Lead/Presenter: Jane Forman,
COIN - Ann Arbor
All Authors: Forman JH ((Center for Clinical Management Research, Ann Arbor, University of Michigan Medical School)), Lewis, CL (University of Colorado School of Medicine), Kerr, EA (Center for Clinical Management Research, Ann Arbor, University of Michigan Health System) Hawley, ST (Center for Clinical Management Research, Ann Arbor, University of Michigan School of Medicine) Zikmund-Fisher, BJ (University of Michigan School of Public Health) Saffar, D (Center for Clinical Management Research, Ann Arbor) Myers, AD (Center for Clinical Management Research, Ann Arbor) Vijan, S (Center for Clinical Management Research, Ann Arbor, University of Michigan Health System) Saini, SD (Center for Clinical Management Research, Ann Arbor, University of Michigan Medical School)
VHA efforts to improve colorectal cancer (CRC) screening use have resulted in increased screening that is not always concordant with benefit, particularly among older Veterans with comorbid illness. Further, Veterans are inadequately informed about the increasing harms and decreasing benefits of screening that accompanies increased age and illness burden. We conducted an RCT testing a decision aid (DA) with tailored and personalized information on screening benefits and harms. In this study, we assessed the DA's influence on Veteran decision-making about CRC screening [NCT02027545].
We conducted semi-structured interviews with 31 Veterans aged 70-75 within a day of their primary care provider (PCP) visit at which they were due for average-risk CRC screening. Veterans received the DA before the visit. We analyzed verbatim interview transcripts using qualitative content analysis and conducted matrix analysis with qualitative themes, PCP visit notes, and screening orders and utilization for each interviewee.
We categorized participants according to whether the DA: (1) influenced them to stop screening; (2) changed how they thought about screening but not their screening preference; or, (3) had no effect on how they thought about screening nor their screening preference. Veterans influenced by the DA to stop screening learned that CRC was slow-growing and that shortened life expectancy decreases screening benefits. Veterans in the second category understood that risk increases with age and, for some, that CRC is slow-growing. However, this information was mitigated by their perceiving themselves as not old enough to stop screening and DA reinforcement of their preference for fecal immunochemical test (FIT) due to its low likelihood of harm compared to colonoscopy. Veterans for whom the DA had no influence had other health problems that they prioritized over CRC decision-making and/or had strong existing screening preferences.
Informing older Veterans of their personal risks and benefits and providing information on CRC and screening can influence preferences and decision-making about whether to undergo screening and which test to use. Health status, established preferences, and desire for risk-avoidance affect DA influence.
VHA should consider providing tailored decision-making information on CRC screening and other tests and treatments for which Veteran preferences are particularly important.