Behavioral Economic Approaches for Population-based Colorectal Cancer Screening

项目总结/摘要 尽管有有效的预防、早期发现和治疗策略，但结直肠癌（CRC） 仍然是美国癌症死亡的第二大原因。虽然有相当多的 尽管政策和系统层面努力提高CRC筛查率，但筛查率仍远低于国家目标， 80%的参与率，种族/民族差异仍然存在。结肠镜检查和FIT被认为是基于证据的 和顶级测试CRC筛查，但大多数筛查计划严重依赖于这些测试之一。 该提案的总体目标是评估一种多层次的干预措施， CRC筛查率通过纳入行为经济学的原则，如选择退出框架，简化 选择和减少努力。通过与宾夕法尼亚大学卫生系统（UPHS）的合作， 我们将制定一个集中的计划，其中包括由电子健康促进的临床医生指导的推动， 记录（EHR）和直接外展到病人。我们还将评估顺序选择的有效性 （结肠镜检查，然后对那些推迟或拒绝的人进行FIT）与仅提供结肠镜检查相比。 这是一项为期3年的实用性临床试验，采用2x 3析因设计，在30个不同的初级保健实践中进行 有两万名平均风险的病人逾期未进行筛查。临床医生将以1：1的比例进行分组随机化 比率（在实践水平）：A）仅结肠镜检查，或B）序贯选择（结肠镜检查，如果否，则FIT 结肠镜检查完成）在门诊访视期间在EHR中轻推（目标1）。同时，患者将 以1：2：2的比例单独随机分配至1）无外展，2）仅结肠镜检查，或3）序贯选择外展 结肠镜检查，然后FIT（目标2）。主要结局是完成指南推荐的结直肠手术 癌症筛查通过调查和定性访谈，我们将探讨患者和临床医生的因素 影响干预的有效性。

PROJECT SUMMARY/ ABSTRACT Despite effective strategies for prevention, early detection, and treatment, colorectal cancer (CRC) remains the second leading cause of cancer death in the United States. While there have been considerable policy and system-level efforts to increase CRC screening rates, uptake remains well below national goals of 80% participation, and racial/ethnic disparities remain. Colonoscopy and FIT are considered evidence-based and top-tier tests for CRC screening, but most screening programs rely heavily on one of these tests. The overall goal of this proposal is to evaluate a multi-level intervention that could durably increase CRC screening rates by incorporating principles of behavioral economics, such as opt-out framing, simplifying choice, and effort reduction. Through partnership with the University of Pennsylvania Health System (UPHS), we will develop a centralized program that includes clinician-directed nudges facilitated by the electronic health record (EHR) and direct outreach to patients. We will also evaluate the effectiveness of sequential choice (colonoscopy, then FIT to those who defer or decline) compared to offering colonoscopy only. This is a 3-year pragmatic clinical trial with 2 x 3 factorial design at 30 diverse primary care practices with 20,000 average-risk patients who are overdue for screening. Clinicians will be cluster randomized in a 1:1 ratio (at the practice level) to A) colonoscopy only, or B) sequential choice (colonoscopy, then FIT if no colonoscopy is completed) nudges in the EHR during clinic visits (Aim 1). Concurrently, patients will be individually randomized in a 1:2:2 ratio to 1) no outreach, 2) colonoscopy only, or 3) sequential choice outreach of colonoscopy, then FIT (Aim 2). The primary outcome is completion of guideline-recommended colorectal cancer screening. Through surveys and qualitative interviews, we will explore patient and clinician factors impacting the effectiveness of the intervention.