Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults
Authors: Saini Sameer D. , Lewis Carmen L. , Kerr Eve A. , Zikmund-Fisher Brian J. , Hawley Sarah T. , Forman Jane H. , Zauber Ann G. , Lansdorp-Vogelaar Iris , van Hees Frank , Saffar Darcy , Myers Aimee , Gauntlett Lauren E. , Lipson Rachel , Kim H. Myra , Vijan Sandeep 
Published: October 2023

ImportanceDespite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults.ObjectiveTo evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening.Design, Setting, and ParticipantsInterventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023.InterventionThe intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening.Main Outcomes and MeasuresThe primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months.ResultsA total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, −4.0 percentage points [pp]; 95% CI, −15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, −13.4 pp; 95% CI, −25.3 to −1.6 pp).Conclusions and RelevanceIn this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening.Trial RegistrationClinicalTrials.gov Identifier: NCT02027545