Patient–Provider Discussions about Colorectal Cancer Screening: Who Initiates Elements of Informed Decision Making?

Abstract

BACKGROUND: Colorectal cancer (CRC) screening rates remain low among low-income minority populations. OBJECTIVE: To evaluate informed decision making (IDM) elements about CRC screening among low-income minority patients. DESIGN: Observational data were collected as part of a patient-level randomized controlled trial to improve CRC screening rates. Medical visits (November 2007 to May 2010) were audio-taped and coded for IDM elements about CRC screening. Near the end of the study one provider refused recording of patients' visits (33 of 270 patients). Among all patients in the trial, agreement to be audio taped was 43.5 % (103/237). Evaluable patient (n=100) visits were assessed for CRC screening discussion occurrence, IDM elements, and who initiated discussion of each IDM element. PARTICIPANTS: Patients were African American (72.2 %), female (63.7 %), with annual household incomes <$20,000 (60.7 %), without health insurance (57.0 %), and limited health literacy (53.7 %). KEY RESULTS: Although CRC screening was mentioned during 48 (48 %) visits, no further discussion about screening occurred in 23 visits (19 times mentioned by the participant with no response from providers). During any visit, the maximum number of IDM elements was five; however, only two visits included five elements. The most common IDM element discussed in addition to the nature of the decision was the assessment of the patient's understanding in 16 (33.3 %) of the visits that included a CRC discussion. CONCLUSIONS: A patient activation intervention initiated CRC screening discussions with health care providers; however, limited IDM occurred about CRC screening during medical visits of minority and low-income patients.

Physician Communication Regarding Prostate Cancer Screening: Analysis of Unannounced Standardized Patient Visits

“…In particular, similar to what has been found in previous studies, 8,[13][14][15] we found that there was a significant lack of effort to elicit patients' perspectives (knowledge, concerns, values, preferences), which is a critical component of shared decision making. [9][10][11] Given that more than 90% of physician participants self-reported that they usually took their patients' preferences into account when making treatment decisions (compared with only about 20% who explicitly told the standardized patient that decisions should be based on the patient's values and preferences), there may be a large gap between (1) the physicians' perception of or belief in their communication skill and their actual communication behavior, and (2) between the physicians' assumption of their patients' perspectives and their patients' actual perspectives.…”

“…6 In general, existing literature suggests that shared decision making requires that physicians engage in 3 broad groups of behaviors during consultations regarding PSA testing: (1) provision of information, ie, provision of balanced and evidence-based information regarding prostate cancer and prostate cancer screening options, including potential harms and benefits of each option; (2) elicitation of the patient's perspective, ie, assessing a patient's wish to be actively involved in decision making, asking about his prior experience, and eliciting his concerns about prostate cancer, as well as his values and preferences regarding different screening options; and (3) guiding final decision making, ie, providing guidance without being overly directive. [7][8][9][10][11] Even though physicians typically report that they engage in shared decision making about cancer screening, patients commonly deny having any such discussion with their physician. [12][13][14][15] To understand how the physician approached discussions of risk and uncertainty around prostate cancer screening, we undertook a transcript analysis of standardized patient clinic encounters, examining (1) which elements of shared decision making occurred when physicians were prompted to discuss prostate cancer screening, (2) whether intervention physicians engaged in more behaviors related to the 3 elements of shared decision making, and (3) whether intervention physicians were more neutral than control physicians in their final recommendations for screening and ordering PSA screening tests.…”

Shared decision-making about colorectal cancer screening: A conceptual framework to guide research

“…Importantly, screening behavior was not evaluated [26]. In a recent study, researchers found that CRC screening was mentioned in 48% of the primary care visits; however, in almost half of those visits, no additional discussion of CRC screening occurred [25]. One-third of those visits included both a discussion of CRC screening and an assessment of the patient’s understanding of CRC screening [25].…”

“…In a recent study, researchers found that CRC screening was mentioned in 48% of the primary care visits; however, in almost half of those visits, no additional discussion of CRC screening occurred [25]. One-third of those visits included both a discussion of CRC screening and an assessment of the patient’s understanding of CRC screening [25]. However, only 6% of those CRC screening discussions included assessment of patient test preferences; therefore low levels of IDM were found [25].…”

Cost-Containment Redux: Time for Physicians to Engage

“…Missed opportunities to engage in shared decision making also emerge in the paper by Katz et al,6 who showed that even when patients were activated to discuss CRC screening, the topic came up in just 48 of 100 visits, and there was no further discussion in 23 of those 48 visits. Finally, the article by Shah et al…”