Exploring the Lack of Concordance between the Preferred and Actual Approach to Colorectal Cancer Screening in Older Adults: A Qualitative Study

Abstract

Background

Concordance, or alignment of care with patients’ preferences, is a key component of high-quality decision making. Some patients may not have a clear preference, and others may not receive care aligned with their preference—both situations indicating a lack of concordance. The reasons behind these situations remain poorly understood. This study explores the reasons for lack of concordance in colorectal cancer screening among older adults.

Methods

Interviews were conducted with 160 older adults from the Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults trial (NCT03959696) who did not meet the criteria for concordance. A thematic analysis of 152 analyzable interviews was performed to explore reasons for lack of concordance.

Results

Four themes summarize the different reasons for the lack of concordance: 1) provider discussion and the need for more guidance (e.g., patients reported very limited discussion and desire for more information), 2) age-related considerations (e.g., patients acknowledge that at their age, screening may no longer be needed), 3) changes in health condition (e.g., patients report other health issues that take priority over screening), and 4) the impact of COVID-19 and practical barriers (e.g., patients report a desire to avoid hospitals and procedures).

Conclusions

The lack of concordance stemming from limited discussion, guidance, or lack of clear preference signal low decision quality, whereas the lack of concordance from changing patient preferences over time has implications for timing of measurement. To improve concordance, patients need support to clarify their preferences as well as support to implement their preferred approach.

Highlights

• Limited provider discussion, age-related factors, changing health priorities, and COVID-19–related or practical challenges were identified as key contributors to lack of concordance.

• Achieving high concordance will require helping patients clarify their preferences, strengthening shared decision making, and providing implementation support.

• Researchers also need to be aware of evolving preferences and implications for timing of preference measurements.