Colorectal Cancer Screening Among Primary Care Physicians of the Swiss Sentinel Surveillance Network
Condition: Colorectal Cancer
MeSH terms: Colorectal Neoplasms
Study type: Interventional

Summary: 
      Colorectal cancer (CRC) is the third leading cause of cancer mortality in Switzerland, and
      kills 1600 people annually. Most deaths could be prevented by screening, but the 2012 Swiss
      national health survey found that only 40% of 50-75-year-olds had been tested within
      recommended intervals (26% with colonoscopy in the last 10 year, 7% with fecal occult blood
      test [FOBT] in the last 2 years, and 7% with both). If screening starts at age 50, in the
      average risk population absolute risk of dying from CRC at age 80 can be cut from 2% to 1%,
      reducing relative risk by 50%. Since 2013, Switzerland has reimbursed screening by
      colonoscopy every 10 years or FOBT every 2 years for adults 50-69 years old. Conforming to
      current recommendations, the Federal Office of Public Health (FOPH) officially recognizes
      both screening modalities.

      When patients are offered a choice of screening test (colonoscopy vs. FOBT), they are as
      likely to opt for one as the other. Patient preferences are unlikely to vary much between PCP
      practices, so distribution of colonoscopy and FOBT within each practice should also be
      roughly equal. Family physicians are recognized as the most trusted professional to discuss
      CRC screening in Switzerland. However, many primary care physicians (PCPs) prefer prescribing
      colonoscopy over FOBT, but physician preference for method seems to vary widely between
      regions. If physician preferences and local medical culture currently influence choice of
      method more strongly than patient preferences, encouraging PCPs to diagnose patient
      preferences for screening method may reduce the number of PCPs who prescribe only one method.
      An earlier study in Switzerland showed that training PCPs and giving them educational support
      and decision aids raised the number who intend to prescribe colonoscopy and FOBT in equal
      proportions. A randomized controlled trial in the US showed that when patients were offered
      both FOBT and colonoscopy rather than only colonoscopy alone, more patients were screened for
      CRC. Offering choice of method may thus increase overall screening rates.

      The Swiss Sentinel Surveillance Network (Sentinella) is a cooperative surveillance project
      including the Federal Office of Public Health (FOPH), PCPs representatives and the five Swiss
      institutes of family medicine. A sample of 150 to 250 general practitioners, internists and
      pediatricians in private practices from all regions of Switzerland report weekly morbidity
      data to the network using irreversibly anonymized patient data collected during
      consultations. In 2017, 91 out of 129 eligible PCPs of the Sentinella network participated in
      a cross-sectional data collection on CRC screening. The Sentinella network appears ideally
      suited to perform an intervention in order to modify screening practices and measure outcomes
      using the same collection form as in 2017.

      This study will test the benefits of a prepackaged training program in participatory medicine
      sent by post to PCPs in Switzerland. The package is designed to improve their diagnoses of
      patient preferences for screening and screening method (colonoscopy or FOBT). The study
      begins with the hypothesis that giving PCPs evidence summaries on CRC screening, decision
      aids for patients, and performance feedback on the 2017 data collection will increase the
      number of PCPs whose patients include at least one screened with FOBT, and who will prescribe
      at least one FOBT/FIT (Fecal Immunochemical Test) instead of prescribing only colonoscopy.
      This might reduce variation in care between PCP practices by increasing variation in methods
      of screening prescribed within each PCP practices. Analyses from the 2017 data collection
      suggest that fewer patients refused CRC testing in practices that offered both methods than
      in practices that offered only colonoscopy. This intervention might increase screening rates
      overall, while respecting patient's autonomy to refuse the test and to be prescribed the test
      they prefer.

      The study will compare outcomes among PCPs allocated to the intervention group to those in
      the control group, and will be measured by collecting anonymous structured patient data on 40
      consecutive patients by PCPs and questionnaires filled by PCPs.

      The study is designed to fit within the Reach, Effectiveness, Adoption, Implementation and
      Maintenance (RE-AIM) framework for structuring data collection. RE-AIM ensures that a study's
      outcomes for future implementation and dissemination works are collected. The RE-AIM criteria
      will be used to identify the translatability and public health impact of this intervention,
      and for making clear to future stakeholders the internal and external validity of study
      results.
    


Intervention name(s): Mailed training intervention
Intervention type(s): Other
Intervention description(s): PCPs from the intervention group will be mailed an intervention package that includes:
2-page structured evidence summary on CRC screening and information about Colonoscopy & FIT ("Decision box")
patient decision aid (20-page booklet) on CRC screening for distribution to patients (Decision Aid)
video example for the PCP, which illustrates a participatory approach to discussing CRC screening with a patient
4-page abridged version of the booklet to support PCPs when they discuss CRC screening with patients during a clinical visit ("Decision Board")
individualized 1-page summary of PCP screening practices comparing their individual prescription patterns to group patterns, based on the data collected in 2017 ("Performance card")
2-page document that encourages PCPs still using the inferior guaiac-based FOBT to switch to FIT and includes list of laboratories from which they can order FIT
sample FIT for PCPs who may not be familiar with its contents and use
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Screening