Facilitating Shared Decisionmaking About Prostate Cancer Screening
Melissa R. Partin PhD
VA Medical Center
Minneapolis, MN
Funding Period: July 2000 - December 2002

BACKGROUND/RATIONALE:
Due to the disputed efficacy of prostate cancer (CaP) screening and treatment, most authorities recommend that providers inform and involve patients in CaP screening decisions.

OBJECTIVE(S):
This study evaluated two interventions designed to facilitate this process.

METHODS:
1152 male veterans age 50+ with no CaP and primary care appointments at four VA medical facilities in VISN 23 were randomly assigned to one of three groups: mailed pamphlet intervention, mailed video intervention, or usual care (control). Intervention materials were mailed two weeks prior to a target primary care appointment and patient telephone surveys were conducted one week (T1) and one year (T2) after the target appointment. Outcomes included: a 10- item validated knowledge index; responses to questions on CaP natural history, treatment efficacy, PSA accuracy, and expert disagreement about the PSA; whether screening was discussed with provider; scores on decision information seeking, participation and satisfaction scales; screening and treatment preferences; and PSA testing rates.

FINDINGS/RESULTS:
The survey response rates were 80% at T1 and 70% at T2 (81% for those completing the T1 survey). Mean scores on the knowledge index were higher for video (7.44, p=.001) and pamphlet (7.26, p=.03) subjects, relative to controls (6.90 ). Video and pamphlet subjects reported significantly higher percentages of correct responses relative to controls to questions on CaP natural history (63, 63, and 54% respectively); treatment efficacy (19, 20, and 5%) and expert discagreement (28, 19, and 8%), but not PSA accuracy (28, 22, and 22%). The percent of pamphlet subjects discussing screening with their provider was significantly higher relative to controls (41 versus 32%, p=.03) but the percent of video subjects was not (35%, p=.33). Video and pamphlet subjects were less uncertain about CaP screening decisions, as indicated by significantly lower scores on O'Connor's Factors Contributing to Uncertainty scale. Pamphlet subjects were significantly more likely than controls to seek information on CaP screening at their last visit, but video subjects were not, as indicated by scores on Lerman's Information Seeking scale. Both intervention groups were significantly more likely than controls to participate in decisions about CaP screening, as indicated by their higher scores on Lerman's Decision Making participation scale. There were no differences across groups on Holmes-Rovner's Satisfaction with Decision scale. The percentage of subjects intending to have a PSA test in the next year was significantly higher for controls (74%), relative to both video (63%, p=.003) and pamphlet (65%, p=.02) subjects. The percentage of subjects preferring watchful waiting as a treatment option was significantly lower for controls (44%) relative to both video (56%, p=.003) and pamphlet (54%, p=.02) subjects. The percentage of video, pamphlet and control subjects receiving a PSA did not differ significantly across grops at either two weeks (29, 28, and 29% respectively) or one year (70, 67, and 69%) post target appointment. Knowledge declined between T1 and T2 for both intervention groups, but at T2 video subjects continued to show significant improvement over the control group. The pamphlet group only retained significant improvement over the control group at T2 for the treatment efficacy question. T2 screening and treatment preference contrasts with controls were only significant for video subjects.

IMPACT:
Patient knowledge and decision participation can be enhanced through the use of either of the study interventions. The pamphlet is lowere cost and has a more pronounced effect on decision participation, but the video has a more lasting effect on knowledge and preferences.

PUBLICATIONS:

Journal Articles

1. Partin MR, Nelson D, Flood AB, Friedemann-Sánchez G, Wilt TJ. Who uses decision aids? Subgroup analyses from a randomized controlled effectiveness trial of two prostate cancer screening decision support interventions. Health Expectations. 2006; 9(3): 285-95.
2. Taylor BC, Wilt TJ, Clothier B, Grill JP, Partin MR. Assessing health status in older men with lower urinary tract symptoms. Federal Practitioner. 2006; 23(7): 29-40.
3. Wilt TJ, Partin MR. Reducing PSAnxiety: The importance of noninvasive chronic disease management in prostate cancer detection and treatment. American Journal of Medicine. 2004; 117(10): 796-8.
4. Partin MR, Nelson D, Radosevich D, Nugent S, Flood AB, Dillon N, Holtzman J, Haas M, Wilt TJ. Randomized trial examining the effect of two prostate cancer screening educational interventions on patient knowledge, preferences, and behaviors. Journal of General Internal Medicine. 2004; 19(8): 835-42.
5. Radosevich DM, Partin MR, Nugent S, Nelson D, Flood AB, Holtzman J, Dillon N, Haas M, Wilt TJ. Measuring patient knowledge of the risks and benefits of prostate cancer screening. Patient Education and Counseling. 2004; 54(2): 143-52.
6. Wilt TJ, Partin MR. Prostate cancer intervention. Involving the patient in early detection and treatment. Postgraduate Medicine. 2003; 114(4): 43-9; quiz 50.

DRA: Chronic Diseases, Health Services and Systems
DRE: Communication and Decision Making, Prevention
Keywords: Cost effectiveness, Education (patient), Screening
MeSH Terms: Decision Making, Health Behavior, Patient Education, Decision Support Systems, Management