Research article
Effectiveness of a Web-Based Colorectal Cancer Screening Patient Decision Aid: A Randomized Controlled Trial in a Mixed-Literacy Population

https://doi.org/10.1016/j.amepre.2011.02.019Get rights and content

Background

Colorectal cancer (CRC) screening reduces mortality yet remains underutilized. Low health literacy may contribute to this underutilization by interfering with patients' ability to understand and receive preventive health services.

Purpose

To determine if a web-based multimedia CRC screening patient decision aid, developed for a mixed-literacy audience, could increase CRC screening.

Design

RCT. Patients aged 50–74 years and overdue for CRC screening were randomized to the web-based decision aid or a control program seen immediately before a scheduled primary care appointment.

Setting/participants

A large community-based, university-affiliated internal medicine practice serving a socioeconomically disadvantaged population.

Main outcome measures

Patients completed surveys to determine their ability to state a screening test preference and their readiness to receive screening. Charts were abstracted by masked observers to determine if screening tests were ordered and completed.

Results

Between November 2007 and September 2008, a total of 264 patients enrolled in the study. Data collection was completed in 2009, and data analysis was completed in 2010. A majority of participants (mean age=57.8 years) were female (67%), African-American (74%), had annual household incomes of <$20,000 (76%), and had limited health literacy (56%). When compared to control participants, more decision-aid participants had a CRC screening preference (84% vs 55%, p<0.0001) and an increase in readiness to receive screening (52% vs 20%, p=0.0001). More decision-aid participants had CRC screening tests ordered (30% vs 21%) and completed (19% vs 14%), but no statistically significant differences were seen (AOR=1.6, 95% CI=0.97, 2.8, and AOR=1.7, 95% CI=0.88, 3.2, respectively). Similar results were found across literacy levels.

Conclusions

The web-based decision aid increased patients' ability to form a test preference and their intent to receive screening, regardless of literacy level. Further study should examine ways the decision aid can be combined with additional system changes to increase CRC screening.

Trial registration

NCT00558233

Section snippets

Background

Colorectal cancer (CRC) is the fourth most common noncutaneous cancer in the U.S., and the second-leading cause of cancer death.1 In order to both prevent CRC and reduce its associated mortality, several national organizations recommend routine CRC screening beginning at age 50 years.2, 3 A variety of CRC screening tests are cost effective, giving patients and clinicians a choice of screening options.4

Despite the widespread recommendations for routine screening, CRC screening remains

Methods

The study was conducted at a community-based university-affiliated internal medicine faculty–resident practice serving a primarily socioeconomically disadvantaged patient population. The Wake Forest University IRB approved the study protocol, and all participants provided written informed consent.

Participants were patients aged 50–74 years who were scheduled for a routine (non-urgent care) medical visit and were overdue for CRC screening, defined as not having completed a home fecal occult

Results

Between November 2007 and September 2008, research assistants reached 401 eligible patients by telephone who agreed to participate. Of these 401 patients, 264 arrived to the clinic 45 minutes early as directed, were confirmed eligible, and were enrolled. An equal number were randomized to the CRC decision aid (CHOICE) and the control program (Figure 2). While abstracting charts for the outcomes of interest, study staff discovered that 16 randomized patients met exclusion criteria (15 were up to

Discussion

The web-based decision aid (CHOICE) increased patients' ability to state a test preference and their readiness to receive screening, regardless of literacy level. In addition, more CHOICE patients had CRC screening tests immediately ordered and completed, but these differences were modest and did not reach significance.

Prior studies have examined the use of video or web-based interventions to increase CRC screening. Patient education videos without a decision-aid component have shown mixed

Conclusion

The web-based CRC screening decision aid (CHOICE) increased test preferences and patients' readiness to receive screening, irrespective of literacy level. The decision aid's ability to effectively convey information with little staff involvement may make it a valuable resource for time-strapped clinics. Future research should focus on ways decision aids such as CHOICE can be combined with other system-level interventions to increase CRC screening.

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