Table 4.
Illustrative Quotations Regarding Challenges of SDM for LCS Implementation
| Challenges of SDM for LCS Implementation | Quotation No. | Illustrative Quotation (Study Respondent Letter) |
|---|---|---|
| Time constraints | 1 | “So they’re supposed to be identifying patients who need the flu shot, they’re supposed to be identifying patients who need the shingles shot, so there’s a lot of competing agendas, and they don’t have any protected time for do this work.” (20A) |
| 2 | “It’s, I guess, certainly a daunting task there. If you do well it probably takes several minutes, and it could kind of be a hard sell getting an already busy clinician who’s, um, dealing with three or four chronic medical problems in a 15-minute time slot to commit to actually have the discussion . . . . We made a video and a couple of nurse practitioner[s] and I, uh, who worked on this basically had a shared decision-making visit into a camera with the thought being that, you know, someone could be put in the room for primary care visit. This video could, you know, then be played while they’re waiting on the provider to come in and to start the visit.” (5A) | |
| Knowledge and beliefs about SDM for LCS | 3 | “I think initially this is a very new concept, uh, the concept of a shared decision-making visit before a cancer screening test. We don’t do that for colon cancer screening, don’t really do it for breast cancer screening, anything, or anything else.” (5A) |
| 4 | “I don’t think there was a lot of information, to be honest in general, regarding shared decision-making. It was just one more element. There was more emphasis in, having a program to report to CMS the data.” (3A) | |
| 5 | “Primary care providers in particular, but really all referring clinicians, were feeling like they didn’t necessarily have the in-depth knowledge about lung cancer screening and what the tradeoff[s] of that were to be able to conduct the full shared decision-making process.” (14A) | |
| 6 | “We try to educate, we do grand rounds, we encourage the primary care providers to refer to our program. We did have paper decision aids that were made available to the primary care providers should they want to engage in that conversation. Um, with time we had some computer-based, uh, web-based decision aids, available through [the] VA, one is, uh, is, lung decision precision.com, which includes the risks and benefits of lung cancer screening as well as an individualized risk for developing lung cancer based on the bock model.” (7B) | |
| Reflecting and evaluating | 7 | “I think we need something like that, but as of now there’s no system in place to monitor the quality of shared decision-making.” (14A) |
| 8 | “I think what we need to do is define the bare minimum, content of a discussion between a patient and a physician that constitutes shared decision-making . . . . I think if we want to audit ourselves as providers we need to be able to go back and see what we did and how we did it and how well we did it, and then see does that to really, does that, you know, connected with patient-centered outcomes, right? . . . . And you know I’ve had conversations with other experts about, how do you even measure the quality of a shared decision-making conversation? Is there some metric that we can come up with? And I think people even struggle with that which is, how do you know whether it’s happened and how do you know whether it’s happened with quality?” (13A) | |
| 9 | “We did surveys of our patients before the visit about their knowledge, um, and then immediately after the visit surveys about their knowledge and whether they felt the visit helped them make an informed decision . . . . Those results had showed, uh, that knowledge at the end of the visit was much better, particularly about the harms of screening. Um, and the patients felt more comfortable with their decisions.” (21A) | |
| 10 | “We have implemented in our EHR that the, uh, a little box comes up if a patient reaches, uh, is correct age, if their smoking history is correct, to remind the physician that this could be a patient that could be eligible for lung cancer screening. When providers order low-dose CT, providers [are] asked to go through the checklist for the CMS, you know, documentation purpose: make sure patients eligible, make sure patient does not have a fever, or come up with any symptom of the cancer, discussed the benefit and risk, um, including false positive, blah, blah, blah. That’s CMS documentation part.” (4A) |