The uptake and effect of a mailed multi-modal colon cancer screening intervention: a pilot controlled trial

Making decisions on your own: Self-administered decision aids about colorectal cancer screening - A systematic review and meta-analyses

OBJECTIVE

To provide a systematic review of self-administered decision aids (DAs) for citizens invited to participate in colorectal cancer screening synthesizing the effectiveness of self-administered DAs on informed choice or the components hereof; knowledge, attitudes, and participation.

METHODS

The literature search was undertaken in PubMed, CINAHL, PsycINFO, Embase and Scopus and last updated 19 March 2021. Results were presented by narrative synthesis, meta-analyses and vote counting based on direction of effect.

RESULTS

Fourteen studies of fair methodological quality were included. One study reported on informed choice and 13 studies reported on the components. Self-administered DAs increased participation and knowledge whereas it was inconclusive with regard to attitudes towards screening. The studies were very heterogeneous with different comparators, outcomes and means of measurement.

CONCLUSION

This systematic review showed a potential for self-administered DAs to support informed choice in colorectal cancer screening, especially by increasing knowledge.

PRACTICE IMPLICATIONS

It seems reasonable to consider informed choice to be one of the main outcomes of self-administered DAs. Yet there is a need for consensus on how to measure informed choice in cancer screening, especially a validated measurement of knowledge defining what constitutes 'adequate knowledge'.

Costs of Two Health Insurance Plan Programs to Mail Fecal Immunochemical Tests to Medicare and Medicaid Plan Members

BeneFIT is a 4-year observational study of a mailed fecal immunochemical test (FIT) program in 2 Medicaid/Medicare health plans in Oregon and Washington. In Health Plan Oregon's (HPO) collaborative model, HPO mails FITs that enrollees return to their clinics for processing. In Health Plan Washington's (HPW) centralized model, FITs are mailed directly to enrollees who return them to a centralized laboratory. This paper examines model-specific Year 1 development and implementation costs and estimates costs per screened enrollee. Staff completed activity-based costing spreadsheets. Non-labor costs were from study and external data. Data matched each plan's 2016 development and implementation dates. HPO development costs were $23.0K, primarily administration (eg, clinic recruitment). HPW development costs were $37.3K, 38.8% for FIT selection and mailing/tracking protocols. Year 1 implementation costs were $51.6K for HPO and $139.7K for HPW, reflecting HPW's greater outreach. Labor was 50.4% ($26.0K) of HPO's implementation costs, primarily enrollee eligibility and processing returned FITs, and was shared by HPO ($17.0K) and 6 participating clinics ($9.0K). Labor was 10.5% of HPW's implementation costs, primarily administration and enrollee eligibility. HPO's implementation costs per enrollee were 12.3% higher ($18.36) than for HPW ($16.34). Similar proportions of completed FITs among screening-eligibles produced a 15% lower cost per completed FIT in HPW ($89.75) vs. HPO ($105.79). Implementation costs for HPO only (without clinic costs) were $15.16/mailed introductory letter, $16.09/mailed FIT, and $87.35/completed FIT, comparable to HPW. Results highlight cost implications of different approaches to implementing a mailed FIT program in 2 Medicaid/Medicare health plans.

Testing a Culturally Adapted Colorectal Cancer Screening Decision Aid Among American Indians: Results from a Pre-Post Trial

Purpose: American Indian adults have not experienced decreases in colorectal cancer (CRC) incidence and mortality observed in other races or ethnic groups and their screening rates are low. Decision aids that explain available CRC screening options are one potential strategy to promote screening. The goal of this study was to test the effect of a culturally adapted decision aid on CRC-related outcomes among American Indian adults, including screening-related knowledge, attitudes, self-efficacy, intentions, and screening modality preferences.

Methods: We recruited American Indian adults aged 50–75 years who were not current with CRC screening. Participants viewed a 9-min multimedia decision aid that used narrative vignettes to provide educational information about screening along with messages to address culturally specific barriers and values uncovered in formative research. We conducted a single-arm (pre–post) study and assessed screening-related outcomes at baseline and immediately after viewing the decision aid.

Results: Among n=104 participants, knowledge scores increased from a mean of 36% correct to 76% correct. Participants also had statistically significant increases in positive attitudes, perceived social norms, self-efficacy, and intent. The proportion of participants who identified a preference for a specific CRC screening modality rose from 81% identified at pre-intervention to 93% post-intervention (p=0.013).

Conclusion: Our study provides promising new findings that our culturally adapted decision aid is efficacious in educating American Indian adults about CRC screening and increases their screening intentions and ability to state modality preferences. Future research is needed to test the decision aid as a component of CRC screening interventions with American Indian adults.

A targeted promotional DVD fails to improve Māori and Pacific participation rates in the New Zealand bowel screening pilot: results from a pseudo-randomised controlled trial

BACKGROUND

New Zealand's Bowel Screening Pilot (BSP) used a mailed invitation to return a faecal immunochemical test. As a pilot it offered opportunities to test interventions for reducing ethnic inequities in colorectal cancer screening prior to nationwide programme introduction. Small media interventions (e.g. educational material and DVDs) have been used at both community and participant level to improve uptake. We tested whether a DVD originally produced to raise community awareness among the Māori population would have a positive impact on participation and reduce the proportion of incorrectly performed tests (spoiled kits) if mailed out with the usual reminder letter.

METHODS

The study was a parallel groups pseudo-randomised controlled trial. Over 12 months, all Māori and Pacific ethnicity non-responders four weeks after being mailed the test kit were allocated on alternate weeks to be sent, or not, the DVD intervention with the usual reminder letter. The objective was to determine changes in participation and spoiled kit rates in each ethnic group, determined three months from the date the reminder letter was sent. Participants and those recording the outcomes (receipt of a spoiled or non-spoiled test kit) were blinded to group assignment.

RESULTS

2333 Māori and 2938 Pacific people participated (11 withdrew). Those who were sent the DVD (1029 Māori and 1359 Pacific) were less likely to participate in screening than those who were not (1304 Māori and 1579 Pacific). Screening participation was reduced by 12.3% (95% CI 9.1-15.5%) in Māori (13.6% versus 25.9%) and 8.3% (95% CI 5.8-10.8%) in Pacific (10.1% versus 18.4%). However, spoiled kit rates (first return) were significantly higher among those not sent the DVD (33.1% versus 12.4% in Māori and 42.1% versus 21.9% in Pacific).

CONCLUSION

The DVD sent with the reminder letter to BSP non-responders reduced screening participation to an extent that more than offset the lower rate of spoiled kits.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry ACTRN12612001259831 . Registered 30 November 2013.

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.

A cost-effectiveness analysis of a colorectal cancer screening program in safety net clinics

STOP CRC is a cluster-randomized pragmatic study of a colorectal cancer (CRC) screening program within eight federally-qualified health centers (FQHCs) in Oregon and California promoting fecal immunochemical testing (FIT) with appropriate colonoscopy follow-up. Results are presented of a cost-effectiveness analysis of STOP CRC. Organization staff completed activity-based costing spreadsheets, assigning labor hours by intervention activity and job-specific wage rates. Non-labor costs were from study data. Data were collected over February 2014-February 2016; analyses were performed in 2016-2017. Incremental cost-effectiveness ratios (ICERs) using completed FITs adjusted for number of screening-eligible patients (SEPs), as the effectiveness measure were calculated overall and by organization. Intervention delivery costs totaled $305 K across eight organizations (range: $10.2 K-$110 K). Overall delivery cost per SEP was $14.43 (range: $10.37-$19.10). The largest cost category across organizations was implementation, specifically mailing preparation. The overall ICER was $483 per SEP-adjusted completed FIT (range: $96-$1021 among organizations with positive effectiveness). Lagged data accounting for implementation delay produced comparable results. The costs of colonoscopies following abnormal FITs decreased the overall ICER to S409 because usual care clinics generated more such colonoscopies than intervention clinics. Using lagged data, follow-up colonoscopies increase the ICER by 4.3% to $460. Results indicate the complex implications for cost-effectiveness of implementing standard CRC screening within a pragmatic setting involving FQHCs with varied patient populations, clinical structures, and resources. Performance variation across organizations emphasizes the need for future evaluations that inform the introduction of efficient CRC screening to underserved populations.

Colorectal cancer and screening awareness and sources of information in the Hungarian population

Background

This study aims to survey the level of awareness of colorectal cancer and screening and to identify sources of information among the population under investigation.

Methods

A cross-sectional study was conducted among 1150 adults between the ages of 40 and 70 using quota sampling. Data were collected through self-made questionnaires to be completed by respondents.

Results

32.7% of the participants correctly identified the recommended beginning of colorectal cancer screening, these participants were more likely to see their physician more frequently in the past years than those answering to the qusetion incorrectly (p = 0.008). 22.4% of the respondents were in possession of appropriate information on the frequency of colorectal cancer screening and had a relatively high level of educational attainment (p < 0.001). Very few respondents were well-informed about the risk factors and symptoms of colorectal cancer. Those who were well-informed were likely to live in a county town (p < 0.001) and to have a relatively high level of educational attainment (p < 0.001). They were most likely to have accessed their information on the internet. 27.0% of respondents had not heard of CRC screening methods before. They were likely to be male and relatively young and to have a relatively low level of educational attainment. Furthermore, they saw their doctor relatively seldom. The respondents who had heard about screening methods were most likely to have gathered their information from health workers. Conclusions: The majority of respondents did not have sufficient information about colorectal cancer and screening. This is particularly true of less educated, younger male participants who do not live in a county town and of respondents who see their physician relatively seldom. Sources of information should be used more effectively, thus yielding an increased level of awareness.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0799-1) contains supplementary material, which is available to authorized users.

Community-Based, Preclinical Patient Navigation for Colorectal Cancer Screening Among Older Black Men Recruited From Barbershops: The MISTER B Trial

OBJECTIVES

To test the effectiveness of a preclinical, telephone-based patient navigation intervention to encourage colorectal cancer (CRC) screening among older Black men.

METHODS

We conducted a 3-parallel-arm, randomized trial among 731 self-identified Black men recruited at barbershops between 2010 and 2013 in New York City. Participants had to be aged 50 years or older, not be up-to-date on CRC screening, have uncontrolled high blood pressure, and have a working telephone. We randomized participants to 1 of 3 groups: (1) patient navigation by a community health worker for CRC screening (PN), (2) motivational interviewing for blood pressure control by a trained counselor (MINT), or (3) both interventions (PLUS). We assessed CRC screening completion at 6-month follow-up.

RESULTS

Intent-to-treat analysis revealed that participants in the navigation interventions were significantly more likely than those in the MINT-only group to be screened for CRC during the 6-month study period (17.5% of participants in PN, 17.8% in PLUS, 8.4% in MINT; P < .01).

CONCLUSIONS

Telephone-based preclinical patient navigation has the potential to be effective for older Black men. Our results indicate the importance of community-based health interventions for improving health among minority men.

Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population: A Randomized Clinical Trial

IMPORTANCE

Colorectal cancer (CRC) screening is underused, especially among vulnerable populations. Decision aids and patient navigation are potentially complementary interventions for improving CRC screening rates, but their combined effect on screening completion is unknown.

OBJECTIVE

To determine the combined effect of a CRC screening decision aid and patient navigation compared with usual care on CRC screening completion.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, data were collected from January 2014 to March 2016 at 2 community health center practices, 1 in North Carolina and 1 in New Mexico, serving vulnerable populations. Patients ages 50 to 75 years who had average CRC risk, spoke English or Spanish, were not current with recommended CRC screening, and were attending primary care visits were recruited and randomized 1:1 to intervention or control arms.

INTERVENTIONS

Intervention participants viewed a CRC screening decision aid in English or Spanish immediately before their clinician encounter. The decision aid promoted screening and presented colonoscopy and fecal occult blood testing as screening options. After the clinician encounter, intervention patients received support for screening completion from a bilingual patient navigator. Control participants viewed a food safety video before the encounter and otherwise received usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was CRC screening completion within 6 months of the index study visit assessed by blinded medical record review.

RESULTS

Characteristics of the 265 participants were as follows: their mean age was 58 years; 173 (65%) were female, 164 (62%) were Latino; 40 (15%) were white non-Latino; 61 (23%) were black or of mixed race; 191 (78%) had a household income of less than $20 000; 101 (38%) had low literacy; 75 (28%) were on Medicaid; and 91 (34%) were uninsured. Intervention participants were more likely to complete CRC screening within 6 months (68% vs 27%); adjusted-difference, 40 percentage points (95% CI, 29-51 percentage points). The intervention was more effective in women than in men (50 vs 21 percentage point increase, interaction P = .02). No effect modification was observed across other subgroups.

CONCLUSIONS AND RELEVANCE

A patient decision aid plus patient navigation increased the rate of CRC screening completion in compared with usual care invulnerable primary care patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02054598.

Improving uptake of flexible sigmoidoscopy screening: a randomized trial of nonparticipant reminders in the English Screening Programme

Background and study aims Uptake of flexible sigmoidoscopy screening in the English Bowel Scope Screening (BSS) Programme is low. The aim of this study was to test the impact of a nonparticipant reminder and theory-based leaflet to promote uptake among former nonresponders (previously did not confirm their appointment) and nonattenders (previously confirmed their appointment but did not attend). Patients and methods Eligible adults were men and women in London who had not attended a BSS appointment within 12 months of their invitation. Individuals were randomized (1:1:1) to receive no reminder (control), a 12-month reminder plus standard information booklet (TMR-SIB), or a 12-month reminder plus bespoke theory-based leaflet (TMR-TBL) designed to address barriers to screening. The primary outcome of the study was the proportion of individuals screened within each group 12 weeks after the delivery of the reminder. Results A total of 1383 men and women were randomized and analyzed as allocated (n = 461 per trial arm). Uptake was 0.2 % (n = 1), 10.4 % (n = 48), and 15.2 % (n = 70) in the control, TMR-SIB, and TMR-TBL groups, respectively. Individuals in the TMR-SIB and TMR-TBL groups were significantly more likely to attend screening than individuals in the control group (adjusted odds ratio [OR] 53.7, 95 % confidence interval [CI] 7.4 - 391.4, P < 0.001 and OR 89.0, 95 %CIs 12.3 - 645.4, P < 0.01, respectively). Individuals in the TMR-TBL group were also significantly more likely to attend screening than individuals in the TMR-SIB group (OR 1.7, 95 %CIs 1.1 - 2.5, P = 0.01). Across all groups, former nonattenders were more likely to participate in screening than former nonresponders (uptake was 14.2 % and 8.0 %, respectively; OR 2.5, 95 %CIs 1.4 - 4.4, P < 0.01). The adenoma detection rate among screened adults was 7.6 %, which is comparable to the rate in initial attenders. Conclusions Reminders targeting former nonparticipants can improve uptake and are effective for both former nonresponders and nonattenders. Theory-based information designed to target barriers to screening added significantly to this strategy.

Patient Decision Aids for Colorectal Cancer Screening: A Systematic Review and Meta-analysis

CONTEXT

Decision aids prepare patients to make decisions about healthcare options consistent with their preferences. Helping patients choose among available options for colorectal cancer screening is important because rates are lower than screening for other cancers. This systematic review describes studies evaluating patient decision aids for colorectal cancer screening in average-risk adults and their impact on knowledge, screening intentions, and uptake.

EVIDENCE ACQUISITION

Sources included Ovid MEDLINE, Elsevier EMBASE, EBSCO CINAHL Plus, Ovid PsycINFO through July 21, 2015, pertinent reference lists, and Cochrane review of patient decisions aids. Reviewers independently selected studies that quantitatively evaluated a decision aid compared to one or more conditions or within a pre-post evaluation. Using a standardized form, reviewers independently extracted study characteristics, interventions, comparators, and outcomes. Analysis was conducted in August 2015.

EVIDENCE SYNTHESIS

Twenty-three articles representing 21 trials including 11,900 subjects were eligible. Patients exposed to a decision aid showed greater knowledge than those exposed to a control condition (mean difference=18.3 of 100; 95% CI=15.5, 21.1), were more likely to be interested in screening (pooled relative risk=1.5; 95% CI=1.2, 2.0), and more likely to be screened (pooled relative risk=1.3; 95% CI=1.1, 1.4). Decision aid patients had greater knowledge than patients receiving general colorectal cancer screening information (pooled mean difference=19.3 of 100; 95% CI=14.7, 23.8); however, there were no significant differences in screening interest or behavior.

CONCLUSIONS

Decision aids improve knowledge and interest in screening, and lead to increased screening over no information, but their impact on screening is similar to general colorectal cancer screening information.

Colorectal Cancer Screening in Vulnerable Patients: Promoting Informed and Shared Decisions

INTRODUCTION

Low-income, low-literacy, limited English-proficient populations have low colorectal cancer (CRC) screening rates and experience poor patient-provider communication and decision-making processes around screening. The purpose of this study was to test the effect of a CRC screening decision aid on screening-related communication and decision making in primary care visits.

STUDY DESIGN

RCT with data collected from patients at baseline and immediately after the provider encounter.

SETTING/PARTICIPANTS

Patients aged 50-75 years, due for CRC screening, were recruited from two safety net clinics in North Carolina and New Mexico (data collection, January 2014-September 2015; analysis, 2015).

INTERVENTION

Participants viewed a CRC screening decision aid or a food safety (control) video immediately before their provider encounter.

MAIN OUTCOME MEASURES

CRC screening-related knowledge, discussion, intent, test preferences, and test ordering.

RESULTS

The study population (N=262) had a mean age of 58.3 years and was 66% female, 61% Latino, 17% non-Latino black, and 16% non-Latino white. Among Latino participants, 71% preferred Spanish. Compared with controls, intervention participants had greater screening-related knowledge (on average 4.6 vs 2.8 of six knowledge items correct, adjusted difference [AD]=1.8, 95% CI=1.5, 2.1) and were more likely to report screening discussion (71.0% vs 45.0%, AD=26.1%, 95% CI=14.3%, 38.0%) and high screening intent (93.1% vs 84.7%, AD=9.0%, 95% CI=2.0%, 16.0%). Intervention participants were more likely to indicate a specific screening test preference (93.1% vs 68.0%, AD=26.5%, 95% CI=17.2%, 35.8%) and to report having a test ordered (56.5% vs 32.1%, AD=25.8%, 95% CI=14.4%, 37.2%).

CONCLUSIONS

Viewing a CRC screening decision aid before a primary care encounter improves knowledge and shared decision making around screening in a racially, ethnically, and linguistically diverse safety net clinic population.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02054598.

Developing and Evaluating a Clinic-Based Decision Aid Delivery System

Background: Despite evidence of their benefits, decision aids (DAs) have not been widely adopted in clinical practice. Quality improvement methods could help embed DA delivery into primary care workflows and facilitate DA delivery and uptake, defined as reading or watching DA materials. Objectives: 1) Work with clinic staff and providers to develop and test multiple processes for DA delivery; 2) implement a systems approach to measuring delivery and uptake; 3) compare uptake and patient satisfaction across delivery models. Methods: We employed a microsystems approach to implement three DA delivery models into primary care processes and workflows: within existing disease management programs, by physician request, and by mail. We developed a database and tracking tools linked to our electronic health record and designed clinic-based processes to measure uptake and satisfaction. Results: A total of 1144 DAs were delivered. Depending on delivery method, 51% to 73% of patients returned to the clinic within 6 months. Nurses asked 67% to 75% of this group follow-up questions, and 65% to 79% recalled receiving the DA. Among them, uptake was 23% to 27%. Satisfaction among patients who recalled receiving the DA was high. Eighty-two to 93% of patients reported that they liked receiving this patient education information, and 82% to 91% reported that receiving patient education information like this is useful to them. Conclusion: Our results demonstrate the realities of clinical practice. One fourth to one third of patients did not return for a follow-up visit. Although nurses were able to assess uptake in the course of their usual duties, the results did not achieve the standards typically expected of clinical research. Despite these limitations, uptake, though modest, was similar across delivery methods, suggesting that there are multiple strategies for implementing DAs in clinical practice.

Development of a Practical Model for Targeting Patient Decision Support Interventions to Promote Colorectal Cancer Screening in Vulnerable Populations

We sought to develop a practical model for predicting probability of colorectal cancer (CRC) screening completion in a diverse safety-net population and a subsequent framework for targeting screening promotion interventions. Data used to construct the models was prospectively collected from a CRC screening intervention. Models were cross-validated by randomly splitting the data into training and validation samples. The predicted probabilities of screening completion from the final model were trichotomized into framework groups and cross-validated by defining cut-points in the training sample, applying them to the validation sample, and comparing across samples for homogeneity. The final model included demographic and simple psychosocial measures and predicted screening behavior adequately (AUROC=0.63). The framework groups (cut-points 0.62 (low), 0.74 (medium), and 1.0 (high)) were homogeneous across the two samples. The model and framework may be useful for designing and delivering targeted interventions to promote CRC screening. Future research should validate the framework groups.

A Randomized Controlled Effectiveness Trial for PSA Screening Decision Support Interventions in Two Primary Care Settings

BACKGROUND

Decision support interventions (DESIs) provide a mechanism to translate comparative effectiveness research results into clinical care so that patients are able to make informed decisions. Patient decision support interventions for prostate-specific antigen (PSA) have been shown to promote informed decision making and reduce PSA testing in efficacy trials, but their impact in real world settings is not clear.

OBJECTIVE

We performed an effectiveness trial of PSA decision support interventions in primary care.

DESIGN

A randomized controlled trial of three distribution strategies was compared to a control.

PARTICIPANTS

Participants included 2,550 men eligible for PSA testing (76.6 % of the eligible population) and 2001 survey respondents (60.1 % survey response rate).

INTERVENTIONS

The intervention groups were: 1) mailed the DESI in DVD format, 2) offered a shared medical appointment (SMA) to view the DESI with other men and discuss, and 3) both options.

MAIN MEASURES

We measured PSA testing identified via electronic medical record at 12 months and DESI use by self-report 4 months after the intervention mailing.

KEY RESULTS

We found no differences in PSA testing across the three distribution strategies over a year-long follow-up period: 21 %, 24 %, 22 % in the DESI, SMA, and combined group respectively, compared to 21 % in the control group (p = 0.51). Self-reported DESI use was low across all strategies at 4 months: 16 % in the mailed DESI group, 6 % in the SMA group, and 15 % in the combined group (p = < 0.0001).

CONCLUSIONS

Mailing PSA decision support interventions or inviting men to shared medical appointments unrelated to a primary care office visit do not appear to promote informed decision making, or change PSA testing behavior.

Comparing the effect of a decision aid plus patient navigation with usual care on colorectal cancer screening completion in vulnerable populations: study protocol for a randomized controlled trial

BACKGROUND

Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screening is underutilized in vulnerable patient populations, particularly among Latinos. Patient-directed decision aids can increase CRC screening knowledge, self-efficacy, and intent; however, their effect on actual screening test completion tends to be modest. This is probably because decision aids do not address some of the patient-specific barriers that prevent successful completion of CRC screening in these populations. These individual barriers might be addressed though patient navigation interventions. This study will test a combined decision aid and patient navigator intervention on screening completion in diverse populations of vulnerable primary care patients.

METHODS/DESIGN

We will conduct a multisite, randomized controlled trial with patient-level randomization. Planned enrollment is 300 patients aged 50 to 75 years at average CRC risk presenting for appointments at two primary clinics in North Carolina and New Mexico. Intervention participants will view a video decision aid immediately before the clinic visit. The 14 to 16 minute video presents information about fecal occult blood tests and colonoscopy and will be viewed on a portable computer tablet in English or Spanish. Clinic-based patient navigators are bilingual and bicultural and will provide both face-to-face and telephone-based navigation. Control participants will view an unrelated food safety video and receive usual care. The primary outcome is completion of a CRC screening test at six months. Planned subgroup analyses include examining intervention effectiveness in Latinos, who will be oversampled. Secondarily, the trial will evaluate the intervention effects on knowledge of CRC screening, self-efficacy, intent, and patient-provider communication. The study will also examine whether patient ethnicity, acculturation, language preference, or health insurance status moderate the intervention effect on CRC screening.

DISCUSSION

This pragmatic randomized controlled trial will test a combined decision aid and patient navigator intervention targeting CRC screening completion. Findings from this trial may inform future interventions and implementation policies designed to promote CRC screening in vulnerable patient populations and to reduce screening disparities.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT02054598.

A conceptual model of the multiple stages of communication necessary to support patient-centered care

Patient-centered care requires that both healthcare providers and patients have access to comparative effectiveness research (CER), which provides direct comparisons of the risks and benefits of available clinical options. However, insufficient attention has been paid to developing the comprehensive communication systems necessary to ensure that CER reaches patients and healthcare providers. In this review, we propose a model of the multiple stages of CER communication necessary for patient-centered care and review the existing research and gaps in knowledge relevant to each stage. These stages include: promotion of the underlying concepts and value of CER; translation of CER results; dissemination of CER results; and utilization of the results of CER in shared decision-making between patients and providers. A comprehensive approach to CER communication is necessary to ensure that the growing interest in and availability of CER is able to support a more patient-centered model of healthcare.

Perceived barriers and facilitators of using a Web-based interactive decision aid for colorectal cancer screening in community practice settings: findings from focus groups with primary care clinicians and medical office staff

BACKGROUND

Information is lacking about the capacity of those working in community practice settings to utilize health information technology for colorectal cancer screening.

OBJECTIVE

To address this gap we asked those working in community practice settings to share their perspectives about how the implementation of a Web-based patient-led decision aid might affect patient-clinician conversations about colorectal cancer screening and the day-to-day clinical workflow.

METHODS

Five focus groups in five community practice settings were conducted with 8 physicians, 1 physician assistant, and 18 clinic staff. Focus groups were organized using a semistructured discussion guide designed to identify factors that mediate and impede the use of a Web-based decision aid intended to clarify patient preferences for colorectal cancer screening and to trigger shared decision making during the clinical encounter.

RESULTS

All physicians, the physician assistant, and 8 of the 18 clinic staff were active participants in the focus groups. Clinician and staff participants from each setting reported a belief that the Web-based patient-led decision aid could be an informative and educational tool; in all but one setting participants reported a readiness to recommend the tool to patients. The exception related to clinicians from one clinic who described a preference for patients having fewer screening choices, noting that a colonoscopy was the preferred screening modality for patients in their clinic. Perceived barriers to utilizing the Web-based decision aid included patients' lack of Internet access or low computer literacy, and potential impediments to the clinics' daily workflow. Expanding patients' use of an online decision aid that is both easy to access and understand and that is utilized by patients outside of the office visit was described as a potentially efficient means for soliciting patients' screening preferences. Participants described that a system to link the online decision aid to a computerized reminder system could promote a better understanding of patients' screening preferences, though some expressed concern that such a system could be difficult to keep up and running.

CONCLUSIONS

Community practice clinicians and staff perceived the Web-based decision aid technology as promising but raised questions as to how the technology and resultant information would be integrated into their daily practice workflow. Additional research investigating how to best implement online decision aids should be conducted prior to the widespread adoption of such technology so as to maximize the benefits of the technology while minimizing workflow disruptions.

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.

"Many miles to go …": a systematic review of the implementation of patient decision support interventions into routine clinical practice

BACKGROUND

Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings.

METHODS

An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment.

RESULTS

After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption.

CONCLUSIONS

It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a 'referral model' consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the 'barriers' and 'facilitators' approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.

A novel community-based study to address disparities in hypertension and colorectal cancer: a study protocol for a randomized control trial

BACKGROUND

Black men have the greatest burden of premature death and disability from hypertension (HTN) in the United States, and the highest incidence and mortality from colorectal cancer (CRC). While several clinical trials have reported beneficial effects of lifestyle changes on blood pressure (BP) reduction, and improved CRC screening with patient navigation (PN), the effectiveness of these approaches in community-based settings remains understudied, particularly among Black men.

METHODS/DESIGN

MISTER B is a two-parallel-arm randomized controlled trial that will compare the effect of a motivational interviewing tailored lifestyle intervention (MINT) versus a culturally targeted PN intervention on improvement of BP and CRC screening among black men aged ≥50 with uncontrolled HTN who are eligible for CRC screening. Approximately 480 self-identified black men will be randomly assigned to one of the two study conditions. This innovative research design allows each intervention to serve as the control for the other. Specifically, the MINT arm is the control condition for the PN arm, and vice-versa. This novel, simultaneous testing of two community-based interventions in a randomized fashion is an economical and yet rigorous strategy that also enhances the acceptability of the project. Participants will be recruited during scheduled screening events at barbershops in New York City. Trained research assistants will conduct the lifestyle intervention, while trained community health workers will deliver the PN intervention. The primary outcomes will be 1) within-patient change in systolic and diastolic BP from baseline to six months and 2) CRC screening rates at six months.

DISCUSSION

This innovative study will provide a unique opportunity to test two interventions for two health disparities simultaneously in community-based settings. Our study is one of the first to test culturally targeted patient navigation for CRC screening among black men in barbershops. Thus, our study has the potential to improve the reach of hypertension control and cancer prevention efforts within a high-risk population that is under-represented in primary care settings.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01092078.

What is lacking in current decision aids on cancer screening?

Recent guidelines on cancer screening have provided not only more screening options but also conflicting recommendations. Thus, patients, with their clinicians' support, must decide whether to get screened, which modality to use, and how often to undergo screening. Decision aids could potentially lead to better shared decision-making regarding screening between the patient and the clinician. A total of 73 decision aids concerning screening for breast, cervical, colorectal, and prostate cancers were reviewed. The goal of this review was to assess the effectiveness of such decision aids, examine areas in need of more research, and determine how the decision aids can be currently applied in the real-world setting. Most studies used sound study designs. Significant variation existed in the setting, theoretical framework, and measured outcomes. Just over one-third of the decision aids included an explicit values clarification. Other than knowledge, little consistency was noted with regard to which patient attributes were measured as outcomes. Few studies actually measured shared decision-making. Little information was available regarding the feasibility and outcomes of integrating decision aids into practice. In this review, the implications for future research, as well as what clinicians can do now to incorporate decision aids into their practice, are discussed.

Testing a Spanish-language colorectal cancer screening decision aid in Latinos with limited English proficiency: results from a pre-post trial and four month follow-up survey

BACKGROUND

Compared with non-Latinos, Latinos in the US have low rates of colorectal cancer (CRC) screening and low rates of knowledge regarding CRC screening tests and guidelines. Spanish speaking Latinos have particularly low CRC screening rates and screening knowledge. Our purpose was twofold: (1) to evaluate the effect of a computer-based, Spanish-language CRC screening decision aid on screening knowledge, intent to obtain screening, and screening self-efficacy in a community sample of Latinos with limited English proficiency (LEP); and (2) to survey these decision aid viewers at four months to determine their rates of CRC discussions with a health care provider as well as their rates of screening test completion.

METHODS

We recruited 50-75 year old Latinos with LEP who were not current with CRC. Participants screening viewed a 14 minute multimedia decision aid that addresses CRC screening rationale, recommendations, and options. We conducted an uncontrolled (pre-post) study in which we assessed screening knowledge, self-efficacy, and intent at baseline and immediately after decision aid viewing. We also conducted a follow-up telephone survey of participants at four months to examine rates of patient-provider screening discussions and test completion.

RESULTS

Among n = 80 participants, knowledge scores increased from 20% (before) to 72% (after) decision aid viewing (absolute difference [95%CI]: 52% [46, 59]). The proportion with high screening self-efficacy increased from 67% to 92% (25% [13, 37]); the proportion with high screening intent increased from 63% to 95% (32% [21, 44]). We reached 68 (85%) of 80 participants eligible for the follow-up survey. Of these 36 (53%) reported discussing screening with a provider and 13 (19%) completed a test.

CONCLUSION

Viewing a Spanish-language decision aid increased CRC screening knowledge, self-efficacy, and intent among Latinos with LEP. Decision aid viewing appeared to promote both CRC screening discussions with health care providers and test completion. The decision aid may be an effective tool for promoting CRC screening and reducing screening disparities in this population.

Two controlled trials to determine the effectiveness of a mailed intervention to increase colon cancer screening

OBJECTIVE

Colorectal cancer (CRC) screening is underutilized. Effective and efficient interventions are needed to increase its utilization in primary care.

METHODS

We used UNC Internal Medicine electronic medical records to perform 2 effectiveness trials. Eligible patients had no documentation of recent CRC screening and were aged 50-75 years. The mailed intervention contained a letter documenting the need for screening signed by the attending physician in wave A and the practice director in wave B, a postcard to request a decision aid about CRC screening options, and information about how to obtain screening.

RESULT

Three-hundred and forty patients of attending physicians in wave A, 944 patients of resident physicians in wave B, and 214 patients of attending physicians in wave B were included. The intervention increased screening compared with controls for attending physicians' patients in wave A (13.1% vs. 4.1%, 95% CI, 3.1%-14.9%) but not for resident physicians' patients in wave B (1.3% vs. 1.9%, 95% CI, -2.2% to 1.0%). A small increase in screening with the intervention was seen in attending physicians' patients in wave B (6.9% vs. 2.4%, 95% CI, -1.4% to 10.5%). Requests for decision aids were uncommon in both waves (12.5% wave A and 7.8% wave B).

LIMITATIONS

The group assignments were not individually randomized, and covariate information to explain the differences in effect was limited.

CONCLUSIONS

The intervention increased CRC screening in attending physicians' patients who received a letter from their physicians, but not resident physicians' patients who received a letter signed by the practice director.

Promoting decision aid use in primary care using a staff member for delivery

OBJECTIVE

To determine the feasibility and effectiveness of in-clinic decision aid distribution using a care assistant.

METHODS

We identified potentially eligible patients scheduled for upcoming appointments in our General Internal Medicine Clinic (n=1229). Patients were deemed eligible for two decision aids: prostate cancer screening and/or weight loss surgery. Patients were approached to view the decision aid in-clinic. Our primary measures were the proportion of decision aids distributed to eligible patients, and the proportion of decision aids viewed.

RESULTS

Among 913 patients who attended their scheduled appointments, 58% (n=525) were approached and eligibility was assessed by the staff member. Among the 471 who remained eligible, 57% (n=268) viewed at least a portion of the target decision aid. The mean viewing time for patients who watched less than the complete decision aid was 13 min.

CONCLUSIONS

In clinic viewing of decision aids may be a feasible and effective distribution method in primary care.

PRACTICE IMPLICATIONS

In clinic distribution requires an electronic health information system to identify potentially eligible patients, and a staff member dedicated to DA distribution. Brief decision aids (less than 10 min) are needed so patients can complete their use prior to the visit to facilitate patient-physician decision making.

Cost-effectiveness of a mailed educational reminder to increase colorectal cancer screening

BACKGROUND

Colorectal cancer (CRC) screening rates are low in many areas and cost-effective interventions to promote CRC screening are needed. Recently in a randomized controlled trial, a mailed educational reminder increased CRC screening rates by 16.2% among U.S. Veterans. The aim of our study was to assess the costs and cost-effectiveness of a mailed educational reminder on fecal occult blood test (FOBT) adherence.

METHODS

In a blinded, randomized, controlled trial, 769 patients were randomly assigned to the usual care group (FOBT alone, n = 382) or the intervention group (FOBT plus a mailed reminder, n = 387). Ten days after picking up the FOBT cards, a 1-page reminder with information related to CRC screening was mailed to the intervention group. Primary outcome was number of returned FOBT cards after 6 months. The costs and incremental cost-effectiveness ratio (ICER) of the intervention were assessed and calculated respectively. Sensitivity analyses were based on varying costs of labor and supplies.

RESULTS

At 6 months after card distribution, 64.6% patients in the intervention group returned FOBT cards compared with 48.4% in the control group (P < 0.001). The total cost of the intervention was $962 or $2.49 per patient, and the ICER was $15 per additional person screened for CRC. Sensitivity analysis based on a 10% cost variation was $13.50 to $16.50 per additional patient screened for CRC.

CONCLUSIONS

A simple mailed educational reminder increases FOBT card return rate at a cost many health care systems can afford. Compared to other patient-directed interventions (telephone, letters from physicians, mailed reminders) for CRC screening, our intervention was more effective and cost-effective.

The role of physician reminders in faecal occult blood testing for colorectal cancer screening

BACKGROUND

Colorectal cancer screening in the form of faecal occult blood (FOB) testing can significantly reduce the burden of this disease and has been used as early as the 1970s. Effective involvement of GPs along with reminding physicians prior to seeing a patient may improve uptake.

OBJECTIVE

This article is a systematic review of published literature examining the uptake of FOB testing after physician reminders as part of the colorectal cancer screening process.

METHODS

Electronic databases were searched from January 1975 to October 2010. All studies comparing physician reminders (Rem) with controls (NRem) were identified. A meta-analysis was performed to obtain a summary outcome.

RESULTS

Five comparative studies involving 25 287 patients were analyzed. There were 12 641 patients were in the Rem and 12 646 in the NRem group. All five studies obtained a higher percentage uptake when physician reminders were given. However, in only two of the studies were the percentage uptake significantly higher. There was significant heterogeneity among trials (I2 = 95%). The combined increase in FOB test uptake was not statistically significant (random effects model: risk difference = 6.6%, 95% CI: -2-14.7%; z = 1.59, P = 0.112).

CONCLUSION

Reminding physicians about those patients due for FOB testing may not improve the effectiveness of a colorectal cancer screening programme. Further studies are required and should focus on areas where there is a lower baseline uptake and areas with high levels of deprivation.

Conducting implementation research in community-based primary care: a qualitative study on integrating patient decision support interventions for cancer screening into routine practice

BACKGROUND

Despite a growing body of evidence supporting the efficacy of patient decision support interventions (DESI), little is known about their implementation in community-based primary care practices.

OBJECTIVE

The goal of this study was to explore the feasibility of integrating the use of DESIs for cancer screening in primary care practices serving patients from diverse backgrounds and learn more about the potential barriers and facilitators of integration.

SETTING

12 community-based primary care practices in metropolitan Los Angeles.

MAIN VARIABLES STUDIED

Qualitative field notes documented the roles played by staff and physicians in accomplishing project goals, the impact of the programmes on the clinical work-flow in the practices and other noteworthy observations.

RESULTS

Practices that were better able to integrate the project had adequate clinic infrastructure, a relatively well-matched patient pool, and positive work and patient care environments. The remaining identified components, including staff facilitation and the physician's role accounted for higher level differences between the clinics, acting as barriers and facilitators that distinguished practices that were able to work independently from those that required more assistance and, to a lesser extent, those clinics that did and those that did not meet the project goals.

DISCUSSION AND CONCLUSIONS

This study suggests that implementation of DESIs to be used immediately before a consultation is feasible if the practice infrastructure can provide sufficient basic accommodation and physician and staff are dedicated to patient care goals that are implicit in the use of these tools. Overall, the physician's role appeared to be the most important factor in determining whether project integration was successful.

Effectiveness of a patient and practice-level colorectal cancer screening intervention in health plan members: the CHOICE trial

BACKGROUND

Colorectal cancer (CRC) screening reduces CRC incidence and mortality but is underused. Effective interventions to increase screening that can be implemented broadly are needed.

METHODS

A controlled trial was conducted to evaluate a patient-level and practice-level intervention to increase the use of recommended CRC screening tests among health plan members. The patient-level intervention was a patient decision aid and included stage-targeted brochures that were mailed to health plan members. Intervention practices received academic detailing to prepare practices to facilitate CRC testing once patients were activated by the decision aid. We used patient surveys and claims data to assess CRC test completion.

RESULTS

Among 443 active participants, 75.8% were ages 52 to 59 years, 80.9% were white, 62.1% were women, and 46.4% had college degrees or greater education. Among 380 active participants with known screening status at 12 months based on survey results, 39% in the intervention group reported receiving CRC screening compared with 32.2% in the usual care group (unadjusted odds ratio [OR], 1.34; 95% confidence interval; [CI], 0.88-2.05; P = .17). After adjusting for baseline differences and accounting for clustering, the effect was somewhat larger (OR, 1.64; 95% CI, 0.98-2.73; P = .06). Claims analysis produced similar effects for active participants. The intervention was more effective in those who had incomes >$50,000 (OR, 2.16; 95% CI, 1.07-4.35) than in those who had lower incomes (OR, 1.25; 95% CI, 0.53-2.94; P = .03 for interaction).

CONCLUSIONS

Interventions combining a patient-directed decision aid and practice-directed academic detailing had a modest but statistically nonsignificant effect on CRC screening rates among active participants.

Cost-effectiveness of patient mailings to promote colorectal cancer screening

BACKGROUND

Programs to promote colorectal cancer screening are common, yet information regarding the cost-effectiveness of such efforts is limited.

OBJECTIVE

To assess the cost-effectiveness of patient mailings to increase rates of colorectal cancer screening.

RESEARCH DESIGN

Incremental cost-effectiveness analysis of a randomized, controlled trial. The intervention involved 21,860 patients aged 50 to 80 years across 11 health centers overdue for colorectal cancer screening. Patients were randomized to receive a mailing that included a tailored letter, educational brochure, and fecal occult blood test kit at baseline and 6 months follow-up.

MEASURES

We calculated the incremental cost-effectiveness of these mailings to promote colorectal cancer screening by fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy using internal cost estimates of labor and supplies.

RESULTS

Colorectal cancer screening rates were higher for patients in the intervention compared with control patients (44% vs. 38%, P < 0.001). The total cost of the intervention was approximately $5.48 per patient, resulting in a cost-effectiveness ratio of $94 per additional patient screened. This estimate ranged from $69 to $156, based on assumptions of the cost of the intervention components, magnitude of intervention effect, age range, and size of the targeted patient population.

CONCLUSION

Tailored patient mailings are a cost-effective approach to improve rates of colorectal cancer screening.

Uptake of colorectal cancer screening: system, provider and individual factors and strategies to improve participation

Colorectal cancer (CRC) accounts for 9% of all new cancer cases worldwide and affects over 1 million people each year. Screening can reduce the mortality associated with the disease, yet participation rates are suboptimal. Compliers with CRC screening are less deprived; they have higher education than noncompliers and tend to be male, white and married. Likely reasons for nonparticipation encompass several 'modifiable' factors that could be targeted in interventions aimed at increasing participation rates. Successful intervention strategies include organizational changes, such as increasing access to fecal occult blood test (FOBT) kits, providing reminders to healthcare providers or users about screening opportunities, and educational strategies to improve awareness and attitudes towards CRC screening. Multifactor interventions that target more than one level of the screening process are likely to have larger effects. The biggest challenge for future research will be to reduce inequalities related to socio-economic position and ethnicity in the uptake of screening.

Effect of Neem (Azadirchta indica) on serum glycoprotein contents of rats administered 1,2 dimethylhydrazine

The present study was designed to investigate the effects of aqueous Azadirchta Indica leaf extract (AAILE) on serum glycoprotein contents and tumor incidence rate in colon of rats subjected to Dimethylhydrazine (DMH) treatment. Forty rats were divided equally and randomly into four groups viz., Group I (normal control), Group II (DMH-treated), Group III (AAILE) and Group IV (DMH + AAILE treated). Group II and IV animals were injected subcutaneously every week with DMH (30 mg/kg b.wt.) for two durations of 10 and 20 weeks. AAILE was given orally three times a week on alternate days (100 mg/kg b.wt.) to animals belonging to groups III and IV. Blood samples were drawn from all the animals by ocular vein puncture every month for the estimation of Total Sialic Acid (TSA) and Lipid Bound Sialic Acid (LSA), which served as markers for the cancer. No incidence of tumor was recorded in the animals given DMH treatment for 10 weeks. However, DMH treatment for 20 weeks showed 100% tumor incidence. Animals treated with DMH for both the time durations showed a significant increase in the levels of TSA in comparison to normal control, which however were decreased significantly following AAILE supplementation. There was no significant difference between LSA levels of DMH-treated animals and normal controls. The present study suggested that supplementation of AAILE in cancer-bearing animals attenuates considerably the molecular events that initiate the development of tumors.

The effectiveness of a secure email reminder system for colorectal cancer screening

This study looks at the effectiveness of using a secure email system linked to an electronic health record to send reminders to patients in an effort to increase colorectal cancer (CRC) screening rates; 1397 subjects were randomized to receive usual care, a letter reminder or an email reminder which invited patients to pick up a fecal occult blood test at the lab for CRC screening. The number of completed CRC screenings was tallied after a 3 month study period. Rates of CRC screening in the 3 groups were 7.8% in the usual care group, 23.6% in the letter reminder group and 22.7% in the email group. Significant statistical difference was seen between usual care group and letter reminders (p<0.0005) and between usual care and email reminders (p<0.0005) but not between the letter reminders and the email reminders (p=7.11). Email reminders are as effective as letter reminders in increasing CRC screening rates.

Using quality improvement techniques to increase colon cancer screening

Screening has been shown to be effective and cost-effective in reducing the incidence of, and mortality from, colorectal cancer. Despite its demonstrated efficacy, colon cancer screening remains underused, with fewer than 60% of age-eligible adults reporting being up to date with recommended screening tests. Several factors account for the low rates of utilization, including patient, provider and system-related issues. Several interventions have been shown to be effective in overcoming these barriers, including the use of patient decision aids. Patient decision aids are tools designed to provide information to patients about screening options, help them consider the pros and cons of the alternatives, and assist them to reach a decision consistent with their values. The use of decision aids in clinical practice can increase screening rates by up to 14 percentage points. Mailing the decision aids to patients in advance of office visits appears to be a cost-effective means of implementation.

Promoting informed decision-making in a primary care practice by implementing decision aids

Empowering patients to be effective advocates for their health requires that they have adequate information and understanding about their health conditions. Many patients have limited health literacy which is a marker for vulnerability and a risk factor for poor health outcomes. Providing vulnerable patients with information in a format they can easily access is challenging. One novel approach is to modify processes of clinical care so that medical practices deliver necessary and accessible information to patients in conjunction with their provider’s visit. The goal is to improve the quality of medical care in clinical practice by promoting informed decision-making.