关于是否停止老年人结直肠癌 (CRC) 筛查测试的决定可能很困难，但可能会受益于共同决策 (SDM)。 评估 SDM 和电子预诊提醒（干预）与仅提醒（干预）方面医生培训的效果（对照）收到患者首选的 CRC 筛查方法以及 12 个月时老年人的总体 CRC 筛查率。这是对促进老年人结直肠癌筛查的知情决策 (PRIMED) 集群随机临床试验的二次分析。在 PRIMED 试验中，来自马萨诸塞州和缅因州 36 个初级保健诊所的初级保健医生 (PCP) 在 2019 年 5 月 1 日至 8 月 30 日期间入组，并被随机分为干预组或比较组。 2019年10月21日至2021年4月8日期间入组的年龄为76至85岁、逾期进行CRC筛查且先前未诊断出CRC的患者。数据分析于2022年5月24日至2023年5月10日期间进行。干预组中的初级保健医生完成了 SDM 培训课程，并收到了有资格进行 CRC 检测讨论的患者的预诊提醒，而比较组中的 PCP 仅收到了提醒。主要结果是一致性，即接受首选筛查的患者百分比方法。进行访视后调查以评估患者对检测的偏好，并使用电子健康记录审查来评估 12 个月时的 CRC 检测。治疗效果的异质性分析检查了研究组之间的相互作用以及不同因素对一致性率的影响。这项研究包括 59 名医生和 466 名老年人。医生的平均年龄 (SD) 为 52.7 (9.4) 岁，平均执业年龄 (SD) 为 21.6 (10.2) 岁； 30 名 (50.8%) 是女性，16 名 (27.1%) 表示之前接受过 SDM 培训。患者的平均 (SD) 年龄为 80.3 (2.8) 岁； 249 名 (53.4%) 为女性，238 名 (51.1%) 表示整体健康状况良好或非常好。患者首选粪便检测（161 [34.5%]），其次是结肠镜检查（116 [24.8%]）或不进行进一步筛查（97 [20.8%]）； 75 人（16.1%）不确定。各组患者偏好的分布相似 (P = .36)。 12 个月时，干预组（29 人 [12.3%] 进行结肠镜检查，62 人 [26.3%] 进行粪便检测，145 人 [61.4%] 未进行检测）和比较组（32 [13.9%] 进行结肠镜检查，35 [15.2%] 进行粪便检查，163 [70.9%] 未进行检查；P = .08）。与对照组相比，干预组中大约一半的患者接受了他们首选的治疗方法（226 名患者中的 115 名患者 [50.9%] vs 223 名患者中的 103 名患者 [46.2%]；P = .47）。治疗效果异质性分析发现，对于有强烈意愿坚持采用首选方法的患者，干预组的发生率显着高于对照组（调整后的比值比 [AOR]，1.79 [95% CI，1.11-2.89]；P = 。 02，互动时 P = .05）以及报告与 PCP 讨论超过 5 分钟（AOR，3.27 [95% CI，1.25-8.59]；互动时 P = .02，互动时 P = .05）的患者筛选。在报告与 PCP 讨论 2 至 5 分钟的患者中也观察到较高的发生率，尽管这一发现并不显着（AOR，1.89 [95% CI，0.93-3.84]；P = .08，P = .05 交互作用） ）。在这项整群随机临床试验的二次分析中，大约一半的老年患者接受了他们首选的 CRC 筛查方法。 SDM 医师培训并未带来总体上较高的一致性率，但可能使某些亚组受益。未来完善和评估临床决策支持（以电子咨询或提醒的形式）的工作以及针对 PCP 的重点 SDM 技能培训可能会促进关于老年人 CRC 检测的高质量、偏好一致的决策。ClinicalTrials.gov Identifier ：NCT03959696。

Decisions about whether to stop colorectal cancer (CRC) screening tests in older adults can be difficult and may benefit from shared decision-making (SDM).To evaluate the effect of physician training in SDM and electronic previsit reminders (intervention) vs reminders only (comparator) on receipt of the patient-preferred approach to CRC screening and on overall CRC screening rates of older adults at 12 months.This was a secondary analysis of the Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED) cluster randomized clinical trial. In the PRIMED trial, primary care physicians (PCPs) from 36 primary care practices in Massachusetts and Maine were enrolled between May 1 and August 30, 2019, and were randomized to the intervention group or the comparator group. Patients aged 76 to 85 years who were overdue for CRC screening and did not have a prior diagnosis of CRC enrolled between October 21, 2019, and April 8, 2021. Data analysis was performed between May 24, 2022, and May 10, 2023.Primary care physicians in the intervention group completed an SDM training course and received previsit reminders of patients eligible for CRC testing discussion, whereas PCPs in the comparator group received reminders only.The primary outcome was concordance, or the percentage of patients who received their preferred screening approach. Postvisit surveys were administered to assess patient preference for testing, and electronic health record review was used to assess CRC testing at 12 months. Heterogeneity of treatment effect analyses examined interaction between study groups and different factors on concordance rates.This study included 59 physicians and 466 older adults. Physicians had a mean (SD) age of 52.7 (9.4) years and a mean (SD) of 21.6 (10.2) years in practice; 30 (50.8%) were women and 16 (27.1%) reported prior training in SDM. Patients had a mean (SD) age of 80.3 (2.8) years; 249 (53.4%) were women and 238 (51.1%) reported excellent or very good overall health. Patients preferred stool-based tests (161 [34.5%]), followed by colonoscopy (116 [24.8%]) or no further screening (97 [20.8%]); 75 (16.1%) were not sure. The distribution of patient preferences was similar across groups (P = .36). At 12 months, test uptake was also similar for both the intervention group (29 [12.3%] for colonoscopy, 62 [26.3%] for stool-based tests, and 145 [61.4%] for no testing) and the comparator group (32 [13.9%] for colonoscopy, 35 [15.2%] for stool-based tests, and 163 [70.9%] for no testing; P = .08). Approximately half of patients in the intervention group received their preferred approach vs the comparator group (115 of 226 [50.9%] vs 103 of 223 [46.2%]; P = .47). Heterogeneity of treatment effect analyses found significantly higher rates with the intervention vs the comparator for patients with a strong intention to follow through with the preferred approach (adjusted odds ratio [AOR], 1.79 [95% CI, 1.11-2.89]; P = .02, P = .05 for interaction) and for patients who reported more than 5 minutes (AOR, 3.27 [95% CI, 1.25-8.59]; P = .02, P = .05 for interaction) of discussion with their PCP regarding screening. Higher rates were also observed among patients who reported 2 to 5 minutes of discussion with their PCP, although this finding was not significant (AOR, 1.89 [95% CI, 0.93-3.84]; P = .08, P = .05 for interaction).In this secondary analysis of a cluster randomized clinical trial, approximately half of older patients received their preferred approach to CRC screening. Physician training in SDM did not result in higher concordance rates overall but may have benefitted some subgroups. Future work to refine and evaluate clinical decision support (in the form of an electronic advisory or reminder) as well as focused SDM skills training for PCPs may promote high-quality, preference-concordant decisions about CRC testing for older adults.ClinicalTrials.gov Identifier: NCT03959696.