PCORI funds implementation projects to increase awareness and promote the use of PCORI-funded research findings to improve healthcare practices and health outcomes. This project is proposing to conduct implementation activities for the results of the research project: “A Randomized Trial to Promote Informed Decisions about Cancer Screening in Older Adults (PRIMED Study),” Co PIs: Karen R. Sepucha and Leigh Simmons.
1. What were the results of the original PCORI-funded study?
This proposal builds on the Promoting Informed Decisions about Colorectal Cancer Screening for Older Adults (PRIMED) Study. This PCORI-funded study focused on decisions about continuing or stopping colorectal cancer (CRC) screening for adults aged 76-85. The cluster randomized trial assigned 67 primary care physicians (PCPs) from 35 practices affiliated with two health systems in Maine and Massachusetts to either the intervention or comparator arms. Intervention arm physicians participated in a two-hour shared decision making (SDM) skills training course and received an electronic reminder of upcoming visits where a patient was due for a discussion about CRC testing. The Comparator arm received the reminders alone. The patients seen by intervention arm physicians reported more SDM (adjusted mean difference 0.36 (95 percent CI (0.08, 0.64), p=0.01), were more likely to discuss CRC testing (72 percent vs. 60 percent, p=0.03), and were more likely to have undergone testing at one year (39 percent vs. 29 percent, p=0.01).) The increased screening was mainly due to increased use of stool-based tests. Further, patients reported higher satisfaction in the intervention arm, and although the difference was not statistically significant, it does provide evidence that raising this sensitive topic did not negatively impact patients’ experience.
2. Why is this research finding(s) important?
As people age and their comorbidities accumulate, medical decisions become more complex, as do conversations about tests, such as cancer screening tests. There is tremendous variability in cancer risk, functional status and life expectancy in older adults, and these factors influence patients’ preferences and decision making about continued CRC screening. Older patients who are at higher risk for complications of colonoscopy may consider switching to a less invasive stool test or may decide to stop altogether, depending on their goals and health priorities. Some older adults may have a long life expectancy and a strong desire to reduce their CRC risk, and for them continued screening may make sense. Clinical guidelines recommend the need to individualize CRC screening decisions in adults 76 and older, indicating broad support of SDM in this setting. Clinicians and their older patients need to have shared decision making conversations to determine the best path, whether that is continuing testing or stopping their CRC screening. Currently there are no available evidence-based tools to help PCPs and patients with these conversations.
3. What is the goal of this project?
The objective of this implementation project is to increase the frequency of discussions and improve the quality of conversations about colorectal cancer testing decisions with primary care clinicians and their older patients. Based on the feedback from PRIMED physicians and review of the literature, the project team identified two clear aims to advance the implementation of these interventions into routine care:
- Automating the reminder in the electronic health record (EHR) and streamlining the SDM training course
- Incorporating strategies (e.g., education, audit and feedback, and external facilitation) to promote use in a broader clinician population
4. What is the project team doing?
The project team plans to work with six hospital systems that operate in different states and employ about 1,146 primary care clinicians in more than 160 practices. There are an estimated 73,000 patients in the target age group (76-85 years old) being cared for by PCPs at these sites who may benefit from these interventions. The team will work with the sites to roll out the best practice advisory (BPA) and the SDM training and will evaluate the implementation of these interventions. The project team is working with experienced teams at each site who routinely roll out practice changes across their health systems.
The main implementation strategies include education, audit and feedback. and external facilitation. These strategies were selected based on feedback from the physician participants and other stakeholder partners, as well as evidence of impact on physician behaviors. Over the course of the project, the team anticipates the electronic alert will reach about 40,000 patient visits and the training will be completed by about half of the PCPs across these health systems.
5. How is the team evaluating this project?
The design and evaluation are guided by well-established implementation frameworks and models. The project team will collect baseline data on practices and physicians including their years in practice, prior experience with SDM training and attitudes toward SDM in this decision context. The team will assess implementation outcomes of reach (proportion of reminders that were acted upon and the number and representativeness of patients reached) and adoption (number of PCPs who complete the training). The project will survey a subset of patients to understand their experience in the visit and specifically to see whether CRC screening was discussed and if so, whether there was an SDM conversation. In addition, the team will collect a sample of visit notes to determine how often CRC testing conversations were documented in the note and the amount of SDM as measured by documentation in visit notes. They will also collect CRC screening rates at sites to examine trends over time and determine the impact of the implementation of the interventions on testing rates. The team will conduct short surveys and brief interviews with selected PCPs and staff at sites to assess experience and satisfaction and identify any unintended negative or positive consequences.
6. How is the team involving patients and others in this project?
The co-principal investigators (PIs) have engaged patient partners as advisors and have sought advice from Patient and Family Advisory Committees from two of the sites. Two of the patient partners who were involved in the original PRIMED study will continue with this implementation project and have been involved in its design. In addition, the co-PIs have engaged stakeholder partners including the Health Care Improvement Foundation (also a stakeholder from original PRIMED study); Colorectal Cancer Alliance (stakeholder from original study); Fight Colorectal Cancer (a new stakeholder partner); implementation scientists and clinical decision support expert; quality improvement, patient experience and patient safety experts. AARP has also indicated interest in joining the advisory committee. These stakeholders have provided critical feedback to shape this project. Over the course of the project, these partners will participate in regular meetings to guide adaptation of the interventions; finalize study design; shape the messaging to practices, PCPs and patients; and promote dissemination when complete.
7. How will this project help ensure future uptake and use of PCORI-funded results?
The PRIMED study engaged about 60 PCPs at 35 primary care practices in New England and sent reminders to promote the CRC screening discussion for 788 patient visits. This project will vastly expand the reach to more than 1,100 PCPs in 163 practices across several states. The project team expects the BPA to fire for an estimated 40,000 patient visits over two years and expects about half of the PCPs to complete the SDM training. The adaptations to the interventions will enhance feasibility and acceptability, greatly expanding their reach, and will facilitate the uptake of the results by other practices in the future.
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.