Low-risk Adenoma Surveillance Decision-making: - PowerPoint Presentation

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Low-risk Adenoma Surveillance Decision-making: Perspectives from Patients and Providers

Indiana Clinical and Translational Sciences Institute 2021 Annual Meeting

Jennifer K. Maratt, MD, MS

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Mentors:

Thomas F. Imperiale, MD1Marianne S. Matthias, PhD11Department of Medicine, Indiana University School of Medicine; Richard L. Roudebush VA Medical Center; Regenstrief Institute, Inc.

Acknowledgment: Indiana Clinical and Translational Sciences Institute (KL2 Program), UL1TR002529 (S. Moe and S.

Weihe

, co-PIs), 5/18/2018 – 4/30/2023 

BackgroundColonoscopy is an important tool for screening and surveillance in gastroenterology (GI)

Common indication for surveillance colonoscopy: post polyp resectionHowever, not all polyps are the sameHigh vs low risk adenomas (high vs low risk of future colorectal cancer)Surveillance colonoscopy is underused for high risk adenomas, overused for low risk adenomasWhat role do patients and providers play? What role do they want to play?

BackgroundThe primary aim of this study is to understand patient and provider perspectives for decision-making for low-risk adenoma surveillance colonoscopy.

Domains covered will include: Perceived involvement with decision-making for surveillanceContent of pre-procedure discussionsPatients’ barriers & facilitators to undergoing colonoscopy

MethodsQualitative approach: semi-structured, one-on-one virtual interviewsPatients and providers at Richard L. Roudebush VA and

Eskenazi:Patients: 50-75 years of age; screening colonoscopy at the VA or Eskenazi with finding of low-risk adenomasPrimary care providers and gastroenterologistsPlanned to recruit 8 patients and 8 providers per siteThematic saturationData collection and analysis: Immersion-crystallization framework

Results

ThemePrimary Care Providers (n=8)Gastroenterologists (n=6) Timing of surveillanceMost PCPs believed that guidelines were difficult to keep up with, therefore, rarely use them in practice. Most rely on either colonoscopy reports, pathology letters, and/or reminders through EHR for timing of repeat colonoscopy.If interval recommended is a range of years, then most will recommend shortest interval.Some believed that giving PCPs a range of years for surveillance interval could confuse them.When a range of years is recommended based on guidelines (i.e., 7-10 years for LRAs), most recommend the shortest interval within the range.If a patient presents before they are due, most proceed with the colonoscopy unless patient prefers otherwise.

Pre-procedure discussionsFew have in-depth discussions aside from whether or not to proceed.

PCPs expressed greater comfort with benefits discussion (vs. risks).

Many defer in-depth discussions to GI. Informed consent obtained at time of meeting patient right before colonoscopy.

All elements discussed except most believed that a discussion about alternatives not relevant at that time and place more emphasis on risks (vs benefits).Surveillance decision-makingWhen asked whose domain surveillance decision-making is currently in, most believed that it was either shared equally between GIs and PCPs, or more in GI’s domainWhen asked whose domain it should be in, most said GI where as few said PCP

When asked

whose domain surveillance decision-making is currently in

, all believed that it was in GI’s domain

When asked

whose domain it should be in

, most said GI where as few said PCP

Patients for whom decision-making is perceived as difficult

Older adults

Those with multiple comorbidities, on anticoagulation

Those who are hesitant/reluctant

Older adults

Those with multiple comorbidities

Frail adults

When to stop surveillance

Results

ThemePatients (n=16) Timing of surveillance/involvement with surveillance decision-makingMost felt very involved in the decision-making although relied heavily on PCPs’ recommendations.Most rely on PCPs to remind them when they are due (in VA—many also recalled receiving a reminder letter in mail). Trust in PCPs cited as most common reason. Pre- and post-procedure discussionsMost do not recall pre-procedure discussions, including indication, risks, alternatives.Most recalled receiving letters with results, few recalled details of letters.Difficulty with recollection of recommended surveillance intervalBarriers to undergoing colonoscopyCultural – some prefer home remedies over Western medicine

Hearing about bad experiences through social networksBowel preparation

Facilitators to undergoing colonoscopy

Ease of testSocial support through relatives, friendsHaving a driverFeeling engaged in their own healthcare

Future DirectionsNeed to understand decision-making for high-risk adenoma surveillance Findings from these studies will be used to develop an intervention to optimize efficiency of endoscopy use