02 Participatory methods promote participatory decisions in colorectal cancer screening

The study applied community-engaged participatory methods and included primary care and specialist physicians, epidemiologists, and patients. Participants helped design and conduct interventions and interpret results. Primary care physicians developed and tested a data collection they later used to collect data on colorectal cancer screening (colonoscopy within 10 years or faecal occult blood testing within 2 years) from 40 consecutive patients to determine if screening had been performed already if they discussed screening during the visit and the decision taken (refusal of screening / plans for a screening). After a first data collection, researchers conducted a randomized controlled trial among physicians in a practice-based research network. In parallel, researchers randomized 12 quality circles of physicians to implement the intervention in routine clinical care and determine if the intervention improved quality of care.

People have a 2% risk of dying of colorectal cancer. Screening halves that risk, but 60% of the eligible Swiss population is unscreened or under-screened. Guidelines recommend colonoscopy every 10 years or faecal occult blood tests every 2 years, setting a 65% target. But the only test offered by most primary care physicians is colonoscopy. Few patients are offered the less invasive faecal occult blood test. If primary care physicians offer patients both options, more might choose to be screened; studies indicate about half of patients offered a choice will select the less invasive test.

The goal was to encourage primary care physicians to offer eligible patients a choice of colonoscopy or faecal occult blood test for colorectal cancer screening. Researchers developed and tested a multi-part data-driven quality improvement intervention that trains primary care physicians about best practices and guidelines in colorectal cancer screening and promotes participatory decision-making in screening discussions with eligible patients. The intention was to increase the proportion of faecal occult blood test to colonoscopy prescriptions in their daily practice.

Data collection began in a practice-based research network, where 91/120 (71%) physicians contributed data on 3,451 patients: 45% had been tested for colorectal cancer (41% colonoscopy, 4% faecal occult blood test). Proportions of patients tested, and method varied widely between physicians. Physicians discussed screening with 51% of eligible patients. Physicians who only prescribed colonoscopy had higher rates of refusal than those who prescribed both screening methods. Of the 109 PCP randomized, 79 (64%) collected data on 3,017 patients. The multidimensional mailed intervention increased the number of PCP who prescribed at least one faecal occult blood test. Of the 120 quality circles we invited, 12 participated and 9 collected data after 12 months: 63 physicians collected data on 2,114 patients. The multilevel intervention in quality circles of physicians raised screening rates by 15% at 12-month follow-up.

Significance of the results for research and practice

If researchers use participatory methods to define outcomes, collect, and interpret data, primary care physicians in Switzerland will participate in quality improvement interventions, collect data on their prescriptions for colorectal cancer screening, and discuss this data among peers. Implementing these successfully tested interventions and tools promoting participatory decisions should reduce variation in care between physician practices and raise colorectal cancer screening across Switzerland to meet the minimum 65% target specified by guidelines.

Shared decision making in colorectal cancer screening in primary care: a cluster randomized controlled trial