Simple Patient Info Sheet Not Enough to Dissuade Low-Value Screening

By Lori Solomon, Editor, Diagnostic Testing & Emerging Technologies

Simple, brief, information sheets are unlikely to change patients' intentions to participate in low-value screenings, according to a study published online Dec. 28, 2015 in JAMA Internal Medicine. To reduce overused screening services—including prostate cancer and osteoporosis screening in low-risk men and women and colorectal cancer screening in the elderly—more intensive and comprehensive campaigns will be needed, targeting both patients and clinicians, the authors say.

Low-value services have been defined as those in which the degree of benefit does not justify the harms and costs, and have been estimated to cost $192 billion annually in the United States. In the current study, selected services had either net harm at the population level (prostate cancer screening in men ages 50 to 69 years) or small net benefit (some individuals would benefit, but some would be harmed; for example, osteoporosis screening in low-risk women ages 50 to 64 years or colorectal cancer screening in older men and women ages 76 to 85 years).

"Decisions about screening are driven by a complex interplay of attitudes, social norms, and self-efficacy, many of which often strongly favor screening," write the authors led by Stacey Sheridan, M.D., from University of North Carolina, Chapel Hill. "Furthermore, many decision-makers rely on emotions and heuristic decision-making, rather than the rational processes involved in weighing harms and benefits, and are subject to a host of cognitive biases that make foregoing health care services difficult."

In the present study, alternate formats for informing patients about benefits and harms were evaluated for their effect on reducing overuse. In total, 775 individuals were randomized to receive information about one of the three screening services during their scheduled visit at their community-based primary care clinician (September 2012 to June 2014).

The four intervention arms differed in presentation format: words (n=195), numbers (n=192), numbers plus narratives (n=196), or numbers plus a framed presentation (n=192). Information sheets included a description of the disease screened for (including disease incidence and mortality rates), a description of the screening test and its benefits (primarily disease-specific mortality reduction), and harms (including physical and psychological harms across the screening cascade).

Within each intervention arm, participants were distributed evenly across the three screening services. Patients read their assigned evidence-based decision support information sheet and completed pre- and post-intervention surveys, but did not discuss the materials with their clinicians.

The researchers found that intentions to screen were high before the intervention. The narrative format had lower intention-to-accept screening at post-intervention compared with pre-intervention, but other interventions arms had no changes from baseline. Results were similar when assessed by screening service.

"Given the highly educated sample and small increases in knowledge found, it seems that acceptance of screening was largely unrelated to transferred knowledge, at least as communicated on a single-page information," writes Judith Prochaska, Ph.D., from Stanford University, in an accompanying editorial. "That most of the study sample had been screened prior, likely within the clinical practice through which the intervention was being tested, without ill-reported effects and with intention to screen again, suggests the appropriateness of a more personalized and multilevel systems approach."