How Shared-Decision Making is Improving Colorectal Cancer Screening Rates

A Blue Cross Blue Shield of Massachusetts (BCBS-MA) pilot increased rates while signaling a shift to home-based screening.

"This is the beginning of the shift from colonoscopy to home screening."

This from Laura Carr, PharmD, director of Provider Performance at BCBS-MA.

The beginning she refers to is a BCBS-MA pilot with Beth Israel Lahey Health (BILH) and healthcare data analytics company Arcadia. The pilot used shared decision-making (SDM) to help patients choose whether office or facility-based colorectal cancer (CRC) screening was best for them. With SDM, patients, providers, and payers partner on treatment and care decisions for better outcomes.

In an exclusive interview with HealthLeaders, Dr. Carr detailed the goals and results of the pilot, the use of text-based messaging to jump start patient engagement, the role of the EMR in identifying screening gaps, and how SDM approaches support health equity.

CRC screening pilot goals and results

The pilot's goal was to improve CRC screening rates, starting with the patient-PCP visit. In a November 2022 webinar on the pilot, hosted by Arcadia, Carr stated: "SDM was a new approach, overall and for CRC screening options."

She noted that BCBS-MA wanted to:

• improve quality outcomes
   
• address disparities
   
• give patients choice
   
• demonstrate the power of tracking and reporting
   
• exceed national CRC screening goals.

From January 2022 to September 2022, completed CRC screenings have increased 10%. Within that group, the number of patients choosing a home-based CRC screening versus a colonoscopy increased from 5% to 20%.

A text-based patient communications campaign was central. During the pilot, BILH sent 17,000 text messages—more than 13,000 in three languages—to patients with a CRC screening gap.

That gap included patients aged 45-49. In 2018, the American Cancer Society recommended that initial CRC screening be lowered from age 50 to prevent emerging, earlier-age CRC cases and deaths—particularly among racial and ethnic minority groups. In 2021, the United States Preventive Services Task Force followed suit, along with multiple cancer stakeholder groups.

"As a provider, your entire patient pop ages into CRC screening. Going back further to catch ages 45-49 is a big group. Pre-pilot, the screening rate for that group was low. So the objective is, 'How can we help get all necessary screening done.' If you're at lower risk for CRC, you have more options."

This from Tim Carey, clinical operations project manager (Performance Network) at BILH, as quoted from the Arcadia webinar.

Identifying patients, selecting outreach methods

BILH and BCBS-MA used the patient data stored on their Arcadia platform to identify the right patients. They set parameters to contact patients within the eligible age range for CRC screening (45-75). 

During the first year of the partnership, the group designed the project, educated providers, surveyed patients for baseline, and decided on their patient outreach methods. The group landed on text outreach, paired with a patient SDM decision aid for CRC.

"We decided to send the decision aid in advance of the doctor visit because we want patients to learn about their options so they can have an informed discussion with their provider and then come to a shared decision about which tests to undergo, if any."

That's from Dr. Kim Ariyabuddhiphongs, associate chief medical officer at BILH's Performance Network, in a BCBS-MA article stating that patients and clinicians provided input on the decision aid, which was translated into six languages.

The power of text and the EMR

At a time when digital health is focused on apps and AI, why did the pilot focus on text communication?

"The first phase of the pilot was to demonstrate the effectiveness of SDM," Carr said. "The BILH providers could operationalize text efficiently and create and modify those messages to inform patients of the SDM tool."

In addition, data from the Arcadia webinar shows that younger patients are more likely than older ones to use a cell phone—important to know when you want to improve CRC screening rates among that population.

In the Blues-BILH pilot, 84% of patients aged 40-49 received text messages compared to 55% of patients aged 70-79.

Provider EMR capabilities also play an important role, both for identifying gaps and putting SDM tools at the fingertips of PCPs while they meet with patients.

"EMRs can generally flag for gaps in care including cancer screening. Different EMRs have different capabilities, which impacts the effectiveness of these flags," Carr said.

She added: "Outside the EMRs, providers still have online and paper-based tools for patients in the pilot who couldn't access the tool through the text message. Some EMRs allow the shared decision-making tool to be embedded right in the visit note or a link to it. We're trying to work with providers to get the tool embedded right in the EMR."

Carr notes that the pilot's four-fold increase in CRC screening completion using shared-decision making can help the industry exceed national CRC screening goals—which is currently 80% and largely unmet. In the webinar, she stresses: "The more cases found and found early, the more lives saved and beyond the colonoscopy status quo … This is the beginning of the shift from coloscopy to home screening."

Nina Zelcer agrees. She is senior manager of Life Sciences at Arcadia, which "transforms data from disparate sources into targeted insights and puts them in the decision-making workflow to improve lives and outcomes," per a company representative.

In her company's webinar, Zelcer noted: "Pilots like this shift VBC from facilities to wherever you can get care. It stresses the importance of bringing care into the home that occurred due to COVID."

The power of SDM and its link to health equity

Despite its effectiveness, SDM is still catching on.

"The resistance to shared decision-making comes because not everyone is familiar with it. Another factor is ensuring SDM tools are easy to use and that the best resources are available to enable provider conversations with patients," Carr said.

She added: "Uptake of the model can be slow because the upfront time to implement it can be seen as a barrier. There is some provider hesitation due to the perceived added time that SDM will take. But the BILH provider experience did not bear this out.

"Shared decision-making allows providers to truly operationalize patient-centered care so that patients can understand, make informed decisions, and be empowered. The provider hears the patient's preferences and circumstances and incorporates them. It really is a win-win-win for patients, providers, and health plans."

Carr noted that BCBS-MA plans are working with multiple providers to expand SDM's use. Health equity is a big reason why.

"Shared decision-making is a tool that helps improve equity," she said. "SDM helps patients and providers make choices together that will work better for the patient, which can help prevent delays in screenings. In the case of colorectal cancer, the longer screening is delayed, the poorer the outcomes. Early is better."