Idea to Spur Colonoscopy Use Fails Test

Having to opt out to stop receiving sales pitches that I never requested annoys me. Now, some health-care leaders want to use opt-out requirements to improve patients’ decision-making and adherence to medical advice. Instead of making patients who want certain health services to opt in by seeking them, the usual approach in health care, they want to make patients opt out if they don’t want them. They say this would help patients make better choices. A new study hints that this approach might backfire, at least for screening colonoscopy.

Colonoscopy detects colorectal cancer, a top cause of cancer deaths. It involves threading a thin, flexible tube, with a tiny camera attached, through the rectum and the entire colon. It enables doctors to spot cancer before symptoms appear, when it responds well to treatment. At the same time, they can remove any abnormal growths found.

A poster child for dreaded medical tests

Expert medical groups deem screening for colorectal cancer a must for adults starting by age 50. Along those lines, most, but not all, doctors view colonoscopy as the gold standard. Yet, “many people who should undergo a colonoscopy do not,” according to the authors of the new study.

Having a tube placed into the rectum sounds undignified, but patients particularly hate the bowel cleansing needed before the test. It requires them to miss work, avoid solid food, take a laxative or other bowel-clearing product, and stay near a toilet. In addition, patients worry that the test might harm them. Some procrastinate because they fear learning that they have cancer, and the cost of colonoscopy worries many.

Framing the decision

Research shows that treating one behavior as the default—that is, fallback in lieu of an active choice–prods people into performing that behavior. In the medical world, studies hint that people are likelier to get vaccinations and HIV testing if skipping them requires opting out, although not all studies agree. In 2006, the Centers for Disease Control began urging health-care providers to test most patients for HIV unless patients opt out. Doctors are supposed to tell patients that testing will occur unless patients refuse.

Getting back to colonoscopies, one of my relatives, whom I’ll call Jason, encountered a similar tactic at his last check-up. His primary-care doctor tried to book a colonoscopy for him without asking whether he wanted one and if so, when. The new study looked at whether a similar strategy prods more patients to get a colonoscopy.

The study assigned 81 patients between 60 and 70 years old to either opt-in or opt-out scheduling. All received a letter from their gastroenterologist stating that the time had come for their next colonoscopy. The letter for the opt-in group directed patients to call the office to schedule it. The opt-out letter told patients that the office had booked them for a colonoscopy; it gave them the date and time of the appointment. It told them to call to confirm the appointment or, if the timing didn’t work for them, to change or cancel it.

The researchers expected that patients who opted in to colonoscopy would be more likely to follow through with it than those who didn’t opt out. After all, they reasoned, people are more likely to pursue goals that they themselves choose. Furthermore, they wrote, opt-out scheduling may make patients “feel that they are being forced to engage in anxiety-provoking behaviors,” prompting them to “push back in a reactionary way.”

A win for opt in

As predicted, the opt-in tactic worked better than booking patients without their say-so. In fact, 85 percent of those in the opt-in group, but only 62 percent in the opt-out group, showed up for their screening. The researchers think that the opt-in condition empowered patients. They wrote that although modifying the default to an opt-out situation encourages some health-care behaviors, it might not spur people to get more invasive procedures.

Despite claims that default options “influence decisions without restricting choice,” in reality, patients often hesitate to challenge or disagree with their doctors. As I’ve written before, they fear that doing so could spoil the doctor-patient relationship and hinder their care. Such worries could keep them from exercising their right to opt out.

On top of that, scheduling patients for a test they might not want does little to address their concerns about screening or help them weigh their options. Jason said his doctor never told him why he needed a colonoscopy, much less discuss the pros and cons of other tests for colorectal cancer. When the doctor set off to book Jason’s colonoscopy, Jason told him to wait until he could check his schedule. Months later, Jason has taken no steps toward getting checked for colorectal cancer.

 

Photo copyright Stuart Miles/123rf.com stock photo

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Dear Readers,

What do you think of opt-out strategies for colorectal cancer screening? Are they an idea whose time has come or a return to doctor-knows-best? Whether you’re a patient, medical professional, or researcher, I invite you to comment.

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