Adult Patients' Perspectives on the Benefits and Harms of Overused Screening Tests: a Qualitative Study.

BACKGROUND: In recent years, there has been a growing interest in reducing the overuse of healthcare services. However, little is known about how patients conceptualize the benefits and harms of overused screening tests or how patients make decisions regarding these tests. OBJECTIVE: To determine how patients think about the harms and benefits of overused screening tests and how they consider these and other factors when making decisions. DESIGN: Semi-structured, qualitative interviews. PARTICIPANTS: The study comprised 50 patients, ages 50-84, who had previously received or not received any of four overused screening services: 1) prostate cancer screening (men ages 50-69), 2) colon cancer screening (men and women ages 76-85), 3) osteoporosis screening (low-risk women ages 50-64), or 4) cardiovascular disease screening (low-risk men and women ages 50-85). APPROACH: We conducted a thematic analysis, using a hybrid inductive-deductive approach. Two independent coders analyzed interview transcriptions to identify themes and exemplifying quotes. KEY RESULTS: Many patients could not name a harm of screening. When they did name harms, patients often focused on only the harms of the screening test itself and rarely mentioned harms further along the screening cascade (e.g., from follow-up testing and treatment). In contrast, patients could easily name benefits of screening, although many seemed to misunderstand or overestimate the magnitude of the benefits. Furthermore, patients described many additional factors they considered when making screening decisions, including their clinicians' recommendations, their age, family or friends' experiences with disease, and insurance coverage. CONCLUSIONS: This study highlights the need to help adults recognize and understand the benefits and harms of screening and make appropriate decisions about overused screening tests.

Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening.

BACKGROUND: Primary-care providers may contribute to the use of low-value cancer screening. OBJECTIVE: We sought to examine circumstances under which primary-care providers would discuss and recommend two types of cancer screening services across a spectrum of net benefit and other factors known to influence screening. PATIENTS AND METHODS: This was a cross sectional survey of 126 primary-care providers in 24 primary-care clinics in the US. Participants completed surveys with two hypothetical screening scenarios for prostate or colorectal cancer (CRC). Patients in the scenarios varied by age and screening-request status. For each scenario, providers indicated whether they would discuss and recommend screening. Providers also reported on their screening attitudes and the influence of other factors known to affect screening (short patient visits, worry about lawsuits, clinical reminders/performance measures, and screening guidelines). We examined associations between providers' attitudes and their screening recommendations for hypothetical 90-year-olds (the lowest-value screening). RESULTS: Providers reported they would discuss cancer screening more often than they would recommend it (P<0.001). More providers would discuss and recommend screening for CRC than prostate cancer (P<0.001), for younger than older patients (P<0.001), and when the patient requested it than when not (P<0.001). For a 90-year-old patient, every point increase in cancer-specific screening attitude increased the likelihood of a screening recommendation (30% for prostate cancer and 30% for CRC). DISCUSSION: While most providers' reported practice patterns aligned with net benefit, some providers would discuss and recommend low-value cancer screening, particularly when faced with a patient request. CONCLUSION: More work appears to be needed to help providers to discuss and recommend screening that aligns with value.

A Comparative Effectiveness Trial of Alternate Formats for Presenting Benefits and Harms Information for Low-Value Screening Services: A Randomized Clinical Trial.

IMPORTANCE: Healthcare overuse, the delivery of low-value services, is increasingly recognized as a critical problem. However, little is known about the comparative effectiveness of alternate formats for presenting benefits and harms information to patients as a strategy to reduce overuse. OBJECTIVE: To examine the effect of different benefits and harms presentations on patients' intentions to accept low-value or potentially low-value screening services (prostate cancer screening in men ages 50-69 years; osteoporosis screening in low-risk women ages 50-64 years; or colorectal cancer screening in men and women ages 76-85 years). DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of 775 individuals eligible to receive information about any 1 of the 3 screening services and scheduled for a visit with their clinician. Participants were randomized to 1 of 4 intervention arms that differed in terms of presentation format: words, numbers, numbers plus narrative, and numbers plus framed presentation. The trial was conducted from September 2012 to June 2014 at 2 family medicine and 2 internal medicine practices affiliated with the Duke Primary Care Research Consortium. The data were analyzed between May and September of 2015. INTERVENTIONS: One-page evidence-based decision support sheets on each of the 3 screening services, with benefits and harms information presented in 1 of 4 formats: words, numbers, numbers plus narratives, or numbers plus a framed presentation. MAIN OUTCOMES AND MEASURES: The primary outcome was change in intention to accept screening (on a response scale from 1 to 5). Our secondary outcomes included general and disease-specific knowledge, perceived risk and consequences of disease, screening attitudes, perceived net benefit of screening, values clarity, and self-efficacy for screening. RESULTS: We enrolled and randomly allocated 775 individuals, aged 50 to 85 years, to 1 of 4 intervention arms: 195 to words, 192 to numbers, 196 to narrative, and 192 to framed formats. Intentions to accept screening were high before the intervention and change in intentions did not differ across intervention arms (words, -0.07; numbers, -0.05; numbers plus narrative, -0.12; numbers plus framed presentation, -0.02; P = .57 for all comparisons). Change in other outcomes also showed no difference across intervention arms. Results were similar when stratified by screening service. CONCLUSIONS AND RELEVANCE: Single, brief, written decision support interventions, such as the ones in this study, are unlikely to be sufficient to change intentions for screening. Alternate and additional interventions are needed to reduce overused screening services. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01694784.

Clinicians' perceptions of the benefits and harms of prostate and colorectal cancer screening.

BACKGROUND: Clinicians' perceptions of screening benefits and harms influence their recommendations, which in turn shape patients' screening decisions. We sought to understand clinicians' perceptions of the benefits and harms of cancer screening by comparing 2 screening tests that differ in their balance of potential benefits to harms: colonoscopy, which results in net benefit for many adults, and prostate-specific antigen (PSA) testing, which may do more harm than good. METHODS: In this cross-sectional study, 126 clinicians at 24 family/internal medicine practices completed surveys in which they listed and rated the magnitude of colonoscopy and PSA testing benefits and harms for a hypothetical 70-year-old male patient and then estimated the likelihood that these tests would cause harm and lengthen the life of 100 similar men in the next 10 years. We tested the hypothesis that the availability heuristic would explain the association of screening test to perceived likelihood of benefit/harm and a competing hypothesis that clinicians' gist of screening tests as good or bad would mediate this association. RESULTS: Clinicians perceived PSA testing to have a greater likelihood of harm and a lower likelihood of lengthening life relative to colonoscopy. Consistent with our gist hypothesis, these associations were mediated by clinicians' gist of screening (balance of perceived benefits to perceived harms). LIMITATIONS: Generalizability beyond academic clinicians remains to be established. CONCLUSIONS: Targeting clinicians' gist of screening, for example through graphical displays that allow clinicians to make gist-based relative magnitude comparisons, may influence their risk perception and possibly reduce overrecommendation of screening.