Partnering With Patients To Make Decisions About Colorectal Cancer Screening

Colorectal cancer is the second leading cause of cancer-related deaths in the United States and the leading cause of cancer deaths among nonsmokers, according to the Centers for Disease Control and Prevention. But in Minnesota, MN Community Measurement has found that only 64 percent of people are getting appropriate colorectal cancer screenings.

To help health care providers talk with patients about the benefits and risks of all their colorectal cancer screening options, the Institute for Clinical Systems Improvement (ICSI) developed an innovative pilot project. It set out to train the staff of two primary care clinics to use shared decision-making techniques in discussions with patients about colorectal cancer screening options.

“Our philosophical approach is that clinicians should engage with the patient as a partner in making shared decisions about care, and that should be woven into everyday practice,” said Jan Schuerman, MBA, team director for ICSI, which is a partner in the Minnesota AF4Q Alliance.

With funding from Aligning Forces for Quality (AF4Q), ICSI developed curriculum materials and began the training sessions in July 2011. The two primary care practices that participated are part of a physician-owned family practice group in Saint Paul, MN, called Entira Family Clinics.

“We chose to join the pilot because these two clinics—our White Bear Lake/Banning Avenue location and our White Bear Lake/Bellaire Avenue location—are becoming certified by the Minnesota Department of Health as health care homes,” explained Kathleen Conboy, director of clinical practice and quality for Entira Family Clinics. “Shared decision making has to be introduced as part of the certification process, and we realized this is a great opportunity to get educated about it.”

At each clinic, the staffers who received the training were part of the “health care home team.” This team consists of three providers, a care manager, a clinic manager, and a certified medical assistant. Through three individualized, face-to-face training sessions and one webinar, they learned how to work collaboratively with patients to make informed decisions about colorectal cancer screening. In a shared decision-making conversation, the provider describes the benefits and risks of all the relevant screening options, and the patient expresses his or her preferences and values. Ultimately, they arrive at a decision together.

The clinics use evidence-based guidelines developed by ICSI to help determine appropriate treatment methodology for patients at average and increased risk for developing colorectal cancer. These guidelines also include resources such as a description of the set of skills needed to engage the patient in a “collaborative conversation.”

ICSI’s Patient Advisory Council reviewed all of the materials that were incorporated in the training sessions in advance to ensure they were easy for patients to understand. Some patients on the council also volunteered to participate in a webinar and share their experiences with colorectal cancer screening and patient- and family-centered care in Minnesota.

“The patients talked about the logistics of making an appointment for a screening, filling out the required forms in person or via email, which information they received prior to the appointment and at other stages of the process—they showed the clinicians how things look through the patients’ eyes,” said Schuerman.

“Involving the patients in the training was instrumental to the success of the project,” she added. “The training sessions that included patients were the ones that most engaged the physicians.”

After the training sessions, the health care home team members at both clinics began implementing shared decision making with appropriate patients. David C. Thorson, MD, a physician at Entira Family Clinics’ White Bear Lake/Banning Avenue location who participated in the pilot, said the staff wound up spending more time discussing the full range of screening options. Rather than focusing mainly on the pros and cons of colonoscopies, staff devoted more attention to talking about options like a fecal occult blood test (FOBT) and flexible sigmoidoscopy.

“The providers had a pretty good handle on who should be screened, but the thing we didn’t necessarily do as well in the past was to talk with the patients who said no to a colonoscopy and find out what the barrier was for them,” Thorson said.

He noted providers often view colonoscopy as the gold standard for colorectal cancer screening, but for lower risk patients, a number of other methods are adequate and should be discussed. One option is for patients to be screened initially using a less-invasive test like an FOBT. If that comes back positive, they can get a colonoscopy. By talking more about the different screening options, the team at the Banning Avenue clinic increased the number of patients who chose to get screened for colorectal cancer. In many cases, those patients chose an FOBT rather than a colonoscopy.

Before the pilot began in 2011, 67 percent of eligible patients at the Banning Avenue clinic were screened for colorectal cancer using one of three methods. In 2012, after shared decision making was implemented, 71 percent of eligible patients were screened. At the Bellaire Avenue clinic, the screening rate rose from 66 percent in 2011 to 74 percent in 2012.

Clinic staff filled out surveys at the beginning, middle, and end of the pilot, and patients completed surveys at the beginning and end. These surveys were conducted for quality improvement purposes, and the sample sizes weren’t large enough to be statistically significant. The patient surveys at both clinics reflected that there had been more discussions about different types of screening, and patients felt they could make an informed decision. The White Bear Lake clinic staff reported that shared decision making is more involved than they had expected, and it can be difficult to conduct a shared decision-making conversation within the confines of a 15-minute appointment. Schuerman said she observed during the pilot that one of the biggest challenges of implementing shared decision making is that there are already so many competing demands on physicians’ time.

In the future, Thorson said his team at the Banning Avenue clinic plans to continue using shared decision-making techniques, but it won’t always be the physicians who conduct the conversation.

“Some of the shared decision-making tools require 15 to 30 minutes of active, facilitated conversation, and the physician does not have the time to do that—the visit will run too late. We’re exploring having another member of the team, such as the care manager, facilitate the conversation right after an appointment with the physician or at another time,” said Thorson.

He pointed out that the current payment model makes it difficult to allocate resources and staff for this, but Entira Family Clinics is nonetheless interested in moving toward more of a team-based approach to providing shared decision making. The pilot also laid the foundation for them to start using shared decision making in discussions of mammography and back surgery options.

In the meantime, ICSI also will be applying what it learned from the pilot to other projects, such as a low-backpain initiative. In addition, it’s sharing its experiences with the advisory committee of a large colorectal cancer community health project called Colorectal Cancer Screening With Improved Shared Decision Making (CRCS-WISDM). “We’ll be drawing on the knowledge that we gained about shared decision making in lots of our future efforts,” Schuerman said.

Lessons Learned

• Since health care providers in Minnesota publicly report rates of colorectal cancer screening as a quality measure, some may be reluctant to engage in shared decision making with patients for fear the patients may elect not to have any screening at all. Lower screening rates could have a negative impact on the provider’s “score,” quality rating, and in some instances, income. If new measures are developed in the future so providers are publicly reporting on shared decision making as well, that could help mitigate these problems.

• A significant barrier to providing shared decision making is that the active conversation with the patient can take 15 to 30 minutes, and physicians often cannot devote this much time to it. Clinics should explore the possibility of having other staff members besides the physician—such as a care manager or certified medical assistant—receive training and facilitate the shared decision-making conversations with patients. This conversation could take place after the appointment with the physician or at another time.

• It’s essential to incorporate the voices of patients in shared decision-making training materials. In the webinars ICSI developed, patients talk about patient and family-centered care and share their experiences with colorectal cancer screening. ICSI found clinic staff really appreciated hearing the patient’s perspectives, and training materials that include patient voices are much better received than those that do not.