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Shared Decision Making for Lung Cancer Screening

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Some examples of shared decision making for lung cancer screening and draft requirements

Published in: Health & Medicine
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Shared Decision Making for Lung Cancer Screening

  1. 1. Shared Decision Making Aid for Lung Cancer Screening Discussion
  2. 2. Elements of shared decision making • Understands the risk or seriousness of the disease or condition • Understands the preventive service, including the risks, benefits, alternatives and uncertainties • Have weighed his/her values regarding the potential harms and benefits associated with the service • Have engaged in decision-making at a level he or she desires and feels comfortable Sheridan SL, Harris RP, Woolf SH. Shared Decision making about screening and chemoprevention, a suggested approach from the U.S. Preventive Services Task Force. American journal of preventive medicine. 2004;26(1):55-56
  3. 3. CMS Draft Recommendation Requirements A lung cancer screening counseling and shared decision making visit includes the following elements (and is appropriately documented in the beneficiary’s medical records): ◦Determination of beneficiary eligibility including age, absence of signs or symptoms of lung disease, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting; ◦Shared decision making, including the use of one or more decision aids, to include benefits, harms, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure; ◦Counseling on the importance of adherence to annual LDCT lung cancer screening, impact of comorbidities and ability or willingness to undergo diagnosis and treatment; ◦Counseling on the importance of maintaining cigarette smoking abstinence if former smoker, or smoking cessation if current smoker and, if appropriate, offering additional Medicare-covered tobacco cessation counseling services; and ◦If appropriate, the furnishing of a written order for lung cancer screening with LDCT. Written orders for both initial and subsequent LDCT lung cancer screenings must contain the following information, which must also be documented in the beneficiaries’ medical records: Beneficiary date of birth, Actual pack-year smoking history (number); Current smoking status, and for former smokers, the number of years since quitting smoking; Statement that the beneficiary is asymptomatic; and NPI of the ordering practitioner.
  4. 4. Implementation possibilities and challenges would benefit from pilot program approach to development and evaluation • Some studies show distributing the decision aide prior to the shared discussion is most effective • Variations in health literacy (and patient activation) levels may necessitate diverse approaches (multiple messaging and distribution channels) • Not all physicians comfortable or competent in SDM.
  5. 5. Examples of Shared Decision Aides
  6. 6. Examples of Shared Decision Aides – Cancer Treatment Centers of America – pages 1-3
  7. 7. Examples of Shared Decision AidesCancer Treatment Centers of America – pages 4 and 5
  8. 8. Examples of Shared Decision Aides – 40 Page Patient Pre-discussion booklet for FOBT Screening (low health literacy population)
  9. 9. Draft Requirements • Automatically generate electronic physician order • Shared decision discussion and outcome recorded in the patient EMR • “proof” each required element covered during the discussion • Automatically populate the appropriate data elements into the national screening registry “data set” • “Modular” Design implementable in various media and distribution channels – print, video, internet • Modules can be combined in any order and used individually as appropriate. • Allows for re-use of modules in other health care settings and generic health care discussions • patient eligibility module at lung cancer screening site • smoking cessation module during any health care provider patient visit
  10. 10. Shared Decision Aid for Lung Cancer Screening – Modules • Patient Risk Module: Discuss lung cancer epidemiology (e.g. risk in targeted population, five year survival rates, general risks for lung cancer). The individual risk discussion should include all known risks regardless of whether they are included in the recommended to screen criteria; age, pack years smoking history – convert other tobacco use into equivalent pack years, years since quit if former smoker, history of cancer, family history of cancer, exposure to radon, asbestos, arsenic, cadmium, chromium, diesel fumes, nickel, silica, second hand smoke, air pollution, and/or cooking fires (if grew up in developing countries). Consider using Tammemagi risk model for specific risk calculation • Eligibility Module: Assess eligibility for USPSTF or CMS criteria as appropriate including patient being asymptomatic. • Lung Cancer Screening Discussion Module:. Define a low dose CT scan, discuss the NLST process and results. Discuss benefits, harms, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure. Describe the process the patient would experience from decision to screen through follow-up for various CT scan result scenarios. • Patient Preference and Decision Module: Counseling on the importance of adherence to annual LDCT lung cancer screening, impact of patient comorbidities and patient ability or willingness to undergo diagnosis and treatment. Discussion of patient preference, willingness and desire to comply with screening follow-up and recurrent annual screening during eligibility period (i.e. age and time since quit smoking). • Smoking Cessation Module: Counseling on the importance of maintaining cigarette smoking abstinence or smoking cessation if current smoker. Use the 2008 Clinical Practice Guideline 5 key steps for smoking intervention.

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