Table 2.
Illustrative Quotations Regarding Characteristics of SDM Models Implemented for LCS
| SDM Model Characteristic | Quotation No. | Illustrative Quotation (Study Respondent Letter) |
|---|---|---|
| SDM for LCS process | 1 | “Our decentralized program will usually start with primary care . . . after identifying eligible patients we’ve discussed the risks and benefits of screening, we include briefly what the risks are, you know, radiation exposure, overdiagnosis, false positive, unnecessary procedures, and the patient agrees that they are willing and able to undergo the CT and any recommended follow-up. Um, and then from that point the patient, when they place the order, the patient will be contacted to schedule the CT scan, um, and again the CT scan could happen at a variety of imaging centers around our area.” (19A) |
| 2 | “It is centralized. I conduct all of the consults. Um, the patient is referred from their primary care provider to our program and then once a patient’s referred, they are contacted by a medical assistant who will call the patient, confirm eligibility, or just confirm it according to what’s, in the referral, and then, get the patient in for the consult. So schedule the patient for the consult and then the patient is able to walk down the hall to radiology to have the imaging, after the consult.” (6A) | |
| 3 | “We have hybrid program either they can order it on their own or they can send it to our centralized program. When they decide to do it on their own it’s like, oh well, I can do the shared decision-making, um, just as much as, as you can.” (7B) | |
| SDM for LCS evolution | 4 | “I just think you know as we’ve evolved through this process over the last couple years. We’ve understood how complex that it is, in terms of really running a quality program, making sure that smoking cessation is the center of our program and that patients have the resources for that . . . . We are in the process of somewhat decentralizing, um, as we’ve recently acquired some satellite locations and it becomes more widespread and understood and so we are educating our primary doctors, on doing shared decision-making with the patients, then they will order, the primary care doctor will perform the shared decision-making and order the scan and all abnormal screens will come to our clinic.” (18A) |
| 5 | “What drove the change was, um, they were realizing that there were patients being referred into the program who were not necessarily, even eligible for lung cancer screening or had active symptoms of lung cancer. There was some misunderstanding among referring providers about screening vs diagnostic CTs, they felt like they wanted a little bit more control over the process and decided to shift that responsibility to the, lung cancer screening nurse coordinator.” (14A) | |
| Implementation leaders | 6 | “We have a group of providers from the chest radiology, PCP, and also pulmonary, so we are the core people. We work with, uh, multidiscipline oncology group but pretty much we just report it back to them what we decide just to make sure they know. Um, so the decision we made ‘this is the way we want to do’ is basically, based on what was available. So, we cannot do the centralized system because we don’t have the budget for nurse navigator.” (4A) |
| 7 | “We had a steering committee that consisted of, uh, thoracic surgery, radiation oncology, the chief of radiology, the chief for primary care. All of us got together before we ever started to implement, enroll out and so shared decision-making was one of the components of implementing lung screening.” (7B) | |
| Access-quality tradeoff | 8 | “There is a tension between sort of the centralization of the process that is everyone comes to a central place to get their shared decision-making conversation, to get their tobacco cessation counseling, and to get their screening. I’m absolutely certain that is the highest-quality way to provide a lung cancer screening program. The problem I think is the reach for that is limited and there’s an unquantifiable number of people that just will never get screened who may benefit from screening because they don’t have the wherewithal or the desire to travel an hour, two hours, three or even sometimes four hours to get to that centralized clinic.” (13A) |
| 9 | “We felt like, funneling the patients through a single care provider or office would limit the growth and access to lung cancer screenings so we wanted to leave it in the hands of the ordering provider.” (2A) | |
| 10 | “So we do a large, uh, community outreach portion and our community outreach is done by our patient navigators who bring in hard-to-reach patients and through that they help to facilitate that conversation so they help find out what the patients’ needs are in terms of lung cancer screening, smoking cessation, and from there then they can communicate to providers to help fill the provider in with what that patient needs to help facilitate that conversation. . . . I think one of the things we do really well is including that community engagement piece into our clinical health programs, our implementation science program, so really being able to reach marginalized communities, is an important component of this.” (16A) | |
| 11 | “One of our sites is doing this by [a proprietary online meeting service] so the patient comes in to the clinic locally where they have a video monitor and connects with the more central site by video monitor. There has to be a nurse in the room with the patient for that to be a billed event, but that way we are doing some remote, shared decision-making as well.” (17A) | |
| 12 | “Because it’s a centralized program, you know, we had input from the primary care providers, very shortly, and after implementation they were thrilled that they did not have to do these conversations. One, they didn’t have the time in a busy clinic practice to do shared decision-making, two, they didn’t understand the nuisances of risks and benefits for screening. They’d rather just leave it for the trained experts.” (7B) | |
| 13 | “We have discovered that not all providers answer the questions. And they would just skip over it. In April we have, um, an upgrade to [proprietary EHR vendor]. During that, um [proprietary EHR vendor], upgrade the, the questions regarding decision-making and smoking cessation will be hard stop questions and a provider must order the, or answer them, in order to move forward. So, it will be mandatory to be answered.” (9A) | |
| 14 | “CMS has certain requirements for what needs to be documented, so we can monitor for that. So, if you were to argue that you know appropriately documenting the things CMS requires to be documented as quality, that we can monitor, but what really is happening in terms of, you know, quality, no.” (20A) | |
| 15 | “Although when you look at the documentation there’s a checked box indicated the right CMS verbiage for billing, but whether or not they’re actually conducting a shared decision-making visit is hard for us to know.” (7B) | |
| 16 | “[T]he con of centralized, or you could say the benefit of doing it decentralized, physician recommendation really matters to patients like it’s out in the literature. It’s like, you know when your doctor tells you to do some kind of cancer screening at least in the other cancer screenings you know, it’s, it’s highly predictive of the patient doing it . . . . But, when we put a team on things and that team is not, you know, speaking with the voice of the physician I think patients ignore it.” (20A) |
CMS = Centers for Medicare and Medicaid Services; EHR = electronic health record; PCP = primary care physician. See Table 1 legend for expansion of other abbreviations.