Responses to a Decision Aid on Prostate Cancer Screening in Primary Care Practices

doi:10.1016/j.amepre.2015.03.002

American Journal of Preventive Medicine

Volume 49, Issue 4, October 2015, Pages 520-525

https://doi.org/10.1016/j.amepre.2015.03.002 Get rights and content

Introduction

Prostate-specific antigen (PSA) testing remains controversial, with most guidelines recommending shared decision making. This study describes men’s PSA screening preferences before and after viewing a decision aid and relates these preferences to subsequent clinician visit content.

Methods

Men were recruited from two health systems in 2009–2013. Participants answered a questionnaire before and after decision aid viewing addressing PSA screening preferences and five basic knowledge questions. At one health system, participants also answered a survey after a subsequent clinician visit. Data were analyzed in 2014.

Results

One thousand forty-one predominantly white, well-educated men responded to the pre- and post-viewing questionnaire (25% and 29% response rates at the two sites). After viewing, the proportion of patients leaning away from PSA screening increased significantly (p<0.001), with 386 (38%) leaning toward PSA screening versus 436 (43%) before viewing; 174 (17%) unsure versus 319 (32%) before; and 448 (44%) leaning away versus 253 (25%) before. Higher knowledge scores were associated with being more likely to lean against screening and less likely to be unsure (p<0.001). Among 278 men who also completed a questionnaire after a subsequent clinician visit, participants who planned to discuss PSA screening with their clinicians were significantly more likely to report such discussions than participants who did not (148/217 [68%] vs 16/46 [35%], respectively [p<0.001]).

Conclusions

A decision aid reduces men’s interest in PSA screening, particularly among the initially unsure. Men who plan to discuss PSA screening with their clinician after a decision aid are more likely to do so.

Introduction

Recent clinical practice guidelines have recommended a shared decision-making approach between clinicians and men considering a prostate-specific antigen (PSA) test for early detection of prostate cancer.1, 2, 3 Even the U.S. Preventive Services Task Force, which recently recommended against routine PSA screening, acknowledged that PSA tests would continue to be offered and requested, and stated that

physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by the patients. Similarly, patients requesting PSA screening should be provided with the opportunity to make informed choices to be screened that reflect their values about specific benefits and harms.⁴

Yet, others have questioned the practicality of a shared decision-making approach for PSA screening, concerned that it is not commonly done in the busy world of office practice, or that patients would not be swayed by evidence about its pros and cons.5, 6, 7

A network of primary care practices in the U.S. has been working to incorporate a shared decision-making process into the workflow of day-to-day primary care. A patient decision aid on PSA screening was used to facilitate the shared decision-making process at two sites. The purpose of this paper is to report the proportion of patients who wanted PSA screening after being fully informed in a standardized way about the potential benefits and risks, and to describe the relationship between how well informed men are and their leanings about PSA screening. To address concerns that clinicians might override patient preferences regarding PSA screening, we also seek to relate patients’ leanings about PSA screening after viewing a decision aid before a clinician visit to their ratings of the content of the visit afterwards.

Section snippets

Methods

The setting for this study was primary care practices affiliated with two health systems that successfully responded to a request for proposals for decision aid implementation projects funded by the Informed Medical Decisions Foundation. The participating health systems were Dartmouth-Hitchcock Medical Center (DHMC) and Massachusetts General Hospital (MGH). Both systems are academic medical centers, including largely fee-for-service primary care practices with long-established electronic

Results

A total of 1,041 participants returned a pre- and post-viewing questionnaire between November 2009 and April 2013 at the two sites. The response rates to the pre- and post-viewing survey was 586/2,331 (25%) at DHMC and 455/1,564 (29%) at MGH. Table 1 provides the demographic data on the viewers. Almost half of participants were aged 50–59 years, and half had had a prior PSA test. Twenty-six percent were high school graduates or less, whereas 56% were college graduates; participants were

Discussion

Among men prescribed a decision aid as part of routine care addressing PSA screening for early detection of prostate cancer, key knowledge about PSA screening was high, consistent with previous randomized trials of earlier versions of this PSA decision aid.10, 11, 12 Post-viewing, men became less enthusiastic about PSA screening, with most of the shift occurring among men who were not sure about PSA screening beforehand leaning against PSA screening afterward. Moreover, better-informed men, as

Acknowledgments

Financial disclosure: MJB, RW, BG, VS, and FJF receive salary support from the Informed Medical Decisions Foundation, which is now a part of Healthwise, a not-for-profit foundation that develops and distributes patient education and decision support materials. The Foundation co-produced the prostate-specific antigen decision aid used in this study with Health Dialog, and had a royalty relationship with Health Dialog that ended December 31, 2013. MJB, CDB, and KS have received grant support from

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There are more references available in the full text version of this article.

Cited by (29)

Feasibility study of an EHR-integrated mobile shared decision making application
2019, International Journal of Medical Informatics
Citation Excerpt :
Engaging patients in shared decision making (SDM) is important to optimize patient-centered outcomes, provide high quality care, and help control health care costs [1–3].
Integrating mobile applications (apps) into users’ standard electronic health record (EHR) workflows may be valuable, especially for apps that both read and write data. This report details the lessons learned during the integration of a patient decision aid - prostate specific antigen (PSA) testing for prostate cancer screening - into our users' standard EHR workflow for a small usability assessment.
This feasibility study included two steps. First we enabled realtime, secure bidirectional data exchange between the mobile app and EHR for 14 data elements, and second we pilot tested the production environment app with 9 primary care patients aged 60–65 years. Our primary usability metric was a net promoter score (NPS), based on users’ recommendation of the app to a friend or family member; we also assessed the proportion of users who 1) updated their prostate cancer risk factor information present in the EHR and 2) submitted more than one unique response regarding their preference to have PSA testing.
The seven web services necessary to read and write data required considerable configuration, but successfully delivered risk factor-specific educational content and recorded patients’ values and decision preference directly within the EHR. Seven of the 9 patients (78%) would recommend this app to a friend/family member (NPS = 55.6%), one patient used the app to update risk factor information, and 4/9 (44%) changed their decision preference while using the app.
It is feasible to implement a decision aid directly into users’ standard EHR workflow for limited usability testing. Broad scale implementation may have a positive effect on patient engagement and improve shared decision making, but several challenges exist with proprietary EHR vendor application programming interfaces (API)s.
Prostate Cancer Screening Patient Decision Aids: A Systematic Review and Meta-analysis
2018, American Journal of Preventive Medicine
Citation Excerpt :
Furthermore, one large uncontrolled before–after study39 supported this change in intention (Appendix Figure 4, available online). However, the overall effect from three before–after studies39,42,41 and before–after results from five RCTs34,44,48,49,53 that studied eight DAs, suggests a significant increase (p=0.04 and p<0.01, respectively) in the number of men who did not want to be screened after using a DA. These analyses (Appendix Figure 5, available online) did not identify a significant effect of DAs on the proportion of men who were undecided about their screening strategy.
Although screening recommendations for prostate cancer using prostate-specific antigen testing often include shared decision making, the effect of patient decision aids on patients’ intention and uptake is unclear. This study aimed to review the effect of decision aids on men's screening intention, screening utilization, and the congruence between intentions and uptake.
Data sources were searched through April 6, 2018, and included MEDLINE, Scopus, CENTRAL, CT.gov, Cochrane report, PsycARTICLES, PsycINFO, and reference lists. This study included RCTs and observational studies of decision aids that measured prostate screening intention or behavior. The analysis was completed in April 2018.
Eighteen studies (13 RCTs, four before–after studies, and one non-RCT) reported data on screening intention for ≅8,400 men and screening uptake for 2,385 men. Compared with usual care, the use of decision aids in any format results in fewer men (aged ≥40 years) planning to undergo prostate-specific antigen testing (risk ratio=0.88, 95% CI=0.81, 0.95, p=0.006, I²=66%, p<0.001, n=8). Many men did not follow their screening intentions during the first year after using a decision aid; however, most men who were planning to undergo screening did so (probability that men who wanted to be screened would receive screening was 95%).
Integration of decision aids in clinical practice may result in a decrease in the number of men who elect prostate-specific antigen testing, which may in turn reduce screening uptake. To ensure high congruence between intention and screening utilization, providers should not delay the shared decision-making discussion after patients use a decision aid.
Quality Improvement Summit 2016: Shared Decision Making and Prostate Cancer Screening
2018, Urology Practice
The American Urological Association Quality Improvement Summit occurs regularly to provide education and promote dialogue around the issues of quality improvement and patient safety. Nearly all prostate cancer screening guidelines recommend shared decision making strategies when determining whether prostate specific antigen testing is right for a specific patient. This summit, held in partnership with the Society for Medical Decision Making, focused on techniques to identify and understand patient values in relation to prostate cancer screening and treatment, and to promote incorporation of shared decision making into prostate cancer screening discussions.
Information presented at the Quality Improvement Summit was provided by physicians and leading experts in the field of shared decision making. The open forum of this summit encouraged contributions from participants about their personal experiences with shared decision making and their thoughts on the tools presented during the day.
Shared decision making supports collaboration between physician and patient in situations where there are multiple preference sensitive options.
Practitioners should include formal shared decision making procedures surrounding prostate specific antigen testing in their practices to ensure that testing is in accordance with patient values and desired outcomes. Tools and strategies like those reviewed in this Quality Improvement Summit are invaluable for alleviating potential burden on providers, ensuring communication and improving quality of care.
Prevention of Prostate Cancer Morbidity and Mortality: Primary Prevention and Early Detection
2017, Medical Clinics of North America
Citation Excerpt :
The number of participants who felt close to making a decision about PSA screening increased from 57% before viewing to 75% after viewing (P<.001). Also, men who answered more of the after viewing knowledge questions correctly were more likely to lean against screening.89 Many physicians recall the upsetting 2004 essay by Dr Daniel Merenstein, who described his experience of meeting a patient once during his residency with whom he discussed the risks and benefits of PSA testing and documented that conversation.
Editorial Comment
2017, Urology
Shared medical decision in prostate cancer screening in primary care: a systematic literature review of current evidence
2024, International Urology and Nephrology

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Research ArticleResponses to a Decision Aid on Prostate Cancer Screening in Primary Care Practices

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgments

J Urol

Am J Prev Med

American Cancer Society guideline for the early detection of prostate cancer: update 2010

CA Cancer J Clin

Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians

Ann Intern Med

Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement

Ann Intern Med

A piece of my mind: making the call

JAMA

Research Article
Responses to a Decision Aid on Prostate Cancer Screening in Primary Care Practices