A digital health intervention with a colorectal cancer screening decision aid and the option of self-ordering tests increases routine screening
EBM Focus - Volume 13, Issue 16
- Routine colorectal cancer (CRC) screening is recommended for adults ≥ 50 years old.
- A randomized trial of 450 adults visiting their primary health care provider compared screening rates with a digital health intervention vs. a control intervention. The digital health intervention consisted of a CRC screening decision aid and an option to self-order tests with reminder texts or emails. The control intervention consisted of a video on diet and exercise. Both were delivered with an iPad application just before the visit.
- Rates of CRC screening within 24 weeks of the visit were 30% with the digital health intervention and 15% with the control (p < 0.05).
CRC screening is recommended for adults ≥ 50 years old (CMAJ 2016, JAMA 2016), but screening rates can be improved. A recent randomized trial evaluated CRC screening rates with a digital health intervention compared to a control intervention in 450 adults 50-74 years old who were scheduled to visit their primary care provider and were due for routine CRC screening. The digital health intervention consisted of an iPad application the patients interacted with before their visit that included a 8.6 minute CRC screening decision aid and allowed patients to self-order a screening test at a future visit with a colonoscopy or a fecal occult blood test. Patients who ordered a test received follow-up reminder texts or emails. The control intervention consisted of a 4.3 minute video about diet and exercise viewed on the iPad. The patients were from a socioeconomically diverse population served by several community-based primary care practices in the United States. Almost all patients (88%) owned a cell phone, 63% reported using the internet within the past month, 51% had an annual income < $21,000 US, and 37% expressed low confidence in filling out medical forms without assistance. Patients with a family history of CRC or a personal history of CRC or colonic polyps were excluded.
The digital health intervention had greater rates of chart-verified CRC screening tests within 24 weeks of the visit (30% vs. 15% with the control intervention, p < 0.05, NNT 7) and colorectal neoplasia detection (7.2% vs. 2.6%, p < 0.05) (presumably due to the increased screening). It also had greater rates of measures of patient engagement: 97% vs. 71% (p < 0.05) were able to state a CRC screening preference at a survey immediately after the intervention and 76% vs. 48% (p < 0.05) reported discussing screening options with their primary health care provider (among 410 patients who responded to a next-day telephone interview).
The digital health intervention in this trial increased rates of guideline-recommended colorectal cancer screening and colorectal neoplasia detection. However, because it was compared to a video about diet and exercise, there are some questions regarding which specific components of the intervention most contributed to the effect and if simpler interventions may be similarly effective. For example, would follow-up texts or emails about CRC screening or a simple paper-based decision aid also increase screening rates? Exploratory analyses in this trial and comparisons with previous research partly speak to this concern, but direct comparisons would help answer these questions. Also, long-term clinical outcomes were not evaluated in this trial, but previous trials have shown that CRC screening may reduce CRC-related mortality (NEJM 2013, BMJ 2014). Finally, the findings of the current trial support the overall point that decision aids and related interventions can increase patient engagement and agency and improve patient adherence to guideline recommendations.