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Combination of decision aid, patient navigation increases colorectal cancer screening rates

In vulnerable primary care patients, an intervention that combined a patient decision aid and patient navigation substantially increased the rate of colorectal cancer screening completion compared with usual care, according to research published in JAMA Internal Medicine.

“Colorectal cancer is the third-leading cause of cancer death in men and women in the United States,” Daniel S. Reuland, MD, MPH, from the division of general internal medicine and clinical epidemiology at the University of North Carolina School of Medicine, and colleagues wrote.

Colorectal cancer screening effectively reduces mortality and is recommended by the USPSTF. However, screening is underused, particularly among vulnerable patients, such as those with Medicaid or no health insurance, and those ethnic/racial minority groups. Thus, interventions addressing several patient- and system-level screening barriers are warranted, according to the researchers.

Between January 2014 and March 2016, Reuland and colleagues performed a randomized clinical trial at two primary care community health center practices that serve vulnerable populations to examine the effect of combining a colorectal cancer screening decision aid and patient navigation on screening completion at 6 months. A total of 265 patients aged 50 to 75 years (65% female; 62% Latino; 15% white non-Latino; 23% black or mixed race) with an average colorectal cancer risk and who were not up-to-date with screening recommendations were enrolled in the study. The researchers noted that 78% of participants had a household income of less than $20,000, 38% had low literacy, 28% were on Medicaid and 34% were uninsured. Participants were randomized 1:1 to an intervention or control group.

Immediately before meeting with their clinician, participants in the intervention group viewed a colorectal cancer screening decision aid that promoted screening through colonoscopy or fecal occult blood testing. After meeting with the clinician, a bilingual patient navigator provided support for screening completion for patients in the intervention group. Participants in the control group were assigned to watch a food safety video and received usual care.

Data indicated that completion of colorectal cancer screening within 6 months was significantly greater in the intervention group (68% vs. 27%; adjusted-difference, 40 percentage points; 95% CI, 29-51). Effectiveness of the intervention was more prominent in women than men (50 vs. 21 percentage point increase; P = .02). Other subgroups did not show effect modification.

“We have shown that this intervention substantially increases [colorectal cancer] screening completion rates in diverse, vulnerable patients, and does so in a way that acknowledges and leverages informed patient preferences,” Reuland and colleagues concluded. “Broader implementation will require that primary practices have the resources to systematically identify patients due for screening and deliver the intervention components. To substantially increase rates of [colorectal cancer] screening in the United States, payment models that allow primary care practices to become true medical homes are needed.” – by Alaina Tedesco

Disclosure: The researchers report funding from the American Cancer Society. Please see full study for complete list of all author’s relevant financial disclosures.