Project Overview +

Colorectal cancer (CRC) is the third most prevalent cancer in the U.S. Dept. of Veteran Affairs (VA) and the second most costly cancer. This study aims to increase the number of VA patients who complete a CRC screening. It integrates an innovative and flexible preference elicitation methodology, conjoint analysis, into a decision tool to help VA patients clarify their preferences for characteristics of CRC screening tests.

Aims +

Aim 1. Evaluate the effectiveness of a preference-tailored intervention vs. standard information delivered via computer for increasing VA patients' adherence to CRC screening guidelines in a randomized controlled trial.

Aim 2. Assess the impact of the intervention on patient perceptions of informed decision making, knowledge about CRC screening, decisional conflict and satisfaction, and intention to get screened 3 days after a primary care visit.

Aim 3. Conduct a cost effectiveness analysis of a preference-based strategy for increasing CRC screening use across the VA.

Participants +

Five hundred people who are part of either the Ann Arbor or Pittsburgh VA health care systems, 50-79 years of age, have never been screened for CRC, or are out of date for CRC screening, have no personal history of CRC or colon polyps, and have no family history of CRC.

Intervention +

Participants arrive at the VA 40 minutes before their scheduled appointment. A research assistant (RA) reviews the study with them and takes them to the computer set up with the program. Participants are randomly assigned to receive the intervention or standard CRC screening information upon logging into the program.

Control participants review information about colon cancer, the screening tests available, and are asked to choose a test they prefer. Upon completion of the entire program, they receive a copy of the CDC Screen For Life Fact Sheet on Colorectal Cancer Screening to take to their visit. This includes a brief overview of all screening options, but does not list the participant's final test preference.

Intervention participants read an overview about CRC, descriptions of four screening tests available to them, and definitions of key screening test terms used in the study's conjoint analysis exercise.

Each intervention participant then sees 20 screens, each with a hypothetical screening test scenario. Each screen shows participants two choices with different characteristics. For example:

  • Option 1: test every 5 to 10 years, follow-up tests needed.
  • Option 2: yearly testing, no follow-up tests.

Option 1 words and images are on the left side of the screen, while Option 2 is on the right. Participants choose one point on a 9-point scale ("I strongly prefer Option 1" to "I strongly prefer Option 2") and their responses are stored in a database for later conjoint analysis.

After completing the scenarios, participants review a page that lists their "Top 3 test attributes" (e.g., frequency, accuracy, preparation). They also see the screening test that is most consistent with their top attributes (e.g., FOBT) and basic information about this test. They may view more information if they choose. Additionally, they see a list of other test options and may view more information about each one. Finally, they choose the test they would prefer from a list of all four test options. A final screen lists their preference-matched test, determined by the conjoint analysis exercise, their preferences and their final choice. A printout of this screen is provided to the participant, with a brief description of each of the screening options included on the back of the printout.

All participants are encouraged to share the handout information with their physician during their visit. Participants receive a follow-up telephone call approximately 3 days after their visit to complete a 30-minute telephone interview. A medical chart audit 12 months later assesses use of services.

Findings +

Preliminary findings as of February, 2012:

468 subjects have been enrolled from two VAs (234 per group). CRC screening adherence 6-months post-enrollment was 38.6% and was not significantly different between groups (37.4% intervention, 39.7% control). Of those, most were adherent with fecal occult blood test (22.4%), followed by colonoscopy (16.7%). The most commonly recommended test by physicians was COL (59.2% of tests recommended), though Veterans most commonly stated a preference for FOBT (60.1%). The features of tests most important to Veterans were nature of the test (32.8%), effectiveness (27.1%), and risk of complications (17%). Adherence was significantly (P<0.001) higher with the test that the patient indicated s/he preferred post-intervention (20.2% vs. 6.9% % for FOBT and 32.6% vs. 7.8% for COL) than with a different test.