The increase in CRC screening rates among average-risk adults is a significant reason for the decline in CRC mortality in the U.S.1,3
Unfortunately, CRC disparities exist among minority and low-income populations partially due to lower CRC screening rates.31
To reduce CRC disparities, it is imperative to increase CRC screening rates among underserved populations. Patient–provider CRC screening discussions are central to this issue since a healthcare providers’ recommendation is the single most important factor to get individuals to complete CRC screening.32,33
In this study, evaluated audio recordings were from medical visits of average-risk minority and low-income patients who were in need of CRC screening and who participated in a RCT of two CRC screening educational interventions.29
Based on previous studies which have shown that provider recommendation and patient preference are important for completing CRC screening, IDM about CRC screening has been recommended by the USPSTF.6–8,32,33
Our study corroborates other studies that indicate that either no CRC screening discussion occurs or that limited information is exchanged in patient–provider discussions about CRC screening,9–12,17,27,28
however, only a few studies have analyzed recorded patient–provider discussions.10,12,28
In the current study, the IDM element discussed most often (48 %) was the nature of the decision. Among the 48 patients, sixteen patients had their understanding assessed, a screening test was ordered for 13 patients, with nine of the 16 (56.3 %) patients completing CRC screening. Among 32 patients who did not have their understanding assessed, a screening test was ordered for 17 patients, and nine of the 32 (28.1 %) patients completed screening (p
0.058). This is similar to findings from Ling and colleagues, where 6 % of 91 patients had their understanding assessed and those patients completed more tests than patients who did not have their understanding assessed (100 % vs. 35 %; p
In addition, Ling and colleagues found a negative association with completing CRC screening and discussing pros and cons of screening (12 % when discussed vs. 46 % when not discussed; p
0.01) and addressing patient preferences for screening (6 % when discussed vs. 47 % when not discussed; p
In two additional studies analyzing recordings of patient–provider CRC screening discussions, a limited number of IDM elements were evaluated and occurred during recorded discussions..10,28
Overall, it is difficult to make definitive conclusions about the value of IDM to improve CRC screening rates based on findings from these few studies. In the current study, since the discussion of IDM elements was very limited and the CRC screening rate was low (14.8 %), it is difficult to conclude if specific IDM elements, the number of IDM elements included, or who initiates discussion of a specific IDM elements other than the nature of the decision to be made may lead to improved CRC screening rates. There is a suggestion that a patient or provider checking the patient’s understanding of CRC screening may be important. Results from our study suggest that patients may mention CRC screening to providers; however, that action may not always lead to CRC screening discussions or the ordering of CRC screening tests.29
This finding is especially disappointing and may reflect providers’ barriers to recommending CRC screening, especially their attitudes about recommending CRC screening tests other than colonoscopy.33
The results of this study focused not only on IDM elements discussed during patient visits but also on who initiated the IDM elements during the discussion. This analysis demonstrated that patients may mention CRC screening to healthcare providers (especially if they were activated to discuss screening with providers) but that many of the other elements involved in the IDM process are initiated by the healthcare providers. These findings suggest that patients do not want to bring up other IDM elements for some unknown reason(s) or, more likely, that patients lack awareness of the different issues associated with undergoing CRC screening (e.g. pros and cons of CRC screening tests). This finding may be critical when planning the content of CRC screening interventions for patients versus interventions for healthcare providers.
This study is not without limitations. First, participants were from a RCT testing two educational interventions about CRC screening. Thus, the number of IDM elements about CRC screening initiated by patients may be artificially increased compared to other adults coming for non-acute medical visits. Second, there were a limited number of evaluable CRC screening discussions that occurred in the study. One provider near the end of the study no longer permitted recording of their patients’ medical visits without providing a reason for this decision. Although the analysis of the CRC screening discussion was not the primary outcome of the RCT, recorded discussions provide valuable process information. Initially, it was thought that the patient population was suspicious of researchers wanting to record their medical visits. However, since patient agreement rates varied among the three research assistants, patient refusals were more likely due to assistants’ experience and comfort working with patients. Although the number of discussions evaluated is small, distinct patterns emerged for the IDM elements and who initiated each element. Third, the study was cross-sectional and CRC screening discussions may have occurred during patients’ previous medical visits. Finally, the generalizability of findings is limited since the study was conducted among mostly minority patients who spoke English in one FQHC.
In spite of limitations, this study documented the IDM elements about CRC screening that were initiated by patients or members of the healthcare team. This information may be useful to plan effective interventions to increase CRC screening among a mostly minority and low-income population. Additionally, since some IDM elements identified in CRC screening discussions occurred with staff members and not providers, it is important to test new strategies aimed at multiple levels (patient, provider, clinic) related to the CRC screening process and that include the entire healthcare team.