Promoting Veteran-Centered Colorectal Cancer Screening

背景：结直肠癌筛查是一项被广泛推荐的循证预防服务。 传统上，这一点一直没有得到充分利用。在过去的十年里，退伍军人健康组织的努力 政府(VHA)在退伍军人中增加结直肠癌人口筛查的努力取得了成功。但 这些以人群为中心的努力以一种并不总是一致的方式增加了筛查利用率 有筛查福利，特别是患有合并症的老年退伍军人。随着患者年龄的增长和 一旦发现健康问题，筛查的好处就会减少，筛查的潜在危害就会增加。 然而，现有的以人口为中心的努力未能充分告知年长、健康状况较差的患者这一点。 改变利与害的平衡，往往会产生与效益不一致的筛选利用。 目标：(1)评估以退伍军人为中心的三部分干预(VC)与务实对照的影响 (PC)关于整群随机对照试验中CRC筛查顺序的频率； 过程评估，以确定实施以退伍军人为中心的结直肠癌筛查的障碍和促进者 以及我们干预的任何意想不到的负面影响；以及，(3)制定一个可实施的、经验丰富的- CRC筛查的以中心为中心的性能衡量，纳入了对 决策过程以及是否进行了筛查。 方法：我们提出一项研究，旨在促进在个体中进行更多以退伍军人为中心的结直肠癌筛查。 年龄70-75岁，患有合并症。在目标1中，我们将测试由三部分组成的干预措施：(1)辅助决策 帮助退伍军人做出明智的筛查决定；(2)教育提供者了解筛查的好处 根据年龄和健康状况的不同而不同；以及(3)修改绩效测量和临床 提醒系统，允许退伍军人在知情的情况下做出筛查决定(包括知情的 决定不进行筛选)。干预措施将在一项务实的整群随机对照试验中进行测试 (群集=提供商)位于退伍军人事务部医疗保健系统的两个站点。主要结果将是 在诊所就诊时要求进行筛查。我们亦会评估甄别令是否适当(即， 筛查是否与筛查效益一致)、筛查的概念性理解、 筛查讨论中讨论的知情决策要素，以及筛查利用情况 月份。在目标2中，我们将进行一次进程评估，为今后的执行工作提供信息。最后，在AIM中 3，我们将使用在目标1和目标2中收集的信息，并与退伍军人和 由VHA运营部门的专家和合作伙伴组成的顾问小组，以制定更以退伍军人为中心的绩效 CRC筛查的措施。 影响：该项目将导致一项以退伍军人为中心的结直肠癌筛查在更广泛的 规模，有机会衡量这种做法的效果。此外，这将导致 开发以退伍军人为中心的绩效衡量标准，可以进行测试，并有可能推广到其他 筛查和预防服务。从这项工作中吸取的经验教训最终可能为 以更加以退伍军人为中心的方式提供预防性护理。

Background: Colorectal cancer (CRC) screening is a widely recommended, evidence-based preventive service that has traditionally been underused. Over the last decade, organized efforts by the Veterans Health Administration (VHA) to increase population screening for CRC among Veterans have been successful. But these population-centered efforts have increased screening utilization in a way that is not always concordant with screening benefit, particularly among older Veterans with comorbid illness. As patients get older and acquire health problems, the benefit of screening decreases and the potential harm of screening increases. Yet, existing population-centered efforts fail to adequately inform older, less healthy patients about this changing balance in benefit and harm, often yielding screening utilization that is discordant with benefit. Objectives: (1) to evaluate the impact of a 3-part Veteran-centered intervention (VC) versus pragmatic control (PC) on the frequency of CRC screening orders in a cluster-randomized controlled trial; (2) to perform a process evaluation to identify barriers and facilitators to implementation of Veteran-centered CRC screening as well as any unintended negative effects of our intervention; and, (3) to develop an implementable, Veteran- centered performance measure of CRC screening that incorporates an assessment of the quality of the decision-making process as well as whether or not screening was performed. Methods: We propose a study aimed at promoting more Veteran-centered CRC screening among individuals aged 70-75 with comorbid illness. In Aim 1, we will test a 3-part intervention consisting of: (1) a decision aid to help Veterans make informed screening decisions; (2) education for providers on how the benefits of screening vary according to age and health status; and (3) modification of performance measurement and clinical reminder systems to allow Veterans to make informed decisions about screening (including the informed decision to not be screened). The intervention will be tested in a pragmatic cluster-randomized controlled trial (cluster = provider) at two sites in the VA Ann Arbor Healthcare System. The primary outcome will be whether screening was ordered at the clinic visit. We will also assess the appropriateness of screening orders (i.e., whether screening is ordered in concordance with screening benefit), conceptual understanding of screening, elements of informed decision-making addressed in the screening discussion, and screening utilization at 6 months. In Aim 2, we will perform a process evaluation to inform future implementation efforts. Finally, in Aim 3, we will use the information collected in Aims 1 and 2 and work with an advisory panel of Veterans and an advisory panel of experts and partners from VHA operations to develop a more Veteran-centered performance measure of CRC screening. Impacts: This project will lead to an implementation study of Veteran-centered CRC screening on a broader scale, with the opportunity to measure the effects of such an approach. Furthermore, it will lead to the development of Veteran-centered performance measures that can be tested and potentially extended to other screening and preventive services. Lessons learned from this work may ultimately provide a model for delivering preventive care in a more Veteran-centered way.