CHIBE-affiliated faculty member Shivan Mehta, MD, MBA, has been awarded a 5-year grant totaling $3.25 million from the NIH’s National Cancer Institute to use behavioral economic approaches to increase population-based colorectal cancer screening.
This 3-year trial will involve a multi-level intervention focused on clinicians and patients and will test different approaches for offering two types of screening: colonoscopy or fecal immunochemical testing (FIT).
Today, most practices rely on primary care providers recommending colonoscopies to patients when they come into the office. Previous research has shown that clinician-directed strategies and patient-directed outreach can help increase screening rates, but the interventions have been limited to large delivery systems or may be difficult to sustain.
Both colonoscopy and FIT are effective tests to screen for colorectal cancer, but the two strategies have pros and cons for patients. Mailed FIT to patients’ homes is effective, but patients have to complete it every year, whereas colonoscopies have longer-term benefits but can be more burdensome for patients.
Previous work led by Dr. Mehta demonstrated that offering a choice of either colonoscopy or FIT to patients led to a lower screening rate compared to offering FIT alone—perhaps due to choice overload. (Read more about the effects of sequential or active choice for screening outreach here in JAMA Network Open.)
Status quo bias and decision fatigue may contribute to issues of colorectal cancer screening uptake. However, behavioral economics tools can help overcome these biases.
“Switching choice architecture of mailed FIT outreach from opt-in to opt-out increased participation from 10% to 29%, and programming defaults in the clinician workflow can increase colonoscopy ordering,” the investigators noted in their proposal. “Lessons from the retail industry also demonstrate that reducing friction and eliminating effort in the screening process could also increase uptake by patients and clinicians.”
This pragmatic clinical trial will take place at 30 diverse primary care practices with 20,000 average-risk patients who are overdue for screening.
Clinicians will be randomized to:
– EHR-directed nudges to offer colonoscopy to patients
– Sequential choice: EHR-directed nudges to offer colonoscopy, then nudges to offer FIT if the patient does not complete colonoscopy
Patients will also be randomized to:
– No outreach
– Recommendation of colonoscopy
– Sequential choice outreach of recommending colonoscopy, then FIT
In addition to determining which strategy is associated with the highest completion rate of screening, the investigators will also conduct surveys and qualitative interviews to look at patient and clinician factors that might impact the effectiveness of the interventions.
“Our early work evaluating behavioral interventions provided us with important insights with short-term results,” Dr. Mehta said. “It will be helpful to have funding to evaluate the effectiveness of these approaches in a 3-year trial with longer-term outcomes.”
Dr. Mehta is the associate chief innovation officer at Penn Medicine and an assistant professor of medicine and health policy at the Perelman School of Medicine. He is also the co-director of quality for the Division of Gastroenterology.