Research articlePatient–Physician Colorectal Cancer Screening Discussions: Delivery of the 5A's in Practice
Introduction
Studies1, 2 addressing factors associated with colorectal cancer (CRC) screening highlight the importance of physician recommendations. The U.S. Preventive Services Task Force (USPSTF)3 has advocated use of an informed and joint decision-making process when making preventive service recommendations. As part of this recommendation, they suggest using the 5A's framework (assess, advise, agree, assist, and arrange). Despite the USPSTF's4 and others'5, 6 calls for such an approach, the extent to which it is used in practice is not known.
Data from patient reports7 and small observational studies8, 9 identify variation in conversation content when CRC screening is discussed. Even when most patients report their physician recommending CRC screening, far fewer report being asked about their preferences or being offered a choice among screening modalities.7 Findings from qualitative analyses of office visit audio-recordings has identified similar themes.8 Likewise, in another observational study, Ling and colleagues found little informed decision making during patient–physician discussions of CRC screening.9
To date, no study has used direct observation to determine whether patient–physician discussions of CRC screening include the 5A's as recommended by the USPSTF. Using data from a large study on patient–physician CRC screening decision making in primary care, the aims of the current study are to use direct observation among a large sample of primary care patient–physician interactions to (1) describe use of the 5A's framework in CRC screening discussions; (2) report the CRC screening modalities recommended by primary care physicians; and (3) test whether the 5A's content of patient–physician discussions and physician-recommended CRC screening modality is associated with patients' adherence to prior physician recommendation for CRC screening.
Section snippets
Study Setting
Physician and patient samples were identified from an integrated delivery system in southeast Michigan. The system includes a 1000-member, salaried medical group that staffs 26 clinics in Detroit and surrounding suburbs. Patient participants were enrolled in an affiliated health plan with a covered benefit for CRC screening. Since 2006, the medical group's electronic medical record (EMR) has included a preventive health services prompt that includes CRC screening.
Participant Eligibility Criteria and Recruitment
Eligible clinician participants
Sample Characteristics
Among the 500 consenting patient participants, there were 485 audible recordings. Excluded from consideration are visits with no talk related to CRC screening (n=29) or for which talk indicated the patient was not due for screening (n=12). Also excluded are visits in which the patient had screening scheduled at the time of presentation (n=25), presented in the midst of an ongoing workup for symptoms (n=1) or for whom the pre-survey was not available (n=3). The resultant sample consists of 415
Discussion
In a large, integrated healthcare system, almost all patients (412 of 415) due for CRC screening at the time of a periodic health examination received a physician recommendation for screening. This represents a substantive improvement over rates observed in a direct observation study in the mid-1990s that found physician recommendation for screening occurred in less than half of visits by patients due for CRC screening.16 Further, physician recommendations for screening were often repeat
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