Aiding shared decision making in lung cancer screening: two decision tools.
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ABSTRACT: Background
Shared decision making (SDM) preceding lung cancer screening is important for populations that are underrepresented in lung cancer screening trials. Current evidence-based guidelines; however, do not address personal risk and outcomes in underrepresented populations. This study compared two SDM decision aids (Option Grids and Shouldiscreen.com) for SDM efficacy, decision regret and knowledge.Methods
We conducted a prospective trial of lung cancer screening patients (N = 237) randomized to SDM with Option Grids or Shouldiscreen.com. To evaluate the SDM process after lung cancer screening, patients answered two questionnaires: CollaboRATE and Decision Regret. Patients also completed a questionnaire to test their knowledge of lung cancer screening.Results
Patients were predominantly African American (61.6%), though multiple races, varying education levels and equal genders were represented. Patients in both Option Grids and Shouldiscreen.com groups reported favorable SDM experiences (P = 0.60) and equivalent knowledge about lung cancer screening (P = 0.43). Patients using Shouldiscreen.com had less knowledge regarding the potential complications of subsequent testing (P = 0.02). Shouldiscreen.com patients had increased regret regarding their decision to pursue screening (P = 0.02).Conclusions
Option Grids and Shouldiscreen.com both facilitated a meaningful SDM process. However, Option Grids patients experienced decreased decision regret and enhanced knowledge of the potential complications of screening.
SUBMITTER: Sferra SR
PROVIDER: S-EPMC8458019 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundShared decision-making (SDM) is widely recommended and required by the Centers for Medicare and Medicaid for patients considering lung cancer screening (LCS).ObjectiveWe examined clinicians' communication practices and perceived barriers of SDM for LCS at three medical centers with established screening programs.DesignMulticenter qualitative study of clinicians participating in LCS.ApproachWe performed semi-structured interviews, which were transcribed and analyzed using directed content analysis, guided by a theoretical model of patient-clinician communication.ParticipantsWe interviewed 24 clinicians including LCS coordinators (2), pulmonologists (3), and primary care providers (17), 4 of whom worked for the LCS program, a thoracic surgeon, and a radiologist.ResultsAll clinicians agreed with the goal of SDM, to ensure the screening decision was congruent with the patient's values. The depth and type of information presented by each clinician role varied considerably. LCS coordinators presented detailed information including numeric estimates of benefit and harm. Most PCPs explained the process more generally, focusing on logistics and the high rate of nodule detection. No clinician explicitly elicited values or communication preferences. Many PCPs tailored the conversation based on their implicit understanding of patients' values and preferences, gained from past experiences. PCPs reported that time, lack of detailed personal knowledge of LCS, and patient preferences were barriers to SDM. Many clinicians perceived that a significant proportion of patients were not interested in specific percentages and preferred to receive a clinician recommendation.ConclusionsOur results suggest that clinicians support the goal of SDM for LCS decisions but PCPs may not perform some of its elements. The lack of completion of some elements, such as PCPs' lack of in-depth information exchange, may reflect perceived patient preferences for communication. As LCS is implemented, further research is needed to support a personalized, patient-centered approach to produce better outcomes.
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Project description:BackgroundDecisions about lung cancer screening are inherently complex and create a need for methods to convey the risks and benefits of screening to patients.Research questionWhat kind of decision aids or tools are available to support shared decision-making for lung cancer screening? What is the current evidence for the effectiveness, acceptability, and feasibility of those tools?Study design and methodsWe conducted a systematic review of studies and searched PubMed, MEDLINE, EMBASE, Cochrane Clinical Trials Register, and ClinicalTrials.gov from inception to December 2019 for studies that evaluated the effectiveness and acceptability of tools to promote shared decision-making for patients who are considering lung cancer screening.ResultsAfter screening 2,427 records, we included one randomized control trial, two observational studies, 11 before/after studies of a decision aid or an educational tool. Fifteen distinct tools in various formats were evaluated in 14 studies. Most studies were of fair quality. Studies reported improvement in patients' knowledge of lung cancer screening (n = 9 studies), but improvements in specific areas of knowledge were inconsistent. Decisional conflict was low or reduced after the administration of the tools (n = 7 studies). The acceptability of tools was rated as "high" by patients (n = 7 studies) and physicians (n = 1 study). Low dose CT scan completion rates varied among studies (n = 6 studies).InterpretationEvidence from 14 studies suggests that some elements of existing tools for lung cancer screening may help to prepare patients for decision-making by improving knowledge and reducing decisional conflict. Such tools generally are acceptable to patients and providers. Further studies that use consistent measures and reporting methods and assess relevant decisional and clinical outcomes are needed to determine the comparative effectiveness and feasibility of implementation of these tools.Clinical trial registrationPROSPERO 2018 CRD4201874814.
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Project description:ObjectiveWe describe primary care providers' current practice patterns related to smoking cessation counseling and lung cancer screening (LCS).MethodsFamily, internal medicine, and pulmonary medicine providers from two medical centers were asked to complete an electronic survey to report their practice patterns.ResultsOf 52 participating providers, most reported initiating three major components of a smoking cessation intervention often or very often: advise to quit (50, 96%), assess willingness to quit (47, 90%), and assist with counseling or pharmacotherapy (49, 94%). However, other components were less commonly initiated such as arranging follow-ups (only 11 providers indicated recommending them often or very often, 21%) and less than half of providers reported that they often or very often recommend cessation counseling or pharmacotherapy of any type (except varenicline), though family medicine providers were more likely to recommend pharmacotherapy compared to the other specialists (p < 0.01). The majority of providers (47, 92%) reported that they engage in informed/shared decision-making about LCS, although only about one-third (17, 33%) indicated using a patient decision aid. Pulmonary medicine providers were more likely to use decision aids than providers from internal or family medicine (p < 0.04).ConclusionsWithin the context of LCS, primary care providers report often having conversations about smoking cessation with their patients who smoke, have no clear preference for type of treatment, and rarely use follow-up calls or visits pertaining to quitting smoking. While many providers report engaging in shared decision-making about LCS, few use a decision aid for this conversation.
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Project description:BACKGROUND:Guidelines recommend, and Medicare requires, shared decision-making between patients and clinicians before referring individuals at high risk of lung cancer for chest CT screening. However, little is known about the extent to which shared decision-making about lung cancer screening is achieved in real-world settings. OBJECTIVE:To characterize patient and clinician impressions of early experiences with communication and decision-making about lung cancer screening and perceived barriers to achieving shared decision-making. DESIGN:Qualitative study entailing semi-structured interviews and focus groups. PARTICIPANTS:We enrolled 36 clinicians who refer patients for lung cancer screening and 49 patients who had undergone lung cancer screening in the prior year. Participants were recruited from lung cancer screening programs at four hospitals (three Veterans Health Administration, one urban safety net). APPROACH:Using content analysis, we analyzed transcripts to characterize communication and decision-making about lung cancer screening. Our analysis focused on the recommended components of shared decision-making (information sharing, deliberation, and decision aid use) and barriers to achieving shared decision-making. KEY RESULTS:Clinicians varied in the information shared with patients, and did not consistently incorporate decision aids. Clinicians believed they explained the rationale and gave some (often purposely limited) information about the trade-offs of lung cancer screening. By contrast, some patients reported receiving little information about screening or its trade-offs and did not realize the CT was intended as a screening test for lung cancer. Clinicians and patients alike did not perceive that significant deliberation typically occurred. Clinicians perceived insufficient time, competing priorities, difficulty accessing decision aids, limited patient comprehension, and anticipated patient emotions as barriers to realizing shared decision-making. CONCLUSIONS:Due to multiple perceived barriers, patient-clinician conversations about lung cancer screening may fall short of guideline-recommended shared decision-making supported by a decision aid. Consequently, patients may be left uncertain about lung cancer screening's rationale, trade-offs, and process.
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Project description:Current US colorectal cancer screening guidelines that call for shared decision making regarding the choice among several recommended screening options are difficult to implement. Multicriteria decision analysis (MCDA) is an established method well suited for supporting shared decision making. Our study goal was to determine whether a streamlined form of MCDA using rank-order-based judgments can accurately assess patients' colorectal cancer screening priorities.We converted priorities for 4 decision criteria and 3 subcriteria regarding colorectal cancer screening obtained from 484 average-risk patients using the analytic hierarchy process (AHP) in a prior study into rank-order-based priorities using rank order centroids. We compared the 2 sets of priorities using Spearman rank correlation and nonparametric Bland-Altman limits of agreement analysis. We assessed the differential impact of using the rank-order-based versus the AHP-based priorities on the results of a full MCDA comparing 3 currently recommended colorectal cancer screening strategies. Generalizability of the results was assessed using Monte Carlo simulation.Correlations between the 2 sets of priorities for the 7 criteria ranged from 0.55 to 0.92. The proportions of differences between rank-order-based and AHP-based priorities that were more than ±0.15 ranged from 1% to 16%. Differences in the full MCDA results were minimal, and the relative rankings of the 3 screening options were identical more than 88% of the time. The Monte Carlo simulation results were similar.Rank-order-based MCDA could be a simple, practical way to guide individual decisions and assess population decision priorities regarding colorectal cancer screening strategies. Additional research is warranted to further explore the use of these methods for promoting shared decision making.
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Project description:Eliciting patient preferences within the context of shared decision making has been advocated for colorectal cancer (CRC) screening, yet providers often fail to comply with patient preferences that differ from their own.To determine whether risk stratification for advanced colorectal neoplasia (ACN) influences provider willingness to comply with patient preferences when selecting a desired CRC screening option.Randomized controlled trial.Asymptomatic, average-risk patients due for CRC screening in an urban safety net health care setting.Patients were randomized 1:1 to a decision aid alone (n= 168) or decision aid plus risk assessment (n= 173) arm between September 2012 and September 2014.The primary outcome was concordance between patient preference and test ordered; secondary outcomes included patient satisfaction with the decision-making process, screening intentions, test completion rates, and provider satisfaction.Although providers perceived risk stratification to be useful in selecting an appropriate screening test for their average-risk patients, no significant differences in concordance were observed between the decision aid alone and decision aid plus risk assessment groups (88.1% v. 85.0%,P= 0.40) or high- and low-risk groups (84.5% v. 87.1%,P= 0.51). Concordance was highest for colonoscopy and relatively low for tests other than colonoscopy, regardless of study arm or risk group. Failure to comply with patient preferences was negatively associated with satisfaction with the decision-making process, screening intentions, and test completion rates.Single-institution setting; lack of provider education about the utility of risk stratification into their decision making.Providers perceived risk stratification to be useful in their decision making but often failed to comply with patient preferences for tests other than colonoscopy, even among those deemed to be at low risk of ACN.
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Project description:BackgroundThe Centers for Medicare and Medicaid Services stipulate shared decision-making (SDM) counseling as a prerequisite to lung cancer screening (LCS) reimbursement, despite well-known challenges implementing SDM in practice.Research questionHow have health-care organizations implemented SDM for LCS?Study design and methodsFor this qualitative study, we used data from in-depth, semistructured interviews with key informants directly involved in implementing SDM for LCS, managing SDM for LCS, or both. We identified respondents using a snowball sampling technique and used template analysis to identify and analyze responses thematically.ResultsWe interviewed 30 informants representing 23 health-care organizations located in 12 states and 4 Census regions. Respondents described two types of SDM for LCS programs: centralized models (n = 7), in which front-end practitioners (eg, primary care providers) referred patients to an LCS clinic where trained staff (eg, advanced practice nurses) delivered SDM at the time of screening, or decentralized models (n = 10), in which front-end practitioners delivered SDM before referring patients for screening. Some organizations used both models simultaneously (n = 6). Respondents discussed tradeoffs between SDM quality and access. They perceived centralized models as enhancing SDM quality, but limiting patient access to care, and vice versa. Respondents reported ongoing challenges with limited resources and budgetary constraints, ambiguity regarding what constitutes SDM, and an absence of benchmarks for evaluating SDM for LCS quality.InterpretationThose responsible for developing and managing SDM for LCS programs voiced concerns regarding both patient access and SDM quality, regardless of organizational context, or the SDM for LCS model implemented. The challenge facing these organizations, and those wanting to help patients and clinicians balance the tradeoffs inherent with LCS, is how to move beyond a check-box documentation requirement to a process that enables LCS to be offered to all high-risk patients, but used only by those who are informed and for whom screening represents a value-concordant service.
| S-EPMC7893305 | biostudies-literature
Project description:BackgroundProfessional societies recommend shared decision making (SDM) for prostate cancer screening, however, most efforts have promoted informed rather than shared decision making. The objective of this study is to 1) examine the effects of a prostate cancer screening intervention to promote SDM and 2) determine whether framing prostate information in the context of other clearly beneficial men's health services affects decisions.MethodsWe conducted two separate randomized controlled trials of the same prostate cancer intervention (with or without additional information on more clearly beneficial men's health services). For each trial, we enrolled a convenience sample of 2 internal medicine practices, and their interested physicians and male patients with no prior history of prostate cancer (for a total of 4 practices, 28 physicians, and 128 men across trials). Within each practice site, we randomized men to either 1) a video-based decision aid and researcher-led coaching session or 2) a highway safety video. Physicians at each site received a 1-hour educational session on prostate cancer and SDM. To assess intervention effects, we measured key components of SDM, intent to be screened, and actual screening. After finding that results did not vary by trial, we combined data across sites, adjusting for the random effects of both practice and physician.ResultsCompared to an attention control, our prostate cancer screening intervention increased men's perceptions that screening is a decision (absolute difference +41%; 95% CI 25 to 57%) and men's knowledge about prostate cancer screening (absolute difference +34%; 95% CI 19% to 50%), but had no effect on men's self-reported participation in shared decisions or their participation at their preferred level. Overall, the intervention decreased screening intent (absolute difference -34%; 95% CI -50% to -18%) and actual screening rates (absolute difference -22%; 95% CI -38 to -7%) with no difference in effect by frame.ConclusionsSDM interventions can increase men's knowledge, alter their perceptions of prostate cancer screening, and reduce actual screening. However, they may not guarantee an increase in shared decisions.Trial registration#NCT00630188.
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