Clinical Decision Support with or without Shared Decision Making to Improve Preventive Cancer Care: A Cluster-Randomized Trial

Thomas E Elliott, Stephen E Asche, Patrick J O'Connor, Steven P Dehmer, Heidi L Ekstrom, Anjali R Truitt, Ella A Chrenka, Melissa L Harry, Daniel M Saman, Clayton I Allen, Joseph A Bianco, Laura A Freitag, JoAnn M Sperl-Hillen, Thomas E Elliott, Stephen E Asche, Patrick J O'Connor, Steven P Dehmer, Heidi L Ekstrom, Anjali R Truitt, Ella A Chrenka, Melissa L Harry, Daniel M Saman, Clayton I Allen, Joseph A Bianco, Laura A Freitag, JoAnn M Sperl-Hillen

Abstract

Background: Innovative interventions are needed to address gaps in preventive cancer care, especially in rural areas. This study evaluated the impact of clinical decision support (CDS) with and without shared decision making (SDM) on cancer-screening completion.

Methods: In this 3-arm, parallel-group, cluster-randomized trial conducted at a predominantly rural medical group, 34 primary care clinics were randomized to clinical decision support (CDS), CDS plus shared decision making (CDS+SDM), or usual care (UC). The CDS applied web-based clinical algorithms identifying patients overdue for United States Preventive Services Task Force-recommended preventive cancer care and presented evidence-based recommendations to patients and providers on printouts and on the electronic health record interface. Patients in the CDS+SDM clinic also received shared decision-making tools (SDMTs). The primary outcome was a composite indicator of the proportion of patients overdue for breast, cervical, or colorectal cancer screening at index who were up to date on these 1 y later.

Results: From August 1, 2018, to March 15, 2019, 69,405 patients aged 21 to 74 y had visits at study clinics and 25,198 were overdue for 1 or more cancer screening tests at an index visit. At 12-mo follow-up, 9,543 of these (37.9%) were up to date on the composite endpoint. The adjusted, model-derived percentage of patients up to date was 36.5% (95% confidence interval [CI]: 34.0-39.1) in the UC group, 38.1% (95% CI: 35.5-40.9) in the CDS group, and 34.4% (95% CI: 31.8-37.2) in the CDS+SDM group. For all comparisons, the screening rates were higher than UC in the CDS group and lower than UC in the CDS+SDM group, although these differences did not reach statistical significance.

Conclusion: The CDS did not significantly increase cancer-screening rates. Exploratory analyses suggest a deeper understanding of how SDM and CDS interact to affect cancer prevention decisions is needed. Trial registration: ClinicalTrials.gov ID: NCT02986230, December 6, 2016.

Keywords: clinical decision support; cluster-randomized trial; electronic health records; health informatics; implementation research; patient decision aids; primary and secondary cancer prevention; primary care; quality improvement; rural health; shared decision making.

Conflict of interest statement

Declaration of Conflicting Interests

The Authors declare that there is no conflict of interest.

Figures

Figure 1.
Figure 1.
H1 Composite Endpoint Consort diagram Notes: * Women age 21–74, men age 40–74 † Ineligible for analysis includes patients with delayed documentation of screening, patients whose screening status at follow-up could not be determined from EHR data, those no longer at risk, and those whose age at follow-up was higher than ages included in algorithms.

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