{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T21:30:18Z","timestamp":1778880618256,"version":"3.51.4"},"reference-count":40,"publisher":"American Medical Association (AMA)","issue":"12","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Intern Med"],"published-print":{"date-parts":[[2023,12,1]]},"abstract":"Importance<\/jats:title>Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults.<\/jats:p><\/jats:sec>Objective<\/jats:title>To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician\/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023.<\/jats:p><\/jats:sec>Intervention<\/jats:title>The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months.<\/jats:p><\/jats:sec>Results<\/jats:title>A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, \u22124.0 percentage points [pp]; 95% CI, \u221215.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P<\/jats:italic>\u2009=\u2009.049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, \u221213.4 pp; 95% CI, \u221225.3 to \u22121.6 pp).<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening.<\/jats:p><\/jats:sec>Trial Registration<\/jats:title>ClinicalTrials.gov Identifier: NCT02027545<\/jats:ext-link><\/jats:p><\/jats:sec>","DOI":"10.1001\/jamainternmed.2023.5656","type":"journal-article","created":{"date-parts":[[2023,10,30]],"date-time":"2023-10-30T15:37:59Z","timestamp":1698680279000},"page":"1334","source":"Crossref","is-referenced-by-count":4,"title":["Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults"],"prefix":"10.1001","volume":"183","author":[{"given":"Sameer D.","family":"Saini","sequence":"first","affiliation":[{"name":"Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan"},{"name":"Department of Internal Medicine, University of Michigan, Ann Arbor"},{"name":"Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Carmen L.","family":"Lewis","sequence":"additional","affiliation":[{"name":"General Internal Medicine, University of Colorado, Denver"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eve A.","family":"Kerr","sequence":"additional","affiliation":[{"name":"Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan"},{"name":"Department of Internal Medicine, University of Michigan, Ann Arbor"},{"name":"Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brian J.","family":"Zikmund-Fisher","sequence":"additional","affiliation":[{"name":"Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor"},{"name":"Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah T.","family":"Hawley","sequence":"additional","affiliation":[{"name":"Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan"},{"name":"Department of Internal Medicine, University of Michigan, Ann Arbor"},{"name":"Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jane H.","family":"Forman","sequence":"additional","affiliation":[{"name":"Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ann G.","family":"Zauber","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Iris","family":"Lansdorp-Vogelaar","sequence":"additional","affiliation":[{"name":"Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Frank","family":"van Hees","sequence":"additional","affiliation":[{"name":"Maple Health Group, New York, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Darcy","family":"Saffar","sequence":"additional","affiliation":[{"name":"Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aimee","family":"Myers","sequence":"additional","affiliation":[{"name":"Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lauren E.","family":"Gauntlett","sequence":"additional","affiliation":[{"name":"Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rachel","family":"Lipson","sequence":"additional","affiliation":[{"name":"Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"H. Myra","family":"Kim","sequence":"additional","affiliation":[{"name":"Center for Clinical Management Research, LTC Charles S. Kettles VA Healthcare System, Ann Arbor, Michigan"},{"name":"Consulting for Statistics, Computing and Analytics Research (CSCAR), University of Michigan, Ann Arbor"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sandeep","family":"Vijan","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, University of Michigan, Ann Arbor"},{"name":"Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"10","reference":[{"issue":"19","key":"ioi230070r1","doi-asserted-by":"publisher","first-page":"1965","DOI":"10.1001\/jama.2021.6238","article-title":"Screening for colorectal cancer: US Preventive Services Task Force recommendation statement.","volume":"325","author":"Davidson","year":"2021","journal-title":"JAMA"},{"issue":"4","key":"ioi230070r2","doi-asserted-by":"publisher","first-page":"250","DOI":"10.3322\/caac.v68.4","article-title":"Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society.","volume":"68","author":"Wolf","year":"2018","journal-title":"CA Cancer J Clin"},{"issue":"21","key":"ioi230070r3","doi-asserted-by":"publisher","first-page":"2211","DOI":"10.1001\/jama.2014.13933","article-title":"Smarter screening for cancer: possibilities and challenges of personalization.","volume":"312","author":"Saini","year":"2014","journal-title":"JAMA"},{"issue":"12","key":"ioi230070r4","doi-asserted-by":"publisher","first-page":"849","DOI":"10.7326\/0003-4819-150-12-200906160-00008","article-title":"Adverse events after outpatient colonoscopy in the Medicare population.","volume":"150","author":"Warren","year":"2009","journal-title":"Ann Intern Med"},{"issue":"9","key":"ioi230070r5","doi-asserted-by":"publisher","first-page":"627","DOI":"10.7326\/0003-4819-149-9-200811040-00243","article-title":"Screening for colorectal cancer: US Preventive Services Task Force recommendation statement.","volume":"149","author":"US Preventive Services Task Force","year":"2008","journal-title":"Ann Intern Med"},{"issue":"23","key":"ioi230070r6","doi-asserted-by":"publisher","first-page":"2564","DOI":"10.1001\/jama.2016.5989","article-title":"Screening for colorectal cancer: US Preventive Services Task Force recommendation statement.","volume":"315","author":"Bibbins-Domingo","year":"2016","journal-title":"JAMA"},{"key":"ioi230070r7","doi-asserted-by":"publisher","first-page":"g1247","DOI":"10.1136\/bmj.g1247","article-title":"Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study.","volume":"348","author":"Saini","year":"2014","journal-title":"BMJ"},{"issue":"24","key":"ioi230070r8","doi-asserted-by":"publisher","first-page":"2313","DOI":"10.1001\/jama.282.24.2313","article-title":"Informed decision making in outpatient practice: time to get back to basics.","volume":"282","author":"Braddock","year":"1999","journal-title":"JAMA"},{"issue":"4","key":"ioi230070r9","doi-asserted-by":"publisher","first-page":"635","DOI":"10.2105\/AJPH.93.4.635","article-title":"Primary care: is there enough time for prevention?","volume":"93","author":"Yarnall","year":"2003","journal-title":"Am J Public Health"},{"issue":"1","key":"ioi230070r10","doi-asserted-by":"publisher","first-page":"147","DOI":"10.1007\/s11606-022-07707-x","article-title":"Revisiting the time needed to provide adult primary care.","volume":"38","author":"Porter","year":"2023","journal-title":"J Gen Intern Med"},{"issue":"12","key":"ioi230070r11","doi-asserted-by":"publisher","first-page":"2058","DOI":"10.1007\/s11606-008-0805-8","article-title":"The increasing number of clinical items addressed during the time of adult primary care visits.","volume":"23","author":"Abbo","year":"2008","journal-title":"J Gen Intern Med"},{"issue":"1","key":"ioi230070r12","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1186\/s12885-021-09143-2","article-title":"Polygenic risk prediction models for colorectal cancer: a systematic review.","volume":"22","author":"Sassano","year":"2022","journal-title":"BMC Cancer"},{"issue":"3","key":"ioi230070r13","doi-asserted-by":"publisher","DOI":"10.2196\/30430","article-title":"Prostate cancer risk calculators for healthy populations: systematic review.","volume":"7","author":"Bandala-Jacques","year":"2021","journal-title":"JMIR Cancer"},{"issue":"11","key":"ioi230070r14","doi-asserted-by":"publisher","first-page":"e596","DOI":"10.1161\/CIR.0000000000000678","article-title":"2019 ACC\/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines.","volume":"140","author":"Arnett","year":"2019","journal-title":"Circulation"},{"issue":"2","key":"ioi230070r15","doi-asserted-by":"publisher","first-page":"69","DOI":"10.7326\/0003-4819-152-2-201001190-00004","article-title":"Optimizing statin treatment for primary prevention of coronary artery disease.","volume":"152","author":"Hayward","year":"2010","journal-title":"Ann Intern Med"},{"key":"ioi230070r16","doi-asserted-by":"publisher","first-page":"S67","DOI":"10.1093\/geront\/gny172","article-title":"Communicating about stopping cancer screening: comparing clinicians\u2019 and older adults\u2019 perspectives.","volume":"59","author":"Schoenborn","year":"2019","journal-title":"Gerontologist"},{"issue":"4","key":"ioi230070r17","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD001431.pub5","article-title":"Decision aids for people facing health treatment or screening decisions.","volume":"4","author":"Stacey","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"issue":"6","key":"ioi230070r18","doi-asserted-by":"publisher","first-page":"1425","DOI":"10.1053\/j.gastro.2015.07.042","article-title":"Personalizing colonoscopy screening for elderly individuals based on screening history, cancer risk, and comorbidity status could increase cost effectiveness.","volume":"149","author":"van Hees","year":"2015","journal-title":"Gastroenterology"},{"key":"ioi230070r19","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.e5661","article-title":"Consort 2010 statement: extension to cluster randomised trials.","volume":"345","author":"Campbell","year":"2012","journal-title":"BMJ"},{"issue":"7565","key":"ioi230070r20","doi-asserted-by":"publisher","first-page":"417","DOI":"10.1136\/bmj.38926.629329.AE","article-title":"Developing a quality criteria framework for patient decision aids: online international Delphi consensus process.","volume":"333","author":"Elwyn","year":"2006","journal-title":"BMJ"},{"key":"ioi230070r21","doi-asserted-by":"publisher","first-page":"54","DOI":"10.1186\/1472-6947-10-54","article-title":"A targeted decision aid for the elderly to decide whether to undergo colorectal cancer screening: development and results of an uncontrolled trial.","volume":"10","author":"Lewis","year":"2010","journal-title":"BMC Med Inform Decis Mak"},{"issue":"3","key":"ioi230070r22","doi-asserted-by":"publisher","first-page":"844","DOI":"10.1053\/j.gastro.2012.06.001","article-title":"Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.","volume":"143","author":"Lieberman","year":"2012","journal-title":"Gastroenterology"},{"issue":"8","key":"ioi230070r26","doi-asserted-by":"publisher","first-page":"1923","DOI":"10.1007\/s10620-017-4607-x","article-title":"The association between primary source of healthcare coverage and colorectal cancer screening among US veterans.","volume":"62","author":"May","year":"2017","journal-title":"Dig Dis Sci"},{"issue":"5","key":"ioi230070r27","doi-asserted-by":"publisher","first-page":"561","DOI":"10.1007\/s11606-008-0520-5","article-title":"Validation of screening questions for limited health literacy in a large VA outpatient population.","volume":"23","author":"Chew","year":"2008","journal-title":"J Gen Intern Med"},{"issue":"5","key":"ioi230070r28","doi-asserted-by":"publisher","first-page":"614","DOI":"10.1177\/0272989X18773713","article-title":"A decision aid to promote appropriate colorectal cancer screening among older adults: a randomized controlled trial.","volume":"38","author":"Lewis","year":"2018","journal-title":"Med Decis Making"},{"issue":"12","key":"ioi230070r29","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2022.44982","article-title":"Effect of a patient decision aid on preferences for colorectal cancer screening among older adults: a secondary analysis of a randomized clinical trial.","volume":"5","author":"Dalton","year":"2022","journal-title":"JAMA Netw Open"},{"issue":"5","key":"ioi230070r30","doi-asserted-by":"publisher","first-page":"539","DOI":"10.1007\/s11606-016-3629-y","article-title":"An individualized approach to cancer screening decisions in older adults: a multilevel framework.","volume":"31","author":"Breslau","year":"2016","journal-title":"J Gen Intern Med"},{"issue":"7","key":"ioi230070r31","doi-asserted-by":"publisher","first-page":"465","DOI":"10.7326\/0003-4819-150-7-200904070-00006","article-title":"Impact of age and comorbidity on colorectal cancer screening among older veterans.","volume":"150","author":"Walter","year":"2009","journal-title":"Ann Intern Med"},{"key":"ioi230070r32","doi-asserted-by":"publisher","first-page":"123","DOI":"10.1016\/j.ypmed.2014.06.013","article-title":"Longitudinal predictors of colorectal cancer screening among participants in a randomized controlled trial.","volume":"66","author":"Murphy","year":"2014","journal-title":"Prev Med"},{"issue":"11","key":"ioi230070r33","doi-asserted-by":"publisher","first-page":"750","DOI":"10.7326\/M13-2263","article-title":"Should colorectal cancer screening be considered in elderly persons without previous screening? a cost-effectiveness analysis.","volume":"160","author":"van Hees","year":"2014","journal-title":"Ann Intern Med"},{"issue":"11","key":"ioi230070r34","doi-asserted-by":"publisher","first-page":"1500","DOI":"10.1001\/jamainternmed.2020.4001","article-title":"Identifying recommendations for stopping or scaling back unnecessary routine services in primary care.","volume":"180","author":"Kerr","year":"2020","journal-title":"JAMA Intern Med"},{"issue":"1","key":"ioi230070r35","doi-asserted-by":"publisher","first-page":"1","DOI":"10.7326\/M17-2561","article-title":"Identifying patients for whom lung cancer screening is preference-sensitive: a microsimulation study.","volume":"169","author":"Caverly","year":"2018","journal-title":"Ann Intern Med"},{"issue":"1","key":"ioi230070r36","doi-asserted-by":"publisher","first-page":"118","DOI":"10.1016\/j.amepre.2015.08.003","article-title":"Delivering patient-centered cancer screening: easier said than done.","volume":"50","author":"Caverly","year":"2016","journal-title":"Am J Prev Med"},{"issue":"1","key":"ioi230070r37","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1016\/j.cgh.2020.09.042","article-title":"Program components and results from an organized colorectal cancer screening program using annual fecal immunochemical testing.","volume":"20","author":"Selby","year":"2022","journal-title":"Clin Gastroenterol Hepatol"},{"issue":"7","key":"ioi230070r38","doi-asserted-by":"publisher","first-page":"414","DOI":"10.1136\/bmjqs-2021-014236","article-title":"Development and validation of a new ICD-10-based screening colonoscopy overuse measure in a large integrated healthcare system: a retrospective observational study.","volume":"32","author":"Adams","year":"2023","journal-title":"BMJ Qual Saf"},{"issue":"15","key":"ioi230070r39","doi-asserted-by":"publisher","first-page":"1335","DOI":"10.1001\/archinternmed.2011.212","article-title":"Overuse of screening colonoscopy in the Medicare population.","volume":"171","author":"Goodwin","year":"2011","journal-title":"Arch Intern Med"},{"issue":"1","key":"ioi230070r40","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1158\/1055-9965.EPI-22-0544","article-title":"Impact and Recovery from COVID-19-Related disruptions in colorectal cancer screening and care in the US: a scenario analysis.","volume":"32","author":"van den Puttelaar","year":"2023","journal-title":"Cancer Epidemiol Biomarkers Prev"},{"key":"ioi230070r23","unstructured":"Making a decision about colon cancer screening: a guide for older adults. Accessed September 29, 2023. https:\/\/github.com\/ccmrcodes\/promis"},{"key":"ioi230070r24","unstructured":"Should my patient get a screening colonoscopy? Accessed September 29, 2023. http:\/\/screeningdecision.com\/"},{"key":"ioi230070r25","unstructured":"Information about colon cancer screening. Accessed September 29, 2023. https:\/\/github.com\/ccmrcodes\/promis"}],"container-title":["JAMA Internal Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamainternalmedicine\/articlepdf\/2811097\/jamainternal_saini_2023_oi_230070_1701463558.00859.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,12,4]],"date-time":"2023-12-04T16:02:00Z","timestamp":1701705720000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamainternalmedicine\/fullarticle\/2811097"}},"subtitle":["A Cluster Randomized Clinical Trial"],"short-title":[],"issued":{"date-parts":[[2023,12,1]]},"references-count":40,"journal-issue":{"issue":"12","published-print":{"date-parts":[[2023,12,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamainternmed.2023.5656","relation":{},"ISSN":["2168-6106"],"issn-type":[{"value":"2168-6106","type":"print"}],"subject":[],"published":{"date-parts":[[2023,12,1]]}}}