This article is more than 5 years old. Information may no longer be current.
‘Remarkably low’ uptake of shared decision-making visits for lung cancer screening
Participation in shared decision-making visits before low-dose CT screening for lung cancer was “remarkably low” among Medicare enrollees, according to findings published in JAMA Internal Medicine.
“In early 2015, CMS initiated reimbursement for low-dose CT (LDCT) screening for lung cancer in individuals aged 55 to 77 years with a 30 pack-year or greater smoking history,” James S. Goodwin, MD, George and Cynthia Mitchell Distinguished Chair of Geriatric Medicine at The University of Texas Medical Branch, and colleagues wrote. “A unique feature of the CMS approval was a requirement for a separate shared decision-making session before the LDCT. This visit had several required components, including use of a decision aid and counseling on tobacco abstinence.”
Goodwin and colleagues analyzed Medicare data from Jan. 1, 2015, to Dec. 31, 2016 to examine the use of shared decision-making visits among enrollees aged 55 to 77 years who received an LDCT. The participants had complete Medicare Parts A and B coverage and were not enrolled in a health maintenance organization. They were divided into two cohorts by year. The 2015 cohort included 4,192,802 Medicare beneficiaries, whereas the 2016 cohort included 4,138,559.
The researchers used Current Procedural Terminology codes to identify enrollees with charges for an LDCT shared decision-making visit and receipt of LDCT.
In 2016, 19,021 enrollees underwent LDCT. About 9% of whom (n = 1,719) participated in a shared decision-making visit within the prior 3 months. There was a plateau in the monthly percentage of enrollees undergoing LDCT who had a shared decision-making visit at 10%.
Blacks (OR = 0.76; 95% CI, 0.59-0.97), women (OR = 0.88; 95% CI, 0.79-0.98) and patients with higher education (OR = 0.81; 95% CI, 0.68-0.96) were less likely to participate in shared decision-making before LDCT. Participation in shared decision-making varied greatly regionally.
From January through October 2016, 2,154 enrollees participated in shared decision-making, with 60.8% undergoing LDCT in the following 3 months.
“Shared decision-making has rapidly evolved from an abstract concept to mandated implementation,” Goodwin and colleagues concluded. “However, the clinical community has not adopted the CMS mandate for a shared decision-making visit before LDCT screening. Inability or unwillingness to engage in shared decision-making may contribute to the low overall use of LDCT screening and less awareness of its implications among eligible patients.” – by Alaina Tedesco
Disclosures: Goodwin reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.
Perspective
Back to Top
As demonstrated in the National Lung Screening Trial (NLST) in 2011, use of LDCT scan for surveillance purposes can reduce lung cancer mortality by 20% in a high-risk population. In 2015, CMS began reimbursing for these scans in individuals to which these findings could be applied, with the caveat that the care provider must engage in a shared decision-making session prior to the imaging study. The purpose of such a visit is to review the rationale for the screening exam, ensure that the patient understands the implications of the possible findings and to emphasize the importance of tobacco cessation.
Ultimately, it is felt that such a discussion will best prepare patients for the management of potential malignancies and encourage avoidance of behaviors that increase risk for lung cancer, ultimately optimizing outcomes for existing lung cancers and decreasing future development of additional malignancies. While this visit was deemed to be a required component of the process, adherence to this algorithm had not been well elucidated.
Interestingly, Goodwin and colleagues found that adherence to this process was surprisingly low. Moreover, they found that a substantial portion of patients who had shared decision-making visits didn’t end up receiving a CT scan.
There are a multitude of reasons why patients might not have had the decision-making visit documented. It’s certainly possible that decision-making occurred during another patient care encounter, and that the methodology of the study simply failed to capture the shared decision-making because the billing reflected the primary reason for the visit.
However, there may legitimate barriers to conducting the decision-making visit, which ought to be identified. One issue may be a lack of training in decision-making or lack of awareness of the mandate (which came several years after publication of the NSLT).
It is abundantly clear that primary care providers are in need of education overall with regard to lung screening, as utilization of lung cancer screening for eligible patients has been demonstrated to be quite poor by a number of previous investigators. Furthering the education of providers regarding the indications and availability of lung cancer screening needs to be prioritized, and this study by Goodwin et al would suggest the education regarding the decision-making visit ought to be included.
As we aim to provide necessary information to providers and patients regarding the benefits of lung cancer screening, the role of the shared decision-making needs to be emphasized.
It will be of utmost importance to clarify the rationale for the shared decision-making visit, which ultimately aims to ensure best possible outcomes for patients, regardless of the findings. Only through greater efforts to disseminate knowledge to primary health care providers, patients and the general public can we improve the current use of screening CT exams for lung cancer.
Reference:
National Lung Screening Trial Research, T., et al., Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med, 2011. 365(5): p. 395-409.