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- Title
Shared Decision-Making in Colorectal Cancer Screening for Older Adults: A Secondary Analysis of a Cluster Randomized Clinical Trial.
- Authors
Sepucha, Karen R.; Chang, Yuchiao; Valentine, K.D.; Atlas, Steven J.; Han, Paul K. J.; Leavitt, Lauren J.; Mancini, Brittney; Richter, James M.; Siegel, Lydia C.; Fairfield, Kathleen M.; Simmons, Leigh H.
- Abstract
Key Points: Question: Does physician training in shared decision-making (SDM) improve receipt of older patients' preferred approaches to colorectal cancer (CRC) screening? Findings: In this cluster randomized clinical trial with 59 physicians and 466 older adults, 39% of patients in the intervention group and 29% in the comparator group completed CRC screening in the 12 months after the index visit, a nonsignificant difference. Approximately 51% of patients in the intervention group received their preferred approach to screening compared with 46% in the comparator group (nonsignificant difference). Meaning: Approximately half of the older patients in this study received their preferred approach to CRC screening, but these findings indicate that SDM training did not have a meaningful effect on concordance rates or screening rates. This secondary analysis of a cluster randomized clinical trial evaluates the effect of physician training in shared decision-making on receipt of the patient-preferred approach to colorectal cancer screening among older adults. Importance: Decisions about whether to stop colorectal cancer (CRC) screening tests in older adults can be difficult and may benefit from shared decision-making (SDM). Objective: To evaluate the effect of physician training in SDM and electronic previsit reminders (intervention) vs reminders only (comparator) on receipt of the patient-preferred approach to CRC screening and on overall CRC screening rates of older adults at 12 months. Design, Setting, and Participants: This was a secondary analysis of the Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED) cluster randomized clinical trial. In the PRIMED trial, primary care physicians (PCPs) from 36 primary care practices in Massachusetts and Maine were enrolled between May 1 and August 30, 2019, and were randomized to the intervention group or the comparator group. Patients aged 76 to 85 years who were overdue for CRC screening and did not have a prior diagnosis of CRC enrolled between October 21, 2019, and April 8, 2021. Data analysis was performed between May 24, 2022, and May 10, 2023. Interventions: Primary care physicians in the intervention group completed an SDM training course and received previsit reminders of patients eligible for CRC testing discussion, whereas PCPs in the comparator group received reminders only. Main Outcomes and Measures: The primary outcome was concordance, or the percentage of patients who received their preferred screening approach. Postvisit surveys were administered to assess patient preference for testing, and electronic health record review was used to assess CRC testing at 12 months. Heterogeneity of treatment effect analyses examined interaction between study groups and different factors on concordance rates. Results: This study included 59 physicians and 466 older adults. Physicians had a mean (SD) age of 52.7 (9.4) years and a mean (SD) of 21.6 (10.2) years in practice; 30 (50.8%) were women and 16 (27.1%) reported prior training in SDM. Patients had a mean (SD) age of 80.3 (2.8) years; 249 (53.4%) were women and 238 (51.1%) reported excellent or very good overall health. Patients preferred stool-based tests (161 [34.5%]), followed by colonoscopy (116 [24.8%]) or no further screening (97 [20.8%]); 75 (16.1%) were not sure. The distribution of patient preferences was similar across groups (P =.36). At 12 months, test uptake was also similar for both the intervention group (29 [12.3%] for colonoscopy, 62 [26.3%] for stool-based tests, and 145 [61.4%] for no testing) and the comparator group (32 [13.9%] for colonoscopy, 35 [15.2%] for stool-based tests, and 163 [70.9%] for no testing; P =.08). Approximately half of patients in the intervention group received their preferred approach vs the comparator group (115 of 226 [50.9%] vs 103 of 223 [46.2%]; P =.47). Heterogeneity of treatment effect analyses found significantly higher rates with the intervention vs the comparator for patients with a strong intention to follow through with the preferred approach (adjusted odds ratio [AOR], 1.79 [95% CI, 1.11-2.89]; P =.02, P =.05 for interaction) and for patients who reported more than 5 minutes (AOR, 3.27 [95% CI, 1.25-8.59]; P =.02, P =.05 for interaction) of discussion with their PCP regarding screening. Higher rates were also observed among patients who reported 2 to 5 minutes of discussion with their PCP, although this finding was not significant (AOR, 1.89 [95% CI, 0.93-3.84]; P =.08, P =.05 for interaction). Conclusions and Relevance: In this secondary analysis of a cluster randomized clinical trial, approximately half of older patients received their preferred approach to CRC screening. Physician training in SDM did not result in higher concordance rates overall but may have benefitted some subgroups. Future work to refine and evaluate clinical decision support (in the form of an electronic advisory or reminder) as well as focused SDM skills training for PCPs may promote high-quality, preference-concordant decisions about CRC testing for older adults. Trial Registration: ClinicalTrials.gov Identifier: NCT03959696
- Subjects
MASSACHUSETTS; MAINE; FECAL analysis; HEALTH services accessibility; SECONDARY analysis; RESEARCH funding; EARLY detection of cancer; EDUCATIONAL outcomes; LOGISTIC regression analysis; COLORECTAL cancer; DECISION making; DESCRIPTIVE statistics; CHI-squared test; ODDS ratio; MEDICAL appointments; INTRACLASS correlation; RESEARCH; HEALTH care reminder systems; COMPARATIVE studies; CONFIDENCE intervals; DATA analysis software; PATIENTS' attitudes; COLONOSCOPY; OLD age
- Publication
JAMA Network Open, 2024, Vol 7, Issue 8, pe2429645
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.29645