Cancer Screening Adherence through Technology-enhanced Shared Decision Making (CSATS)

1. Cancer Screening Adherence through Technology-enhanced Shared Decision Making (CSATS) Masahito Jimbo Mack Ruffin Donald Nease Department of Family Medicine University of Michigan

2. Today’s Goals • Solidify the conceptual framework of CSATS. • Ensure that all process data outcomes to be collected for the feasibility study are accounted for.

3. Layout of the Presentation • Describe the decisions involved in CRC screening. • Explain the specific process of CSATS. • Describe how Colorectal Web, the decision aid used in CSATS, was developed, and the current theoretical framework. • Describe the feasibility study and the data we intend to collect.

4. Colorectal Cancer (CRC) affects and kills many Americans. • 149,000 new cases in 2006 • 3rd most common • 55,200 deaths in 2006 • 2nd highest Statistics from American Cancer Society

5. Screening for CRC saves lives. • Fecal Occult Blood Test (FOBT) led to fewer incidence and deaths from advanced CRC in 3 large, randomized trials. • Hardcastle (UK) • Kronborg (Denmark) • Mandel (Minnesota)

6. CRC screening is recommended. • All major medical organizations strongly recommend starting CRC screening for all adults aged 50 years and over. • United States Preventive Services Task Force (USPSTF) • American Cancer Society (ACS) • etc., etc.

7. CRC screening remains low. ACS Cancer Prevention & Early Detection Facts & Figures 2006

8. CRC screening entails an extra layer of making a choice. USPSTF, ACS

9. 5 Choices in CRC Screening • FOBT • Easiest. • Cheapest. • Simple. • Need to do every year. • Have to handle stool. • Colonoscopy if something is found. • Least accurate.

10. 5 Choices in CRC Screening • Flexible Sigmoidoscopy • Takes 15-30 minutes. • Relatively cheap. • Once every 5 years. • Looks at lower colon. • Requires preparation. • Colonoscopy if something is found. • Rare risk of damage. • Mild to moderate pain.

11. 5 Choices in CRC Screening • Yearly FOBT and Flexible Sigmoidoscopy every 5 years • The combinations of tests likely prevents more cases of cancer than the either test alone. • Colonoscopy if something is found.

12. 5 Choices in CRC Screening • Double Contrast Barium Enema • Reasonably easy. • Once every 5 years. • Good accuracy. • Requires preparation. • Medium cost. • Mild to moderate pain. • Colonoscopy if something is found. • Radiation (X-ray).

13. 5 Choices in CRC Screening • Colonoscopy • Most accurate. • Once every 10 years. • Expensive. • Requires preparation. • Very painful, requires sedation. • Need chaperone. • Usually miss a day of work.

14. Frequency Preparation for the test Sedation requirement Discomfort Embarrassment Inconvenience Accuracy Need for additional tests Risk of complications Cost Patient preference regarding test factors may influence their choice.

15. Screening option gets limited in patients with increased risk. • Colonoscopy is recommended for people with increased risk: • Personal history of colorectal polyp/cancer, certain other cancers, inflammatory bowel disease • Family history of colorectal cancer and certain other cancers • Overwhelming majority is average risk.

16. Modest success with interventions to increase cancer screening

17. Modest success with interventions to increase cancer screening • Tailored patient education such as decision aids and personalized risk communication tools have shown modest effect. • But, they have been done outside the context of patient-physician encounter, failing to incorporate physician recommendation, a powerful factor for patients to change behavior. Jimbo, Nease, Ruffin, Gupta. CA 2006

18. Shared Decision Making (SDM) • As defined by USPSTF, SDM is a particular process of decision-making by the patient and physician, in which the patient: • Understands the risk or seriousness of the disease or condition to be prevented. • Understands the preventive service, including the risk, benefits, alternatives, and uncertainties. • Has weighed his or her values regarding the potential benefits and harms associated with the service. • Has engaged in decision-making at a level at which he or she desires and feels comfortable.

19. Shared Decision Making (SDM) • Different from Informed Decision Making (IDM) in that it is a joint decision between the patient and physician, rather than the patient only.

20. Shared Decision Making (SDM) • Requires more time and resources than most physicians can access in a visit, especially in the complexity of practice with multiple, competing agendas.

21. Cancer Screening Adherence through Technology-enhanced Shared Decision Making (CSATS) • We propose to use technology to link tailored behavioral intervention with physician recommendation in the context of SDM. • Colorectal Web, an interactive patient decision aid that: • Helps patients choose a CRC screening test by clarifying their risks and preferences. • Offloads the time and effort required for the decision process from the visit to before the visit.

22. Cancer Screening Adherence through Technology-enhanced Shared Decision Making (CSATS) • We propose to use technology to link tailored behavioral intervention with physician recommendation in the context of SDM. • Link the results from Colorectal Web to a physician reminder/prompt system (ClinfoTracker), which has an ability to import data set from any software, to: • Remind the physicians that CRC screening is due. • Make the physicians aware of the patients’ risks, preferences, and test of choice to facilitate SDM.

23. Cancer Screening Adherence through Technology-enhanced Shared Decision Making (CSATS) Shared Decision Making Clarification of patient risk and preferences COLORECTAL WEB Decision aid on risk and preference LINK ClinfoTracker Physician Reminder (Can import data set from any software) (Before Visit) (At Visit)

24. Colorectal Web - Development • Focus Groups • Check of existing Websites on CRC screening • Individual interviews • Randomized controlled trial

25. Focus Groups • Developed themes from patients who have never been screened for CRC. • 10 groups, 100 participants • Adults aged 50 years and over • 50 men, 50 women, 50% African American • Recruited from 3 communities in Michigan • Detroit • Saginaw • Benton Harbor

26. Focus Groups • Why have you not checked? • Doctor did not recommend. • No symptoms, fear, not necessary/never thought about it, man’s disease (women’s perspective) • What would make you get checked? • Doctor recommendation • Change in bowel habits, family/friends experience

27. Focus Groups • What do you like/dislike about each CRC screening test? • Factors in Colorectal Web • Where do you now get information? • Friends/family • TV, radio, magazines • How would you like to get the information? • Online • Library

28. Focus Groups • Information: plain and simple • Facts and statistics • Graphics, but not offensive • Pictures of the tests • Testimonials • Symptoms • Data specific to ethnic groups • “Help me choose!”

29. Check of existing Websites on CRC screening • 2 search engines, 3 reviewers • Key words: Colon, Rectal, Cancer, Prevention, Screening • Over 65 free sites • User directed navigation • Little variation in content • Mostly text, little graphics, high reading level • No interaction: “electronic tri-fold”

30. Design of Colorectal Web • Used content of existing sites • Lower reading level • More graphics • Interactive • Help make a choice • Focus on making a choice • User directed navigation

31. Individual Interviews to Improve Colorectal Web Utility • 30 interviews • Questions regarding content, navigation, and user satisfaction of Colorectal Web • Resulted in a 3rd version: • Help with navigation • Diagrams rather than real pictures • Keep the diagrams 1 click away • “Choosing Widget” helpful

32. Randomized Controlled Trial to Evaluate Efficacy • Block randomization by site, gender and race • Adults aged 50 years, never screened for CRC • Colorectal Web vs. Standard CRC Screening Website • Cancer Research and Prevention Foundation (http://www.preventcancer.org/colorectal/) • Identical content but not interactive and not focusing on making a choice • Evaluation at 2 weeks, 8 weeks, 6 months • Knowledge • Attitude • Preferred screening test • Discussion with physician • CRC screening

33. Preference P < 0.0001

34. CRC Screening P = 0.035

35. Colorectal Web • http://healthmedia.umich.edu/chcr/documents/Dev_csats/ • http://colorectalweb.org:8181/welcome

37. Risk Assessment Tool Will Be Added to Colorectal Web COLORECTAL WEB Preference + Risk Assessment - Average - Increased - Unknown CRC risk Top 3 preferred features Final test of choice Shared Decision Making LINK ClinfoTracker Physician Reminder (Can import data set from any software) (Before Visit) (At Visit)

38. Development of a Conceptual Model • Colorectal Web was designed and refined based on user (patient) and expert input. • It did not start out with a particular theoretical model. • As the tool further evolves and morphs to be applied to other preventive services and conditions, we need a framework to base our design and implementation strategy.

39. Current Conceptual Model

40. Elaboration Likelihood Model • Central and peripheral routes of processing • Central: A person is more likely to be persuaded if s/he can elaborate extensively on a message. The resultant behavior change is long-term. • Peripheral: If a person cannot elaborate on a message extensively, s/he may still be persuaded temporarily by factors that have nothing do with the actual content of the message. Petty, Cacioppo 1980

41. Application of Elaboration Likelihood Model • Information on Colorectal Web motivates a patient to elaborate and process centrally. • Interactive explanations and widgets (Helping to Select) on Colorectal Web enables the patient to elaborate relatively easily. • The interactive nature of the widget may also cue the patient through the peripheral route.

42. Decision Aid Physician Factors Knowledge Attitudes Beliefs Information processing (Elaboration) Patient Factors Demographics Personal history Family history Past screening Physician Recommendation Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Cues to action Self-efficacy Preference Clarification Intent to get CRC screening CRC screening System Factors Access Resources Will It Differ by Context of IDM or SDM?

43. Feasibility Studies • Physician practice focus groups • Study implementation feasibility

44. Physician Practice Focus Groups • Focus groups on 5 of the 13 practices in the Great Lakes Research into Practice Network (GRIN) that participated in a previous study to implement ClinfoTracker to improve CRC screening • Maximal variability in terms of size, location, and technological sophistication • Participants • Clinicians: physicians, nurse practitioners, physician assistants • Clinical support staff: registered nurses, licensed practical nurses, medical assistants • Non-clinical support staff: clinic managers, receptionists, billing clerks

45. Physician Practice Focus Groups • Rationale: The practices have had up to 2 years of experience with ClinfoTracker • Well aware of the advantages and disadvantages of the prompting/reminder system • Could give informed answers to our questions regarding the addition of decision aid component

46. Focus Group Questions: General • Could you tell me how prevention and screening is currently incorporated into your practice? • What is the process for informing patients about prevention and screening? • Tell me how colorectal cancer screening currently fits in your practice? • How do you use the resources you have now to discuss colorectal screening with patients? • If you had all the resources you needed how would you improve your current methods for discuss colorectal screening? • What would be most helpful for you at your practice to improve your ability to introduce and discuss colorectal screening with patients?

47. Focus Group Questions: CSATS • To what extent are you (physicians and staff) currently using ClinfoTracker? • Do you think adding this new component to ClinfoTracker will be helpful to patients? To physicians? • How can adding the layer be facilitated most easily? You would most likely receive the information about the patient’s preference on a form that would be printed out as part of the visit. The form would include prompts about each test and the patient’s responses to questions in Colorectal Web. Would this work for your practice? • What other features might be helpful to you as staff? • What other features might be helpful to you as a physician? • Do you feel it is feasible for your patients to use Colorectal Web?

48. Focus Group Questions: CSATS • Do you know approximately how many of your patients have access to the Internet? • For those that do not, what might be a good way to get them to visit the Web site? Could a computer be set up in your waiting area? • What other obstacles do you see to your patients using Colorectal Web? • What suggestions do you have to overcoming those obstacles? • When does it make the most sense for patients to use Colorectal Web? Should they use it before the office visit? • Would a paper/pencil technique be better or easier for your patients? • What if the contents of the Colorectal Web were presented in a workbook style with pictures and text for the patient to fill out independently?

49. Focus Group Questions: CSATS • Does the flowchart seem to work within your current workflow? • Does it make sense for the patient to visit Colorectal Web before they visit the physician? • Does it make more sense for them to visit Colorectal Web after their appointment? • Should the patient be filling out anything during the visit? • In what format would you expect to see the data from Colorectal Web? • What methods should be used to remind patients to visit Colorectal Web? • Does a postcard make sense for their practice? • Should it be pre-formatted so they just fill in the patient name/address? • What other concerns do you have about the process as described? • Are there other ways to aid patient and physician interaction with ClinfoTracker?

50. Study Implementation Feasibility • Designed to minimize the disruption in the workflow of the PCP offices by having the patients access Colorectal Web and answer the surveys before the scheduled health maintenance visit.