While the majority of patients did not report being confused about CRC screening options, our findings are consistent with the results of qualitative studies that suggest presenting multiple options for CRC screening may increase patient confusion (3
). In our sample, respondents who reported discussing only one screening option were significantly less likely to report confusion than those who discussed two to four options, as recent guidelines recommend (24
). Our findings also are consistent with those of Lafata et al. (17
) who reported that offering multiple screening options reduced the likelihood of screening adherence. To our knowledge, however, our study provides the first empiric evidence linking multiple options with confusion and linking confusion with screening adherence.
Our findings are consistent with the view expressed by Schwartz (25
) who described a “paradox of choice” in which people desire choices but become overwhelmed and “paralyzed” by the number of options during the decision-making process. This observation supports Neugut and Lebwohl recommendation that clinicians recommend only one test (i.e., colonoscopy) to patients and that the review of a menu of options be eliminated from guidelines (26
). Another argument for promoting a single test is that some screening options are not being used or are not widely available (e.g. flexible sigmoidoscopy or double-contrast barium enema). In general, we observed a threshold effect when more than one option was presented. We saw no evidence of a linear dose-response association between confusion and the number of options presented; however, discussing four options resulted in much greater confusion than one option. Our analyses did not take into account which combination of two or three screening modalities were actually discussed. Further, perhaps clinicians discussed screening options without necessarily giving equal weight to each modality. Thus, although our findings suggest that presenting one screening option may reduce confusion, our data do not indicate which modality should be recommended.
Women were more likely to report confusion than men as were the uninsured, and respondents who reported higher household incomes and more education also were more likely to report being confused. Further research is needed to understand these patterns and to make sense of potentially inconsistent findings (e.g., the uninsured are more likely to have low incomes). Confusion has cognitive and affective components and as such likely encompasses much more than simple knowledge transfer. Psychological and sociological research on the causes and determinants of confusion is important to understand how gender, socioeconomic status, and related covariates (e.g., health literacy) might influence one’s desire and ability to obtain information about options and the risk of becoming confused or overwhelmed by the volume or complexity of information. In the context of a choice presented by a clinician, as in the case of CRC screening, a related question is whether patients’ gender, socioeconomic status, or related covariates influence practitioner behavior in ways that contribute to confusion. In short, while explanations of the complexity of screening need to be improved, it is crucial to better understand the various components of confusion to ultimately aid in patient-physician communication.
The medical literature provides few insights on how screening advice may foment confusion. The most pertinent studies have focused on gaps in information provided during such counseling. In a study of informed decision making elements covered with men during a primary care visit for CRC screening, Ling et al. found that more than 50% of visits included no informed decision elements. In fewer than 6% of visits was there discussion of uncertainties, assessment of patient understanding, probing about input from trusted people, and discussion of the patient’s role in the decision-making (10
). McQueen et al. reported that patients’ confusion persisted even after discussion with their physicians because questions and issues remained unaddressed (18
Our findings should be considered in the context of the following limitations. First, generalizability may be limited because our sample was drawn from primary care practices. Patients must have had an office visit within the past two years to be included, and the sample of uninsured patients was very small. People with more limited access to care may have different experiences with how and from whom they receive information about CRC screening options. Moreover, the practices involved in the study and the geographic areas they represented may differ from other settings. Second, although a slightly larger proportion of non-adherent persons reported confusion than those who were adherent, confusion was reported by only 13.0% of patients in this sample. Further, our sample only included patients who reported discussing options or choices for CRC screening and a large proportion of those patients was screened per recommendations (83.2%), which is much higher than national CRC screening rate (60.8%) (27
). Experiences regarding confusion could have differed in the 49.2% of the parent study sample who did not report discussing CRC screening with their clinician and were not included in this study (only 59.0% of whom were screened per recommendations). Third, this study reports secondary analysis of data originally collected for another purpose – to assess the relative importance of patient-reported barriers to CRC screening (3
). Confusion was measured with only one item. To limit respondent burden, we did not include questions to ask about the determinants or potential domains of confusion. Fourth, this study includes no comparison group because respondents were only asked about their confusion if they reported discussing screening options with their clinician. Fifth, cross-sectional data do not permit the assessment of temporality or causality in the association between confusion and CRC screening adherence. Finally, this study was completed when greater consistency existed among CRC screening guidelines. Now, the recommendations of the American Cancer Society – U.S. Multi-Society Task Force differ from those of the U.S Preventive Services Task Force in that the former recommend more screening options, a situation that could exacerbate confusion for patients.
Given that current guidelines are inconsistent and recommend an even larger number of screening options, such as fecal DNA testing and virtual colonoscopy, confusion likely exists about the recommendations themselves, as well as the different modalities and what they entail (e.g., risks, benefits). One area for future research is to explore the sources and domains of confusion about CRC screening and to develop ways to measure them. Comprehensive measures of confusion about screening guidelines in general and about currently recommended modalities in particular are needed. Given that a cross-sectional association between confusion and screening rates does not prove causality, a prospective randomized trial would be of public health importance to compare screening rates among patients offered one versus multiple tests. Such findings would help determine whether guidelines, and clinicians who counsel patients, should recommend only one test or multiple options to accommodate heterogeneous preferences.