4 physicians ask 4 pointed questions about shared decision-making
Before sending patients for CT lung cancer screening, referring clinicians must show that they shared decision-making around the process with the patient.
CMS requires such documentation, and the agency’s rationale is sound. Make referrers demonstrate appropriate patient selection and proper patient education on risks versus benefits, the logic goes, or imaging overutilization and patient obliviousness may both proliferate.
However, in practice, the policy can hinder suitable candidates from accessing low-dose CT scans that might help save their lives.
Researchers support the argument and flesh out the undesirable dynamic in an opinion piece published in the August edition of JACR [1].
The paper’s lead author is hematologist/oncologist Jennifer Lewis, MD, MPH. Senior author is radiologist Lucy Spalluto, MD, MPH. Both have appointments at Vanderbilt University Medical Center and VA Tennessee Valley Healthcare.
Co-authors are pulmonologists and critical care specialists Renda Soylemez Wiener, MD, MPH, of Boston University Medical Center and VA Boston Healthcare, and Christopher Slatore, MD, of Oregon Health and Science University and Portland VA Medical Center.
Noting that lung cancer screening with annual low-dose chest CT (LDCT) has been shown to cut lung cancer mortality by 20% compared with chest radiography, the authors frame their case around original research published in the same issue of JACR [2].
In that study, Tailor et al. found that well under half of individuals undergoing lung cancer screening, 42%, had shared decision-making documented in their EHR. And of these, only 21.8% included all components CMS calls for.
These and other observations prompted Lewis and co-authors to consider how wide the gap might be between documenting shared decision-making and actually doing it.
Here are four questions they pose and answer en route to arriving at their conclusion in the context of lung cancer screening.
Question 1. Is the CMS Policy That Requires Documenting Shared Decision-Making Working?
Lewis and co-authors acknowledge the importance of shared decision-making in medicine. However, based on the evidence presented in Tailor et al., such patient-clinician collaboration “is not happening and is not being documented in time-constrained primary care clinic visits.” More:
It is of interest that Tailor et al. found that patients actually perceived that shared decision-making occurred more often than it was appropriately documented (71% vs. 21.8%). This suggests there may be a disconnect between what CMS perceives shared decision-making documentation should encompass and what patients actually desire or need (which is the more important). Regardless, it seems that the policy mandating shared decision-making documentation may not support the needs of clinicians or be feasible in routine clinical care.”
Question 2. What Shared Decision-Making Documentation Is Currently Required by CMS for Reimbursement?
After recapping the granular terms of CMS’s expectations around documentation for shared decision-making—including patient eligibility, conversation elements, counseling details and smoking cessation assistance—Lewis and colleagues state flatly: “This is a lot to ask of busy clinicians.” More:
To meet these requirements, healthcare professionals must be familiar with CMS criteria, be prepared with a decision tool that meets CMS criteria, be comfortable with the scientific literature as well as local logistics of screening in their facility, have time in clinic visits to perform shared decision-making with patients, and, finally, document shared decision-making appropriately by CMS standards. A breakdown at any point could result in under-documentation of shared decision-making or underutilization of shared decision-making or lung cancer screening.”
Question 3. Should We Do Shared Decision-Making, and If So, How Should Shared Decision-Making Be Documented?
Answering the first part of this question with an emphatic affirmative, Lewis and co-authors suggest meaningful patient-clinician communication has multiple upsides and no downsides. At the same time, they caution, shared decision-making discussions are means to a specific end. The aim must be to make sure the patient is “fully informed of the process of lung cancer screening and the potential risks and benefits of pursuing lung cancer screening, and to guarantee that an individual’s preferences are fully considered.” More:
But shared decision-making documentation need not be a burden to clinicians, and less documentation requirements would free up clinicians’ time to have more conversations and refer appropriate patients for a potentially lifesaving health intervention. Including a simpler statement that a provider discussed screening with the patient, including potential benefits, risks and screening processes, may better suffice for shared decision-making documentation requirements.”
Question 4. How Can We Improve Shared Decision-Making and Utilization of High-Quality Lung Cancer Screening?
Lewis and co-authors point out that CMS relaxed shared decision-making requirements earlier this year, opening avenues for clinical stakeholders to try new ways of sharing decision-making with patients. Examples might include tapping telemedicine, embedding shared decision-making elements in screening programs and appointing qualified screening coordinators or navigators. “Continued efforts are necessary to better understand what patients and clinicians want,” the authors write.
Shared decision-making must be appropriate for individuals from all backgrounds, levels of health literacy and numeracy, and motivation and must also meet the needs of those with time-constrained visits or take place outside the setting of already busy primary care visits. A critical area for future research is how to conduct high-quality SDM conversations that meet the needs of patients and the healthcare team in very brief conversations (i.e., what are the minimal essential elements to cover in a high-quality SDM discussion?)”
Current CMS Policies ‘A Potential Barrier to Screening Utilization’
Lewis and colleagues close on a sobering reminder: Lung cancer kills more Americans than any other cancer. It also debilitates many of its survivors.
The disease’s prevalence makes it all the more ripe for slashing its toll, the authors suggest.
“Current CMS policies mandating lung cancer screening shared decision-making documentation are a potential barrier to screening utilization,” Lewis et al. assert. “Adapting the current shared decision-making model to a more practical and meaningful opportunity for patient-clinician communication may increase utilization of high-quality lung cancer screening and improve screening equity.”
Dave P. has worked in journalism, marketing and public relations for more than 30 years, frequently concentrating on hospitals, healthcare technology and Catholic communications. He has also specialized in fundraising communications, ghostwriting for CEOs of local, national and global charities, nonprofits and foundations.