Doing vs. Documenting Shared Decision Making for Lung Cancer Screening – Are they the same?

Lung cancer screening (LCS) with annual low-dose chest computed tomography (LDCT) decreases lung cancer mortality by 20% compared to chest radiography.¹ LCS for high-risk individuals carries a United States Preventive Services Task Force Grade B recommendation and is covered by the Centers for Medicare and Medicaid Services (CMS) and third-party insurers.^1,2 Yet, different to other cancer screenings, CMS requires a documented, structured, shared decision-making (SDM) encounter prior to the first screening exam. This policy was intended to reinforce the need to select appropriate individuals for screening, and to counsel them about both the potential benefits and risks of screening and the importance of adherence.²

In the current issue of the Journal, Tailor et al demonstrate that even though required by CMS, documentation of SDM for LCS remains sub-optimal, with only 41.9% of individuals undergoing LCS having SDM documented in their electronic health record (EHR). Further, of the EHR notes documenting SDM, only one-fifth included documentation of all required CMS components.³ These findings support other studies that have demonstrated even lower utilization or documentation of SDM, based on billing codes or audiorecorded clinic visits.^4,5 Interestingly, Tailor et al also found that that patients perceived that SDM occurred more often than it was appropriately documented (71% vs 42%).

The continued sub-optimal utilization and documentation of SDM raises concern and begs the questions…is the CMS policy working? What SDM documentation is currently required by CMS for reimbursement? Should we do SDM, and if so, how should SDM be documented? How can we improve SDM and utilization of high quality LCS? Consideration of these questions can help us look to the future on how to improve SDM and, ultimately, how to increase uptake of high-quality LCS for a diverse range of populations.

Question 1: Is the CMS policy that requires documenting SDM working?

SDM is a critical component to patient-clinician communication, but in its current form, the evidence shows that it isn’t happening and it isn’t being documented in time-constrained primary care clinic visits.^3–5 The policy does not seem to be encouraging clinicians to document CMS-adherent SDM. Perhaps, this is because the documentation requirements set forth in the policy are too cumbersome.

It is of interest that Tailor et al found that patients actually perceived that SDM occurred more often than it was appropriately documented. This suggests there may be a disconnect between what CMS perceives SDM documentation should encompass and what patients actually desire or need (which is the more important). Regardless, it seems that the policy mandating SDM documentation may not support the needs of clinicians or be feasible in routine clinical care.

Question 2: What SDM documentation is currently required by CMS for reimbursement?

During the time period of the study by Tailor et al (2015-2020), CMS required clinicians to document: 1. Determination of eligibility including all criteria (age, symptom status, smoking history including calculation of pack-years, and years since quitting); 2. A SDM conversation including use of a decision aid that met specific criteria (benefits and harms of screening, follow-up diagnostic testing, overdiagnosis, false positive rate and total radiation exposure); 3. Counseling on annual adherence, potential impact of comorbidities, patients’ ability and/or willingness to undergo evaluation and potential treatment for lung cancer; and 4. Smoking cessation counseling and provision of materials on tobacco treatment to individuals who currently smoke.⁶ This a lot to ask busy clinicians, and the complexity may have contributed to low observed rates of CMS-adherent SDM documentation. 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 SDM with patients, and finally, document SDM appropriately by CMS standards. A break down at any point could result in under-documentation of SDM and/or under-utilization of SDM or LCS.

CMS lessened the complexity and burden of SDM documentation in its 2022 Decision Memo with the rationale that LCS has become a more common service.² There is no longer the requirement to document individual eligibility criteria (age, smoking history, etc.) since these are already in the medical record, but the act of determining eligibility must still be documented. Healthcare professionals are still required to document SDM with the use of a decision aid but there is no longer the detailed list of what the aid must include. Healthcare professionals must also document that they counselled patients on the importance of annual screening adherence, the potential impact of comorbidities, and address patients’ ability or willingness to undergo diagnosis and treatment for lung cancer as well as the importance of tobacco cessation. Information on tobacco treatment must also still be provided to individuals who currently smoke.²

Question 3: Should we do SDM, and if so, how should SDM be documented?

In short, yes! SDM is a prime example of patient-centered care, which should be a priority of all medical services – not only LCS. During SDM, patients and providers make health decisions together in a discussion of the scientific evidence for a particular healthcare service and in reflection of the patient’s values, experience, and perspective.⁷ The benefit of SDM is involving the patient directly in their health and making healthcare decisions in partnership. This meaningful patient-clinician communication can increase patient knowledge of their health and healthcare services, improve clinical outcomes, increase patient satisfaction with care, and potentially increase adherence to services such as annual LCS.⁷ The SDM discussion is meant to ensure that an individual is fully informed of the process of LCS, the potential risks and benefits of pursuing LCS and to guarantee that an individual’s preferences are fully considered.⁷ But, SDM documentation need not be a burden to clinicians and less documentation requirements would free up clinician’s time to have more conversations and refer appropriate patients for a potentially life-saving 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 SDM documentation requirements.

Question 4: How can we improve SDM and utilization of high quality LCS?

Thoughtful approaches to redesigning SDM could make it more useful, effective, and more likely to happen. Standardization and embedding SDM within LCS programs can help to ensure SDM is provided by healthcare professionals who are knowledgeable and experienced (e.g., LCS coordinators in centralized programs). The relaxing of CMS restrictions on SDM requirements in the 2022 CMS Decision Memo allows the opportunity to explore novel approaches, such as using other team members like decision coaches or community health workers to support SDM conversations, or new formats such as group SDM visits or SDM by telehealth.⁸ Additionally, wherever possible healthcare systems could automate language and billing codes for screening to lessen the burden of documentation on clinicians and reimbursement on healthcare systems.

Continued efforts are necessary to better understand what patients and clinicians want. Rethinking the current approach to SDM can help to ensure that SDM incorporates the information that potential LCS candidates want, is actually feasible in the real world setting for a diverse range of populations, and achieves its target goal of capturing individual’s preferences for care. SDM must be appropriate for individuals from all backgrounds, levels of health literacy and numeracy, 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 health care team in very brief conversations, i.e., what are the minimal essential elements to cover in a high-quality SDM discussion?⁸

Summary

Lung cancer claims more lives annually than any other cancer.¹ Increasing access to and utilization of high-quality LCS offers an opportunity to decrease lung cancer morbidity and mortality. Current CMS policies mandating LCS SDM documentation are a potential barrier to screening utilization. Adapting the current SDM model to a more practical and meaningful opportunity for patient-clinician communication may increase utilization of high-quality LCS and improve screening equity.

Data access/integrity:

The author(s) declare(s) that they had full access to all of the data in this study and the author(s) take(s) complete responsibility for the integrity of the data and the accuracy of the data analysis.