Implementing communication material to promote shared decision making in colorectal cancer screening in primary care - experiences in Switzerland

Transcription

1 Implementing communication material to promote shared decision making in colorectal cancer screening in primary care - experiences in Switzerland Lugano, September 15th, 2017 Prof. Dr. med Reto Auer Berner Institut für Hausarztmedizin (BIHAM), Bern Policlinique Médicale Universitaire (PMU), Lausanne reto.auer@biham.unibe.ch Twitter

2 Polyps and colon cancer

3 Colonoscopy

4

5 Without screening, about 2 in 100 people will die from colon cancer before the age of 80 in Switzerland. With regular screening, about 1 in 100 people will die from colon cancer before the age of 80 in Switzerland.

6 2 options Fecal occult blood testing Every 2 years Colonoscopy Every 10 years

7 What is your preference with regards to colorectal cancer screening? A. No screening B. Colonoscopy C. Indifferent between colonocopy and fecal occult blood testing D. Fecal occult blood testing E. Other method (sigmoïdoscopy, virtual colonoscopy) F. Don t know

8 Variations in Switzerland Self-reported proportions within last 6 months 100% 80% 60% 47% 40% 20% 0% 1% 19% 9% 24% Selby et al. BMJ Open Variations between family physicians Variations between cantons Variation between health professionals

9 Variations by country Schreuders et al. Gut, 2015

10 The silent misdiagnosis If operating on the wrong leg is considered a medical error, what do we call operating on someone who doesn t need surgery? Jack Wennberg 10

11 11

12 "We have spent a staggering amount of time and energy over the past several decades developing, discussing, and debating guidelines. Professional and advocacy groups have spent much time aggressively advocating the adoption of guidelines supported by their respective groups. It seems that it would be much more productive to devote such energy to educating screening candidates about the harms and benefits of screening and to engaging in shared decision making. Stephanek, E Edward Stefanek. Uninformed Compliance or Informed Choice? A Needed Shift in Our Approach to Cancer Screening. J Natl Cancer Inst. Nov

13 Organized screening program, Vaud Target population: Average risk, aged 50-69, eligible Promotion of systematic informed choice on CRC screening and between two screening methods: Colonoscopy every 10 years Fecal Immunological test (FIT) every 2 years Colonoscopy if FIT test positive

14 Aims of the program Facilitate informed choice for CRC screening Systematic invitation to discuss screening and type of screening with primary care physician (PCP) Reimbursement of screening colonoscopy or FIT by health care insurances since July 1st, 2013 for Adults aged 50 to 69 years old. Payment of deductible for: Coloscopy or FIT test Consultation with PCP: 15/30 min

15 Developed material for invitees and health professionals

16 Self-reported proportions screening prescribed over last 6 months and intentions to prescribe over next 6 months 100% 80% 60% 40% 20% 19% 21% 9% 36% 47% 32% 24% 11% Previous Future 0% 1% 0% Selby et al. BMJ Open. 2016

17 Prescription among PCPs

18 Arch Intern Med 2012;172(7):

19 Recruitment Up to 120 QC eligible in three large networks of family physicians in 3 regions Refusal to participate by QC leaders or members of QC Baseline measure 12 QC in three regions of 8 PCPs each (N=96 PCPs total): - Baseline measures on physician s level and 40 consecutive patients aged (N=2880 pat. total) Randomization Stratified randomization at the level of QC 48 PCPs in 6 QC receive intervention over 12 months: - 2 QC centered on CRC screening - Individual and group level feed-back - Distribution of DA and information material 48 PCPs in 6 QC in control group: -Participate in QC on other topics Measure at 3 months with individualgroup level feed-back and Main analysis Outcome measure at 12 month Outcome measure at 12 month Intervention group participate in other QC Control group receives intervention Measure at 3 months with individualand group level feed-back Maintenance Outcome measure at 24 month Outcome measure at 24 month

20 Conclusions Future of screening programs Systematic choice instead of uninformed compliance Quality metric: proportion with decision, not proportion screened Spend resources in informing and involving invitees in decision, not debating guidelines Provide health professionals with decision aids to help them inform invitees and diagnose preferences Health care providers as trusted advisors for health decisions