Patient–Physician Colorectal Cancer Screening Discussions: Delivery of the 5A's in Practice

doi:10.1016/j.amepre.2011.07.018

American Journal of Preventive Medicine

Volume 41, Issue 5, November 2011, Pages 480-486

https://doi.org/10.1016/j.amepre.2011.07.018 Get rights and content

Background

The U.S. Preventive Services Task Force advocates use of a 5A's framework (assess, advise, agree, assist, and arrange) for preventive health recommendations.

Purpose

To describe 5A content of patient–physician colorectal cancer (CRC) screening discussions and physician-recommended screening modality and to test if these vary by whether patient previously received screening recommendation.

Methods

Direct observation of periodic health examinations in 2007–2009 among average-risk primary care patients aged 50–80 years due for screening. Qualitative content analyses conducted 2008–2010 used to code office visit audio-recordings for 5A and other discussion content.

Results

Among study-eligible visits (N=415), 59% contained assistance (i.e., help scheduling colonoscopy or delivery of stool cards), but the assess, advise, and agree steps were rarely comprehensively provided (1%–21%), and only 3% included the last step, arrange follow-up. Almost all physicians endorsed screening via colonoscopy (99%), either alone (69%) or in combination with other tests (30%). Patients nonadherent to a prior physician screening recommendation (31%) were less likely to have the reason(s) for screening discussed (37% vs 65%) or be told the endoscopy clinic would call them for scheduling (19% vs 27%), and more likely to have fecal occult blood testing (FOBT) alone (34% vs 25%) or FOBT and colonoscopy recommended (24% vs 14%), and a screening plan negotiated (21% vs 14%). Significance level is p<0.05 for all contrasts.

Conclusions

Most patients due for CRC screening discuss screening with their physician, but with limited application of the 5A's approach. Opportunities to improve CRC screening decision-making are great, particularly among patients who are nonadherent to a prior recommendation from a physician.

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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Cited by (30)

Fecal immunochemical test (FIT) versus colonoscopy: Does knowing that a positive FIT requires a follow-up colonoscopy affect initial decision making in the US?
2022, Preventive Medicine Reports
Citation Excerpt :
This is supported by randomized controlled trial data that found that offering patients a choice between colonoscopy or FIT (26.5%) improves screening uptake when compared to only recommending colonoscopy (17.5%; p < 0.001) (Pilonis et al., 2021). However, studies investigating CRC screening discussion patterns found that providers only discuss multiple options with patients up to half the time (Zapka et al., 2011; Wolf et al., 2007; Laiyemo et al., 2014; Lafata et al., 2011). For example, a direct observation study noted that colonoscopy was the only modality offered in 70% of cases (Lafata et al., 2011).
Although many people prefer fecal immunochemical test (FIT) over colonoscopy due to its noninvasive nature, it is unclear whether FIT would still be preferred for colorectal cancer (CRC) screening if they were explicitly informed that + FIT requires follow-up colonoscopy. To address this gap, we administered two conjoint analysis surveys—one that explained the need for a follow-up colonoscopy after + FIT while the other did not—to a US nationwide sample of Americans and then assessed whether there were differences in colonoscopy/FIT preferences between cohorts. We recruited adults ≥ 40yo who had not undergone CRC screening via an online survey research firm. We deployed two surveys that used conjoint analysis to assess decision making surrounding CRC screening tests: Survey 1 (4/2–4/15/2021)—did not inform participants that they need a colonoscopy following a + FIT; Survey 2 (4/29–6/2/2021)—informed respondents of the potential need. Using the conjoint analysis data, we determined the proportion of those who preferred FIT or colonoscopy and then used logistic regression to assess for differences in colonoscopy/FIT preferences between the cohorts. Overall, 501 and 1,000 individuals completed Survey 1 (without description of need for colonoscopy after + FIT) and Survey 2 (with description), respectively. There was no difference in test preference between cohorts after adjusting for covariates in the logistic regression (adjusted p = 0.09): Survey 1 (without description)—colonoscopy 28.5%, FIT 71.5%; Survey 2 (with description)—colonoscopy 26.7%, FIT 73.3%. Thus, knowledge that a + FIT requires a follow-up colonoscopy does not alter people’s strong preference for non-invasive stool testing with FIT.
Patient-Reported Needs Following a Referral for Colorectal Cancer Screening
2019, American Journal of Preventive Medicine
Patient–physician communication about colorectal cancer screening can affect screening use, but discussions often lack information that patients need for informed decision making and seldom address personal preferences or barriers. To address this gap, a series of patient focus groups was conducted to guide the development of an online, interactive decision support program. This article presents findings on patient information needs and barriers to colorectal cancer screening after receiving a screening recommendation from a physician, and their perspectives on using electronic patient portals as platforms for health-related decision support.
Primary care patients with recent colonoscopy or stool testing orders were identified via the centralized data repository of a large Midwestern health system. Seven gender-stratified focus groups (N=45 participants) were convened between April and July 2016. Sessions were audio recorded, transcribed, coded, and analyzed for commonly expressed themes beginning in August 2016.
Findings reveal a consistent need for simple and clear information on colorectal cancer screening. Participants desired step-by-step explanations of the colonoscopy procedure and information about bowel preparation options/alternatives. The desired level of additional information varied: some patients wanted to know about and act on test options, whereas others preferred following their physician-recommended testing path. Fears and concerns were prevalent, particularly about colonoscopy, and patients reported challenges getting these concerns and their informational needs addressed. Finally, they expressed consistent support for using the patient portal to gather additional information from their physician.
Patient portals may offer an opportunity to build sustainable programs for decision support and assistance that are integrated with clinic workflows and processes.
Implementation and Evaluation of a Novel Colorectal Cancer Decision Aid Using a Centralized Delivery Strategy
2018, Joint Commission Journal on Quality and Patient Safety
Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States; however, CRC screening reduces both incidence and mortality rates. Patient decision aids (DAs) are an evidence-based strategy to support patients making health-related decisions. CRC screening DAs can be unsuccessful due to provider preferences for colonoscopy and lack of effective DA implementation strategies within clinical settings.
A hybrid implementation-effectiveness study was conducted testing the feasibility of using an existing centralized preventive health screening outreach infrastructure to implement a novel CRC DA across a health care system. Participants included primary care patients at one of three study clinics. Implementation was assessed by determining whether patients remembered receiving the DA and were aware of CRC screening options. Effectiveness was measured by comparing overall screening rates between the control and intervention groups.
Using a centralized delivery system was a feasible and efficient method for implementing DAs to a large academic health system. More than 90% of the intervention group remembered receiving the DA, and 80% found it helpful in their decision-making process. The DA was successful in improving CRC screening knowledge; however, overall CRC screening rates significantly decreased between the control and intervention periods (50.8% vs. 39.2%, respectively; p = 0.03).
Centralized delivery is a feasible method for DA implementation. Although DAs increase knowledge, the true effectiveness of CRC DAs in clinical settings is unknown, as a result of the number in screening tests, diversity in DA format, and the variability in dissemination and implementation practices.
Engaging Patients in Decisions About Cancer Screening: Exploring the Decision Journey Through the Use of a Patient Portal
2018, American Journal of Preventive Medicine
Engaging patients to make informed choices is paramount but difficult in busy practices. This study sought to engage patients outside the clinical setting to better understand how they approach cancer screening decisions, including their primary concerns and their preferences for finalizing their decision.
Twelve primary care practices offering patients an online personal health record invited eligible patients to complete a 17-item online interactive module. Among 11,458 registered users, invitations to complete the module were sent to adults aged 50–74 years who were overdue for colorectal cancer screening and to women aged 40–49 years and men aged 55–69 who had not undergone a recent mammogram or prostate-specific antigen test, respectively.
The module was started by 2,355 patients and completed by 903 patients. Most respondents (76.8%) knew they were eligible for screening. Preferred next steps were talking to the clinician (76.6%), reading/research (28.6%), and consulting trusted friends/family (16.4%). Priority topics included how much screening improves life expectancy, comparative test performance, and the prevalence/health risks of the cancer. Leading fears were getting cancer/delayed detection (79.2%), abnormal results (40.5%), and testing complications (39.1%), the last referring to false test results, medical complications, or unnecessary treatments. Men eligible for prostate-specific antigen screening were more likely than women eligible for mammography to express concerns about testing complications and to prioritize weighing pros and cons over gut feelings (p<0.05).
Although this sample was predisposed to screening, most patients wanted help in finalizing their decision. Many wanted to weigh the pros and cons and expressed fears of potential harms from screening. Understanding how patients approach decisions may help design more effective engagement strategies.
Sexual health discussions with older adult patients during periodic health exams
2014, Journal of Sexual Medicine
Citation Excerpt :
This study fills a gap in the literature wherein few examples of direct observations of physician–patient discussions about sexual health exist. This article reports data that were collected from a larger study of patient–physician decision making and colorectal cancer screening [24,25]. The Institutional Review Boards of XXX and the XXX Group approved all aspects of the study protocol.
Sexual health is an integral part of overall health across the lifespan. In order to address sexual health issues, such as sexually transmitted infections (STIs) and sexual functioning, the sexual history of adult patients should be incorporated as a routine part of the medical history throughout life. Physicians and health‐care professionals cite many barriers to attending to and assessing the sexual health needs of older adult patients, underscoring the importance of additional research to improve sexual history taking among older patients.
The purpose of this article is to explore the content and context of physician–patient sexual health discussions during periodic health exams (PHEs) with adults aged 50–80 years.
Patients completed a pre‐visit telephone survey and attended a scheduled PHE with their permission to audio‐record the exam. Transcribed audio recordings of 483 PHEs were analyzed according to the principles of qualitative content analysis.
Frequency of sexual history taking components as observed in transcripts of PHEs. Physician characteristics were obtained from health system records and patient characteristics were obtained from the pre‐visit survey.
Analyses revealed that approximately one‐half of the PHEs included some discussion about sexual health, with the majority of those conversations initiated by physicians. A two‐level logistic regression model revealed that patient–physician gender concordance, race discordance, and increasing physician age were significantly associated with sexual health discussions.
Interventions should focus on increasing physician self‐efficacy for assessing sexual health in gender discordant and race/ethnicity concordant patient interactions. Interventions for older adults should increase education about sexual health and sexual risk behaviors, as well as empower individuals to seek information from their health‐care providers. Ports KA, Barnack‐Tavlaris JL, Syme ML, Perera RA, and Lafata JE. Sexual health discussions with older adult patients during periodic health exams. J Sex Med 2014;11:901–908.
Patient-physician colorectal cancer screening discussion content and patients' use of colorectal cancer screening
2014, Patient Education and Counseling
The US Preventive Services Task Force recommends using the 5As (i.e., Assess, Advise, Agree, Assist and Arrange) when discussing preventive services. We evaluate the association of the 5As discussion during primary care office visits with patients’ subsequent colorectal cancer (CRC) screening use.
Audio-recordings of n = 443 periodic health exams among insured patients aged 50–80 years and due for CRC screening were joined with pre-visit patient surveys and screening use data from an electronic medical record. Association of the 5As with CRC screening was assessed using generalized estimating equations.
93% of patients received a recommendation for screening (Advise) and 53% were screened in the following year. The likelihood of screening increased as the number of 5A steps increased: compared to patients whose visit contained no 5A step, those whose visit contained 1–2 steps (OR = 2.96 [95% CI 1.16, 7.53]) and 3 or more steps (4.98 [95% CI 1.84, 13.44]) were significantly more likely to use screening.
Physician CRC screening recommendations that include recommended 5A steps are associated with increased patient adherence.
A CRC screening recommendation (Advise) that also describes patient eligibility (Assess) and provides help to obtain screening (Assist) may lead to improved adherence to CRC screening.

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Research articlePatient–Physician Colorectal Cancer Screening Discussions: Delivery of the 5A's in Practice

Background

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Study Setting

Participant Eligibility Criteria and Recruitment

Sample Characteristics

Discussion

Prev Med

Am J Prev Med

Gastroenterology

Am J Prev Med

Patient Educ Couns

Prev Med

Prev Med

Predictors of colorectal cancer screening behaviors among average-risk older adults in the U.S.

Cancer Causes Control

Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force

Ann Intern Med

American Cancer Society guidelines for the early detection of cancer, 2005

CA Cancer J Clin

Behind closed doors: physician–patient discussions about colorectal cancer screening

J Gen Intern Med

Informed decision-making and colorectal cancer screening: is it occurring in primary care?

Med Care

Development and validation of an instrument to measure factors related to colorectal cancer screening adherence

Cancer Epidemiol Biomarkers Prev

Research article
Patient–Physician Colorectal Cancer Screening Discussions: Delivery of the 5A's in Practice