A Novel Curriculum on Using Life Expectancy to Inform Cancer Screening in Older Adults

Abstract

Background:

Many older adults with limited life expectancy still receive cancer screening. One potential contributor is that primary care providers (PCP) are not trained to incorporate life expectancy in cancer screening recommendations. We describe the development and evaluation of a novel curriculum to address this need.

Methods:

We developed and implemented a web-based learning module within a large Maryland group practice with PCPs for older adults. We assessed attitude, knowledge, self-efficacy, and self-reported behavior outcomes before the module, immediately after completing the module, and 6 months afterwards.

Results:

Of 172 PCPs who were invited, 86 (50%) completed the module and of these, 50 (58.1%) completed the 6-months follow up survey. Immediately after the module, there was a significant increase in perceived importance of life expectancy (increase of 0.50 point on 10-point scale, 95% Confidence Intervals [CI] 0.27-0.73), confidence in predicting life expectancy (increase of 2.32 points on 10-point scale, 95% CI 1.95- 2.70) and confidence in discussion screening cessation (increase of 1.69 points on 10-point scale, 95% CI 1.37- 2.02). Knowledge in patient-preferred communication strategies improved from 55% correct response to 97% (p<0.001). However, most of these improvements dissipated by 6-months and there was no change in self-reported behavior at 6-months compared to baseline (p=0.34).

Conclusion:

Although the module resulted in significant short-term improvement in attitude, knowledge and self-efficacy, the changes were not sustained over time. Educational interventions such as this can be coupled with ongoing reinforcing strategies and/or decision support interventions to improve cancer screening practices in older adults.

Introduction:

Although cancer screening is an important part of preventive primary care to reduce cancer-specific mortality and morbidity, the lag time to benefit for cancer screening is often close to a decade.^1,2 On the other hand, a number of harms and burdens of screening can occur in the short-term, such as complications from the screening and false positive results leading to more invasive tests.^3,4 Traditionally, age-based criteria are used to decide when to stop routine cancer screening.⁵ However, reliance on age alone to determine the appropriateness for cancer screenings can be problematic since health trajectories in older adults of the same age can vary widely.⁶ Life expectancy estimates that incorporate health conditions and functional status along with age are increasingly recognized as an important consideration in cancer screening.^7,8 A growing body of research and clinical practice guidelines now recommend against routine cancer screening for breast, colorectal, and prostate cancers in older adults with limited life expectancy because they are more likely to be harmed than to benefit from routine screening.^{9,10 ,11,12,13,14,15,16} Despite these recommendations, there is overuse of cancer screening in individuals with limited life expectancy, leading to suboptimal use of healthcare resources and psychological and physical harm from complications. ^17,18 At the same time, there is underuse of cancer screening in healthy older adults.^6,19

One potential contributor is that primary care providers (PCP) are not adequately trained to incorporate life expectancy in their cancer screening recommendations. Most PCPs receive no or minimal training in estimating life expectancy and find it stressful and difficult to integrate prognostic information into care discussions.^20,21 Although validated prognostic tools exist, awareness and use of these tools are limited.²¹ There is no existing published curriculum on how to discuss stopping routine preventive services such as cancer screening. As a result, PCPs may be challenged to quantify a patient’s life expectancy and are often uncomfortable in discussing screening cessation with patients with limited life expectancy.^21,22 Although we previously developed and implemented a curriculum to teach first-year internal medicine residents to incorporate prognosis in the care of older adults,²³ this curriculum did not focus on cancer screening, targeted learners at much earlier stages of clinical training, and involved three in-person sessions that were 1-3 hours long which would not be easily feasible for practicing clinicians. In the current project, we describe the development and evaluation of a novel curriculum that teaches primary care physicians to use life expectancy to inform breast, colorectal, and prostate cancer screening in older adults.

Methods:

Curriculum development and implementation

The curriculum was developed during a structured, year-long curriculum development course using methods by Kern et al.²⁴ Our target learners were practicing primary care clinicians who cared for older adults; as such, we informally elicited feedback from 16 primary care physicians from our institution throughout module development and iteratively revised curriculum materials based on their input. The finalized curriculum was a 15-minute web-based asynchronous learning module.

The module included 3 sections. Section 1 focused on the evidence base around the importance of life expectancy in cancer screening; these included discussion of the lag-time to benefit in cancer screening in contrast to the short-term harms and burdens, that older adults of the same age have very heterogeneous health trajectories, and as a consequence, guidelines now increasingly use life expectancy to guide screening decision-making. Section 2 used a demonstration video to showcase available evidence-based prognostic tools (ePrognosis)²⁵ that can aid clinicians in predicting life expectancy. Section 3 presented evidence-based communication strategies for discussing screening cessation with patients. See Appendix for more details about the curriculum content.

We partnered with a large academically affiliated group practice (AGP) with more than 200 primary care providers and a diverse patient base including 254,500 patients, 21% of whom were 65 years or older. The AGP agreed to implement the module as part of a “High-Value Care Initiative” training for their PCPs using their designated online learning platform. The module was approved for both the Maintenance of Certification (MOC) and Continuing Medical Education (CME) credits.

Participants and Recruitment

The module was offered to all employed and clinically active PCPs (physicians, physician’s assistants, and certified registered nurse practitioners) who provided primary care for older adults (65 years or older), including those in Internal Medicine, Family Medicine, or Medicine/Pediatrics clinics. Trainees were excluded from the study. Eligible PCPs received email invitation to take the curriculum and participate in the research study from the AGP leadership. A $10 gift card was provided for completing the module including the baseline and immediately post-module assessments. All PCPs who completed the module were sent email invitations to complete a follow up survey 6 months after module completion. Another $20 gift card was provided for completing the follow up survey. The project was approved by a Johns Hopkins Institutional Review Board. Completion of the module and completion of the follow up survey served as consent to participate in the study.

Curriculum evaluation

The evaluation of the curriculum included assessment at three time points – immediately before the module, immediately after the module completion, and an online survey 6 months after completion of the module. Primary outcomes of the study were any change in attitude, knowledge, self-efficacy, and self-reported behavior regarding incorporating life expectancy in cancer screening. Secondary outcome included acceptability of the curriculum. Details on wording of the evaluation questions are included in the Appendix. We iteratively piloted and revised both the content of the curriculum and the wording of the evaluation questions with primary care physicians not included in the study.

Attitudinal and knowledge measures

At all three time points, we included identical questions that assessed attitude regarding the importance of life expectancy in cancer screening, self-efficacy around confidence to estimate life expectancy and to discuss screening cessation with patients, and knowledge on patient-preferred communication strategies to discuss screening cessation. Attitudes and self-efficacy were measured on a 10-point Likert scale (1=not at all important/confident, 10=extremely important/confident). Knowledge assessment used a multiple-choices question where five phrases to discuss screening cessation are presented; choosing the phrase taught in the curriculum that was shown to be most preferred in a national survey of older patients was coded as “correct;” all other choices were coded as “incorrect.”

Behavior changes

To assess behavior change, we asked, at baseline and at 6 months follow up, about frequency of considering life expectancy in cancer screening decisions of older patients in the past month (<25%, 25%, 50%, 75%, nearly all older patients). We also asked, at 6-months follow up only, how often the respondents have used the module content in their clinical practice around cancer screening of older adults.

Module acceptability

A set of standardized questions used by the AGP on acceptability and general ratings of the curriculum were asked immediately after completing the module, all of which used 5-point Likert scales (1=strongly disagree, 5=strongly agree).

Data Collection and Analysis

We compared responses immediately after module completion to baseline and compared the 6-months follow up responses to baseline. Likert scale responses were compared using the paired t-test. Categorical responses were compared using the McNemar test (for two categories) or the marginal homogeneity test (for more than two categories). Acceptability responses were summarized descriptively. Statistical analyses were performed using STATA 13.0 (StataCorp LP, College Station, TX)

Results:

A total of 179 PCPs met eligibility criteria and were invited to participate in the module in April 2019. Seven PCPs left the practice during the curriculum enrollment (April 2019-January 2020) and were excluded from the study. Eighty-six (50.0%) PCPs from 34 clinics completed the module, the baseline assessment, and the assessment immediate after module completion (Table 1). Participants’ mean age was 47.8 years. Majority were women (62/86, 73.3%) and physicians (62/86, 72.1%). Clinician specialty included internal medicine (39), family medicine (34), Medicine/Pediatrics (11), and Emergency Medicine (2). Of these 86 participants, 50 (58.1%) completed the 6-months follow up survey. Responders and non-responders to the 6-months follow up survey were not significantly different in age, sex, or clinician type.

Table 1:

Baseline Characteristics of Participants: (n=86)

Category		Number (%)
Gender	Male	23 (27)
	Female	63 (73)
Age	20-34	8 (9.3)
	35-44	31 (36)
	45-64	37(43)
	>65	10 (11.6)
Qualifications	Physicians	62 (72.1)
	Nurse Practitioner	20 (23.3)
	Physician Assistant	4(4.7)
Specialty	Internal Medicine	39 (45.3)
	Family Medicine	34 (39.5)
	Medicine/ Pediatrics	11 (12.8)
	Emergency Medicine	2 (2.3)
Ethnicity	White	38 (44.1)
	Asian	20 (23.3)
	Blacks	5 (5.8)
	Hispanic	1 (1.2)
	Middle Eastern	1 (1.2)
	Unknown	21 (24.4)

Comparing responses immediately after module completion to baseline, we found significant increase in all assessment areas (Figure 1). At baseline, perceived importance of life expectancy was 9.02 on a 10-point scale, this increased to 9.52 after module completion (0.50-point improvement, 95% CI 0.27-0.73). The baseline confidence in predicting life expectancy was 5.72 on a 10-point scale, this increased to 8.04 after module completion (2.32 points improvement, 95% CI 1.95- 2.70). The baseline confidence in discussion screening cessation was 6.72 on a 10-point scale, this increased to 8.41 after module completion (1.69 points improvement, 95% CI 1.37- 2.02). Knowledge in patient-preferred communication strategies improved from 55% correct response to 97% (p<0.001).

Figure 1:

Curriculum evaluation results: we assessed: a) attitude regarding importance of life expectancy in cancer screening b) self-efficacy/ confidence regarding estimating life expectancy in older adults, c) self-efficacy/ confidence regarding communicating a recommendation to stop cancer screening in older patients, d) Knowledge regarding patient –preferred strategies to discuss careening cessation.

^a We conducted 2 comparisons: 1) we compared responses immediately after module completion to baseline; 2) we compared the 6-months follow up responses to baseline. Likert scale responses were compared using the paired t-test. Categorical responses were compared using the McNemar test. ** denotes p-value <0.001 * denotes p-value of 0.05.

^b Attitude and self-efficacy questions were measured on a 10-point scale where 1=not at all important and 10=extremely important.

^c Knowledge assessment used a multiple-choices question where five phrases to discuss screening cessation are presented; choosing the phrase taught in the curriculum that was shown to be most preferred in a national survey of older patients was coded as “correct;” all other choices were coded as “incorrect.”

When examining baseline responses to those 6 months after the module, we found that most of these improvements dissipated by 6 months. The improvements were smaller in all assessment areas (Figure 1); the only comparison reaching statistical significance was in confidence predicting life expectancy (0.57-point improvement, 95% CI 0.01-1.14).

In terms of self-reported behavior, we first compared self-reported frequency of considering life expectancy in older patients’ cancer screening decisions in the previous month at baseline and at 6-months follow up. We found that 24/50 (48%) participants reported no change, 10/50 (20%) reported higher frequencies, and 16/50 (32%) reported lower frequencies, but overall, the changes are not statistically significant (p=0.34). We also asked, at 6-months follow up only, how often the respondents used the module content in their clinical practice around cancer screening of older adults. We found that 23/50 (46%) participants reported using the ePrognosis tools at least sometimes and 45/50 (90%) reported using the communication strategies to discuss stopping cancer screening at least sometimes.

Acceptability of the curriculum, as measured immediately after completing the module, was high; 96.5 % of participants reported that they would apply what they learned in their work and 94.2% of participants reported that they would recommend the course (Table 2).

Table 2.

Acceptability and curriculum ratings.

Question	% of 86 participants who agreed or strongly agreed with the statement
1. Educational objectives were clearly stated	96.5
2. Course achieved its educational objectives	96.5
3. The subject matter was clearly presented	97.7
4. The method of instruction was effective	97.7
5. The course was easy to navigate	97.7
6. The length of this course was appropriate	97.7
7. I will apply the information I have learned to my work	96.5
8. I will incorporate the communication strategies for stopping cancer screening in my clinical practice.	96.5
9. I will incorporate evidence- based tools & communication methods preferred by older adults in my clinical practice.	95.3
10. I would recommend this course.	94.2

Discussion:

Despite national guidelines recommending against routine cancer screening in older adults with limited life expectancy,^{9,10,11,12,13,14,15,16} many of these patients continue to receive screening which leads to patient harms and burdens with little chance of benefits.²⁶ Physicians perceptions of cancer screening risk and benefit influence their recommendation which in turn results in patient’s screening decisions.²⁷ A framework that has been widely used to understand the barriers of translating scientific knowledge into clinical practice highlights the importance of clinician knowledge, attitudes, and self-efficacy as necessary first steps before behavior change.²⁸ We developed an online educational module to teach primary care providers how to incorporate life expectancy to guide breast, colorectal, and prostate cancer screening decision-making in their older patients and how to discuss screening cessation. Our curriculum is unique as it offers a comprehensive approach to incorporating life expectancy in cancer screening decisions. The ePrognosis website contains life expectancy calculators and video tools but these are not integrated in a cohesive curriculum.²¹

In this study, we found that the online module was highly rated by primary care providers and a high percentage reported applying module content to their clinical practice at 6 months, suggesting feasibility and acceptability. We found that, at completion of the module, the learners showed significant improvements in perceived importance of life expectancy, their confidence to estimate life expectancy, their confidence to discuss screening cessation recommendations with their patient, and knowledge around patient-preferred strategies to discuss screening cessation. These findings suggest that these domains – attitude, knowledge, self-efficacy, which are all necessary steps prior to behavior change²⁸ - can be impacted by educational intervention.

These improvements, however, waned over time by 6 months. Similar wane of efficacy over time has been shown for a number of other online learning modules, highlighting the critical challenge of knowledge retention from one-time educational interventions.²⁹ Adding more “hands-on” content to the curriculum that allow clinicians to practice applying the knowledge and skills could potentially enhance retention. More importantly, sustained retention of information likely would require continual reinforcement. This is often more easily implemented in undergraduate or graduate medical education and is more challenging for busy practicing clinicians.^30,31 Given that cancer screening is a relatively common decision in primary care setting, potential strategies to reinforce the content from our curriculum and to facilitate behavior change may include incorporating key content summaries within the electronic medical records (EMR), creating EMR templates and tools (such as EPIC dot phrases) to facilitate discussion and documentation of screening cessation, and embedding the e-Prognosis tools within the EMR as part of a decision support tool. Finally, methods of reinforcement that have shown promise in other areas included linking desired behavior change to recognition or rewards.³² As health care is increasingly focused on patient-centered care and limiting unnecessary overuse of resources³³, there may be opportunities where the appropriate cessation of cancer screening can be tied to positive rewards that then reinforce the behavior. For example, the American Geriatrics Society has implemented a “Choosing -Wisely Champion Award” to honor health professionals who choose tests and treatments wisely and inspire others to promote patient-centered, high-value care.³⁴

In terms of behavior change, we found no significant change in how often clinicians reported that they considered life expectancy in cancer screening at baseline versus 6 months after module completion. There is currently no clear consensus if life expectancy should always be considered in cancer screening of adults 65 years or older to guide an optimal target in this area. We were encouraged that almost half of the participants reported using ePrognosis tools and 90% of participants reported using communication strategies from the module after 6 months but we did not assess if this led to more accurate estimates of patients’ life expectancies or more effective clinician-patient communication.

Limitations of the study include that the participants were from a single large group practice and may not be generalizable to clinicians elsewhere. Clinicians who completed the module may be different from those who did not in important ways in terms of their cancer screening practices, resulting in selection bias that could affect the findings from this study. Important next steps to address this limitation and to expand the impact and rigor of this project includes partnering with the group practice to make this module a required training for all PCPs and to measure behavioral outcomes through chart reviews of clinical documentation and actual screening rates. A majority, but not all, of participants completed the follow up survey, resulting in smaller sample size and power to detect significant differences from baseline to 6-months follow up. We did not find significant differences in age, sex, or clinician type between responders and non-responders to the 6-months follow up survey. For some of the outcome measures, such as attitude towards the importance of life expectancy, the rating was high even at baseline so there could have been a ceiling effect in detecting the effect of the curriculum. We did not assess actual screening rates and relied on self-report to characterize behavior change which is subject to recall and social desirability biases and reporting errors. Lastly, this curriculum only aims to address one barrier of suboptimal screening practices, inadequate training of clinicians, but does not address other barriers such as time constraint, malpractice concerns, and age-based quality and performance metrics.¹⁵

In summary, we have developed a novel, feasible and acceptable online educational module for practicing PCPs that resulted in short-term improvement in attitude, knowledge, and self-efficacy on incorporating life expectancy in cancer screening of older patients. Effect waned over time and strategies to sustain and reinforce learning over time are important. Although this educational intervention alone may not be sufficient to effect long-term behavioral change, it can be an important component to be combined with other strategies to effect change in cancer screening practices and improve care of older adults.

Key Points Box:

• A brief web-based learning module was developed to teach primary care clinicians to use life expectancy to inform breast, colorectal, and prostate cancer screenings in older adults.

• The module showed short-term improvements in participants’ attitude, knowledge, self-efficacy but these effects waned by 6 months and there was no change in self-reported behavior at 6-months.

• Educational interventions such as this can be coupled with ongoing reinforcing strategies and/or decision support interventions to improve cancer screening practices in older adults.

“Why this paper matter”

Primary care clinicians are not adequately trained to incorporate life expectancy in cancer screening. Our feasible and acceptable curriculum addresses this need and demonstrates short-term improvement in attitude, knowledge, self-efficacy, which are all necessary steps prior to behavior change.