Shared Decision-Making and Use of Low-Dose CT Screening for Lung Cancer
In a study reported in a research letter in JAMA Internal Medicine, Goodwin et al found that only a small proportion of Medicare enrollees undergoing low-dose computed tomography (CT) screening for lung cancer had a prescreening shared decision-making session, which is mandated by the Centers for Medicare & Medicaid Services (CMS).
CMS initiated reimbursement for low-dose CT lung cancer screening in early 2015 for eligible individuals, with a separate shared decision-making session being a requirement in the CMS approval. The visit includes a number of required components, including the use of a decision aid and counseling on tobacco abstinence.
The study involved evaluation of Medicare data from January 2015 through December 2016 on enrollees from a 20% national sample to identify those who received low-dose CT and had a separate visit for shared decision-making.
Use of Shared Decision-Making
Of the 19,021 enrollees in the 20% sample who underwent low-dose CT in 2016, 1,719 (9.0%) had a separate shared decision-making visit on the day of the CT or within the previous 3 months. After an initial increase in late 2015 and early 2016, the monthly percentage of enrollees undergoing low-dose CT who had a shared decision-making session plateaued at approximately 10%; the slope of the increase was 1.05% per month prior to May 2016 and 0.09% per month after May 2016.
Factors associated with a lower likelihood of having a shared decision-making session before low-dose CT included black vs white race (odds ratio [OR] = 0.76, 95% confidence interval [CI] = 0.59–0.97), female sex (OR = 0.88, 95% CI = 0.79–0.98), and higher education level (OR = 0.81, 95% CI = 0.68–0.96 for highest vs lowest quartile of education). Likelihood of a shared decision-making session also exhibited wide regional variation.
Among the 2,154 enrollees who underwent shared decision-making from January through October 2016, 1,300 (60.8%) underwent low-dose CT in the following 3 months. In multivariate analysis, black race (risk ratio [RR] = 0.81, 95% CI = 0.66–0.97) and female sex (RR = 0.93, 95% CI = 0.86–0.99) were associated with a significantly lower likelihood of undergoing low-dose CT after shared decision-making.
Study Implications
As stated by the investigators, “Early reports suggest that less than 5% of eligible Americans are receiving [low-dose] CT. The 60.8% rate of [low-dose] CT after shared decision-making suggests that a substantial proportion of enrollees are deciding against [low-dose] CT after shared decision-making.”
They concluded: “Shared decision-making has rapidly evolved from an abstract concept to mandated implementation. However, the clinical community has not adopted the CMS mandate for a shared decision-making visit before [low-dose] CT screening. Inability or unwillingness to engage in shared decision-making may contribute to the low overall use of [low-dose] CT screening and less awareness of its implications among eligible patients.”
James S. Goodwin, MD, of the University of Texas Medical Branch, Galveston, is the corresponding author for the JAMA Internal Medicine article.
Disclosure: The study was supported by grants from the Cancer Prevention and Treatment Institute of Texas and the National Institutes of Health. The study authors’ full disclosures can be found at jamanetwork.com.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
