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 results. Two trials found no significant increase in CRC screening,20;21
whereas a third study in a Latino immigrant population and coupled with a provider reminder found increased screening.22
None of these trials assessed patient literacy, and over 50% of patients in the two former trials had at least some years of education beyond high school.
The CRC decision aids have shown more promise. One trial of a videotape-based decision aid and a second trial of a web-based decision aid found increased screening rates.17;23
However, approximately 80% of patients in the videotape decision-aid trial were high school graduates, and the web-based decision aid required reading skills and prior computer experience.
A recent trial tested a CRC decision aid in a population with low educational attainment.24
Literacy levels were not formally measured, and the paper-based decision aid with accompanying DVD was limited to fecal occult blood screening. Informed decision making and knowledge were higher in the decision-aid group, but attitudes toward screening and completion of screening were lower.
This current study represents the first time patient literacy has been measured in a CRC decision- aid trial, allowing the effect of the decision aid to be examined in users with varying literacy levels. This current study adds the important finding that a decision aid developed for a mixed- literacy audience can effectively inform and motivate both low- and adequate-literacy patients. Knowing that patients with varying literacy levels will be amenable to a single easy-to- understand decision aid obviates the need to develop different interventions for different literacy groups. Rather, creating an intervention appropriate for lower-literacy patients should be well accepted across educational levels.
Several mechanisms could explain how CHOICE increased patients’ readiness to be screened. On the simplest level, CHOICE serves as a “just in time” patient reminder, a strategy known to increase screening rates.25;26
CHOICE also addresses lack of awareness of the need for CRC screening, the most common barrier reported by patients.27
In addition, by including reassuring interviews with patients who successfully completed screening, CHOICE may decrease test anxiety and increase patients’ confidence in their ability to complete the screening procedure. Lastly, a direct physician recommendation is one of the most potent predictors of CRC screening, and CHOICE includes a video clip of a physician recommending screening.28
Despite patients’ increased readiness to be screened, only one third of patients who wanted immediate screening had a screening test ordered. This discrepancy suggests the presence of additional system barriers, such as lack of time and competing priorities. Physicians often report insufficient time to address preventive services.29;30
If patients in this study presented with acute problems requiring attention, less time would have been available to address screening needs.
Communication difficulties may also contribute to the gap between patient intent and screening. Low-literacy patients are particularly vulnerable to communication difficulties and are less likely to ask questions in a medical visit.31;32
Although CHOICE encourages patients to discuss their screening decisions with their doctors, further patient coaching may be needed.
Increasing CRC screening will likely require a combination of system changes. One advocated practice structure is the “patient-centered medical home” which states that medical care should be coordinated, leverage information technology, and encourage active patient participation.33
Combining CHOICE with standing orders that allow nurses to order CRC screening tests could lessen the time demands on medical providers and potentially increase screening rates. Telephone follow-up protocols for nursing staff to contact patients several days after viewing CHOICE could provide another opportunity for patient coaching and screening outside the medical visit.
This study has several limitations that should be considered. Despite the randomized design, insurance status was not evenly distributed. For this reason, insurance status was included in all multivariable models although it did not change the results. Second, research assistants who administered post–decision aid questionnaires were not blinded; however, the clinical outcome assessors were. Third, the study was not designed to detect small to modest-sized effects (5%–10% increase in screening effects of the decision aid). Further study is warranted to determine if the observed improvements in screening are robust.
The study was designed to examine the effects of a single administration of decision support on immediate changes in screening readiness and test ordering, as well as test completion over 24 weeks. Reinforcement of the initial message of CHOICE (through reminders or additional information) may produce stronger effects. In addition, the chart reviews may have missed screening performed outside the institution, but anecdotal experience indicates that the practice’s low-income patients rarely receive screening services elsewhere. Although healthcare providers were not notified of their patients’ participation, the participants may have informed their healthcare providers of their enrollment which could affect provider behavior.
Additional factors that may have affected screening utilization, such as transportation difficulties and comorbidities, were not measured. Similarly, the study did not measure whether patients discussed CRC screening with their healthcare providers or why patients failed to complete screening. Lastly, as with any single site study, the findings may not apply to other patient populations.