Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults: A Cluster Randomized Clinical Trial.

Autor:	Saini SD; Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan.; Department of Internal Medicine, University of Michigan, Ann Arbor.; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor., Lewis CL; General Internal Medicine, University of Colorado, Denver., Kerr EA; Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan.; Department of Internal Medicine, University of Michigan, Ann Arbor.; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor., Zikmund-Fisher BJ; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.; Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor., Hawley ST; Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan.; Department of Internal Medicine, University of Michigan, Ann Arbor.; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor., Forman JH; Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan., Zauber AG; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York., Lansdorp-Vogelaar I; Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands., van Hees F; Maple Health Group, New York, New York., Saffar D; Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan., Myers A; Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan., Gauntlett LE; Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan., Lipson R; Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan., Kim HM; Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan.; Consulting for Statistics, Computing and Analytics Research (CSCAR), University of Michigan, Ann Arbor., Vijan S; Department of Internal Medicine, University of Michigan, Ann Arbor.; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.
Jazyk:	angličtina
Zdroj:	JAMA internal medicine [JAMA Intern Med] 2023 Dec 01; Vol. 183 (12), pp. 1334-1342.
DOI:	10.1001/jamainternmed.2023.5656
Abstrakt:	Importance: Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults. Objective: To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening. Design, Setting, and Participants: Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023. Intervention: The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening. Main Outcomes and Measures: The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months. Results: A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp). Conclusions and Relevance: In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening. Trial Registration: ClinicalTrials.gov Identifier: NCT02027545.
Databáze:	MEDLINE
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