compared patient and PCP responses, calculating concordance between patient-physician dyads. Multilevel models tested for differences in preference concordance by arm or time discussing CRC.

RESULTS

382 PCP and patient survey dyads were identified. Most dyads agreed on whether CRC testing was discussed (82%). Only 52% of dyads agreed on the patient's preference. SDM training did not impact accuracy of PCPs preference diagnoses (55%v.48%,p = 0.22). PCPs were more likely to accurately diagnose patient's preferences when discussions occurred, regardless of length.

CONCLUSION

Only half of PCPs accurately identified patient testing preferences. Training did not impact accuracy. Visits where CRC testing was discussed resulted in PCPs better understanding patient preferences.

PRACTICE IMPLICATIONS

PCPs should take time to discuss testing and elicit patient preferences.

Getting patients back for routine colorectal cancer screening: Randomized controlled trial of a shared decision-making intervention

Thousands of colonoscopies were canceled during the initial surge of the COVID-19 pandemic. As facilities resumed services, some patients were hesitant to reschedule. The purpose of this study was to determine whether a decision aid plus telephone coaching would increase colorectal cancer (CRC) screening and improve patient reports of shared decision making (SDM). A randomized controlled trial assigned adults aged 45-75 without prior history of CRC who had a colonoscopy canceled from March to May 2020 to intervention (n = 400) or usual care control (n = 400) arms. The intervention arm received three-page decision aid and call from decision coach from September 2020 through November 2020. Screening rates were collected at 6 months. A subset (n = 250) in each arm was surveyed 8 weeks after randomization to assess SDM (scores range 0-4, higher scores indicating more SDM), decisional conflict, and screening preference. The sample was on average, 60 years old, 53% female, 74% White, non-Hispanic, and 11% Spanish speaking. More intervention arm patients were screened within 6 months (35% intervention vs 23% control, p < 0.001). The intervention respondents reported higher SDM scores (mean difference 0.7 [0.4, 0.9], p < 0.001) and less decisional conflict than controls (-21% [-35%, -7%], p = 0.003). The majority in both arms preferred screening versus delaying (68% intervention vs. 65% control, p = 0.75). An SDM approach that offered alternatives and incorporated patients' preferences resulted in higher screening rates. Patients who are overdue for CRC screening may benefit from proactive outreach with SDM support.

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

Facilitators and Barriers to Implementing a Digital Informed Decision Making Tool in Primary Care: A Qualitative Study

BACKGROUND

Informed decision aids provide information in the context of the patient's values and improve informed decision making (IDM). To overcome barriers that interfere with IDM, our team developed an innovative iPad-based application (aka "app") to help patients make informed decisions about colorectal cancer screening. The app assesses patients' eligibility for screening, educates them about their options, and empowers them to request a test via the interactive decision aid.

OBJECTIVE

The aim of the study is to explore how informed decision aids can be implemented successfully in primary care clinics, including the facilitators and barriers to implementation; strategies for minimizing barriers; adequacy of draft training materials; and any additional support or training desired by clinics.

DESIGN

This work deals with a multicenter qualitative study in rural and urban settings.

PARTICIPANTS

A total of 48 individuals participated including primary care practice managers, clinicians, nurses, and front desk staff.

APPROACH

Focus groups and semi-structured interviews, with data analysis were guided by thematic analysis.

KEY RESULTS

Salient emergent themes were time, workflow, patient age, literacy, and electronic health record (EHR) integration. Saving time was important to most participants. Patient flow was a concern for all clinic staff, and they expressed that any slowdown due to patients using the iPad module or perceived additional work to clinic staff would make staff less motivated to use the program. Participants voiced concern about older patients being unwilling or unable to utilize the iPad and patients with low literacy ability being able to read or comprehend the information.

CONCLUSION

Integrating new IDM apps into the current clinic workflow with minimal disruptions would increase the probability of long-term adoption and ultimate sustainability.

NIH TRIAL REGISTRY NUMBER

R01CA218416-A1.

Informed Consent and Informed Decision-Making in High-Risk Surgery: A Quantitative Analysis

BACKGROUND

Informed consent is an ethical and legal requirement that differs from informed decision-making-a collaborative process that fosters participation and provides information to help patients reach treatment decisions. The objective of this study was to measure informed consent and informed decision-making before major surgery.

STUDY DESIGN

We audio-recorded 90 preoperative patient-surgeon conversations before major cardiothoracic, vascular, oncologic, and neurosurgical procedures at 3 centers in the US and Canada. Transcripts were scored for 11 elements of informed consent based on the American College of Surgeons' definition and 9 elements of informed decision-making using Braddock's validated scale. Uni- and bivariate analyses tested associations between decision outcomes as well as patient, consultation, and surgeon characteristics.

RESULTS

Overall, surgeons discussed more elements of informed consent than informed decision-making. They most frequently described the nature of the illness, the operation, and potential complications, but were less likely to assess patient understanding. When a final treatment decision was deferred, surgeons were more likely to discuss elements of informed decision-making focusing on uncertainty (50% vs 15%, p = 0.006) and treatment alternatives (63% vs 27%, p = 0.02). Conversely, when surgery was scheduled, surgeons completed more elements of informed consent. These results were not associated with the presence of family, history of previous surgery, location, or surgeon specialty.

CONCLUSIONS

Surgeons routinely discuss components of informed consent with patients before high-risk surgery. However, surgeons often fail to review elements unique to informed decision-making, such as the patients' role in the decision, their daily life, uncertainty, understanding, or patient preference.

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.

Interactivity in a Decision Aid: Findings From a Decision Aid to Technologically Enhance Shared Decision Making RCT

INTRODUCTION

Colorectal cancer screening (CRCS) remains underutilized. Decision aids (DAs) can increase patient knowledge, intent, and CRCS rates compared with "usual care," but whether interactivity further increases CRCS rate remains unknown.

STUDY DESIGN

A two-armed RCT compared the effect of a web-based DA that interactively assessed patient CRC risk and clarified patient preference for specific CRCS test to a web-based DA with the same content but without the interactive tools.

SETTING/PARTICIPANTS

The study sites were 12 community- and three university-based primary care practices (56 physicians) in southeastern Michigan. Participants were men and women aged 50-75 years not current on CRCS.

INTERVENTION

Random allocation to interactive DA (interactive arm) or non-interactive DA (non-interactive arm).

MAIN OUTCOME MEASURES

Primary outcome was medical record documentation of CRCS 6 months after the intervention. Secondary outcome was patient decision quality (i.e., knowledge, preference clarification, and intent) measured immediately before and after DA use, and immediately after the office visit. To determine that either DA had a positive effect on CRCS adherence, usual care CRCS rates were determined from the three university-based practices among patients eligible for but not participating in the study.

RESULTS

Data were collected between 2012 and 2014; analysis began in 2015. At 6 months, CRCS rate was 36.1% (95% CI=30.5%, 42.2%) in the interactive arm (n=284) and 40.5% (95% CI=34.7%, 46.6%) in the non-interactive arm (n=286, p=0.29). Usual care CRCS rate (n=440) was 18.6% (95% CI=15.2%, 22.7%), significantly lower than both arms (p<0.001). Knowledge, attitude, self-efficacy, test preference, and intent increased significantly within each arm versus baseline, but the rate was not significantly different between the two arms.

CONCLUSIONS

The interactive DA did not improve the outcome compared to the non-interactive DA. This suggests that the resources needed to create and maintain the interactive components are not justifiable.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01514786.

Impact of including quantitative information in a decision aid for colorectal cancer screening: A randomized controlled trial

OBJECTIVE

Guidelines recommend that decision aids provide quantitative information about risks and benefits of available options. Impact of providing this information is unknown.

METHODS

Randomized trial comparing two decision aids about colorectal cancer (CRC) screening with colonoscopy or fecal immunochemical test (FIT). 688 primary care patients due for CRC screening viewed a decision aid that uses words only (Verbal arm) vs. one that provides quantitative information (Quantitative arm). Main outcomes included perceived CRC risk, intent to be screened, and test preference, measured before and after viewing decision aid, and screening uptake at six months. Analyses were performed with ANCOVA and logistic regression.

RESULTS

Compared to the Verbal arm, those in the Quantitative arm had a larger increase in intent to undergo FIT (p = 0.011) and were more likely to switch their preferred test from non-FIT to FIT (28% vs. 19%, p = .010). There were decreases in perceived risk in the Verbal Arm but not the Quantitative Arm (p = 0.004). There was no difference in screening uptake. Numeracy did not moderate any effects.

CONCLUSIONS

Quantitative information had relatively minor impact and no clearly negative effects, such as reducing uptake.

PRACTICE IMPLICATIONS

Quantitative information may be useful but not essential for patients viewing decision aids.

Patient-Reported Needs Following a Referral for Colorectal Cancer Screening

INTRODUCTION

Patient-physician communication about colorectal cancer screening can affect screening use, but discussions often lack information that patients need for informed decision making and seldom address personal preferences or barriers. To address this gap, a series of patient focus groups was conducted to guide the development of an online, interactive decision support program. This article presents findings on patient information needs and barriers to colorectal cancer screening after receiving a screening recommendation from a physician, and their perspectives on using electronic patient portals as platforms for health-related decision support.

METHODS

Primary care patients with recent colonoscopy or stool testing orders were identified via the centralized data repository of a large Midwestern health system. Seven gender-stratified focus groups (N=45 participants) were convened between April and July 2016. Sessions were audio recorded, transcribed, coded, and analyzed for commonly expressed themes beginning in August 2016.

RESULTS

Findings reveal a consistent need for simple and clear information on colorectal cancer screening. Participants desired step-by-step explanations of the colonoscopy procedure and information about bowel preparation options/alternatives. The desired level of additional information varied: some patients wanted to know about and act on test options, whereas others preferred following their physician-recommended testing path. Fears and concerns were prevalent, particularly about colonoscopy, and patients reported challenges getting these concerns and their informational needs addressed. Finally, they expressed consistent support for using the patient portal to gather additional information from their physician.

CONCLUSIONS

Patient portals may offer an opportunity to build sustainable programs for decision support and assistance that are integrated with clinic workflows and processes.

Use of Visual Decision Aids in Physician-Patient Communication: A Pilot Investigation

INTRODUCTION

A risk calculator paired with a personalized decision aid (RC&DA) may foster shared decision-making in primary care. We assessed the feasibility of using an RC&DA with patients in a primary care outpatient clinic and patients' experiences regarding communication and decision-making.

METHODS

This pilot study was conducted with 15 patients of 3 primary care physicians at a clinic within a tertiary medical center. An atherosclerotic cardiovascular disease (ASCVD) risk calculator was used to generate a personalized RC&DA that displayed absolute 10-year risk information as an icon array graphic. Patient perceptions of utility of the RC&DA, preferences for decision-making, and uncertainty with risk reduction decisions were measured with a semi-structured interview.

RESULTS

Patients reported that the RC&DA was easy to understand and knowledge gained was useful to modify their ASCVD risk. Patients used the RC&DA to make decisions and reported low uncertainty with those decisions.

CONCLUSIONS

Our findings demonstrate the feasibility of, and positive patient experiences related to using, an RC&DA to facilitate shared decision-making between physicians and patients in an outpatient primary care setting.

What Factors are Associated with Consumer Initiation of Shared Decision Making in Mental Health Visits?

Understanding consumer initiation of shared decision making (SDM) is critical to improving SDM in mental health consultations, particularly because providers do not always invite consumer participation in treatment decisions. This study examined the association between consumer initiation of nine elements of SDM as measured by the SDM scale, and measures of consumer illness self-management and the consumer-provider relationship. In 63 mental health visits, three SDM elements were associated with self-management or relationship factors: discussion of consumer goals, treatment alternatives, and pros and cons of a decision. Limitations, implications, and future directions are discussed.

Engaging Patients in Decisions About Cancer Screening: Exploring the Decision Journey Through the Use of a Patient Portal

INTRODUCTION

Engaging patients to make informed choices is paramount but difficult in busy practices. This study sought to engage patients outside the clinical setting to better understand how they approach cancer screening decisions, including their primary concerns and their preferences for finalizing their decision.

METHODS

Twelve primary care practices offering patients an online personal health record invited eligible patients to complete a 17-item online interactive module. Among 11,458 registered users, invitations to complete the module were sent to adults aged 50-74 years who were overdue for colorectal cancer screening and to women aged 40-49 years and men aged 55-69 who had not undergone a recent mammogram or prostate-specific antigen test, respectively.

RESULTS

The module was started by 2,355 patients and completed by 903 patients. Most respondents (76.8%) knew they were eligible for screening. Preferred next steps were talking to the clinician (76.6%), reading/research (28.6%), and consulting trusted friends/family (16.4%). Priority topics included how much screening improves life expectancy, comparative test performance, and the prevalence/health risks of the cancer. Leading fears were getting cancer/delayed detection (79.2%), abnormal results (40.5%), and testing complications (39.1%), the last referring to false test results, medical complications, or unnecessary treatments. Men eligible for prostate-specific antigen screening were more likely than women eligible for mammography to express concerns about testing complications and to prioritize weighing pros and cons over gut feelings (p<0.05).

CONCLUSIONS

Although this sample was predisposed to screening, most patients wanted help in finalizing their decision. Many wanted to weigh the pros and cons and expressed fears of potential harms from screening. Understanding how patients approach decisions may help design more effective engagement strategies.

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.

Harnessing Information Technology to Inform Patients Facing Routine Decisions: Cancer Screening as a Test Case

PURPOSE

Technology could transform routine decision making by anticipating patients' information needs, assessing where patients are with decisions and preferences, personalizing educational experiences, facilitating patient-clinician information exchange, and supporting follow-up. This study evaluated whether patients and clinicians will use such a decision module and its impact on care, using 3 cancer screening decisions as test cases.

METHODS

Twelve practices with 55,453 patients using a patient portal participated in this prospective observational cohort study. Participation was open to patients who might face a cancer screening decision: women aged 40 to 49 who had not had a mammogram in 2 years, men aged 55 to 69 who had not had a prostate-specific antigen test in 2 years, and adults aged 50 to 74 overdue for colorectal cancer screening. Data sources included module responses, electronic health record data, and a postencounter survey.

RESULTS

In 1 year, one-fifth of the portal users (11,458 patients) faced a potential cancer screening decision. Among these patients, 20.6% started and 7.9% completed the decision module. Fully 47.2% of module completers shared responses with their clinician. After their next office visit, 57.8% of those surveyed thought their clinician had seen their responses, and many reported the module made their appointment more productive (40.7%), helped engage them in the decision (47.7%), broadened their knowledge (48.1%), and improved communication (37.5%).

CONCLUSIONS

Many patients face decisions that can be anticipated and proactively facilitated through technology. Although use of technology has the potential to make visits more efficient and effective, cultural, workflow, and technical changes are needed before it could be widely disseminated.

Impact of provider-patient communication on cancer screening adherence: A systematic review

Cancer screening is critical for early detection and a lack of screening is associated with late-stage diagnosis and lower survival rates. The goal of this review was to analyze studies that focused on the role of provider-patient communication in screening behavior for cervical, breast, and colorectal cancer. A comprehensive search was conducted in four online databases between 1992 and 2016. Studies were included when the provider being studied was a primary care provider and the communication was face-to-face. The search resulted in 3252 records for review and 35 articles were included in the review. Studies were divided into three categories: studies comparing recommendation status to screening compliance; studies examining the relationship between communication quality and screening behavior; and intervention studies that used provider communication to improve screening behavior. There is overwhelming evidence that provider recommendation significantly improves screening rates. Studies examining quality of communication are heterogeneous in method, operationalization and results, but suggest giving information and shared decision making had a significant relationship with screening behavior. Intervention studies were similarly heterogeneous and showed positive results of communication interventions on screening behavior. Overall, results suggest that provider recommendation is necessary but not sufficient for optimal adherence to cancer screening guidelines. Quality studies suggest that provider-patient communication is more nuanced than just a simple recommendation. Discussions surrounding the recommendation may have an important bearing on a person's decision to get screened. Research needs to move beyond studies examining recommendations and adherence and focus more on the relationship between communication quality and screening adherence.

Perceived Appropriateness of Shared Decision-making in the Emergency Department: A Survey Study

OBJECTIVES

The objective was to describe perceptions of practicing emergency physicians (EPs) regarding the appropriateness and medicolegal implications of using shared decision-making (SDM) in the emergency department (ED).

METHODS

We conducted a cross-sectional survey of EPs at a large, national professional meeting to assess perceived appropriateness of SDM for different categories of ED management (e.g., diagnostic testing, treatment, disposition) and in common clinical scenarios (e.g., low-risk chest pain, syncope, minor head injury). A 21-item survey instrument was iteratively developed through review by content experts, cognitive testing, and pilot testing. Descriptive and multivariate analyses were conducted.

RESULTS

We approached 737 EPs; 709 (96%) completed the survey. Two-thirds (67.8%) of respondents were male; 51% practiced in an academic setting and 44% in the community. Of the seven management decision categories presented, SDM was reported to be most frequently appropriate for deciding on invasive procedures (71.5%), computed tomography (CT) scanning (56.7%), and post-ED disposition (56.3%). Among the specific clinical scenarios, use of thrombolytics for acute ischemic stroke was felt to be most frequently appropriate for SDM (83.4%), followed by lumbar puncture to rule out subarachnoid hemorrhage (73.8%) and CT head for pediatric minor head injury (69.9%). Most EPs (66.8%) felt that using and documenting SDM would decrease their medicolegal risk while a minority (14.2%) felt that it would increase their risk.

CONCLUSIONS

Acceptance of SDM among EPs appears to be strong across management categories (diagnostic testing, treatment, and disposition) and in a variety of clinical scenarios. SDM is perceived by most EPs to be medicolegally protective.

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.

Characterizing Online Narratives About Colonoscopy Experiences: Comparing Colon Cancer "Screeners" Versus "Survivors"

Effective screening can reduce colorectal cancer mortality; however, screening uptake is suboptimal. Patients' stories about various health topics are widely available online and in behavioral interventions and are valued by patients. Although these narratives may be promising strategies for promoting cancer screening behavior, scant research has compared the influence of different role models. This study involving content analysis of online stories aimed to (a) describe the content of online experiential narratives about colonoscopy; (b) compare narratives from individuals who had a colonoscopy and either had colon cancer (survivors) or did not have colon cancer (screeners); and (c) generate hypotheses for future studies. The authors identified 90 narratives eligible for analysis from 15 websites. More stories were about White patients, men, and routine (vs. diagnostic) colonoscopy. A higher-than-expected number of narratives reported a family history of colorectal cancer or polyps (20%) and a colorectal cancer diagnosis (47%). Colorectal cancer survivor (vs. screener) stories were longer, mentioned symptoms and diagnostic reasons for getting a colonoscopy more often, and described the colonoscopy procedure or referred to it as easy or painless less often. Future studies should examine the effects of the role model's personal characteristics and the colonoscopy test result on reader's perceptions and intentions to have a colorectal cancer screening.

Emergency physician perceptions of shared decision-making

OBJECTIVES

Despite the potential benefits of shared decision-making (SDM), its integration into emergency care is challenging. Emergency physician (EP) perceptions about the frequency with which they use SDM, its potential to reduce medically unnecessary diagnostic testing, and the barriers to employing SDM in the emergency department (ED) were investigated.

METHODS

As part of a larger project examining beliefs on overtesting, questions were posed to EPs about SDM. Qualitative analysis of two multispecialty focus groups was done exploring decision-making around resource use to generate survey items. The survey was then pilot-tested and revised to focus on advanced diagnostic imaging and SDM. The final survey was administered to EPs recruited at four emergency medicine (EM) conferences and 15 ED group meetings. This report addresses responses regarding SDM.

RESULTS

A purposive sample of 478 EPs from 29 states were approached, of whom 435 (91%) completed the survey. EPs estimated that, on average, multiple reasonable management options exist in over 50% of their patients and reported employing SDM with 58% of such patients. Respondents perceived SDM as a promising solution to reduce overtesting. However, despite existing research to the contrary, respondents also commonly cited beliefs that 1) "many patients prefer that the physician decides," 2) "when offered a choice, many patients opt for more aggressive care than they need," and 3) "it is too complicated for patients to know how to choose."

CONCLUSIONS

Most surveyed EPs believe SDM is a potential high-yield solution to overtesting, but many perceive patient-related barriers to its successful implementation.

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.

Older adults' preferences for colorectal cancer-screening test attributes and test choice

BACKGROUND

Understanding which attributes of colorectal cancer (CRC) screening tests drive older adults' test preferences and choices may help improve decision making surrounding CRC screening in older adults.

MATERIALS AND METHODS

To explore older adults' preferences for CRC-screening test attributes and screening tests, we conducted a survey with a discrete choice experiment (DCE), a directly selected preferred attribute question, and an unlabeled screening test-choice question in 116 cognitively intact adults aged 70-90 years, without a history of CRC or inflammatory bowel disease. Each participant answered ten discrete choice questions presenting two hypothetical tests comprised of four attributes: testing procedure, mortality reduction, test frequency, and complications. DCE responses were used to estimate each participant's most important attribute and to simulate their preferred test among three existing CRC-screening tests. For each individual, we compared the DCE-derived attributes to directly selected attributes, and the DCE-derived preferred test to a directly selected unlabeled test.

RESULTS

Older adults do not overwhelmingly value any one CRC-screening test attribute or prefer one type of CRC-screening test over other tests. However, small absolute DCE-derived preferences for the testing procedure attribute and for sigmoidoscopy-equivalent screening tests were revealed. Neither general health, functional, nor cognitive health status were associated with either an individual's most important attribute or most preferred test choice. The DCE-derived most important attribute was associated with each participant's directly selected unlabeled test choice.

CONCLUSION

Older adults' preferences for CRC-screening tests are not easily predicted. Medical providers should actively explore older adults' preferences for CRC screening, so that they can order a screening test that is concordant with their patients' values. Effective interventions are needed to support complex decision making surrounding CRC screening in older adults.

Comparative effectiveness of audit-feedback versus additional physician communication training to improve cancer screening for patients with limited health literacy

BACKGROUND

We designed a continuing medical education (CME) program to teach primary care physicians (PCP) how to engage in cancer risk communication and shared decision making with patients who have limited health literacy (HL).

OBJECTIVE

We evaluated whether training PCPs, in addition to audit-feedback, improves their communication behaviors and increases cancer screening among patients with limited HL to a greater extent than only providing clinical performance feedback.

DESIGN

Four-year cluster randomized controlled trial.

PARTICIPANTS

Eighteen PCPs and 168 patients with limited HL who were overdue for colorectal/breast/cervical cancer screening.

INTERVENTIONS

Communication intervention PCPs received skills training that included standardized patient (SP) feedback on counseling behaviors. All PCPs underwent chart audits of patients' screening status semiannually up to 24 months and received two annual performance feedback reports.

MAIN MEASURES

PCPs experienced three unannounced SP encounters during which SPs rated PCP communication behaviors. We examined between-group differences in changes in SP ratings and patient knowledge of cancer screening guidelines over 12 months; and changes in patient cancer screening rates over 24 months.

KEY RESULTS

There were no group differences in SP ratings of physician communication at baseline. At follow-up, communication intervention PCPs were rated higher in general communication about cancer risks and shared decision making related to colorectal cancer screening compared to PCPs who only received performance feedback. Screening rates increased among patients of PCPs in both groups; however, there were no between-group differences in screening rates except for mammography. The communication intervention did not improve patient cancer screening knowledge.

CONCLUSION

Compared to audit and feedback alone, including PCP communication training increases PCP patient-centered counseling behaviors, but not cancer screening among patients with limited HL. Larger studies must be conducted to determine whether lack of changes in cancer screening were due to clinic/patient sample size versus ineffectiveness of communication training to change outcomes.

Factors influencing participation in colorectal screening

Participation of the target population in coloretal screening is generally low. In addition to demographic and socio-economic factors, the health care system and- in particular – family doctors play an important role. Further, the rate of participation is influenced by psychological, cognitive and behavioural factors, too. The paper analyses factors related to colorectal screening behaviour and potential interventions designed to screening uptake. Orv. Hetil., 2014, 155(27), 1051–1056.

Predictors of shared decision making and level of agreement between consumers and providers in psychiatric care

The purpose of this study was to quantitatively examine elements of shared decision making (SDM), and to establish empirical evidence for factors correlated with SDM and the level of agreement between consumer and provider in psychiatric care. Transcripts containing 128 audio-recorded medication check-up visits with eight providers at three community mental health centers were rated using the Shared Decision Making scale, adapted from Braddock's Informed Decision Making Scale (Braddock et al. 1997, 1999, 2008). Multilevel regression analyses revealed that greater consumer activity in the session and greater decision complexity significantly predicted the SDM score. The best predictor of agreement between consumer and provider was "exploration of consumer preference," with a four-fold increase in full agreement when consumer preferences were discussed more completely. Enhancing active consumer participation, particularly by incorporating consumer preferences in the decision making process appears to be an important factor in SDM.

The effect of a decision aid intervention on decision making about coronary heart disease risk reduction: secondary analyses of a randomized trial

Background

Decision aids offer promise as a practical solution to improve patient decision making about coronary heart disease (CHD) prevention medications and help patients choose medications to which they are likely to adhere. However, little data is available on decision aids designed to promote adherence.

Methods

In this paper, we report on secondary analyses of a randomized trial of a CHD adherence intervention (second generation decision aid plus tailored messages) versus usual care in an effort to understand how the decision aid facilitates adherence. We focus on data collected from the primary study visit, when intervention participants presented 45 minutes early to a previously scheduled provider visit; viewed the decision aid, indicating their intent for CHD risk reduction after each decision aid component (individualized risk assessment and education, values clarification, and coaching); and filled out a post-decision aid survey assessing their knowledge, perceived risk, decisional conflict, and intent for CHD risk reduction. Control participants did not present early and received usual care from their provider. Following the provider visit, participants in both groups completed post-visit surveys assessing the number and quality of CHD discussions with their provider, their intent for CHD risk reduction, and their feelings about the decision aid.

Results

We enrolled 160 patients into our study (81 intervention, 79 control). Within the decision aid group, the decision aid significantly increased knowledge of effective CHD prevention strategies (+21 percentage points; adjusted p<.0001) and the accuracy of perceived CHD risk (+33 percentage points; adjusted p<.0001), and significantly decreased decisional conflict (-0.63; adjusted p<.0001). Comparing between study groups, the decision aid also significantly increased CHD prevention discussions with providers (+31 percentage points; adjusted p<.0001) and improved perceptions of some features of patient-provider interactions. Further, it increased participants’ intentions for any effective CHD risk reducing strategies (+21 percentage points; 95% CI 5 to 37 percentage points), with a majority of the effect from the educational component of the decision aid. Ninety-nine percent of participants found the decision aid easy to understand and 93% felt it easy to use.

Conclusions

Decision aids can play an important role in improving decisions about CHD prevention and increasing patient-provider discussions and intent to reduce CHD risk.

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.

An effort to spread decision aids in five California primary care practices yielded low distribution, highlighting hurdles

Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010-12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care.

Decision Aid to Technologically Enhance Shared decision making (DATES): study protocol for a randomized controlled trial

BACKGROUND

Clinicians face challenges in promoting colorectal cancer screening due to multiple competing demands. A decision aid that clarifies patient preferences and improves decision quality can aid shared decision making and be effective at increasing colorectal cancer screening rates. However, exactly how such an intervention improves shared decision making is unclear. This study, funded by the National Cancer Institute, seeks to provide detailed understanding of how an interactive decision aid that elicits patient's risks and preferences impacts patient-clinician communication and shared decision making, and ultimately colorectal cancer screening adherence.

METHODS/DESIGN

This is a two-armed single-blinded randomized controlled trial with the target of 300 patients per arm. The setting is eleven community and three academic primary care practices in Metro Detroit. Patients are men and women aged between 50 and 75 years who are not up to date on colorectal cancer screening. ColoDATES Web (intervention arm), a decision aid that incorporates interactive personal risk assessment and preference clarification tools, is compared to a non-interactive website that matches ColoDATES Web in content but does not contain interactive tools (control arm). Primary outcomes are patient uptake of colorectal cancer screening; patient decision quality (knowledge, preference clarification, intent); clinician's degree of shared decision making; and patient-clinician concordance in the screening test chosen. Secondary outcome incorporates a Structural Equation Modeling approach to understand the mechanism of the causal pathway and test the validity of the proposed conceptual model based on Theory of Planned Behavior. Clinicians and those performing the analysis are blinded to arms.

DISCUSSION

The central hypothesis is that ColoDATES Web will improve colorectal cancer screening adherence through improvement in patient behavioral factors, shared decision making between the patient and the clinician, and concordance between the patient's and clinician's preferred colorectal cancer screening test. The results of this study will be among the first to examine the effect of a real-time preference assessment exercise on colorectal cancer screening and mediators, and, in doing so, will shed light on the patient-clinician communication and shared decision making 'black box' that currently exists between the delivery of decision aids to patients and subsequent patient behavior.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT01514786.

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.

Breast and colorectal cancer screening: U.S. primary care physicians' reports of barriers

BACKGROUND

Primary care physicians (PCPs) play a key role in performing and referring patients for cancer screening. Understanding barriers to test use is critical to developing strategies that promote adherence to clinical guidelines, but current literature does not distinguish the extent to which barriers may be similar or unique across screening modalities.

PURPOSE

To describe PCPs' self-reported perceptions of barriers to screening for breast and colorectal cancer (CRC) and compare the top three barriers associated with these screening modalities.

METHODS

Cross-sectional data analyzed in 2011 from a nationally representative survey of 2478 PCPs in the U.S. in 2006-2007.

RESULTS

PCPs reported greater barriers for CRC screening than for mammography. Lack of patient follow-through to complete recommended screening and the inability to pay for tests were the main barriers perceived by PCPs for both types of screening. Another major barrier cited was that patients do not perceive CRC as a threat. This was a lesser concern for the well-diffused message about the need for mammography.

CONCLUSIONS

This is the first national study to provide a comparison of physician-perceived barriers to breast and CRC screening. Study results suggest that efforts to improve use of cancer screening, and CRC screening in particular, will require interventions at physician, practice, and health-system levels.

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.

Development of a shared decision making coding system for analysis of patient-healthcare provider encounters

OBJECTIVES

To describe the development and refinement of a scheme, detail of essential elements and participants in shared decision making (DEEP-SDM), for coding shared decision making (SDM) while reporting on the characteristics of decisions in a sample of patients with metastatic breast cancer.

METHODS

The evidence-based patient choice instrument was modified to reflect Makoul and Clayman's integrative model of SDM. Coding was conducted on video recordings of 20 women at the first visit with their medical oncologists after suspicion of disease progression. Noldus Observer XT v.8, a video coding software platform, was used for coding.

RESULTS

The sample contained 80 decisions (range: 1-11), divided into 150 decision making segments. Most decisions were physician-led, although patients and physicians initiated similar numbers of decision-making conversations.

CONCLUSION

DEEP-SDM facilitates content analysis of encounters between women with metastatic breast cancer and their medical oncologists. Despite the fractured nature of decision making, it is possible to identify decision points and to code each of the essential elements of shared decision making. Further work should include application of DEEP-SDM to non-cancer encounters.

PRACTICE IMPLICATIONS

A better understanding of how decisions unfold in the medical encounter can help inform the relationship of SDM to patient-reported outcomes.

A coding system to measure elements of shared decision making during psychiatric visits

OBJECTIVE

Shared decision making is widely recognized to facilitate effective health care. The purpose of this study was to assess the applicability and usefulness of a scale to measure the presence and extent of shared decision making in clinical decisions in psychiatric practice.

METHODS

A coding scheme assessing shared decision making in general medical settings was adapted to mental health settings, and a manual for using the scheme was created. Trained raters used the adapted scale to analyze 170 audio-recordings of medication check-up visits with either psychiatrists or nurse practitioners. The scale assessed the level of shared decision making based on the presence of nine specific elements. Interrater reliability was examined, and the frequency with which elements of shared decision making were observed was documented. The association between visit length and extent of shared decision making was also examined.

RESULTS

Interrater reliability among three raters on a subset of 20 recordings ranged from 67% to 100% agreement for the presence of each of the nine elements of shared decision making and 100% for the agreement between provider and consumer on decisions made. Of the 170 sessions, 128 (75%) included a clinical decision. Just over half of the decisions (53%) met minimum criteria for shared decision making. Shared decision making was not related to visit length after the analysis controlled for the complexity of the decision.

CONCLUSIONS

The rating scale appears to reliably assess shared decision making in psychiatric practice and could be helpful for future research, training, and implementation efforts.

Bringing an organizational perspective to the optimal number of colorectal cancer screening options debate

Improving colorectal cancer (CRC) screening rates represents a challenge for primary care providers. Some have argued that offering a choice of CRC screening modes to patients will improve the currently low adherence rates. Others have raised concerns that offering numerous CRC screening options in practice could overwhelm patients and thus dampen enthusiasm for screening. In this article we assemble evidence to critically evaluate the relative merit of these opposing views. We find little evidence to support the hypothesis that the number of options offered will affect adherence (either positively or negatively), or that expanding the modalities offered beyond FOBT and colonoscopy will improve patient satisfaction. Therefore, we assert future decisions about the number of CRC screening modes to offer would more productively be focused on considerations such as what benefit the health-care organization would derive from offering additional modes, and how this change would affect other critical components of a successful screening program such as timely diagnosis. In light of these organizational level considerations, we agree with the assertion made by others that a screening program limited to FOBT and colonoscopy is likely to be ideal in most settings.

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.

Patient activation increases colorectal cancer screening rates: a randomized trial among low-income minority patients

BACKGROUND

Colorectal cancer (CRC) screening rates remain low among low-income and minority populations. The purpose of this study was to determine whether providing patients with screening information, activating them to ask for a screening test, and telephone barriers counseling improves CRC screening rates compared with providing screening information only.

METHODS

Patients were randomized to CRC screening information plus patient activation and barriers counseling (n = 138) or CRC screening information (n = 132). Barriers counseling was attempted among activated patients if screening was not completed after one month. CRC screening test completion was determined by medical record review at two months after the medical visit. Logistic regression was used to determine whether activated patients were more likely to complete CRC screening, after adjustment for confounding factors (e.g., demographic characteristics and CRC knowledge).

RESULTS

Patients were African American (72.2%), female (63.7%), had annual household incomes less than $20,000 (60.7%), no health insurance (57.0%), and limited health literacy skills (53.7%). In adjusted analyses, more patients randomized to the activation group completed a screening test (19.6% vs. 9.9%; OR = 2.35, 95% CI: 1.14-5.56; P = 0.020). In addition, more activated patients reported discussing screening with their provider (54.4% vs. 27.5%, OR = 3.29, 95% CI: 1.95-5.56; P < 0.001) and had more screening tests ordered (39.1% vs. 17.6%; OR = 3.40, 95% CI: 1.88-6.15; P < 0.001) compared with those in the control group.

CONCLUSION

Patient activation increased CRC screening rates among low-income minority patients.

IMPACT

Innovative strategies are still needed to increase CRC screening discussions, motivate providers to recommend screening to patients, as well as assist patients to complete ordered screening tests.

Patient-physician colorectal cancer screening discussions: delivery of the 5A's in practice

BACKGROUND

The U.S. Preventive Services Task Force advocates use of a 5A's framework (assess, advise, agree, assist, and arrange) for preventive health recommendations.

PURPOSE

To describe 5A content of patient-physician colorectal cancer (CRC) screening discussions and physician-recommended screening modality and to test if these vary by whether patient previously received screening recommendation.

METHODS

Direct observation of periodic health examinations in 2007-2009 among average-risk primary care patients aged 50-80 years due for screening. Qualitative content analyses conducted 2008-2010 used to code office visit audio-recordings for 5A and other discussion content.

RESULTS

Among study-eligible visits (N=415), 59% contained assistance (i.e., help scheduling colonoscopy or delivery of stool cards), but the assess, advise, and agree steps were rarely comprehensively provided (1%-21%), and only 3% included the last step, arrange follow-up. Almost all physicians endorsed screening via colonoscopy (99%), either alone (69%) or in combination with other tests (30%). Patients nonadherent to a prior physician screening recommendation (31%) were less likely to have the reason(s) for screening discussed (37% vs 65%) or be told the endoscopy clinic would call them for scheduling (19% vs 27%), and more likely to have fecal occult blood testing (FOBT) alone (34% vs 25%) or FOBT and colonoscopy recommended (24% vs 14%), and a screening plan negotiated (21% vs 14%). Significance level is p<0.05 for all contrasts.

CONCLUSIONS

Most patients due for CRC screening discuss screening with their physician, but with limited application of the 5A's approach. Opportunities to improve CRC screening decision-making are great, particularly among patients who are nonadherent to a prior recommendation from a physician.

Patient-rated importance and receipt of information for colorectal cancer screening

BACKGROUND

Physician recommendation is one of the most important determinants of obtaining colorectal cancer (CRC) screening; however, little is known about the degree to which CRC screening discussions include information that patients report as important to guide screening decisions. This study examines and compares both patient rated importance and physician communication of key information elements about CRC screening during annual physical examinations.

METHODS

DESIGN

Cross-sectional cohort.

SETTING

26 ambulatory clinics of an integrated delivery system in the Midwest.

PARTICIPANTS

64 primary care physicians and 415 patients aged 50 to 80 due for CRC screening. Patients completed a previsit survey to assess importance of specific information when making a preventive screening decision. Visits were audio recorded to assess the content of screening discussions.

RESULTS

Most patients rated test accuracy (85%), testing alternatives (83%), the pros and cons of testing (86%), and the testing process (78%) very important when making preventive screening decisions. Ninety-one percent of visits included a CRC screening discussion; however, CRC screening talk rarely included information that patients rated as important. Physicians infrequently asked whether patients had questions pertaining to CRC screening (5%); however, 49% of patients asked a CRC screening question, with the vast majority pertaining to screening logistics.

CONCLUSIONS

Audio recordings confirm that discussions of CRC screening are often lacking information that patients indicate is very important when making preventive health decisions and patient questions during the visit are not eliciting information to fill the gap.

IMPACT

These findings provide actionable information to improve CRC screening discussions.

Measuring informed decision making about prostate cancer screening in primary care

PURPOSE

To measure the extent of informed decision making (IDM) about prostate cancer screening in physician-patient encounters, describe the coding process, and assess the reliability of the IDM measure.

METHODS

Audiorecoded encounters of 146 older adult men and their primary care physicians were obtained in a randomized controlled trial of mediated decision support related to prostate cancer screening. Each encounter was dual coded for the presence or absence of 9 elements that reflect several important dimensions of IDM, such as information sharing, patient empowerment, and engaging patients in preference clarification. An IDM-9 score (range = 0-9) was determined for each encounter by summing the number of elements that were coded as present. Estimates of coding reliability and internal consistency were calculated.

RESULTS

Male patients tended to be white (59%), married (70%), and between the ages of 50 and 59 (70%). Physicians tended to be white (90%), male (74%), and have more than 10 years of practice experience (74%). IDM-9 scores ranged from 0 to 7.5 (mean [SD], 2.7 [2.1]). Reliability (0.90) and internal consistency (0.81) of the IDM-9 were both high. The IDM dimension observed most frequently was information sharing (74%), whereas the dimension least frequently observed was engagement in preference clarification (3.4%).

CONCLUSIONS

In physician-patient encounters, the level of IDM concerning prostate cancer screening was low. The use of a dual-coding approach with audiorecorded encounters produced a measure of IDM that was reliable and internally consistent.

Physicians' colorectal cancer screening discussion and recommendation patterns

BACKGROUND

Primary care physician (PCP) actions are pivotal to colorectal cancer (CRC) screening performance, and guidelines recommend discussion with patients about test options and potential benefits and harms. This article profiles patterns of discussion about and recommendations for screening and explores potential associations with multilevel factors (patient, clinician, practice, and environment).

METHODS

In 2009, we analyzed data from 1,266 physicians responding to the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Breast, Cervical, Colorectal, and Lung Cancer Screening (absolute response rate=69.3%; cooperation rate=75.0%). Descriptive statistics examined physicians' reports of discussion and recommendations. Multivariate analyses assessed the associations of these practices with multilevel factors.

RESULTS

Although few respondents reported discussion of all options, 46% usually discuss more than one option; the vast majority of these respondents discuss fecal occult blood testing (FOBT) and colonoscopy (49%) or FOBT, sigmoidoscopy, and colonoscopy (32%). Of physicians who discuss more than one option, a majority reported usually recommending one or more test options, most commonly colonoscopy alone (43%) and FOBT and colonoscopy (43%). Several personal characteristics (specialty), perceived patient characteristics (prefer physician to decide), practice characteristics (geographic location), and community barriers (specialist availability) were independently associated with discussion and/or recommendation patterns.

CONCLUSIONS

PCPs do not discuss the full menu of test options, but many report selecting one or two options for discussion and recommendation. To ensure that patients' perspectives and concerns are elicited and considered, patient decision-making approaches should be considered.

IMPACT

Attention to informed decision making in CRC screening will be important for enhancing patient-centered quality care.

Eliminating disparities in cancer screening and follow-up of abnormal results: what will it take?

Health and health care disparities related to cancer are a major public health problem in the United States. Providing care that is truly patient-centered could address disparities in cancer screening and follow-up through better alignment between patient needs and health care resources available to address those needs. Key health care reforms offer promise for doing so.

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.

Electronic patient messages to promote colorectal cancer screening: a randomized controlled trial

BACKGROUND

Colorectal cancer is a leading cause of cancer mortality, yet effective screening tests are often underused. Electronic patient messages and personalized risk assessments delivered via an electronic personal health record could increase screening rates.

METHODS

We conducted a randomized controlled trial in 14 ambulatory health centers involving 1103 patients ranging in age from 50 to 75 years with an active electronic personal health record who were overdue for colorectal cancer screening. Patients were randomly assigned to receive a single electronic message highlighting overdue screening status with a link to a Web-based tool to assess their personal risk of colorectal cancer. The outcomes included colorectal cancer screening rates at 1 and 4 months.

RESULTS

Screening rates were higher at 1 month for patients who received electronic messages than for those who did not (8.3% vs 0.2%, P < .001), but this difference was no longer significant at 4 months (15.8% vs 13.1%, P = .18). Of 552 patients randomized to receive the intervention, 296 (54%) viewed the message, and 47 (9%) used the Web-based risk assessment tool. Among 296 intervention patients who viewed the electronic message, risk tool users were more likely than nonusers to request screening examinations (17% vs 4%, P = .04) and to be screened (30% vs 15%, P = .06). One-fifth of patients (19%) using the risk assessment tool were estimated to have an above-average risk for colorectal cancer.

CONCLUSION

Electronic messages to patients produce an initial increase in colorectal cancer screening rates, but this effect is not sustained over time.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01032746.

Is discussion of colorectal cancer screening options associated with heightened patient confusion?

BACKGROUND

Clinical guidelines recommend offering patients options for colorectal cancer (CRC) screening, but the modalities vary by frequency, accuracy, preparations, discomfort, and cost, which may cause confusion and reduce screening rates. We examined whether patients reported confusion about the options and whether confusion was associated with socio-demographic characteristics, number of options discussed, and adherence.

METHODS

Patients ages 50 to 75 years who had visited a clinician within 2 years were randomly selected for a cross-sectional study (n = 6,100). A questionnaire mailed in 2007 asked the following: whether a clinician had ever discussed CRC screening options; which of four recommended tests (i.e., fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema) were presented; and whether the options were confusing. Analyses were restricted to respondents who reported discussing one or more screening options (n = 1,707). Weighted frequencies were calculated and multivariate logistic regression was done.

RESULTS

The sample was 55.5% female, 15.6% African American, and 83.2% adherent to screening recommendations, and 56.0% had discussed two or more screening options. In adjusted analyses, nonadherent patients reported greater confusion than adherent patients (P < 0.01). Adults who discussed two or more options were 1.6 times more likely to be confused than those who discussed one option [95% confidence interval (CI), 1.08-2.26]. Patients who reported being confused were 1.8 times more likely to be nonadherent to screening than those who did not (95% CI, 1.14-2.75).

CONCLUSIONS

Our study provides the first empirical evidence linking multiple options with confusion and confusion with screening adherence.

IMPACT

Confusion may act as a barrier to screening and should be considered in public health messages and interventions.

Decision-making processes for breast, colorectal, and prostate cancer screening: the DECISIONS survey

BACKGROUND

Patients should understand the risks and benefits of cancer screening in order to make informed screening decisions.

OBJECTIVES

To evaluate the extent of informed decision making in patient-provider discussions for colorectal (CRC), breast (BrCa), and prostate (PCa) cancer screening.

SETTING

National sample of US adults identified by random-digit dialing.

DESIGN

Cross-sectional survey conducted between November 2006 and May 2007.

PARTICIPANTS

English-speaking US adults aged 50 y and older who had discussed cancer screening with a health care provider within the previous 2 y.

MEASUREMENTS

Cancer screening survey modules that asked about demographic characteristics, cancer knowledge, the importance of various sources of information, and self-reported cancer screening decision-making processes.

RESULTS

Overall, 1082 participants completed 1 or more of the 3 cancer modules. Although participants generally considered themselves well informed about screening tests, half or more could not correctly answer even 1 open-ended knowledge question for any given module. Participants consistently overestimated risks for being diagnosed with and dying from each cancer and overestimated the positive predictive values of prostate-specific antigen tests and mammography. Providers were the most highly rated information source, usually initiated screening discussions (64%-84%), and often recommended screening (73%-90%). However, participants reported that providers elicited their screening preferences in only 31% (CRC women) to 57% (PCa) of discussions. Although more than 90% of the discussions addressed the pros of screening, only 19% (BrCa) to 30% (PCa) addressed the cons of screening.

LIMITATIONS

Recall bias is possible because screening process reports were not independently validated.

CONCLUSIONS

Cancer screening decisions reported by patients who discussed screening with their health care providers consistently failed to meet criteria for being informed. Given the high ratings for provider information and frequent recommendations for screening, providers have important opportunities to ensure that informed decision making occurs for cancer screening decisions.

Quality assurance of endoscopy in colorectal cancer screening

This chapter explores the concept of quality assurance of colorectal cancer screening. It argues that effective quality assurance is critical to ensure that the benefits of screening outweigh the harms. The three key steps of quality assurance, definition of standards, measurement of standards and enforcement of standards, are explained. Quality is viewed from the perspective of the patient and illustrated by following the path of patients accessing endoscopy within screening services. The chapter discusses the pros and cons of programmatic versus non-programmatic screening and argues that quality assurance of screening can and should benefit symptomatic services. Finally, the chapter emphasises the importance of a culture of excellence underpinned by continuous quality improvement and effective service leadership.