Study Suggests Personalized Multi-Level Intervention Helps Veterans Make Best Decisions about Colorectal Cancer Screening

BACKGROUND:
Current guidelines recommend routine screening for colorectal cancer (CRC) in individuals from ages 45-75 at average risk. However, as individuals gets older, acquire health problems, and undergo negative CRC screening tests, the benefit of screening may decrease while potential harm increases. A more systematic, scalable, and patient-centered approach is needed to guide older adults who may otherwise “qualify” for screening but have competing health issues that make the screening decision more complex. This unmasked, cluster-randomized controlled trial was conducted from November 2015 to February 2019 in two VAMCs to evaluate the effect of a personalized multi-level intervention on screening orders in older adults due for average-risk CRC screening. Investigators assigned 431 older Veterans (ages 70-75) at average risk of CRC to an intervention arm (n=258) or control arm (n=173). Patients in the intervention arm were presented with detailed, personalized information about the benefits and harms of colon cancer screening just before a primary care visit, with the goal of promoting appropriate use of screening. Veterans in the control arm received a brief booklet on CRC screening that had a similar format to the decision aid but comprised only the background educational content. The primary outcome was whether CRC screening was ordered within 2 weeks of the primary care visit. Secondary outcomes included benefit-concordance of screening orders and screening utilization within 6 months of the primary care visit, assessed through manual record review.

FINDINGS:

• Compared to Veterans who received a simple educational booklet (control arm), those who received personalized information (intervention arm) were more likely to get a “benefit-concordant” screening order—that is, they were significantly less likely to get an order if low benefit, and more likely to get one if high benefit. Notably, in the control group, screening orders occurred at nearly twice the rate among the lowest-benefit study participants compared to the highest-benefit participants, suggesting substantial opportunity for practice improvement.
• Intervention patients were significantly less likely to complete screening overall at six months, reflecting a reduction in the use of low-value care.

IMPLICATIONS:

• Study results suggest that a personalized decision aid, in the context of a multi-level intervention, could be efficacious in enhancing appropriate ordering of CRC screening—and in reducing use of CRC screening overall, even in a population that is not highly educated.

LIMITATIONS:

• The predominant mode of screening was FIT (fecal immunochemical test) testing, which is unlikely to cause direct harm and could have made screening more attractive than in a setting where colonoscopy is the dominant mode of screening.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D (IIR 12-411). Drs. Saini (Director) and Kerr are part of the Center for Clinical Management Research (CCMR) in Ann Arbor, MI.

Saini S, Lewis C, Kerr E, et al. The Effect of Personalizing a Multi-Level Intervention to Improve Appropriate Use of Colorectal Cancer Screening in Older Adults: A Cluster Randomized Controlled Trial. JAMA Internal Medicine.2023 Dec 1;183(12):1334-1342