Lead/Presenter: Sameer Saini, COIN - Ann Arbor
All Authors: Saini SD (Center for Clinical Management Research, Ann Arbor, University of Michigan Medical School), Zikmund-Fisher, BJ (University of Michigan School of Public Health), Kerr, EA (Center for Clinical Management Research, Ann Arbor, University of Michigan Health System) Lewis, CL (University of Colorado School of Medicine) Hawley, ST (Center for Clinical Management Research, Ann Arbor, University of Michigan School of Medicine) Lipson, R (Center for Clinical Management Research, Ann Arbor) Zauber, AG (Memorial Sloan Kettering Cancer Center, New York) Lansdorp-Vogelaar, I (Erasmuc MC Department of Public Health, the Netherlands) Saffar, D (Center for Clinical Management Research, Ann Arbor) Myers, AD (Center for Clinical Management Research, Ann Arbor) Vijan, S (Center for Clinical Management Research, Ann Arbor, University of Michigan Health System)
Many average-risk older Veterans who have previously been screened and/or have comorbid health problems receive colorectal cancer (CRC) screening that is unlikely to benefit them and may put them at risk for harm. In this context, we designed and evaluated the impact of a decision aid (DA to align screening use with screening benefit on the frequency of benefit-concordant CRC screening orders in a cluster-randomized controlled trial (RCT) [NCT02027545].
We recruited average-risk, screen-due Veterans aged 70-75 attending a primary care visit at 2 VA facilities. The intervention group received a DA with detailed information on screening benefits/harms that were personalized for each subject based on age, gender, prior screening, and comorbidity. Both the intervention and control groups received primary care provider (PCP) education and performance measurement and clinical reminder modification to allow Veterans and PCPs to make informed decisions about screening (including the decision to not be screened). The primary outcome was whether screening was ordered within 2 weeks of the clinic visit. Data were analyzed using a multi-level clustered logistic regression model, with a pre-specified interaction analysis examining whether the DA had a differential effect by magnitude of screening benefit.
1,562 Veterans were eligible in the 30-month RCT period. 434 (28%) completed the study visit across 66 PCPs. 261 (60%) were randomized to intervention and 173 (40%) to control. 81% had undergone prior screening. The mean benefit of screening (CRCs prevented per 1,000 individuals screened) was 11.2, standard deviation 8.2. Screening orders were placed for 164/261 (63%) intervention versus 114/173 (66%) control patients (p = 0.57). In our pre-specified interaction analysis, low-benefit intervention patients were less likely to receive screening orders than low-benefit controls; high-benefit intervention patients were more likely to receive orders than high-benefit controls (p = 0.047).
Veterans presented with detailed, individualized information about screening benefits/harms are more likely to make a screening decision that is concordant with benefit than those who are not provided with such information.
Engaging older Veterans in decisions about cancer prevention results in more appropriate and efficient use of resources in a way that is aligned with preferences and net benefit.