Results Summary

What was the research about?

For older adults ages 76–85, clinical guidelines note that the benefits of screening for colorectal cancer, or CRC, may not outweigh the harms. For this reason, the guidelines recommend that clinicians, such as doctors and nurse practitioners, work together with patients to make the screening decisions that work best for each patient. Shared decision making, or SDM, is a process in which patients and clinicians work together to make healthcare decisions.

In this study, the research team compared two approaches to improve SDM about CRC screening for older adults:

  • Electronic alert alone. Clinicians received an email or alert in a patient's electronic health record two or three days before meeting with the patient. The alert encouraged clinicians to talk with their patients about CRC screening.
  • Clinician training plus electronic alert. Along with an email or alert, clinicians took a two-hour online training. The training had examples of SDM and helped clinicians talk with their patients about CRC screening.

What were the results?

Compared with patients in the electronic alerts alone group, patients in the clinician training and electronic alerts group:

  • Reported more SDM about CRC screening
  • Were more likely to discuss CRC screening with their clinician
  • Had more intention to follow through with their preferred type of CRC screening
  • Received more CRC screenings after one year

The two groups didn’t differ in:

  • How much patients knew about CRC screening
  • How satisfied patients were with their visit
  • How many patients received their preferred type of CRC screening
  • How confident clinicians were in their ability to do SDM
  • How often clinicians used SDM in practice sessions during training activities

Who was in the study?

The study included 466 patients ages 76–85 who were due or overdue for CRC screening. All received care from one of 67 primary care clinicians at 35 clinics in Massachusetts and Maine. Among patients, 93 percent were White, and 7 percent were non-White or Hispanic. The average age was 79, and 53 percent were women.

What did the research team do?

The research team assigned clinicians by chance to one of the two approaches.

Clinicians filled out an online survey about SDM at the start of the study and again after patient visits. Soon after their visit, patients filled out a survey about the level of SDM. The research team looked at health records to find the number of CRC screenings.

Patients, advocacy groups, and clinicians helped design the study.

What were the limits of the study?

Patient visits happened during the COVID-19 pandemic, which caused disruptions to care. Also, most patients in the study were White. Results may have differed if more patients from other racial backgrounds were part of the study.

Future research could look at ways to improve SDM with clinicians who provide care for patients from other racial backgrounds.

How can people use the results?

Health systems can use the results when considering ways to help older patients and their clinicians make decisions about CRC screening.

Final Research Report

View this project's final research report.


Related PCORI Dissemination and Implementation Project

Journal Citations

Article Highlight: For older adults, guidelines recommend clinicians and patients work together to make decisions about colorectal cancer screening (CRC). However, these conversations must consider several factors and can be challenging. This study compared two ways to help clinicians and older patients make colorectal cancer screening decisions. The objective of the study was to promote shared decision making for CRC testing decisions among older patients. In results appearing in an August 2022 issue of the Journal of General Internal Medicine, the research team found that physician training plus electronic reminders when patients are eligible for a discussion about screening increased shared decision making and frequency of colorectal cancer testing discussions in an age group where shared decision making is essential.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study. 

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.   

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following: 

  • The reviewers felt that the report overstated the effectiveness of their intervention on improving shared decision making (SDM) and asked researchers to be more conservative in their conclusions and suggest that their intervention shows only the promise of an effective approach to increasing SDM. The researchers agreed that the size of the intervention effect on SDM was modest but disagreed that the study results showed only a promise of effectiveness for their intervention, noting that patients in the intervention arm were more likely to hear about options in colorectal cancer screenings and patients felt more like they engaged in SDM with providers. 

  • The reviewers requested more information about involvement of the study stakeholders, particularly during study implementation, analysis and interpretation. The researchers expanded their description of stakeholder engagement, explaining that the workgroups of patient and stakeholder partners were most active in the first year of the study when decisions were needed regarding study implementation. Once the study was underway these groups met less often as the focus changed to adherence to the intervention and study protocols. 

  • The reviewers were unclear regarding blinding procedures in the study. The researchers explained that it was not possible to blind physicians to intervention assignment since they received the SDM training. Patients, however, were not told what interventions were being tested nor whether their physician was in the treatment or comparator arm. 

  • The reviewers asked the researchers to comment on the high non-response rate, with almost 40% of the patients of the participating physicians not providing follow-up information and therefore not contributing to analyses. The researchers explained that they only considered patients study participants if they did provide follow-up information but acknowledged that patients who did respond could be different from patients who did not respond, creating the potential for a biased study sample. They added this concern to their limitations. 

Conflict of Interest Disclosures

Project Information

Karen Sepucha, PhD, and Leigh Simmons, MD
Massachusetts General Hospital
A Randomized Trial to Promote Informed Decisions about Cancer Screening in Older Adults (PRIMED Study)

Key Dates

August 2018
May 2023

Study Registration Information


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Populations Populations PCORI is interested in research that seeks to better understand how different clinical and health system options work for different people. These populations are frequently studied in our portfolio or identified as being of interest by our stakeholders. View Glossary
Intervention Strategy Intervention Strategies PCORI funds comparative clinical effectiveness research (CER) studies that compare two or more options or approaches to health care, or that compare different ways of delivering or receiving care. View Glossary
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Last updated: April 16, 2024