Reduce screening | | |
• Do not bring up the topic | For topics with negative recommendations, especially strong recommendations against screening, do not bring up the subject | For women younger than 50 y of age, choose to discuss other preventive issues, not mammography, unless the woman asks |
• Reduce unnecessary testing | Screen only the population at sufficient risk so that the potential benefits are greater than the potential harms of screening | Do not screen people before the recommended interval, as they are at very low risk. There is minimal benefit, while the risk of harms is similar to when done at the appropriate interval (eg, false positives) |
Improve patient communication | | |
• Share decision making | Patient and physician need to discuss the harms and benefits of screening. Consider patient preferences and values | Share screening decisions with patients to reduce decisional conflict |
• Effectively communicate both harms and benefits to patients | Use measures of outcome and effect size that are most easily understood by patients | Use natural frequencies and absolute risk reduction with baseline estimate (eg, mammography screening helps 1 woman in 1000)33 |
• Use knowledge translation tools and patient decision aids | Tools improve patient understanding of harms and benefits of screening | Use 1000-person diagrams34 or “fact boxes” (from the Harding Centre for Risk Literacy)35 that outline the harms and benefits of the action |
• Manage emotional outcomes of harms | Prepare strategies to manage patients who have experienced harms associated with screening | Help patients who decided not to screen realize that their decision was sensible when they made it, and to understand that their outcome might be no different than if they had been screened |
Fully understand screening | | |
• Understand the limitations of the screening test and its variability | All laboratory tests, imaging, and clinical assessments have measurement variation | Understand that frequent repeat testing is not helpful (eg, DEXA bone density test results have greater variation than annual changes in bone density do)36 |
• Understand screening test quality | Be aware of quality markers for screening (eg, positive results for mammography vary from 4% to 9% among radiologists)37,38 | Refer to the highest-quality laboratory or service. Focus on correct disease detection and excess positive rates |
• Understand natural history of disease | Know the course a disease takes (without medical interference) in individual persons from its inception until its eventual resolution through complete recovery or death | Acknowledge the pool of undiagnosed disease that would never affect people’s lives (overdiagnosis). The proportion depends on the disease and person’s life stage |
• Use knowledge of epidemiology of disease | Disease probability changes with age and risk factors, so chance of benefit changes accordingly | Decide whether to start screening for cervical cancer, about 10 years after first sexual activity, not based just on age 21 or 25 |
Adopt organizational strategies | | |
• Develop a follow-up approach to positive test results | Use less-invasive strategies to manage positive test results | Repeat marginally elevated tests (eg, cholesterol, blood pressure) to decide if it is a chance variation |
• Develop recall processes | Processes can be developed in a practice, region, or province to proactively recall patients for screening | Advocate for such processes to recommend shared decision making between patient and physician not to simply tell patients to do the test |