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Provider perspectives on the utility of a colorectal cancer screening decision aid for facilitating shared decision making

Paul C. Schroy III MD MPH,* Shamini Mylvaganam MPH� and Peter Davidson MD� *Director of Clinical Research, Section of Gastroenterology, Boston Medical Center, Boston, MA, �Study Coordinator, Section of Gastroenterology, Boston Medical Center, Boston, MA and �Clinical Director, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA

Correspondence

Paul C. Schroy III, MD MPH

Boston Medical Center

85 E. Concord Street

Suite 7715

Boston

MA 02118

USA

E-mail: [email protected]

Accepted for publication

8 August 2011

Keywords: decision aids, informed decision making, shared decision

making

Abstract

Background Decision aids for colorectal cancer (CRC) screening

have been shown to enable patients to identify a preferred screening

option, but the extent to which such tools facilitate shared decision

making (SDM) from the perspective of the provider is less well

established.

Objective Our goal was to elicit provider feedback regarding the

impact of a CRC screening decision aid on SDM in the primary care

setting.

Methods Cross-sectional survey.

Participants Primary care providers participating in a clinical trial

evaluating the impact of a novel CRC screening decision aid on

SDM and adherence.

Main outcomes Perceptions of the impact of the tool on decision-

making and implementation issues.

Results Twenty-nine of 42 (71%) eligible providers responded,

including 27 internists and two nurse practitioners. The majority

(>60%) felt that use of the tool complimented their usual approach,

increased patient knowledge, helped patients identify a preferred

screening option, improved the quality of decision making, saved

time and increased patients� desire to get screened. Respondents were more neutral is their assessment of whether the tool improved

the overall quality of the patient visit or patient satisfaction. Fewer

than 50% felt that the tool would be easy to implement into their

practices or that it would be widely used by their colleagues.

Conclusion Decision aids for CRC screening can improve the

quality and efficiency of SDM from the provider perspective but

future use is likely to depend on the extent to which barriers to

implementation can be addressed.

doi: 10.1111/j.1369-7625.2011.00730.x

� 2011 John Wiley & Sons Ltd 27 Health Expectations, 17, pp.27–35

Introduction

Engaging patients to participate in the decision-

making process when confronted with prefer-

ence-sensitive choices related to cancer screening

or treatment is fundamental to the concept of

patient-centred care endorsed by the Institute of

Medicine, US Preventive Services Task Force

and the Centers for Disease Control and Pre-

vention. 1–3

Ideally, this process should occur

within the context of shared decision making

(SDM), whereby patients and their health-care

providers form a partnership to exchange

information, clarify values and negotiate a

mutually agreeable medical decision. 4,5

SDM,

however, has been difficult to implement into

routine clinical practice in part owing to lack of

time, resources, clinician expertise and suitabil-

ity for certain patients or clinical situations. 6,7

The use of patient-oriented decision aids outside

of the context of the provider–patient interac-

tion has been proposed as a potentially effective

strategy for circumventing several of these bar-

riers. 3,8

Decision aids are distinct from patient

education programmes in that they serve as

tools to enable patients to make an informed,

value-concordant choice about a particular

course of action based on an understanding of

potential benefits, risks, probabilities and sci-

entific uncertainty. 9–11

Besides facilitating

informed decision making (IDM), decision aids

also have the potential to facilitate SDM by

improving the quality and efficiency of the

patient–provider encounter and by empowering

users to participate in the decision-making

process. 11

Studies to date have demonstrated

that while decision aids enhance knowledge,

reduce decisional conflict, increase involvement

in the decision-making process and lead to

informed value-based decisions, their impact on

the quality of the decision, satisfaction with the

decision making process and health outcomes

remains unclear. 11

Besides enabling patients to make informed

choices, decision aids also have the potential to

facilitate SDM by improving the quality and

efficiency of the patient–provider encounter.

Relatively few studies have examined the utility

of decision aids for promoting effective SDM

from the perspective of the provider. Studies to

date have largely focused on provider perspec-

tives on the quality of the decision tools

themselves or issues related to implementation

into clinical practice. 11–15

The overall objective

of this study was to elicit provider feedback

regarding the extent to which the use of a novel

colorectal cancer (CRC) screening decision aid

facilitated SDM in the primary care setting

within the context of a randomized clinical

trial.

Methods

Brief overview of decision aid and randomized

clinical trial

Details of the decision aid, recruitment process,

study design and secondary outcome results

have been previously published. 16

The overall

objective of the trial was to evaluate the impact

of a novel computer-based decision aid on SDM

and patient adherence to CRC screening rec-

ommendations. The decision aid uses video-

taped narratives and state-of-the-art graphics in

digital video disc (DVD) format to convey key

information about CRC and the importance of

screening, compare each of five recommended

screening options using both attribute- and

option-based approaches, and elicit patient

preferences. A modified version of the tool also

incorporated the web-based �Your Disease Risk (YDR)� CRC risk assessment tool (http:// www.yourdiseaserisk.wustl.edu). To assess its

impact on SDM and screening adherence,

average-risk, English-speaking patients 50–

75 years of age due for CRC screening were

randomized to one of the two intervention arms

(decision aid plus the YDR personalized risk

assessment tool with feedback or decision aid

alone) or a control arm, each of which involved

an interactive computer session just prior to a

scheduled visit with their primary care provider

at either the Boston Medical Center or the

South Boston Community Health Center. After

completing the computer session, patients met

with their providers to discuss screening and

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson

� 2011 John Wiley & Sons Ltd Health Expectations, 17, pp.27–35

identify a preferred screening strategy. Although

providers were blinded to their patients� ran- domization status, they received written notifi-

cation in the form of a hand-delivered flyer from

all study patients acknowledging that they were

participating in the �CRC decision aid study� to ensure that screening was discussed. Outcomes

of interest were assessed using pre ⁄ post-tests, electronic medical record and administrative

databases. The study to date has found that the

tool enables users to identify a preferred

screening option based on the relative values

they place on individual test features, increases

knowledge about CRC screening, increases sat-

isfaction with the decision-making process and

increases screening intentions compared to non-

users. The study also finds that screening

intentions and test ordering are negatively

influenced in situations where patient and pro-

vider preferences differ. The tool�s impact on patient adherence awaits more complete follow-

up data, which should be available in early

2011.

Study design

We conducted a cross-sectional survey of

primary care providers participating in the ran-

domized clinical trial in January and February

of 2009. At the time of the survey, 725 eligible

patients had been randomized to one of the three

study arms. The surveys were distributed just

prior to monthly business meetings conducted

by the Sections of General Internal Medicine

and Women�s Health at Boston Medical Center and Adult Medicine at the South Boston Com-

munity Health Center. Respondents were asked

to sign an attestation sheet if they completed the

survey to identify providers not in attendance.

For those who were not in attendance, the sur-

vey was distributed electronically as an email

attachment; respondents were asked to return

the survey via facsimile to preserve anonymity.

Two email reminders with attached surveys were

sent 2 weeks apart after the initial email to

optimize response. The study was deemed

exempt by the Institutional Review Boards at

both participating institutions.

Subjects

The survey sample included board-certified

primary care providers (general internists and

nurse practitioners) at Boston Medical Center

and the South Boston Community Health Center

who had referred patients to the randomized

clinical trial. Of the 50 providers who had referred

patients to the study since its commencement in

2005, 42 were still practicing at the participating

sites at the time of the survey. All had exposure to

at least one patient in an intervention arm and at

least one patient in the control arm; all but two of

the targeted providers had multiple patients in

each arm. None of the participants had formally

reviewed the content of the decision aid nor

received special training in SDM.

Practice settings

The Boston Medical Center is a private, non-profit

academic medical centre affiliated with the Boston

University School of Medicine, which serves a

mostly minority patient population (only 28%

White, non-Hispanic). The South Boston Com-

munity Health Center is a community health centre

affiliated with BMC, which serves a mostly White,

non-Hispanic, low-income patient population.

Survey instrument

The survey instrument included a cover letter, 23

closed-ended questions and two open-ended

questions. Much of the content was derived from

instruments used in previously published studies

by Holmes-Rovner et al. and Graham et al. 6,15

The cover letter briefly described the purpose of

the study, a statement that participation was

completely voluntary, the approximate amount

of time required to complete the survey, and a

statement that all responses are anonymous and

confidential. The closed-ended questions include

one item related to eligibility [confirmation of

participation in the clinical trial (yes ⁄ no)], two items related to demographics (provider degree

and year of graduation), 12 items related to

perspectives on the impact of the tool on various

patient and provider components of SDM for

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson

� 2011 John Wiley & Sons Ltd Health Expectations, 17, pp.27–35

CRC screening (see Table 1), and eight items

related to perspectives on implementation or

content modification (see Tables 2 and 3). The

framing of the questions inferred a comparison

between patients exposed to the decision aid and

those not exposed, i.e., standard care patients,

regardless of their involvement in the study. All

of the items related to SDM used a 5-point Likert

scale ranging from 1 (strongly disagree) to 5

(strongly agree). Six of the items related to

implementation or content modification also

used the same 5-point Likert scale, and two used

a single best answer format. The two open-ended

questions inquired about suggestions for

improving the decision aid and complaints. The

questionnaire took �10 min to complete.

Statistical analyses

Descriptive statistics were used to characterize

the study population and response data for all

closed-ended questions. Frequency data for the

5-point Likert scale items were collapsed into

three categories: �agreed ⁄ strongly agreed�, �neu-

tral� and �disagreed ⁄ strongly disagreed�. Mean response scores ± standard deviations were

also calculated for the same data using Micro-

soft Excel functions. Responses to open-ended

questions were summarized according to themes.

Results

Study population

In total, 29 of the 42 (71%) possible providers,

including 27 physicians and two nurse practitio-

ners, responded to the survey and acknowledged

that they had referred patients to the randomized

clinical trial. Of the 29 respondents, 4 (14%) had

received their degrees between 2000 and 2009, 15

(52%) between 1990 and 1999, and 6 (28%)

before 1990; two declined to answer the question.

Perspectives on SDM

As shown in Table 2, the majority of providers

(>60%) agreed or strongly agreed that the

decision aid complemented their usual approach

Table 1 Provider perspectives on the utility of the decision aid for facilitating SDM

From my clinical perspective, the decision aid

Response category, n (%)

Mean item

score (SD)*

Strongly

agree ⁄ agree Neutral

Strongly

disagree ⁄ disagree

4. Complemented my usual approach to CRC screening 24 (86) 4 (14) 0 4.3 ± 0.7

5. Improved my usual approach to CRC screening 16 (59) 8 (30) 3 (11) 3.7 ± 1.0

6. Helped me tailor my counselling about CRC

screening to my patient�s needs 12 (44) 11 (41) 4 (15) 3.5 ± 1.0

7. Saved me time 18 (64) 6 (21) 4 (14) 3.8 ± 1.0

8. Improved the quality of patient visits 14 (52) 9 (33) 4 (15) 3.6 ± 1.0

9. Increased my patients� satisfaction with my care 10 (40) 13 (52) 2 (8) 3.4 ± 0.8 10. Is an appropriate use of my patient�s clinic time 27 (93) 1 (3) 1 (3) 4.1 ± 0.6 11. Increase patient knowledge about the different

CRC screening options

26 (90) 3 (10) 0 4.3 ± 0.6

12. Helped patients understand the benefits ⁄ risks of the recommended screening options

24 (83) 5 (17) 0 4.1 ± 0.7

13. Helped patients in identifying preferred

screening option

21 (72) 7 (24) 1 (3) 4.0 ± 0.8

14. Improved the quality of the decision making 22 (79) 6 (21) 0 4.0 ± 0.7

15. Increased patients� desire to get screened 21 (75) 5 (18) 2 (7) 3.9 ± 0.9

CRC, colorectal cancer; SD, standard deviation; SDM, shared decision making.

*1 = strongly disagree; 5 = strongly agree.

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson

� 2011 John Wiley & Sons Ltd Health Expectations, 17, pp.27–35

to CRC screening, was an appropriate use of

their patient�s clinic time, saved them time, increased patient knowledge about the various

CRC screening options and their risks and

benefits, helped the patients identify a preferred

screening option, improved the quality of deci-

sion making, and increased their patients� desire to get screened. Providers were more neutral in

their assessment of the decision aid�s utility for improving their usual approach to CRC

screening, helping them tailor their counselling

style to their patients� needs, improving the quality of patient visits, and increasing patient

satisfaction with their care. Relatively few pro-

viders disagreed or strongly disagreed with any

of these measures.

Perspectives on clinical use and content

modification

There was less consensus when asked about

implementation of the tool into routine clinical

practice. As shown in Table 2, <50% of

respondents agreed or strongly agreed that the

decision aid would be easy to use in their prac-

tice outside of a research setting or that it would

be used by most of their colleagues. A slim

majority (58%) also believed that implementa-

tion would require reorganization of their

practice. Respondents mostly agreed or were

neutral in their assessment of whether the deci-

sion aid should be disseminated as an Internet-

or DVD-based tool. When asked to identify a

preferred time for having their patients review

the tool (Table 3), 72% chose prior to initiating

the CRC screening discussion, 21% chose after

initiating the screening discussion, and 7% chose

both. Among the 21 providers who chose the

pre-visit approach, 13 preferred that the tool be

used in the office just prior to the pre-arranged

visit, five preferred at home use and three pre-

ferred both; among the six providers who chose

the post-visit approach, five preferred in-office

use and one preferred at home use.

There was also a lack of consensus when

asked about content modification. Whereas 50%

of respondents agreed or strongly agreed that

the decision aid should include a discussion of

costs, 31% disagreed or strongly disagreed

Table 2 Provider perspectives on decision aid implementation

The decision aid

Response category, n (%)

Mean item

score (SD)*

Strongly

agree ⁄ agree Neutral

Strongly

disagree ⁄ disagree

16. Would be easy to use in my practice

outside of a research stetting

12 (48) 9 (36) 4 (16) 3.4 ± 1.0

17. Use would require reorganization of my

practice for routine clinical use

14 (58) 6 (25) 4 (17) 3.6 ± 1.1

18. Is likely to be used by most of my colleagues 11 (41) 12 (44) 4 (15) 3.4 ± 0.9

19. Should include a discussion of costs 13 (50) 5 (19) 8 (31) 3.5 ± 1.2

20. Should be disseminated as an Internet-based tool 17 (63) 8 (30) 2 (7) 3.7 ± 0.9

21. Should be disseminated as a DVD-based tool 15 (56) 8 (30) 4 (15) 3.6 ± 0.9

DVD, digital video disc; SD, standard deviation.

*1 = strongly disagree; 5 = strongly agree.

Table 3 Preferences for clinical use and content modification

Item N (%)

22. When would you want your patient to

view the decision aid:

Before initiating CRC screening discussion

(pre-visit)

21 (72)

After initiating CRC discussion (post-visit) 6 (21)

Both 2 (7)

23. Would you prefer the decision aid to

contain information about:

All of the recommended screening options 15 (52)

A more restricted list of options 12 (41)

No opinion 2 (7)

CRC, colorectal cancer.

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson

� 2011 John Wiley & Sons Ltd Health Expectations, 17, pp.27–35

(Table 2). Similarly, whereas 52% of providers

preferred that the decision aid include a discus-

sion of all of the recommended screening

options, 41% preferred a more restricted list of

options and 7% had no opinion on the issue

(Table 3).

Only seven providers made suggestions for

improving the current decision aid. These

included creating non-English versions of the

tool (n = 2), clearly distinguishing colonoscopy

as the best screening option (n = 2), enabling

patients to print out their preferred screening

option (n = 2), and taking into consideration

that patients may not have access to the Internet

at home if the decision aid was to be dissemi-

nated as a web-based tool (n = 1). There were

no complaints.

Discussion

Decision aids are evidence-based tools that

enable patients to make informed, value-con-

cordant choices, but the extent to which such

tools facilitate SDM from the perspective of the

provider is less well established. In an effort to

gain new insight into the issue, we conducted a

survey of primary care providers participating in

a clinical trial evaluating the impact of a novel,

DVD-formatted decision aid on SDM and

adherence to CRC screening. Our study finds

that a majority of providers perceived that the

tool was a useful, time-saving adjunct to their

usual approach to counselling about CRC

screening and increased the overall quality of

decision making. Moreover, providers also felt

that review of the tool just prior to a scheduled

office visit was an appropriate use of patient�s time as it enabled the patient to make an

informed choice among the different screening

options. Together, these findings suggest that

much of the tool�s perceived utility was related to its ability to better prepare patients for the

screening discussion outside of the clinical

encounter and, in so doing, increased both the

efficiency and quality of the interaction.

Few studies have explored provider perspec-

tives on the utility of decision aids for improving

SDM. A trial by Green et al. evaluating the

effectiveness of genetic counselling vs. counsel-

ling preceded by use of a computer-based deci-

sion aid for breast cancer susceptibility found

that although there were no significant differ-

ences in perceived effectiveness, use of the tool

saved time and shifted the focus away from basic

education towards a discussion of personal risk

and decision making. 17

A second study by Sim-

inoff et al. found that a decision aid for breast

cancer adjuvant therapy facilitated a more

interactive, informed discussion and helped

physicians understand patient preferences. 13

Similarly, Brackett et al. also found that pre-

visit use of decision aids for prostate and CRC

screening was associated with greater physician

satisfaction, as it saved time during the visit and

changed the conversation from one of the

informational exchanges to one of the values

and preferences. 18

A fourth study by Graham

et al. explored provider perceptions of three

decision aids prior to their actual use. 15

Although responses were based on perceptions

alone and not on clinical experience, their find-

ings were similar to our own. A majority agreed

or strongly agreed that the decision aids could

meet patients� informational needs about risks and benefits and enable patients to make

informed decisions. Similarly, although many

felt that the decision aids were likely to com-

plement their usual approach, responses were

more neutral when asked about the overall

impact of the tools on the quality of the patient

encounter, patient satisfaction and issues related

to implementation. The most striking difference,

however, was that relatively few of the respon-

dents in the study by Graham et al. felt that use

of the tool saved time, which could be a reflec-

tion of either the complexity of the decisions

under consideration and ⁄ or the lack of explicit instructions regarding how the tools were to be

used with respect to the timing of the interven-

tion and ⁄ or need for provider involvement. Our findings also corroborate a more exten-

sive body of literature on barriers to the imple-

mentation of decision aids into clinical

practice. 14

Even though our study design cir-

cumvented many of the barriers related to

workflow, accessibility and costs, only 48% of

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson

� 2011 John Wiley & Sons Ltd Health Expectations, 17, pp.27–35

providers felt that actual implementation of the

decision aids into their practices outside of the

context of a clinical trial would be easy. Based

on their feedback, however, most preferred that

the tool be used prior to initiating the screening

discussion rather than after initiation of the

discussion. Moreover, regardless of the timing, a

majority preferred that the tool be used in the

office rather than at home. Although it is quite

possible that their preferences reflected their

personal experiences with our study protocol,

Brackett et al. also found that pre-visit use was

preferred over post-visit use. 18

One of the most commonly cited barriers to

implementation of SDM is the time requirement.

Although studies to date have provided con-

flicting data regarding the impact of decision

aids on consultation time for other condi-

tions, 17–22

we postulated that by educating

patients about the risks and benefits of the dif-

ferent screening options and facilitating IDM

prior to the provider–patient encounter, our

decision aid would have the potential of

improving the efficiency of SDM and thus save

time, as noted by Green et al. and Brackett

et al. 17,18

We found that although a majority of

providers agreed or strongly agreed that pre-visit

use of the tool saved time, 21% were neutral on

the issue and 14% disagreed or strongly dis-

agreed. It is conceivable that this diversity of

opinion might be a reflection of the extent to

which provider and patient preferences agreed or

disagreed. In instances where there was concor-

dance between preferences, as was often the case

that since colonoscopy was preferred by major-

ity of both patients and providers, 16

one would

expect that the time required for deliberation

and negotiation would be substantially shorter

than in situations where there was discordance.

Alternatively, these differences might reflect

differences in case mix with respect to patient

factors, such as literacy level or desired level of

participation in the decision-making process.

A secondary objective of our study was to

elicit provider feedback regarding content and

format preferences to gain insight into potential

modifications that might enhance future uptake.

Because of an ongoing debate in the CRC

screening literature, 23–27

we focused on content

issues related to cost information and number of

screening options to include in the decision aid.

Both questions elicited a divergence of opinions.

Whereas nearly 50% of respondents felt that

cost information should be included, the

remainder was either neutral or opposed to its

inclusion. Similarly, when asked about the

number of screening options to include, �50% preferred the full menu of options and �40% preferred a more limited menu. This diversity of

opinion highlights some of the key challenges in

designing tools with broad dissemination

potential. In the light of recent evidence sug-

gesting that the number of screening options

may influence test choice but not interest in

screening and that the importance of out-of-

pocket costs declines as the number of screening

options discussed increases, 26

one approach

would be to develop one tool that presents the

full menu of screening options without cost

information and a second that includes a more

limited set of options with cost information. A

more appealing approach would be to develop a

more comprehensive tool that includes both the

full menu of options and cost information in a

format that permits navigation so that patients

could tailor their use to fit their own informa-

tional needs and ⁄ or recommendations of their provider. Internet-based tools are ideally suited

for this purpose but, as noted by several par-

ticipants in our study, access remains a potential

barrier for a sizeable, albeit declining, propor-

tion of the target population. Providers in our

study felt that both Internet- and DVD-for-

matted tools were viable options for dissemina-

tion, even though the DVD-formatted tool

offers less navigation potential.

Our study has several notable limitations.

First, the survey was conducted among primary

care providers at only two institutions, and

hence, the findings may not be generalizable to

providers in other health care settings. It is

noteworthy, however, that the study was con-

ducted among a diverse patient population with

respect to both race ⁄ ethnicity and educational status.

16 Second, as participating providers

never formally reviewed the decision aid, we

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson

� 2011 John Wiley & Sons Ltd Health Expectations, 17, pp.27–35

were unable to assess their opinions with respect

to actual content or format. Third, the content

of our survey instrument did not allow us to

tease out the extent to which use of the decision

aid impacted on individual steps of the SDM

process. 4,5

Even though satisfaction with the

decision-making process was universally high

among patients participating in the clinical

trial, 16

especially those in the intervention

groups, only a relative minority of providers felt

that use of the tool helped them tailor their

counselling about CRC screening to their

patients� needs or increased patient satisfaction with their care. Fourth, the anonymous nature

of our survey precluded any attempt to correlate

response data with exposure rates. It is con-

ceivable that the perceptions of providers

exposed to multiple patients in the intervention

arms might differ from those exposed to only a

few patients. Lastly, we cannot rule out the

possibility of social response bias, whereby

respondents may have felt compelled to offer

more positive responses than they actually

believed.

In conclusion, our study finds that a majority

of providers perceived that pre-clinic use of our

decision aid for CRC screening was a useful,

time-saving adjunct to their usual approach to

counselling about CRC screening and increased

the overall quality of decision making. Never-

theless, many of the providers felt that imple-

mentation of the decision aid into their practices

outside of the context of a clinical trial would be

challenging, thus highlighting the need for cost-

effective strategies for addressing provider,

practice and organizational level barriers to

routine use. We speculate that Internet-based

tools with enhanced navigation functionality

have the greatest dissemination potential, as

they offer a feasible, low-cost solution to many

of the structural barriers to implementation, as

well as a way to reconcile the diversity of opin-

ion related to content.

Acknowledgement

None.

Conflicts of interest

The authors have no conflict of interests.

Funding

This study was supported by grant RO1

HS013912 from the Agency for Healthcare

Research and Quality.

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� 2011 John Wiley & Sons Ltd Health Expectations, 17, pp.27–35

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