Advertisement

What Exactly Is Shared Decision-Making? A Qualitative Study of Shared Decision-Making in Lung Cancer Screening

  • Anne C MelzerEmail author
  • Sara E. Golden
  • Sarah S. Ono
  • Santanu Datta
  • Kristina Crothers
  • Christopher G. Slatore
Article

Abstract

Background

Shared decision-making (SDM) is widely recommended and required by the Centers for Medicare and Medicaid for patients considering lung cancer screening (LCS).

Objective

We examined clinicians’ communication practices and perceived barriers of SDM for LCS at three medical centers with established screening programs.

Design

Multicenter qualitative study of clinicians participating in LCS.

Approach

We performed semi-structured interviews, which were transcribed and analyzed using directed content analysis, guided by a theoretical model of patient-clinician communication.

Participants

We 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.

Results

All 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.

Conclusions

Our 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.

KEY WORDS

lung cancer screening shared decision-making communication 

Notes

Funding Information

This project was funded by a grant from the American Cancer Society (RSG-15-155-01, Slatore (PI)). The study was supported by resources from the VA Portland Health Care System, Portland, OR, and the Minneapolis VA Health Care System, Minneapolis, MN.

Compliance with Ethical Standards

The study was IRB-approved at each site (VAPORHCS #3482; Minneapolis VA #4645-B; Duke #Pro00073394).

Conflict of Interest

The authors have no financial conflicts of interest to declare. ACM, KC, and CGS are medical directors of lung cancer screening programs at the institutions where they are employed but do not receive additional compensation for these roles.

Disclaimer

The Department of Veterans Affairs did not have a role in the conduct of the study, in the collection, management, analysis, interpretation of data, or in the preparation of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. Government.

Supplementary material

11606_2019_5516_MOESM1_ESM.docx (21 kb)
ESM 1 (DOCX 21 kb)

References

  1. 1.
    Moyer VA. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:330-338.PubMedGoogle Scholar
  2. 2.
    Mazzone P, Powell CA, Arenberg D, et al. Components necessary for high-quality lung cancer screening: American college of chest physicians and american thoracic society policy statement. Chest. 2015;147:295-303.PubMedCrossRefGoogle Scholar
  3. 3.
    Miranda LS, Datta S, Melzer AC, et al. Rationale and Design of the Lung Cancer Screening Implementation. Evaluation of Patient-Centered Care Study. Ann Am Thorac Soc. 2017;14:1581-1590.PubMedCrossRefGoogle Scholar
  4. 4.
    Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409.PubMedCrossRefGoogle Scholar
  5. 5.
    Wood DE. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for Lung Cancer Screening. Thoracic Surgery Clinics. 25:185-197.PubMedCrossRefGoogle Scholar
  6. 6.
    Harris RP, Sheridan SL, Lewis CL, et al. The harms of screening: A proposed taxonomy and application to lung cancer screening. JAMA Intern Med. 2014;174:281-286.PubMedCrossRefGoogle Scholar
  7. 7.
    Slatore CG, Sullivan DR, Pappas M, Humphrey LL. Patient-Centered Outcomes among Lung Cancer Screening Recipients with Computed Tomography: A Systematic Review. J Thorac Oncol. 2014;9:927-934.PubMedCrossRefGoogle Scholar
  8. 8.
    Centers for Medicare & Medicaid Services. Decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439 N). Baltimore: Centers for Medicare and Medicaid, U.S. Department of Health and Human Services. (https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId = 274. Accessed August 30, 2019.)
  9. 9.
    Sheridan SL, Harris RP, Woolf SH, Force SD. Shared decision making about screening and chemoprevention: a suggested approach from the US Preventive Services Task Force. Am J Prev Med. 2004;26:56-66.PubMedCrossRefGoogle Scholar
  10. 10.
    Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA. 1996;275(2):152-156.PubMedCrossRefGoogle Scholar
  11. 11.
    Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med (1982). 2000;51:1087-1110.CrossRefGoogle Scholar
  12. 12.
    Elwyn G, Cochran N, Pignone M. Shared decision making—the importance of diagnosing preferences. JAMA Intern Med. 2017;17:1239-1240.CrossRefGoogle Scholar
  13. 13.
    Elwyn G, Frosch D, Thomson R, et al. Shared Decision Making: A Model for Clinical Practice. J Gen Intern Med. 2012;27:1361-1367.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Kanodra NM, Pope C, Halbert CH, Silvestri GA, Rice LJ, Tanner NT. Primary Care Provider and Patient Perspectives on Lung Cancer Screening. A Qualitative Study. Ann Am Thorac Soc. 2016;13:1977-1982.PubMedCrossRefGoogle Scholar
  15. 15.
    Triplette M, Kross EK, Mann BA, et al. An Assessment of Primary Care and Pulmonary Provider Perspectives on Lung Cancer Screening. Ann Am Thorac Soc. 2018;15:69-75.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Brenner AT, Malo TL, Margolis M, et al. Evaluating Shared Decision Making for Lung Cancer Screening. JAMA Intern Med. 2018,178:1311-1316PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Ersek JL, Eberth JM, McDonnell KK, et al. Knowledge of, attitudes toward, and use of low-dose computed tomography for lung cancer screening among family physicians. Cancer. 2016Google Scholar
  18. 18.
    Sandelowski M. Sample size in qualitative research. Res Nurs Health. 1995;18(2):179-183.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277-1288.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Callon W, Beach MC, Links AR, Wasserman C, Boss EF. An expanded framework to define and measure shared decision-making in dialogue: A ‘top-down’ and ‘bottom-up’ approach. Patient Educ Couns. 2018;101:1368-1377.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Elkin EB, Kim SH, Casper ES, Kissane DW, Schrag D. Desire for information and involvement in treatment decisions: elderly cancer patients’ preferences and their physicians’ perceptions. J Clin Oncol. 2007;25:5275-5280.PubMedCrossRefGoogle Scholar
  22. 22.
    Bruera E, Willey JS, Lynn Palmer J, Rosales M. Treatment decisions for breast carcinoma. Cancer. 2002;94:2076-2080.PubMedCrossRefGoogle Scholar
  23. 23.
    Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42:1871-1894.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Caverly TJ, Hayward RA, Burke JF. Much to do with nothing: microsimulation study on time management in primary care. BMJ. 2018,363:k4983.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Carter-Harris L, Gould MK. Multilevel Barriers to the Successful Implementation of Lung Cancer Screening: Why Does It Have to Be So Hard? Ann Am Thorac Soc. 2017;14:1261-1265.PubMedCrossRefGoogle Scholar
  26. 26.
    Huo J, Shen C, Volk RJ, Shih Y-CT. Use of CT and Chest Radiography for Lung Cancer Screening Before and After Publication of Screening Guidelines: Intended and Unintended Uptake. JAMA Intern Med. 2017;177:439-441.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Henderson LM, Jones LM, Marsh MW, Benefield T, Rivera MP, Molina PL. Lung Cancer Screening Practices in North Carolina CT Facilities. J Am Coll Radiol. 2017;14:166-170.PubMedCrossRefGoogle Scholar
  28. 28.
    Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Sci Med (1982). 1997;44:681-692.CrossRefGoogle Scholar
  29. 29.
    Murray E, Charles C, Gafni A. Shared decision-making in primary care: tailoring the Charles et al. model to fit the context of general practice. Patient Educ Couns. 2006;62:205-211.PubMedCrossRefGoogle Scholar
  30. 30.
    Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations. Health Expect. 2007;10:248-258.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Kraetschmer N, Sharpe N, Urowitz S, Deber RB. How does trust affect patient preferences for participation in decision-making? Health Expect. 2004;7:317-326.PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med. 2005;20:531-535.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Crothers K, Kross E, Reisch LM, et al. Patients’ Attitudes Regarding Lung Cancer Screening and Decision Aids: A Survey and Focus Group Study. Ann Am Thorac Soc. 2016;13:1992-2001PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Wiener RS, Koppelman E, Bolton R, et al. Patient and Clinician Perspectives on Shared Decision-making in Early Adopting Lung Cancer Screening Programs: a Qualitative Study. J Gen Intern Med. 2018;33:1035-1042.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Legare F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff (Millwood). 2013;32:276-284.PubMedCrossRefGoogle Scholar
  36. 36.
    Friedberg MW, Van Busum K, Wexler R, Bowen M, Schneider EC. A Demonstration Of Shared Decision Making In Primary Care Highlights Barriers To Adoption And Potential Remedies. Health Affairs. 2013;32:268-275.PubMedCrossRefGoogle Scholar
  37. 37.
    Golden SE, Wiener RS, Sullivan D, Ganzini L, Slatore CG. Primary Care Providers and a System Problem: A Qualitative Study of Clinicians Caring for Patients With Incidental Pulmonary Nodules. Chest. 2015;148:1422-1429.PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Iaccarino JM, Simmons J, Gould MK, et al. Clinical Equipoise and Shared Decision-making in Pulmonary Nodule Management. A Survey of American Thoracic Society Clinicians. Ann Am Thorac Soc. 2017;14:968-975.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Rocque G, Miller-Sonnet E, Balch A, et al. Engaging Multidisciplinary Stakeholders to Drive Shared Decision-Making in Oncology. J Palliat Care. 2019;34:29-31.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Zeuner R, Frosch DL, Kuzemchak MD, Politi MC. Physicians’ perceptions of shared decision-making behaviours: a qualitative study demonstrating the continued chasm between aspirations and clinical practice. Health Expect. 2015;18:2465-2476.PubMedCrossRefGoogle Scholar
  41. 41.
    Golden SE, Thomas CR, Jr., Moghanaki D, Slatore CG. Dumping the information bucket: A qualitative study of clinicians caring for patients with early stage non-small cell lung cancer. Patient Educ Couns. 2017;100:861-870.PubMedCrossRefGoogle Scholar
  42. 42.
    Lillie SE, Partin MR, Rice K, et al. VA Evidence-based Synthesis Program Reports. The Effects of Shared Decision Making on Cancer Screening - A Systematic Review. Washington (DC): Department of Veterans Affairs (US); 2014.Google Scholar
  43. 43.
    Vogel BA, Leonhart R, Helmes AW. Communication matters: the impact of communication and participation in decision making on breast cancer patients’ depression and quality of life. Patient Educ Couns.. 2009;77:391-397.PubMedCrossRefGoogle Scholar
  44. 44.
    Mazzone PJ, Tenenbaum A, Seeley M, et al. Impact of a Lung Cancer Screening Counseling and Shared Decision-Making Visit. Chest. 2017;151:572-578.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  • Anne C Melzer
    • 1
    • 2
    Email author
  • Sara E. Golden
    • 3
  • Sarah S. Ono
    • 3
    • 4
  • Santanu Datta
    • 5
  • Kristina Crothers
    • 6
    • 7
  • Christopher G. Slatore
    • 3
    • 8
    • 9
  1. 1.Center for Care Delivery and Outcomes ResearchMinneapolis VA Healthcare SystemMinneapolisUSA
  2. 2.Division of Pulmonary and Critical Care, Department of MedicineUniversity of MinnesotaMinneapolisUSA
  3. 3.Center to Improve Veteran Involvement in CareVA Portland Health Care SystemPortlandUSA
  4. 4.Department of Family MedicineOregon Health & Science UniversityPortlandUSA
  5. 5.Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamUSA
  6. 6.Section of Pulmonary, Critical Care and Sleep MedicineVA Puget Sound Health Care SystemSeattleUSA
  7. 7.Division of Pulmonary, Critical Care and Sleep Medicine, Department of MedicineUniversity of WashingtonSeattleUSA
  8. 8.Division of Pulmonary & Critical Care Medicine, Department of MedicineOregon Health & Science UniversityPortlandUSA
  9. 9.Section of Pulmonary & Critical Care MedicineVA Portland Health Care SystemPortlandUSA

Personalised recommendations