Cost effectiveness of interventions to promote screening for colorectal cancer: a randomized trial

Extending analytic methods for economic evaluation in implementation science

Background

Economic evaluations of the implementation of health-related evidence-based interventions (EBIs) are conducted infrequently and, when performed, often use a limited set of quantitative methods to estimate the cost and effectiveness of EBIs. These studies often underestimate the resources required to implement and sustain EBIs in diverse populations and settings, in part due to inadequate scoping of EBI boundaries and underutilization of methods designed to understand the local context. We call for increased use of diverse methods, especially the integration of quantitative and qualitative approaches, for conducting and better using economic evaluations and related insights across all phases of implementation.

Main body

We describe methodological opportunities by implementation phase to develop more comprehensive and context-specific estimates of implementation costs and downstream impacts of EBI implementation, using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. We focus specifically on the implementation of complex interventions, which are often multi-level, resource-intensive, multicomponent, heterogeneous across sites and populations, involve many stakeholders and implementation agents, and change over time with respect to costs and outcomes. Using colorectal cancer (CRC) screening EBIs as examples, we outline several approaches to specifying the “boundaries” of EBI implementation and analyzing implementation costs by phase of implementation. We describe how systems mapping and stakeholder engagement methods can be used to clarify EBI implementation costs and guide data collection—particularly important when EBIs are complex. In addition, we discuss the use of simulation modeling with sensitivity/uncertainty analyses within implementation studies for projecting the health and economic impacts of investment in EBIs. Finally, we describe how these results, enhanced by careful data visualization, can inform selection, adoption, adaptation, and sustainment of EBIs.

Conclusion

Health economists and implementation scientists alike should draw from a larger menu of methods for estimating the costs and outcomes associated with complex EBI implementation and employ these methods across the EPIS phases. Our prior experiences using qualitative and systems approaches in addition to traditional quantitative methods provided rich data for informing decision-making about the value of investing in CRC screening EBIs and long-term planning for these health programs. Future work should consider additional opportunities for mixed-method approaches to economic evaluations.

Examining the Effectiveness of Provider Incentives to Increase CRC Screening Uptake in Neighborhood Healthcare: A California Federally Qualified Health Center

As an awardee of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, the California Department of Public Health partnered with Neighborhood Healthcare to implement evidence-based interventions and provider incentives (incentives offered to support staff, e.g., medical assistants, phlebotomists, front office staff, lab technicians) to improve colorectal cancer screening uptake. The objective of this study was to evaluate the effectiveness and cost of the provider incentive intervention implemented by Neighborhood Healthcare to increase colorectal cancer screening uptake. We collected and analyzed process and cost data to assess fecal immunochemical test (FIT) kit return rates to the health centers and the number of completed FIT kits. We estimated the costs of the preexisting interventions and the new interventions. Analyses were conducted for two time periods: preimplementation and implementation. Most Neighborhood Healthcare health centers experienced an increase in the percentage of FIT kit returns (average of 3.6 percentage points) and individuals screened (an average increase of 111 FIT kits per month) from the baseline period through the implementation period. The cost of the incentive intervention for each additional screen was $66.79. In conclusion, the results indicate that incentive programs can have an overall positive impact on both the percentage of FIT kits returned and the number of individuals screened.

Interventions for increasing colorectal cancer screening uptake among African-American men: A systematic review and meta-analysis

BACKGROUND

African-American men have the lowest 5-year survival rate in the U.S. for colorectal cancer (CRC) of any racial group, which may partly stem from low screening adherence. It is imperative to synthesize the literature evaluating the effectiveness of interventions on CRC screening uptake in this population.

MATERIALS AND METHODS

In this systematic review and meta-analysis, Medline, CINAHL, Embase, and Cochrane CENTRAL were searched for U.S.-based interventions that: were published after 1998-January 2020; included African-American men; and evaluated CRC screening uptake explicitly. Checklist by Cochrane Collaboration and Joanna Brigg were utilized to assess risk of bias, and meta-regression and sensitivity analyses were employed to identify the most effective interventions.

RESULTS

Our final sample comprised 41 studies with 2 focused exclusively on African-American men. The most frequently adopted interventions were educational materials (39%), stool-based screening kits (14%), and patient navigation (11%). Most randomized controlled trials failed to provide details about the blinding of the participant recruitment method, allocation concealment method, and/or the outcome assessment. Due to high heterogeneity, meta-analysis was conducted among 17 eligible studies. Interventions utilizing stool-based kits or patient navigation were most effective at increasing CRC screening completion, with odds ratios of 9.60 (95% CI 2.89-31.82, p = 0.0002) and 2.84 (95% CI 1.23-6.49, p = 0.01). No evidence of publication bias was present for this study registered with the International Prospective Registry of Systematic Reviews (PROSPERO 2019 CRD42019119510).

CONCLUSIONS

Additional research is warranted to uncover effective, affordable interventions focused on increasing CRC screening completion among African-American men. When designing and implementing future multicomponent interventions, employing 4 or fewer interventions types may reduce bias risk. Since only 5% of the interventions solely focused on African-American men, future theory-driven interventions should consider recruiting samples comprised solely of this population.

Economic Evaluation of Tailored Web versus Tailored Telephone-Based Interventions to Increase Colorectal Cancer Screening among Women

Screening for colorectal cancer is cost-effective, but many U.S. women are nonadherent, and the cost-effectiveness of web-based tailored screening interventions is unknown. A randomized controlled trial, COBRA (Increasing Colorectal and Breast Cancer Screening), was the source of information for the economic evaluation. COBRA compared screening among a Usual Care group to: (i) tailored Phone Counseling intervention; (ii) tailored Web intervention; and (iii) tailored Web + Phone intervention groups. A sample of 1,196 women aged 50 to 75 who were nonadherent to colorectal cancer screening were recruited from Indiana primary care clinics during 2013 to 2015. Screening status was obtained through medical records at recruitment with verbal confirmation at consent, and at 6-month follow-up via medical record audit and participant self-report. A "best sample" analysis and microcosting from the patient and provider perspectives were applied to estimate the costs and effects of the interventions. Statistical uncertainty was analyzed with nonparametric bootstrapping and net benefit regression analysis. The per participant cost of implementing the Phone Counseling, Web-based, and Web + Phone Counseling interventions was $277, $314, and $336, respectively. The incremental cost per person screened for the Phone Counseling compared with no intervention was $995, while the additional cost of Web and the Web + Phone compared with Phone Counseling did not yield additonal persons screened. Tailored Phone Counseling significantly increased colorectal cancer screening rates compared with Usual Care. Tailored Web interventions did not improve the screening rate compared with the lower cost Phone Counseling intervention.

Economics of Multicomponent Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening: A Community Guide Systematic Review

CONTEXT

The Community Preventive Services Task Force recently recommended multicomponent interventions to increase breast, cervical, and colorectal cancer screening based on strong evidence of effectiveness. This systematic review examines the economic evidence to guide decisions on the implementation of these interventions.

EVIDENCE ACQUISITION

A systematic literature search for economic evidence was performed from January 2004 to January 2018. All monetary values were reported in 2016 US dollars, and the analysis was completed in 2018.

EVIDENCE SYNTHESIS

Fifty-three studies were included in the body of evidence from a literature search yield of 8,568 total articles. For multicomponent interventions to increase breast cancer screening, the median intervention cost per participant was $26.69 (interquartile interval [IQI]=$3.25, $113.72), and the median incremental cost per additional woman screened was $147.64 (IQI=$32.92, $924.98). For cervical cancer screening, the median costs per participant and per additional woman screened were $159.80 (IQI=$117.62, $214.73) and $159.49 (IQI=$64.74, $331.46), respectively. Two studies reported incremental cost per quality-adjusted life year gained of $748 and $33,433. For colorectal cancer screening, the median costs per participant and per additional person screened were $36.63 (IQI=$7.70, $139.23) and $582.44 (IQI=$91.10, $1,452.12), respectively. Two studies indicated a decline in incremental cost per quality-adjusted life year gained of $1,651 and $3,817.

CONCLUSIONS

Multicomponent interventions to increase cervical and colorectal cancer screening were cost effective based on a very conservative threshold. Additionally, multicomponent interventions for colorectal cancer screening demonstrated net cost savings. Cost effectiveness for multicomponent interventions to increase breast cancer screening could not be determined owing to the lack of studies reporting incremental cost per quality-adjusted life year gained. Future studies estimating this outcome could assist implementers with decision making.

Colorectal cancer screening interventions in 2 health care systems serving disadvantaged populations: Screening uptake and cost-effectiveness

BACKGROUND

The objectives of the current study were to assess changes in colorectal cancer (CRC) screening uptake and the cost-effectiveness of implementing multiple evidence-based interventions (EBIs). EBIs were implemented at 2 federally qualified health centers that participated in the Colorado Department of Public Health and Environment's Clinic Quality Improvement for Population Health initiative.

METHODS

Interventions included patient and provider reminder systems (health system 1), provider assessment and feedback (health systems 1 and 2), and numerous support activities (health systems 1 and 2). The authors evaluated health system 1 from July 2013 to June 2015 and health system 2 from July 2014 to June 2017. Evaluation measures included annual CRC screening uptake, EBIs implemented, funds received and expended by each health system to implement EBIs, and intervention costs to the Colorado Department of Public Health and Environment and health systems.

RESULTS

CRC screening uptake increased by 18 percentage points in health system 1 and 10 percentage points in health system 2. The improvements in CRC screening uptake, not including the cost of the screening tests, were obtained at an added cost ranging from $24 to $29 per person screened.

CONCLUSIONS

In both health systems, the multicomponent interventions implemented likely resulted in improvements in CRC screening. The results suggest that significant increases in CRC screening uptake can be achieved in federally qualified health centers when appropriate technical support and health system commitment are present. The cost estimates of the multicomponent interventions suggest that these interventions and support activities can be implemented in a cost-effective manner.

The cost of implementing two small media interventions to promote HPV vaccination

OBJECTIVE

To estimate the cost of implementing lay health worker delivered print-based photonovella intervention and iPad-based tailored interactive multimedia intervention (TIMI) to promote Human Papillomavirus (HPV) vaccine uptake and completion among Hispanic parents of daughters 9-17years old.

METHODS

We recruited 301 participants in control, 422 in photonovella, and 239 in TIMI clinics. Intervention costs were estimated using micro-costing from the societal perspective. Cost included time spent planning, training the promotoras, recruiting study participants, and delivering the interventions. Overhead for utilities and project administration was estimated at 30% of direct costs.

RESULTS

The total cost per person for the photonovella and TIMI interventions were $88 and $108, respectively. Less than 10% of costs were fixed and therefore the average cost estimates were insensitive to the size of the target groups.

CONCLUSION

The electronic medium for HPV vaccine education was 23% more costly than the standard low-tech print based approach. The cost difference should be considered relative to the effectiveness of these methods in achieving increases in immunization rates. The cost estimates provide information for cost-effectiveness and budget impact assessments of new HPV immunization intervention programs.

Optimising colorectal cancer screening acceptance: a review

The study aims to review available evidence concerning effective interventions to increase colorectal cancer (CRC) screening acceptance. We performed a literature search of randomised trials designed to increase individuals' use of CRC screening on PubMed, Embase, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects. Small (≤ 100 subjects per arm) studies and those reporting results of interventions implemented before publication of the large faecal occult blood test trials were excluded. Interventions were categorised following the Continuum of Cancer Care and the PRECEDE-PROCEED models and studies were grouped by screening model (opportunistic vs organised). Multifactor interventions targeting multiple levels of care and considering factors outside the individual clinician control, represent the most effective strategy to enhance CRC screening acceptance. Removing financial barriers, implementing methods allowing a systematic contact of the whole target population, using personal invitation letters, preferably signed by the reference care provider, and reminders mailed to all non-attendees are highly effective in enhancing CRC screening acceptance. Physician reminders may support the diffusion of screening, but they can be effective only for individuals who have access to and make use of healthcare services. Educational interventions for patients and providers are effective, but the implementation of organisational measures may be necessary to favour their impact. Available evidence indicates that organised programmes allow to achieve an extensive coverage and to enhance equity of access, while maximising the health impact of screening. They provide at the same time an infrastructure allowing to achieve a more favourable cost-effectiveness profile of potentially effective strategies, which would not be sustainable in opportunistic settings.

An economic evaluation of colorectal cancer screening in primary care practice

INTRODUCTION

Recent colorectal cancer screening studies focus on optimizing adherence. This study evaluated the cost effectiveness of interventions using electronic health records (EHRs); automated mailings; and stepped support increases to improve 2-year colorectal cancer screening adherence.

METHODS

Analyses were based on a parallel-design, randomized trial in which three stepped interventions (EHR-linked mailings ["automated"]; automated plus telephone assistance ["assisted"]; or automated and assisted plus nurse navigation to testing completion or refusal [navigated"]) were compared to usual care. Data were from August 2008 to November 2011, with analyses performed during 2012-2013. Implementation resources were micro-costed; research and registry development costs were excluded. Incremental cost-effectiveness ratios (ICERs) were based on number of participants current for screening per guidelines over 2 years. Bootstrapping examined robustness of results.

RESULTS

Intervention delivery cost per participant current for screening ranged from $21 (automated) to $27 (navigated). Inclusion of induced testing costs (e.g., screening colonoscopy) lowered expenditures for automated (ICER=-$159) and assisted (ICER=-$36) relative to usual care over 2 years. Savings arose from increased fecal occult blood testing, substituting for more expensive colonoscopies in usual care. Results were broadly consistent across demographic subgroups. More intensive interventions were consistently likely to be cost effective relative to less intensive interventions, with willingness to pay values of $600-$1,200 for an additional person current for screening yielding ≥80% probability of cost effectiveness.

CONCLUSIONS

Two-year cost effectiveness of a stepped approach to colorectal cancer screening promotion based on EHR data is indicated, but longer-term cost effectiveness requires further study.

Communication preference moderates the effect of a tailored intervention to increase colorectal cancer screening among African Americans

OBJECTIVE

Test the impact of tailoring CRC screening messages for African Americans (AAs) using novel theoretical variables and to examine moderating effect of communication preferences.

METHODS

Participants were randomized to receive two minimally tailored or two enhanced tailored print newsletters addressing CRC. The enhanced intervention was tailored on Self-Determination Theory and other novel psychological constructs. Minimal tailoring only used information available in the patient's EHR. The primary outcome was CRC screening based on EHR. Participants were AA members aged 50-74 of an integrated health care delivery system not up to date on CRC screening.

RESULTS

We enrolled 881 participants. CRC screening participation rates at 1-year follow up were 20.5% and 21.5% in the minimally and enhanced tailored groups, respectively. Communication preferences moderated the impact of the intervention. Specifically, among those with an autonomous communication preference, screening rates in the minimally and enhanced tailored groups were 17.1% and 25.9%, respectively, while no intervention effect was evident among those with a directive preference.

CONCLUSION

Future research is needed to explore the impact of communication preference tailoring for other health behaviors and among other populations.

PRACTICE IMPLICATIONS

Tailored communications should consider communication style preference to help guide the content and tone of messages.

Cost-effectiveness of a standard intervention versus a navigated intervention on colorectal cancer screening use in primary care

BACKGROUND

Colorectal cancer (CRC) screening is cost-effective but underused. The objective of this study was to determine the cost-effectiveness of a mailed standard intervention (SI) and tailored navigation interventions (TNIs) to increase CRC screening use in the context of a randomized trial among primary care patients.

METHODS

Participants (n = 945) were randomized either to a usual care control group (n = 317), to an SI group (n = 316), or to a TNI group (n = 312). The SI group was sent both colonoscopy instructions and stool blood tests irrespective of baseline preference. TNI group participants were sent instructions for scheduling a colonoscopy, a stool blood test, or both based on their test preference, as determined at baseline; then, they received a navigation telephone call. Activity cost estimation was used to determine the cost of each intervention and to compute incremental cost-effectiveness ratios. Statistical uncertainty within the base case was assessed with 95% confidence intervals derived from net benefit regression analysis. The effects of uncertain parameters, such as the cost of planning, training, and involvement of those receiving "investigator salaries," were assessed with sensitivity analyses.

RESULTS

Program costs of the SI were $167 per participant. The average cost of the TNI was $289 per participant.

CONCLUSIONS

The TNI was more effective than the SI but substantially increased the cost per additional individual screened. Decision-makers need to consider cost structure, level of planning, and training required to implement these 2 intervention strategies and their willingness to pay for additional individuals screened to determine whether a tailored navigation would be justified and feasible.

Public awareness of colorectal cancer screening: knowledge, attitudes, and interventions for increasing screening uptake

Colorectal cancer ranks as one of the most incidental and death malignancies worldwide. Colorectal cancer screening has proven its benefit in terms of incidence and mortality reduction in randomized controlled trials. In fact, it has been recommended by medical organizations either in average-risk or family-risk populations. Success of a screening campaign highly depends on how compliant the target population is. Several factors influence colorectal cancer screening uptake including sociodemographics, provider and healthcare system factors, and psychosocial factors. Awareness of the target population of colorectal cancer and screening is crucial in order to increase screening participation rates. Knowledge about this disease and its prevention has been used across studies as a measurement of public awareness. Some studies found a positive relationship between knowledge about colorectal cancer, risk perception, and attitudes (perceived benefits and barriers against screening) and willingness to participate in a colorectal cancer screening campaign. The mentioned factors are modifiable and therefore susceptible of intervention. In fact, interventional studies focused on average-risk population have tried to increase colorectal cancer screening uptake by improving public knowledge and modifying attitudes. In the present paper, we reviewed the factors impacting adherence to colorectal cancer screening and interventions targeting participants for increasing screening uptake.

Get screened: a randomized trial of the incremental benefits of reminders, recall, and outreach on cancer screening

BACKGROUND

Rates of breast cancer (BC) and colorectal cancer (CRC) screening are particularly low among poor and minority patients. Multifaceted interventions have been shown to improve cancer-screening rates, yet the relative impact of the specific components of these interventions has not been assessed. Identifying the specific components necessary to improve cancer-screening rates is critical to tailor interventions in resource limited environments.

OBJECTIVE

To assess the relative impact of various components of the reminder, recall, and outreach (RRO) model on BC and CRC screening rates within a safety net practice.

DESIGN

Pragmatic randomized trial.

PARTICIPANTS

Men and women aged 50-74 years past due for CRC screen and women aged 40-74 years past due for BC screening.

INTERVENTIONS

We randomized 1,008 patients to one of four groups: (1) reminder letter; (2) letter and automated telephone message (Letter + Autodial); (3) letter, automated telephone message, and point of service prompt (Letter + Autodial + Prompt); or (4) letter and personal telephone call (Letter + Personal Call).

MAIN MEASURES

Documentation of mammography or colorectal cancer screening at 52 weeks following randomization.

KEY RESULTS

Compared to a reminder letter alone, Letter + Personal Call was more effective at improving screening rates for BC (17.8 % vs. 27.5 %; AOR 2.2, 95 % CI 1.2-4.0) and CRC screening (12.2 % vs. 21.5 %; AOR 2.0, 95 % CI 1.1-3.9). Compared to letter alone, a Letter + Autodial + Prompt was also more effective at improving rates of BC screening (17.8 % vs. 28.2 %; AOR 2.1, 95 % CI 1.1-3.7) and CRC screening (12.2 % vs. 19.6 %; AOR 1.9, 95 % CI 1.0-3.7). Letter + Autodial was not more effective than a letter alone at improving screening rates.

CONCLUSIONS

The addition of a personal telephone call or a patient-specific provider prompt were both more effective at improving mammogram and CRC screening rates compared to a reminder letter alone. The use of automated telephone calls, however, did not provide any incremental benefit to a reminder letter alone.

A lesson in business: cost-effectiveness analysis of a novel financial incentive intervention for increasing physical activity in the workplace

BACKGROUND

Recently both the UK and US governments have advocated the use of financial incentives to encourage healthier lifestyle choices but evidence for the cost-effectiveness of such interventions is lacking. Our aim was to perform a cost-effectiveness analysis (CEA) of a quasi-experimental trial, exploring the use of financial incentives to increase employee physical activity levels, from a healthcare and employer's perspective.

METHODS

Employees used a 'loyalty card' to objectively monitor their physical activity at work over 12 weeks. The Incentive Group (n=199) collected points and received rewards for minutes of physical activity completed. The No Incentive Group (n=207) self-monitored their physical activity only. Quality of life (QOL) and absenteeism were assessed at baseline and 6 months follow-up. QOL scores were also converted into productivity estimates using a validated algorithm. The additional costs of the Incentive Group were divided by the additional quality adjusted life years (QALYs) or productivity gained to calculate incremental cost effectiveness ratios (ICERs). Cost-effectiveness acceptability curves (CEACs) and population expected value of perfect information (EVPI) was used to characterize and value the uncertainty in our estimates.

RESULTS

The Incentive Group performed more physical activity over 12 weeks and by 6 months had achieved greater gains in QOL and productivity, although these mean differences were not statistically significant. The ICERs were £2,900/QALY and £2,700 per percentage increase in overall employee productivity. Whilst the confidence intervals surrounding these ICERs were wide, CEACs showed a high chance of the intervention being cost-effective at low willingness-to-pay (WTP) thresholds.

CONCLUSIONS

The Physical Activity Loyalty card (PAL) scheme is potentially cost-effective from both a healthcare and employer's perspective but further research is warranted to reduce uncertainty in our results. It is based on a sustainable "business model" which should become more cost-effective as it is delivered to more participants and can be adapted to suit other health behaviors and settings. This comes at a time when both UK and US governments are encouraging business involvement in tackling public health challenges.

Colorectal cancer in the Kingdom of Saudi Arabia: need for screening

BACKGROUND AND OBJECTIVES

Colorectal cancer (CRC) is a major health problem in the Kingdom of Saudi Arabia (KSA). Our aim was to characterize the epidemiology of CRC in the Saudi population.

DESIGN AND SETTING

Retrospective analysis of all cases of CRC recorded in the Saudi Cancer Registry (SCR) between January 2001 and December 2006 amongst Saudi citizens in KSA.

PATIENTS AND METHODS

Data were retrieved from the database of the SCR. Descriptive statistics was performed using SPSS.

RESULTS

A total of 4,201 cases of CRC were registered in the SCR. The incidence of CRC increased between 2001 and 2006. The mean age of patients at the time of diagnosis was 58 years; most patients were above 45 years of age (n=3322; 79.1%). At the time of diagnosis, 977 patients (23.0%) presented with localized disease and 1,018 (24.0%) had distant metastasis. The most frequent pathological variant was adenocarcinoma (73%), with grade 2 (moderately differentiated) being the most common grade among all variants (61%). For all cancer grades, the frequency of CRC was significantly higher among patients >45 years (P=0.004), who presented with more advanced disease (stages III and IV) (P=0.012). Based on logistic regression, age >45 years was associated with advanced regional presentation (P=0.001). Tumor grade was associated with advanced regional presentation and metastasis.

CONCLUSION

There was an increase in the incidence of CRC between 2001 and 2006. The age at the time of diagnosis was low when compared with reports from developed countries. A nationwide approach is needed to encourage and illustrate the importance of screening programs.

An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial

BACKGROUND

Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals.

OBJECTIVE

To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years.

DESIGN

4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047)

SETTING

21 primary care medical centers.

PATIENTS

4675 adults aged 50 to 73 years not current for CRC screening.

INTERVENTION

Usual care, EHR-linked mailings ("automated"), automated plus telephone assistance ("assisted"), or automated and assisted plus nurse navigation to testing completion or refusal ("navigated"). Interventions were repeated in year 2.

MEASUREMENTS

The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2).

RESULTS

Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]).

LIMITATION

Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability.

CONCLUSION

Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Although screening is usually perceived as good for the health of the population, there are risks associated with the tests involved. Achieving both adequate involvement of consumers and informed decision making are now seen as important goals for screening programmes. Personalised risk estimates have been shown to be effective methods of risk communication.

OBJECTIVES

To assess the effects of personalised risk communication on informed decision making by individuals taking screening tests. We also assess individual components that constitute informed decisions.

SEARCH METHODS

Two authors searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2012), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EbscoHOST) and PsycINFO (OvidSP) without language restrictions. We searched from 2006 to March 2012. The date ranges for the previous searches were from 1989 to December 2005 for PsycINFO and from 1985 to December 2005 for other databases. For the original version of this review, we also searched CancerLit  and Science Citation Index (March 2001). We also reviewed the reference lists and conducted citation searches of included studies and other systematic reviews in the field, to identify any studies missed during the initial search.

SELECTION CRITERIA

Randomised controlled trials incorporating an intervention with a 'personalised risk communication element' for individuals undergoing screening procedures, and reporting measures of informed decisions and also cognitive, affective, or behavioural outcomes addressing the decision by such individuals, of whether or not to undergo screening.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each included trial for risk of bias, and extracted data. We extracted data about the nature and setting of interventions, and relevant outcome data. We used standard statistical methods to combine data using RevMan version 5, including analysis according to different levels of detail of personalised risk communication, different conditions for screening, and studies based only on high-risk participants rather than people at 'average' risk. 

MAIN RESULTS

We included 41 studies involving 28,700 people. Nineteen new studies were identified in this update, adding to the 22 studies included in the previous two iterations of the review. Three studies measured informed decision with regard to the uptake of screening following personalised risk communication as a part of their intervention. All of these three studies were at low risk of bias and there was strong evidence that the interventions enhanced informed decision making, although with heterogeneous results. Overall 45.2% (592/1309) of participants who received personalised risk information made informed choices, compared to 20.2% (229/1135) of participants who received generic risk information. The overall odds ratios (ORs) for informed decision were 4.48 (95% confidence interval (CI) 3.62 to 5.53 for fixed effect) and 3.65 (95% CI 2.13 to 6.23 for random effects). Nine studies measured increase in knowledge, using different scales. All of these studies showed an increase in knowledge with personalised risk communication. In three studies the interventions showed a trend towards more accurate risk perception, but the evidence was of poor quality. Four out of six studies reported non-significant changes in anxiety following personalised risk communication to the participants. Overall there was a small non-significant decrease in the anxiety scores. Most studies (32/41) measured the uptake of screening tests following interventions. Our results (OR 1.15 (95% CI 1.02 to 1.29)) constitute low quality evidence, consistent with a small effect, that personalised risk communication in which a risk score was provided (6 studies) or the participants were given their categorised risk (6 studies), increases uptake of screening tests. 

AUTHORS' CONCLUSIONS

There is strong evidence from three trials that personalised risk estimates incorporated within communication interventions for screening programmes enhance informed choices. However the evidence for increasing the uptake of such screening tests with similar interventions is weak, and it is not clear if this increase is associated with informed choices. Studies included a diverse range of screening programmes. Therefore, data from this review do not allow us to draw conclusions about the best interventions to deliver personalised risk communication for enhancing informed decisions. The results are dominated by findings from the topic area of mammography and colorectal cancer. Caution is therefore required in generalising from these results, and particularly for clinical topics other than mammography and colorectal cancer screening.