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Decision aid, support strategy boosts colorectal testing for groups with low screening

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Helping patients understand colonoscopy alternatives and make a colorectal cancer screening choice based on their own values — combined with one-on-one support — dramatically increases screening completion among patients with historically lower screening rates, a new study finds. Colorectal cancer is the second leading cause of cancer death in the United States.

In the Journal of the American Medical Association Internal Medicine, researchers from the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center report a 40 percent increase in screening rates for patients at two community health centers in North Carolina and New Mexico using a decision aid and support from a trained navigator.

Michael Pignone, M.D., a former researcher at UNC and chair of the Department of Internal Medicine at Dell Medical School at The University of Texas at Austin, co-authored the study.

"This study gives us one model for effective health interventions in vulnerable populations," said Pignone. "There's no doubt that colon cancer screening is beneficial when implemented in the right age group. The question is, how far are care providers willing to go to bring those benefits to people with barriers to screening?"

Regular screening for colorectal cancer is recommended for people between 50 and 75 years of age. But research shows rates are low in some groups, particularly for people who are low-income, on Medicaid, have limited English proficiency and some minority groups. The majority of the 265 patients in the UNC study fit the profile of those with typically lower screening rates.

"We've shown that if we structure care such that we catch patients right when they are seeing their doctor, systematically provide them with clear and compelling information about screening and what their choices are, and then give them personal support they need to get the screening test they prefer, we can substantially improve rates," said the study's lead author, Dan Reuland, M.D., MPH, a UNC Lineberger member and professor in the UNC School of Medicine.

Before their appointments, patients watched a decision-aid video in English or in Spanish (per primary language) about their colon cancer screening options, which include colonoscopy or a home test that allows patients to mail in a sample of their stool. Then, patients met one-on-one with a navigator who followed up about their plans for a colonoscopy appointment or home tests.

Overall, 68 percent of patients who watched the video and met with a patient navigator were screened for colorectal cancer within six months, compared with 27 percent of patients who did not receive the intervention.

"Colonoscopy is just one of several screening tests recommended by the U.S. Preventive Services Task Force," said Alison Brenner, PhD, MPH, associate program director of the Decision Support Lab at UNC's Cecil G. Sheps Center for Health Services Research. "Studies have shown that offering colonoscopy only results in lower adherence to screening than offering a choice, and our study appears to confirm that."

The video aid helped patients make an informed discussion with their physician about screening and share in decision-making. Due to time constraints of appointments, physicians aren't always able to elicit patients' preferences regarding screening tests, but this intervention facilitated the conversation.

Combining the decision aid with support from a trained navigator also contributed to the success, researchers concluded. Navigators helped to make sure patients received a stool test kit if they wanted it, completed the test, accessed financial assistance programs, and scheduled a colonoscopy if needed.

Shared decision-making is a key component of patient-centered health care, one that Dell Medical School is embedding into its curriculum, clinical care and community outreach efforts, Pignone said. He plans to adapt the principles from the UNC study to initiatives in Travis County to measurably improve health in the community.

One barrier to replicating the intervention model is the cost to community health centers for navigator salaries. Follow-up studies are planned to analyze the cost-effectiveness of the method so that it could be improved and implemented in a value-based health care framework.

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In addition to Reuland, Brenner and Pignone, study authors include: Richard Hoffman, M.D., MPH; Andrew McWilliams, M.D., MPH; Robert Rhyne, M.D.; Christina Getrich, Ph.D.; Hazel Tapp, Ph.D.; Mark A. Weaver, Ph.D.; Danelle Callan, M.A.; Laura Cubillos, MPH; and Brisa Urquieta de Hernandez.

The study was primarily supported by the American Cancer Society. Additional funding was provided by the University of New Mexico Clinical and Translational Science Center, the North Carolina Translational and Clinical Sciences Institute at the University of North Carolina, and UNC Lineberger. Individual researchers were supported by the Agency for Healthcare Research and Quality's National Research Service Award, and the National Center for Advancing Translational Sciences.

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