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Shared decision making in colorectal cancer screening in primary care: a cluster randomized controlled trial

English title Shared decision making in colorectal cancer screening in primary care: a cluster randomized controlled trial
Applicant Auer Reto
Number 167519
Funding scheme NRP 74 Smarter Health Care
Research institution Berner Institut für Hausarztmedizin BIHAM Universität Bern
Institution of higher education University of Berne - BE
Main discipline Cancer
Start/End 01.04.2017 - 31.03.2021
Approved amount 351'241.00
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All Disciplines (5)

Discipline
Cancer
Methods of Epidemiology and Preventive Medicine
Clinical Cancer Research
Internal Medicine
Public Health and Health Services

Keywords (9)

shared decision making; family practice; quality improvement; randomized controlled trial; patient’s values and preferences; participatory research; colorectal cancer screening; quality circles of physicians; variations in care

Lay Summary (German)

Lead
Nur jeder fünfte Schweizer über 50 Jahre nimmt in der Schweiz am Darmkrebs-Screening teil. Viele wissen gar nicht, dass ein Test sinnvoll wäre und erst recht nicht, dass es unterschiedliche Screeningmethoden gibt. Umso wichtiger ist die Schulung der Hausärztinnen und Hausärzte in partizipativer Medizin, damit ihre Patienten eine informierte Entscheidung treffen können.
Lay summary

Ausganglage: Durch Früherkennungsprogramme kann die Darmkrebsmortalität um die Hälfte reduziert werden. Zwei Vorsorgeuntersuchungen werden von der Grundversicherung übernommen: Die Darmspiegelung, mit der genaue Ergebnisse erzielt werden, und der etwas angenehmere Stuhlanalyse. Doch nur wenige Personen werden über die Darmkrebsvorsorge und die verschiedenen Screening-Möglichkeiten informiert. Im Kanton Waadt wurde deshalb ein Screening-Programm lanciert, damit Betroffene mit ihrem Hausarzt eine informierte Entscheidung treffen können.

Ziele: Zuerst soll die Screening-Praxis der Hausärztinnen und Hausärzte untersucht werden. Es soll erfasst werden, wie vielen Patientinnen und Patienten ein Screening angeboten wird, wie viele das Angebot ablehnen und welche Untersuchung sie wählen. Die Erkenntnisse werden dann in einer Hausärzte-Schulung verwendet, in der die Ärztinnen und Ärzte ihr Vorgehen mit Kollegen vergleichen können. So soll der Anteil der Patientinnen und Patienten, die über das Screening-Angebot informiert werden, erhöht und die unterschiedliche Handhabung in hausärztlichen Praxen reduziert werden.

Bedeutung: Die Studie verfolgt einen partizipativen Ansatz, der sich an den Nutzerinnen und Nutzern des Gesundheitswesens orientiert. Sie begünstigt einen Paradigmenwechsel weg von der strikten Einhaltung der ärztlichen Vorgaben hin zu einer informierten Wahl. Es werden neue Methoden für die Schulung von Hausärztinnen und Hausärzten in partizipativer Medizin entwickelt und getestet, die die Wünsche und Werte der betroffenen Personen berücksichtigen. Diese Methoden könnten rasch angepasst und auf andere Bereiche ausgeweitet werden.

Direct link to Lay Summary Last update: 13.03.2017

Responsible applicant and co-applicants

Employees

Project partner

Publications

Publication
Offering patients a choice for colorectal cancer screening: a quality improvement pilot study in a quality circle of primary care physicians
Martin Yonas, Braun Leo Alexander, Janggen Marc-Andrea, Tal Kali, Biller-Andorno Nikola, Ducros Cyril, Selby Kevin, Auer Reto, Rohrbasser Adrian (2019), Offering patients a choice for colorectal cancer screening: a quality improvement pilot study in a quality circle of primary care physicians, in BMJ Open Quality, 8(4), e000670-e000670.
Variation in colorectal cancer testing between primary care physicians: a cross-sectional study in Switzerland
Braun Alexander Leonhard, Prati Emanuele, Martin Yonas, Dvořák Charles, Tal Kali, Biller-Andorno Nikola, Bulliard Jean-Luc, Cornuz Jacques, Selby Kevin, Auer Reto (2019), Variation in colorectal cancer testing between primary care physicians: a cross-sectional study in Switzerland, in International Journal of Public Health, 64(7), 1075-1083.
Screening Refusal Associated with Choice of Colorectal Cancer Screening Methods. A Cross-sectional Study Among Swiss Primary Care Physicians
Martin Yonas, Braun Alexander Leonhard, Biller-Andorno Nikola, Bulliard Jean-Luc, Cornuz Jacques, Selby Kevin, Auer Reto (2019), Screening Refusal Associated with Choice of Colorectal Cancer Screening Methods. A Cross-sectional Study Among Swiss Primary Care Physicians, in Journal of General Internal Medicine, 34(8), 1409-1411.

Collaboration

Group / person Country
Types of collaboration
Annick Rywalski, Krebsliga Expertengruppe Darmkrebsscreening Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
Cyril Ducros, Fondation vaudoise pour le dépistage du cancer, Lausanne Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
- Research Infrastructure
Claudia Weiss, Swiss Cancer Screening Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
Andreas Birrer, BAG, Abteilung Übertragbare Krankheiten Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
Charles Dvorak, Vallorbe Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
- Research Infrastructure
Raphael Rytz, BAG, Abteilung Übertragbare Krankheiten Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
Marco Zoller, Z-med Switzerland (Europe)
- Exchange of personnel
Sébastien Jotterand, Médecin de Famille Vaud (MFVaud) Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results

Scientific events

Active participation

Title Type of contribution Title of article or contribution Date Place Persons involved
SMDM Leiden Poster P385 - Variations in discussion rate on colorectal cancer (CRC) screening among previously untested patients in primary care and decision taken after discussion: results from a systematic data collection in the Swiss Sentinella Network (Yonas Martin) 12.06.2018 Leiden, Netherlands Martin Yonas; Auer Reto;
SGAIM Basel Talk given at a conference Variation in care for colorectal cancer testing between primary care physicians 31.05.2018 Basel, Switzerland Braun Alexander Leonhard; Auer Reto;
SGAIM Basel Poster Poster über P385 - Variations in discussion rate on colorectal cancer (CRC) screening among previously untested patients in primary care and decision taken after discussion: results from a systematic data collection in the Swiss Sentinella Network (Yonas 30.05.2018 Basel, Switzerland Auer Reto; Martin Yonas;
SGAIM Basel Talk given at a conference Association between colorectal cancer testing and insurance status: evidence from the Swiss Health Interview Surveys 2007 and 2012 30.05.2018 Basel, Switzerland Braun Alexander Leonhard; Auer Reto;
Wennberg International Conference Zürich Talk given at a conference Colorectal cancer screening practices in Swiss primary care: Variation in care between physicians reporting for the Sentinella Network 12.04.2018 Zürich, Switzerland Auer Reto; Martin Yonas;
Wennberg International Conference Zürich Talk given at a conference Colorectal cancer testing in Swiss primary care practices: A cross-sectional study in the Sentinella Network – Emanuele Prati 12.04.2018 Zürich, Switzerland Auer Reto;


Knowledge transfer events

Active participation

Title Type of contribution Date Place Persons involved
SGAIM, Vortrag Partizipative Entscheidungsfindung: Resultate eines Pilotprojektes im Qualitätszirkel Talk 01.06.2018 Basel, Switzerland Auer Reto;
SGAIM, Vortrag über sinnvolle Screenings in der Praxis Talk 31.05.2018 Basel, Switzerland Auer Reto;
Säntismed Workshop Workshop 03.05.2018 Schwägalp, Switzerland Auer Reto;
Medbase Moderatorentreffen QZ Workshop 31.10.2017 Zürich, Switzerland Auer Reto;
Zmed Moderatorentreffen Workshop 26.10.2017 Zürich, Switzerland Auer Reto;
Vortrag Krebsliga über Partizipative Entscheidungsfindung und Risikokommunikation in Krebs Screening Talk 19.09.2017 Bern, Switzerland Auer Reto;
Choosing Wisely Konferenz, erste Resultate von der Vorstudie präsentiert Talk 15.09.2017 Lugano, Switzerland Auer Reto;


Communication with the public

Communication Title Media Place Year
Media relations: print media, online media Ankündigung Studie BIHAM Webseite German-speaking Switzerland 2018
New media (web, blogs, podcasts, news feeds etc.) Publikation Ergebnisse Twitter und andere Socialmedia German-speaking Switzerland 2018

Abstract

Colorectal cancer (CRC) is a prime example of a preventable, non-communicable disease (NCD). The relative risk of ever dying of CRC is low (2%), and that number is halved when those over 50 are screened by colonoscopy or faecal immunological test (FIT). Despite the effectiveness of these tests, only 22% of the eligible Swiss population is up-to-date with screening. Guidelines for screening recommend either colonoscopy, an invasive procedure with a 2/1000 risk for serious bleeding, or FIT, which requires people to sample their faeces (a distasteful prospect for many), after which colonoscopy may still be recommended if the FIT test is positive. In Switzerland, there is not yet enough data for us to judge whether people are making an informed choice congruent with their values when they refuse screening, if they are afraid of being screened, or if their primary care physician (PCP) failed to offer them the option of screening. In 2015, the canton of Vaud launched the first organized screening program in Switzerland. Instead of presuming all eligible persons should be screened, the Vaud program will help them make an informed choice about: (a) whether to be screened for CRC and, (b) which method of screening (FIT or colonoscopy) is best for them. Over the next 5 years, all 170’000 eligible citizens of Vaud will be invited to discuss their choices for CRC screening with their PCPs, in a 15 to 30-minute, deductible-free, shared decision making (SDM) visit. We believe the Vaud program is the first to shift the paradigm from “uniformed compliance” to “informed choice”. In informed choice programs, the outcome shifts from the percentage of the population screened to the percentage of the population that makes an informed decision about screening. The biggest challenge the Vaud program faces is the variation in care for CRC screening between PCPs, a variation reflected across Switzerland. Some PCPs do not offer eligible patients the option to be screened (there is under-use of screening), some offer only colonoscopy, some only FIT (there is over-use of one screening method over the other). Experimental data from the US and Europe indicate that, when patients are offered an informed choice about CRC screening with a decision aid, some refuse screening, and about half prefer FIT over colonoscopy. PCPs who successfully help patients to arrive at an informed decision about screening will have variation in care within their practices, since some patients refuse, some will opt for FIT, and others for colonoscopy. We have developed decision aids for patients and a training program for PCPs. In a pilot evaluation of the training program, we increased the proportion of PCPs who intended to present the choice of both FIT and colonoscopy to their patients. We now need to expand and evaluate this training program so it can be adapted and disseminated in other parts of Switzerland. Our proposal directly addresses the aims of Module 1 of the NRP 74 call: Countering under- and overuse to improve allocation of resources.OVERARCHING AIM: To increase the proportion of patients who meet with their PCPs to make a shared, informed decision about (a) colorectal cancer screening (counting refusal of screening as a choice) and, (b) CRC screening method (FIT or colonoscopy). We describe our goals in more detail, below.GOAL 1: Develop and validate a method to continuously monitor shared decision making (SDM) about CRC screening in primary care practice. We will measure, within each participating primary care practice, the proportion of patients with whom PCPs discuss CRC screening and options for tests (FIT vs colonoscopy). We will collect data on patient refusal, choice of FIT or colonoscopy, and assess prior screening and contra-indication for screening. To validate data collection, we will measure (a) the proportion of patients screened and, (b) method of screening after 6 months. We will describe variations in care between and within PCP practices. We will identify actionable determinants of CRC screening on the PCP level and compare changes in CRC screening over time.METHOD: (Design phase) We will adapt a validated method from the practice-based research network Sentinella to continuously monitor PCPs’ activities and prescription patterns. We will take a participatory approach to developing and testing the data collection tool among 10 PCP practices in two regions (Bern and Vaud), and involve 14 patients in two regions in two advisory boards. (Conduct phase) We will extend the method to the 100-150 PCPs who participate in Sentinella, and they will provide us with nationally representative data of CRC screening in primary care. PCPs will record their CRC screening practice among 40 consecutive patients, 50-69 years old, over two weeks. We will survey PCPs on demographics, practice organization, measures of SDM and knowledge of CRC screening. The measure will be repeated yearly to capture changes over time.GOAL 2: Test the effect of a multi-component data-driven training program that targets quality circles. We intend to increase the (a) proportion of patients who opt for screening, including patient’s refusal of screening. Our main outcome (b) will also be the change in the number of PCP practices where patients opt for FIT or colonoscopy in equal proportions (between 40-60%). Overall, the goal is to reduced variation in care between PCPs and increase variation within PCP practices.METHOD: (Design phase) We will first develop and adapt the intervention in two QCs (8-10 PCPs each), in two regions, together with the members of advisory boards. (Conduct phase) Then we will conduct a pragmatic cluster randomized trial that allocates 96 PCPs (not part of the Sentinella network) in 12 QCs to either the multi-component training program or usual care. The control group will receive the intervention after 12 months of usual care. At baseline, all PCPs will use the data collection form developed for Goal 1 to collect data on their CRC screening practices. In the intervention groups, we will use this baseline data to give PCPs feedback on their performance and discuss the results with them in 2 QC meetings. We will use clinical evidence summaries and propose the use of decision aids to facilitate SDM. We will repeat data collection in the intervention group after 3 months, and discuss those results in two more QCs. (Evaluation phase) After 12 months, PCPs will again collect data on their CRC screening practices. To prepare a future, larger RCT trial, we will verify if the main outcomes translate into increases in screening rates, and shift the type of screening performed. After 24 months, we will repeat the data collection in all groups. IMPLEMENTATION: Our model of conduct and evaluation is based on an outcome oriented logic model. We depend on the reach, effectiveness, adoption, implementation, and maintenance framework (RE-AIM) to evaluate the intervention we develop to meet Goal 2. We will involve PCPs and patients in the design-, conduct-, evaluation- and dissemination- phases of the project.SIGNIFICANCE: The doctoral position we fund in preventive oncology with a focus on clinical epidemiology, shared decision making, and methods for changing the behaviour of health professionals will help ensure that the next generation of clinician-researchers promote user-centred participatory medicine. We intend to shift the paradigm of CRC screening from uninformed compliance to informed choice by developing and deploying a new method for measuring PCP screening practices and a novel approach to PCP training in SDM. Both citizen-users and PCPs will help us develop the SDM measure and training program around CRC screening in primary care. If our approach to participatory development of SDM tools and PCP training for CRC is successful, the approach could be adopted to increase SDM and to inform patient choice in other screening and treatment decisions.
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