Randomized trial of Veteran peer navigators to promote Shared Decision Making for PSA screening

Background: Prostate cancer is the most common non-cutaneous malignancy among men in the United States, accounting for one third of VA’s new cancer diagnoses. The United States Preventive Services Task Force (USPSTF) and VHA Clinical Preventive Services guidance recommend a Shared Decision Making (SDM) approach to prostate-specific antigen (PSA) screening due to the tradeoff between modest population-

level survival benefits and the cost of over-detection of low-risk disease. Significance: The limited time available for primary care office visits makes covering all the beneficial USPSTF recommendations challenging. USPSTF and VHA Clinical Preventive Services recommend a SDM approach for PSA screening decisions where patients discuss the best evidence for and against screening with

clinicians and are supported to make high quality decisions. SDM is underutilized in clinical practice and is rarely achieved in prostate cancer screening decisions. Veteran peer navigators are ideal decision coaches to improve patient knowledge and promote SDM among Veterans. We propose a Veteran-peer-navigator-led

decision coaching (PDC) program for PSA screening to promote SDM and potentially lighten the burden of this type of counseling for VA primary care providers. Preliminary data will be collected to inform workflow improvements addressing HSRD priorities of access and quality of care, since SDM is a required quality of

care goal that is yet to be universally implemented among PCPs. Innovation and Impact: 1) The novel use of Veteran peer navigators in a “deliberative” role to promote and facilitate SDM with Veteran patients and their providers is responsive to the USPSTF and HSR&D research priorities. 2) The project will assess the PDC intervention’s workflow effects from the perspectives of key

stakeholders, including Veterans, peer navigators, and clinicians. This study will comprehensively assess the effects of a PDC intervention among Veterans and providers, additionally exploring workflow considerations and factors critical to dissemination. 3) The project will address the cost implications and sustainability of the

decision coaching intervention. 4) The intervention is tailored for current health care delivery, including the use of telehealth. Specific Aims: Aim 1: Test the effect of PDC on decision quality, Veteran-provider communication, and screening experience for Veterans considering PSA screening using validated surveys and theory-based

qualitative interviews. Aim 2: Evaluate PDC’s effect on provider and administrator experience with PSA counseling and clinic workflow using validated surveys and theory-based qualitative interviews. Aim 3: Determine the cost and budget impact of a PDC program for PSA screening. Methodology: The objective in this proposal is to test the efficacy of a PDC program to facilitate SDM for PSA

screening among Veterans at VA New York Harbor Healthcare System. We will randomize Veterans seeking primary care to receive 1) a standard of care screening decision aid along with PDC on PSA screening (intervention), or 2) the same decision aid without counseling (control). To accomplish this goal, a mixed

methods approach will be used combining quantitative data (collected from surveys and patient records to understand healthcare utilization) and qualitative methods (to explore stakeholder experience and perspectives on PSA screening and clinic workflow). Next Steps/Implementation: To promote the implementation of USPSTF and VHA Clinical Preventive

Services PSA screening recommendations, we propose a PDC program in VA with high potential for scalability and public health impact. We will study the intervention across communication format and race to ensure its compatibility with health system goals and initiatives. We will determine efficacy, participant experience, and

cost outcomes critical to system-wide implementation.