Research articlePatient–Physician Colorectal Cancer Screening Discussions and Screening Use
Introduction
Routine colorectal cancer (CRC) screening is recommended for average-risk individuals aged 50 and older.1, 2, 3, 4, 5, 6, 7 Many guidelines note that while sufficient evidence exists to recommend screening, evidence regarding the “best” screening modality is more ambiguous. Recommended modalities include: (1) annual fecal occult blood test (FOBT), (2) flexible sigmoidoscopy every 5 years, (3) annual FOBT combined with flexible sigmoidoscopy every 5 years, (4) double-contrast barium enema (BE) every 5 to 10 years, and (5) colonoscopy every 10 years. Despite such recommendations and options, screening rates among the general population,5, 8, 9, 10 Medicare beneficiaries,11, 12 and primary care patients are relatively low.13, 14, 15
Physician recommendation repeatedly has been found to be associated with CRC screening use.16, 17, 18, 19 Recent efforts highlight that physicians discuss cancer screening differently20 and that many patients do not adhere to physician recommendations for CRC screening.21 The U.S. Preventive Services Task Force (Task Force), while not endorsing a specific style of physician–patient interaction when making preventive service recommendations to patients, recently advocated for the use of shared decision making.22 As part of this recommendation, the Task Force outlined five points to address during a conversation about screening: assess, advise, agree, assist, and arrange (or the 5A’s). This approach to discussing preventive health services begins with an assessment of patients’ needs for preventive services, factors that would effect behavior change, and desire to be involved in decision making. The next step, advise, involves conveying information about the recommended preventive service(s), such as the associated benefits, harms, alternatives and scientific uncertainties, and providing behavior change advice. The third step, agree, requires that a course of action be negotiated that aligns with the patients’ preferences, interest, and willingness to screen. The fourth step entails delivering or prescribing the recommended service (assist). The process ends with the arrangement of follow-up or a plan to revisit in the future. Although this framework was developed for and is increasingly used to guide health behavior–change interventions, its use as a guide for the development of screening interventions is also warranted.22 Because of the flexibility of this model to vary and alter the intensity of each element according to the screening procedure chosen and the characteristics of the patient, this framework could be particularly facilitative when the screening decision is complex, as is the case with CRC screening where multiple accepted screening modalities exist. Yet, as pointed out by the Task Force22 and others,23, 24 the use of a shared decision-making process and the 5A’s can be recommended on ethical and other grounds, but whether their use leads to improved adherence, or ultimately improved health, remains a subject of debate.
Patient characteristics associated with a patient-reported patient–physician CRC screening discussion are described. Among those reporting a discussion, the patient-reported screening discussion content, including the 5A’s, is described. Survey discussion content data are linked with automated clinical and administrative data available within an integrated healthcare system to evaluate the association of patient-reported discussion content with CRC screening use.
Section snippets
Study Setting
A cohort was identified of primary care patients receiving care from a salaried medical group that is part of an integrated healthcare delivery system serving southeast Michigan. At the time of the study, approximately one third of the patients receiving care from the medical group were members of an affiliated health plan. Also at the time of the study, the medical group had neither guidelines nor a clinical informatics system in place that addressed CRC screening. In 2000, the system’s health
Sample Characteristics
From among the cohort mailed the survey (n =4966), 2501 returned the survey (50.4% response rate). Compared to survey responders, nonresponders were significantly younger and more likely to be male and black or of another minority race/ethnicity (Table 1). They also differed in terms of their income and use of annual HMEs, and were significantly less likely to have used CRC screening tests/procedures in the previous 5 years. Just over half of responders (54%) received recommended CRC screening
Discussion
Among a cohort of primary care patients, most report having discussed CRC screening with their physician. Yet, the patient-reported content of these discussions varied, and only 54% were screened for CRC. Findings that some patients report a physician recommendation and referral for CRC screening, but have not been screened, are consistent with those of others. Brawarsky et al.32, 33 found that only 81% of individuals reporting a recommendation for CRC screening also reported receiving the
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