Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED Study): a Physician Cluster Randomized Trial

Abstract

Background: For adults aged 76-85, guidelines recommend individualizing decision-making about whether to continue colorectal cancer (CRC) testing. These conversations can be challenging as they need to consider a patient's CRC risk, life expectancy, and preferences.

Objective: To promote shared decision-making (SDM) for CRC testing decisions for older adults.

Design: Two-arm, multi-site cluster randomized trial, assigning physicians to Intervention and Comparator arms. Patients were surveyed shortly after the visit to assess outcomes. Analyses were intention-to-treat.

Participants and setting: Primary care physicians affiliated with 5 academic and community hospital networks and their patients aged 76-85 who were due for CRC testing and had a visit during the study period.

Interventions: Intervention arm physicians completed a 2-h online course in SDM communication skills and received an electronic reminder of patients eligible for CRC testing shortly before the visit. Comparator arm received reminders only.

Main measures: The primary outcome was patient-reported SDM Process score (range 0-4 with higher scores indicating more SDM); secondary outcomes included patient-reported discussion of CRC screening, knowledge, intention, and satisfaction with the visit.

Key results: Sixty-seven physicians (Intervention n=34 and Comparator n=33) enrolled. Patient participants (n=466) were on average 79 years old, 50% with excellent or very good self-rated overall health, and 66% had one or more prior colonoscopies. Patients in the Intervention arm had higher SDM Process scores (adjusted mean difference 0.36 (95%CI (0.08, 0.64), p=0.01) than in the Comparator arm. More patients in the Intervention arm reported discussing CRC screening during the visit (72% vs. 60%, p=0.03) and had higher intention to follow through with their preferred approach (58.0% vs. 47.1, p=0.03). Knowledge scores and visit satisfaction did not differ significantly between arms.

Conclusion: Physician training plus reminders were effective in increasing SDM and frequency of CRC testing discussions in an age group where SDM is essential.

Trial registration: The trial is registered on clinicaltrials.gov (NCT03959696).

Keywords: colorectal cancer screening; online training; patient preferences/patient engagement; shared decision-making.

Conflict of interest statement

With regards to potential conflicts of interest for this study, all authors except Dr. Siegel report grant support from PCORI (CDR-2017C3-9270) for the study activities. Dr. Sepucha reports grants from PCORI and Agency for Healthcare Research and Quality, outside the submitted work during the conduct of the study. Dr. Siegel reports personal fees from EBSCO/DynaMed Scientific Advisory Board Member, outside the submitted work. Dr. Atlas reports grants from the National Cancer Institute (NCI) outside submitted work. Dr. Richter reports consulting from Iterative Scopes, Policy Analysis and World Care International outside the submitted work, co-Chair of Quality Leaders Council for American Gastroenterological Association, and about 25% of his income comes from performing colonoscopies. Dr. Korsen reports grants from NIH, Maine Cancer Foundation and Bristol Myers Squibb Foundation; advisory board for AHRQ and leadership role Maine Health Data Organization, outside submitted work. Dr. Simmons reports data advisory board participation and expert witness testimony, outside submitted work.

© 2022. The Author(s).

Figures

Figure 1

CONSORT diagram for physician and patient enrollment.