Evaluating Shared Decision Making for Lung Cancer Screening,JAMA Internal Medicine

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Evaluating Shared Decision Making for Lung Cancer Screening
JAMA Internal Medicine ( IF 22.5 ) Pub Date : 2018-10-01 , DOI: 10.1001/jamainternmed.2018.3054
Alison T Brenner _{1,

2} , Teri L Malo ₂ , Marjorie Margolis ₃ , Jennifer Elston Lafata _{2,

4} , Shynah James ₃ , Maihan B Vu _{3,

5} , Daniel S Reuland _{1,

2}

Affiliation

Importance The US Preventive Services Task Force recommends that shared decision making (SDM) involving a thorough discussion of benefits and harms should occur between clinicians and patients before initiating lung cancer screening (LCS) with low-dose computed tomography. The Centers for Medicare & Medicaid Services require an SDM visit using a decision aid as a prerequisite for LCS coverage. However, little is known about how SDM about LCS occurs in practice. Objective To assess the quality of SDM about the initiation of LCS in clinical practice. Design, Setting, and Participants A qualitative content analysis was performed of transcribed conversations between primary care or pulmonary care physicians and 14 patients presumed to be eligible for LCS, recorded between April 1, 2014, and March 1, 2018, that were identified within a large database. Main Outcomes and Measures Independent observer ratings of communication behaviors of physicians using the OPTION (Observing Patient Involvement in Decision Making) scale, a validated 12-item measure of SDM (total score, 0-100 points, where 0 indicates no evidence of SDM and 100 indicates evidence of SDM at the highest skill level); time spent discussing LCS during visits; and evidence of decision aid use. Results A total of 14 conversations about initiating LCS were identified; 9 patients were women, and 5 patients were men; the mean (SD) patient age was 63.9 (5.1) years; 7 patients had Medicare, and 8 patients were current smokers. Half the conversations were conducted by primary care physicians. The mean total OPTION score for the 14 LCS conversations was 6 on a scale of 0 to 100 (range, 0-17). None of the conversations met the minimum skill criteria for 8 of the 12 SDM behaviors. Physicians universally recommended LCS. Discussion of harms (such as false positives and their sequelae or overdiagnosis) was virtually absent. The mean total visit length of a discussion was 13:07 minutes (range, 3:48-27:09 minutes). The mean time spent discussing LCS was 0:59 minute (range, 0:16-2:19 minutes), or 8% of the total visit time (range, 1%-18%). There was no evidence that decision aids or other patient education materials for LCS were used. Conclusions and Relevance In this small sample of recorded encounters about initiating LCS, the observed quality of SDM was poor and explanation of potential harms of screening was virtually nonexistent. Time spent discussing LCS was minimal, and there was no evidence that decision aids were used. Although these findings are preliminary, they raise concerns that SDM for LCS in practice may be far from what is intended by guidelines.

中文翻译：

评估肺癌筛查的共同决策

重要性美国预防服务工作组建议，在开始使用低剂量计算机断层扫描进行肺癌筛查 (LCS) 之前，临床医生和患者应进行共同决策 (SDM)，包括对益处和危害进行彻底讨论。医疗保险和医疗补助服务中心要求使用决策辅助进行 SDM 访问，作为 LCS 承保的先决条件。然而，关于 LCS 的 SDM 在实践中如何发生却知之甚少。目的评价临床实践中LCS启动的SDM质量。设计、设置和参与者对初级保健或肺部保健医生与 14 名被认为有资格接受 LCS 的患者之间的转录对话进行了定性内容分析，这些对话记录在 2014 年 4 月 1 日至 2018 年 3 月 1 日之间，这些对话是在大型数据库。主要成果和措施使用 OPTION（观察患者参与决策）量表对医生沟通行为进行独立观察者评分，该量表是经过验证的 12 项 SDM 测量（总分 0-100 分，其中 0 表示没有 SDM 证据， 100 表示最高技能水平的 SDM 证据）；访问期间讨论濒海战斗舰所花费的时间；以及决策辅助使用的证据。结果共识别出 14 条关于启动 LCS 的对话；女性9例，男性5例；患者平均年龄 (SD) 为 63.9 (5.1) 岁； 7 名患者有医疗保险，8 名患者目前吸烟。一半的谈话是由初级保健医生进行的。 14 个 LCS 对话的平均总选项得分为 6，评分范围为 0 到 100（范围为 0-17）。这些对话均不符合 12 种 SDM 行为中 8 种的最低技能标准。医生普遍推荐 LCS。实际上没有讨论危害（例如误报及其后遗症或过度诊断）。讨论的平均总访问时长为 13:07 分钟（范围为 3:48-27:09 分钟）。讨论 LCS 的平均时间为 0:59 分钟（范围，0:16-2:19 分钟），占总访问时间的 8%（范围，1%-18%）。没有证据表明使用了 LCS 决策辅助工具或其他患者教育材料。结论和相关性在这个有关启动 LCS 的小样本记录中，观察到的 SDM 质量很差，并且几乎不存在对筛查潜在危害的解释。讨论濒海战斗舰的时间很少，而且没有证据表明使用了决策辅助工具。尽管这些发现是初步的，但它们引起了人们的担忧，即实践中的濒海战斗舰的 SDM 可能与指南的预期相去甚远。

更新日期：2018-10-01

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