- Patient-facing decision aids used in tandem with patient navigators are effective in improving the rate of preventive cancer screenings, according to a study published in the Journal of the American Medical Association.
Despite general consensus that early detection and cancer treatment are beneficial for decreasing mortality rates, many patients go without preventive screenings.
“Screening remains underused, especially among vulnerable populations, including those with Medicaid, no health insurance, low educational attainment, limited English proficiency, and members of racial/ethnic minority groups,” the researchers said.
Many cancer care experts, such as those presiding in the US National Colorectal Cancer Roundtable, have put high priority on increasing the rate of preventive cancer screenings. The Roundtable recently set the goal of increasing screenings to 80 percent by 2018, the researchers reported.
Approaching patient barriers on two fronts is an effective strategy for increasing the preventive colorectal cancer (CRC) screening rate.
“To increase CRC screening nationally, interventions that address multiple patient- and system-level screening barriers are needed, particularly in care settings where diverse, vulnerable populations are served,” the team explained.
The researchers tested the use of decision aids and patient navigators on patients facing colorectal cancer screenings, hoping to fill in both educational and logistical challenges to obtaining those screenings.
The team introduced the tools to older, vulnerable patient populations in two community healthcare centers in New Mexico and North Carolina. Participating patients had allowed their regular preventive screenings to lapse and were proficient in either English or Spanish.
Intervention patients used the decision aid before their primary care encounters. The aid promoted CRC screenings and presented colonoscopy and fecal occult blood screenings as test options.
Following the care encounter, these patients had access to a patient navigator who helped patients overcome logistical barriers to receiving their preventive screening.
The researchers found that this two-pronged intervention increased the number of patients receiving a preventive colorectal cancer screening within six months of their primary care appointment. Sixty-eight percent of intervention patients received a screening within six months, compared to 27 percent of usual care patients.
“The intervention was broadly effective, improving screening completion across multiple subgroups known to have low CRC screening rates, including those with low-income, Spanish-speaking Latinos, those with low education levels, and those with Medicaid insurance,” the researchers reported.
The dual-layered intervention was likely successful because it addressed multiple patient challenges, both with regard to patient education and logistical health system barriers.
“Decision aids act ‘proximally’ in the screening process to enhance patients’ initial awareness of screening, promote patient-clinician communication, build intent, and clarify preferences,” the research team pointed out. “Patient navigation acts more ‘distally’ to address other (often practical) barriers to CRC screening completion that vulnerable patient populations face once an individual decides to be screened.”
The researchers did not know which component of the intervention was more effective because they did not test each variable individually. However, part of the findings underscored the need for clinicians to address multiple patient barriers to see optimal improvements, the researchers maintained.
The timing of the intervention’s delivery also contributed to success, the team said.
“For many patients, particularly those in vulnerable groups for whom cancer screening may not be salient during their day-to-day lives, an optimal time to deliver the decision aid is during primary care visits,” the researchers explained. “This allows care team members to facilitate viewing and to help patients act on their enhanced intent and informed preferences.”
Introducing the decision aids at the primary care visit may have also contributed to the perception that choosing the colorectal cancer screening was clinician-endorsed.
The colorectal cancer screening rates improved to such an extent that the researchers said further research is necessary to determine how to scale the intervention. The decision aids and patient navigation pairing can help vulnerable patients at-risk for colorectal cancer, as well as all patients.
“Although our intervention was effective, the feasibility of its widespread implementation remains unclear,” the researchers stated.
“Broader implementation will require that primary practices have the resources to systematically identify patients due for screening and deliver the intervention components,” the team concluded. “To substantially increase rates of CRC screening in the United States, payment models that allow primary care practices to become true medical homes are needed.”