Alison T. Brenner

The effect of offering different numbers of colorectal cancer screening test options in a decision aid: a pilot randomized trial

BackgroundDecision aids can improve decision making processes, but the amount and type of information that they should attempt to communicate is controversial. We sought to compare, in a pilot randomized trial, two colorectal cancer (CRC) screening decision aids that differed in the number of screening options presented.MethodsAdults ages 48–75 not currently up to date with screening were recruited from the community and randomized to view one of two versions of our previously tested CRC screening decision aid. The first version included five screening options: fecal occult blood test (FOBT), sigmoidoscopy, a combination of FOBT and sigmoidoscopy, colonoscopy, and barium enema. The second discussed only the two most frequently selected screening options, FOBT and colonoscopy. Main outcomes were differences in screening interest and test preferences between groups after decision aid viewing. Patient test preference was elicited first without any associated out-of-pocket costs (OPC), and then with the following costs: FOBT-

Conjoint Analysis Versus Rating and Ranking for Values Elicitation and Clarification in Colorectal Cancer Screening

10, sigmoidoscopy-

The uptake and effect of a mailed multi-modal colon cancer screening intervention: a pilot controlled trial.

50, barium enema-

Beyond Informed Consent: Educating the Patient

50, and colonoscopy-

Adherence to Competing Strategies for Colorectal Cancer Screening Over 3 Years.

200.Results62 adults participated: 25 viewed the 5-option decision aid, and 37 viewed the 2-option version. Mean age was 54 (range 48–72), 58% were women, 71% were White, 24% African-American; 58% had completed at least a 4-year college degree. Comparing participants that viewed the 5-option version with participants who viewed the 2-option version, there were no differences in screening interest after viewing (1.8 vs. 1.9, t-test p = 0.76). Those viewing the 2-option version were somewhat more likely to choose colonoscopy than those viewing the 5-option version when no out of pocket costs were assumed (68% vs. 46%, p = 0.11), but not when such costs were imposed (41% vs. 42%, p = 1.00).ConclusionThe number of screening options available does not appear to have a large effect on interest in colorectal cancer screening. The effect of offering differing numbers of options may affect test choice when out-of-pocket costs are not considered.

Patient Trust in Physician Influences Colorectal Cancer Screening in Low-Income Patients

To compare two techniques for eliciting and clarifying patient values for decision making about colorectal cancer (CRC) screening: choice-based conjoint analysis and a rating and ranking task. Using our decision lab registry and university e-mail lists, we recruited average risk adults ages 48–75 for a written, mailed survey. Eligible participants were given basic information about CRC screening and six attributes of CRC screening tests, then randomized to complete either a choice-based conjoint analysis with 16 discrete choice tasks or a rating and ranking task. The main outcome was the most important attribute, as determined from conjoint analysis or participant ranking. Conjoint analysis-based most important attribute was determined from individual patient-level utilities generated using multinomial logistic regression and hierarchical Bayesian modeling. Of the 114 eligible participants, 104 completed and returned questionnaires. Mean age was 57 (range 48–73), 70% were female, 88% were white, 71% were college graduates, and 62% were up to date with CRC screening. Ability to reduce CRC incidence and mortality was the most frequent most important attribute for both the conjoint analysis (56% of respondents) and rating/ranking (76% of respondents) groups, and these proportions differed significantly between groups (absolute difference 20%, 95% CI 3%, 37%, p =0.03). There were no significant differences between groups in proportion with clear values (p = 0.352), intent to be screened (p = 0.226) or unlabelled test preference (p = 0.521) Choice-based conjoint analysis produced somewhat different patterns of attribute importance than a rating and ranking task, but had little effect on other outcomes.ABSTRACTPURPOSETo compare two techniques for eliciting and clarifying patient values for decision making about colorectal cancer (CRC) screening: choice-based conjoint analysis and a rating and ranking task.METHODSUsing our decision lab registry and university e-mail lists, we recruited average risk adults ages 48–75 for a written, mailed survey. Eligible participants were given basic information about CRC screening and six attributes of CRC screening tests, then randomized to complete either a choice-based conjoint analysis with 16 discrete choice tasks or a rating and ranking task. The main outcome was the most important attribute, as determined from conjoint analysis or participant ranking. Conjoint analysis-based most important attribute was determined from individual patient-level utilities generated using multinomial logistic regression and hierarchical Bayesian modeling.RESULTSOf the 114 eligible participants, 104 completed and returned questionnaires. Mean age was 57 (range 48–73), 70% were female, 88% were white, 71% were college graduates, and 62% were up to date with CRC screening. Ability to reduce CRC incidence and mortality was the most frequent most important attribute for both the conjoint analysis (56% of respondents) and rating/ranking (76% of respondents) groups, and these proportions differed significantly between groups (absolute difference 20%, 95% CI 3%, 37%, p =0.03). There were no significant differences between groups in proportion with clear values (p = 0.352), intent to be screened (p = 0.226) or unlabelled test preference (p = 0.521)CONCLUSIONSChoice-based conjoint analysis produced somewhat different patterns of attribute importance than a rating and ranking task, but had little effect on other outcomes.

Effect of combined patient decision aid and patient navigation vs usual care for colorectal cancer screening in a vulnerable patient population: A randomized clinical trial

BackgroundWe sought to determine whether a multi-modal intervention, which included mailing a patient reminder with a colon cancer decision aid to patients and system changes allowing direct access to scheduling screening tests through standing orders, would be an effective and efficient means of promoting colon cancer screening in primary care practice.MethodsWe conducted a controlled trial comparing the proportion of intervention patients who received colon cancer screening with wait list controls at one practice site. The intervention was a mailed package that included a letter from their primary care physician, a colon cancer screening decision aid, and instructions for obtaining each screening test without an office visit so that patients could access screening tests directly. Major outcomes were screening test completion and cost per additional patient screened.ResultsIn the intervention group, 15% (20/137) were screened versus 4% (4/100) in the control group (difference 11%; (95%; CI 3%;18% p = 0.01). The cost per additional patient screened was estimated to be

Promoting decision aid use in primary care using a staff member for delivery

94.ConclusionA multi-modal intervention, which included mailing a patient reminder with a colon cancer decision aid to patients and system changes allowing patients direct access to schedule screening tests, increased colon cancer screening test completion in a subset of patients within a single academic practice. Although the uptake of the decision aid was low, the cost was also modest, suggesting that this method could be a viable approach to colon cancer screening.

Colorectal Cancer Screening in Vulnerable Patients: Promoting Informed and Shared Decisions.

The informed consent doctrine was conceived as a basis for allowing patients to meaningfully participate in the decision-making process. It has evolved into a formal, legal document that reflects a desire by physicians and surgeons to have patients execute “waivers of liability.” In the process it has lost its educational value by shifting the emphasis to obtaining a “preoperative release” from an exchange of information upon which a patient can make important decisions about their healthcare choices. This is unfortunate because, in the process, both patients and physicians have suffered. Patients have become alienated from the informed consent process and, paradoxically, physicians and surgeons may have created more liability exposure through this alienation. We propose that by returning to an educational model, the patients will develop a greater sense of control, become more compliant, and potentially experience improved healthcare outcomes. There may also develop an alliance between the patient and the physician or surgeon, such that the seeds of an antagonistic or litigious relationship will not be planted before treatment begins. Liability reduction, therefore, may more likely arise from the educational model.

Beyond the Standard of Care: A New Model to Judge Medical Negligence

Objectives:We have shown that, in a randomized trial comparing adherence to different colorectal cancer (CRC) screening strategies, participants assigned to either fecal occult blood testing (FOBT) or given a choice between FOBT and colonoscopy had significantly higher adherence than those assigned to colonoscopy during the first year. However, how adherence to screening changes over time is unknown.Methods:In this trial, 997 participants were cluster randomized to one of the three screening strategies: (i) FOBT, (ii) colonoscopy, or (iii) a choice between FOBT and colonoscopy. Research assistants helped participants to complete testing only in the first year. Adherence to screening was defined as completion of three FOBT cards in each of 3 years after enrollment or completion of colonoscopy within the first year of enrollment. The primary outcome was adherence to assigned strategy over 3 years. Additional outcomes included identification of sociodemographic factors associated with adherence.Results:Participants assigned to annual FOBT completed screening at a significantly lower rate over 3 years (14%) than those assigned to colonoscopy (38%, P<0.001) or choice (42%, P<0.001); however, completion of any screening test fell precipitously, indicating the strong effect of patient navigation. In multivariable logistic regression analysis, being randomized to the choice or colonoscopy group, Chinese language, homosexuality, being married/partnered, and having a non-nurse practitioner primary care provider were independently associated with greater adherence to screening (P<0.01).Conclusions:In a 3-year follow-up of a randomized trial comparing competing CRC screening strategies, participants offered a choice between FOBT and colonoscopy continued to have relatively high adherence, whereas adherence in the FOBT group fell significantly below that of the choice and colonoscopy groups. Patient navigation is crucial to achieving adherence to CRC screening, and FOBT is especially vulnerable because of the need for annual testing.