The Effect of a Shared Decision-Making Process on Acceptance of Colorectal Cancer Screening

THE INNOVATION

Despite the availability of convenient, noninvasive screening tests such as Fecal Immunochemical Test (FIT) and multi-target stool DNA test (Mt-SDNA or Cologuard), only 69% of average risk individuals aged ≥50 years are up to date with recommended colorectal cancer (CRC) screening.¹ Guidelines recommend conducting shared decision making covering multiple test choices²; however, clinicians largely fail to present options in a balanced approach that considers patient values and preferences. Many clinicians are biased to recommend colonoscopy for a multitude of reasons, including perceived superior sensitivity and time constraints preventing detailed discussion of options. To increase screening rates and understand impact on test choice when options are presented in a balanced manner, while acknowledging limited time to counsel, we implemented a shared decision-making process to educate patients on risks, harms, and benefits of testing, and encouraged them to choose the best test for themselves based on their understanding and preferences.

WHO & WHERE

Patients aged 50 to 75 years of 8 primary care offices in metro Denver participated. Eligible patients had commercial or Medicare Advantage insurance, were due for CRC screening and had a scheduled appointment with their clinician. The shared decision-making information sheet (Supplemental Figure 1) and process was developed in collaboration with practice leaders. A complementary clinician reference sheet (Supplemental Figure 2) presented information in a format preferred by clinicians, along with talking points.

HOW

We conducted brief training sessions with clinicians to ground them on the performance and outcomes of each screening option. To reduce variability between clinicians’ approach to the CRC screening discussion, we asked them to use the information sheet with relevant test performance data and a suggested guided conversation that covered salient points about the importance of screening, differences between options, and implications of each choice. Clinic staff flagged eligible patients and ensured the information sheet was provided for patient-clinician discussion. Clinicians emphasized that patients could choose any test or decline screening. Patients completed the validated 4-item “SURE” test of decisional conflict to judge competence and confidence in reaching their decision.³ Pre and post-project surveys of clinicians (Supplemental Table 1) assessed attitudes, preferences, and practices for CRC screening at baseline, and ascertained feedback about their experience using the new process.

Between November 2019 and February 2020, 207 unique patients engaged in a CRC screening discussion using the shared decision-making process. Before implementation, 35% of patients declined screening. Of patients undergoing screening, 76% used colonoscopy, 20% used FIT, and 4% used Mt-SDNA. After implementation, 12 (6%) patients declined screening or elected to defer their decision; 195 (94%) chose a screening test. Fifty-seven (29%) chose colonoscopy, 115 (59%) chose Mt-SDNA, and 23 (12%) chose FIT. Test choice largely shifted toward noninvasive tests while the decline rate observed was lower than pre-implementation. Of the 188 patients who took the SURE test, 99% answered all 4 questions in the affirmative, confirming their confidence in making their decision. Ninety-six percent of clinicians either strongly or somewhat agreed that the shared decision-making process was useful for facilitating the CRC screening discussion. Seventy-eight percent of clinicians spent 4-6 minutes counseling on CRC screening, whereas before implementation 34% spent 4-6 minutes and 62% spent 1-3 minutes counseling.

LEARNING

In-office shared decision-making processes for CRC screening facilitated by information and guidance for clinicians helps patients select the best CRC screening test for themselves. Adoption can help practices increase screening rates, as many patients averse to an invasive colonoscopy may be willing to do a noninvasive test. To further enhance efficiency and improve the patient experience, future work will assess the impact of enabling patients to choose and order a test using digital asynchronous shared decision-making tools in advance of an appointment.