As the second most common cancer diagnosed in Veterans (18%) and the leading cause of cancer-related death for Veterans cared for by the US Veterans Health Administration (VHA), lung cancer (LC) is a critical health care problem among Veterans. The National Lung Cancer Screening Trial (NLST) was transformative, demonstrating the efficacy of Low Dose Computed Tomography (LDCT). The United States Preventive Services Task Force (USPSTF) published a recommendation giving LC screening a Grade B recommendation citing adequate evidence to screen asymptomatic patients aged 55-80 with significant tobacco use history. As a result of the NLST, the recommendations for LC screening by the USPSTF, and the high burden of LC among Veterans, the VHA has embarked upon a three year LC Screening Demonstration project at 8 VAMC to determine the feasibility of implementing a LC screening program.
A primary consideration of any cancer screening test is that patients have made an informed decision about whether or not to have screening. According to the US Preventive Services Task Force, an informed decision is one in which patients: (1) understood the condition or disease, the tests that are used to detect it, and their personal risk, (2) their preferences were considered during the decision-making process, and (3) they participated in making the decision at their desired level.
The proposed research built on and extended our previous research on beliefs about LC screening among Veterans in several important ways. Our approach determined whether Veterans were making informed decisions about LC screening based on the current methods established by the NCP to implement LC screening or if tailored strategies (such as eliciting their preferences for information, structured teach back, etc.) were needed to facilitate informed decisions about using this modality. Our study was the first to examine decision outcomes (e.g., satisfaction and regret) about LC screening among Veterans who recently made a decision about LC screening based on the patient's racial background, cultural beliefs and values, health care experiences and perceptions about medical care in the VA.
The objectives of this study were to: (a) assess the degree to which high-risk Veterans are making informed decisions regarding LC screening based on their beliefs and attitudes about LC screening; and (b) evaluate the association between these beliefs and attitudes and patient's perceptions about their provider's communication about LC screening on decision satisfaction and regret about LC screening.
The purpose of the proposed prospective observational mixed methods study was to characterize patient perceptions of provider discussions about benefits, limitations, and risks of screening, as well as solicitation of their preferences about screening, and their level of involvement making a decision to accept or decline LC screening. We first identified Veterans who were most and least likely to have made an informed decision about LC screening; to do this, we evaluated the decision satisfaction and regret for LC screening based on racial background, gender, age, education level, socioeconomic status, trust in the VHA, and beliefs about LC and LC screening among Veterans who have accepted or declined LC screening since the start of the LCDP. The design of an explanatory prospective observational mixed methods study used a qualitative strand to explain the implications of quantitative findings. Subjects were recruited from the Ralph H. Johnson VA Site where the LCDP was being implemented; to be eligible for participation, patients must have been at high-risk for developing lung cancer as determined by the USPSTF recommendation for LC screening and referred for LC screening.
We examined the effects of the SDM intervention delivered on constructs from the Ottawa Decision Support Framework. This commonly-used evidence-based theoretical framework of decision making separates the process into 3 constructs: Decisional Quality, Decisional Impact, and Decisional Action. In addition to examining decisional outcomes, we also measured the association between cultural beliefs and values and LCS decisions.
We used the Satisfaction With Decisions (SWD) scale 17 to evaluate informed decision-making based on the extent to which LCS decisions were theirs to make, were the best for them, were informed choices, and were consistent with their values. Items were summed to create a total score; higher scores reflected greater satisfaction with decisions to accept or decline LCS. The SWD had good internal consistency (Cronbach's alpha=0.95). All participants were highly satisfied with their decision about LCS score of 24.6 (SD 5.6). There was no difference in SWD between those accepting and declining screening (25.9 versus 24.1, respectively, p=0.13)
Decision quality was measured in terms of decision conflict at the one month follow up survey after participants had made a decision about LCS. The Decisional Conflict Scale was used to evaluate how much patients experienced conflict after deciding to accept or decline LCS. Items from this validated Likert-style questionnaire were summed such that a lower score reflected less decisional conflict. Decision conflict was low with an overall score of 12.1 (SD 3.4). In addition, there was no difference in conflict between those accepting and declining screening (11.7 vs 11.8,p=0.89).
As of November 10, 2014 the Centers for Medicare and Medicaid (CMS) approved coverage for the Medicare population meeting criteria for LC screening in certified centers. CMS recognized the issues with informed decision-making surrounding LC screening in that those that qualify may not fully understand the risk versus benefit. To address this, CMS plans to cover a shared decision making visit/consultation prior to LC screening. The current way the LCDP is set up in the VA does not include such a visit. Instead, a brochure with risk and benefit is distributed to the Veteran followed by a phone call from a nurse coordinator to discuss further.
The goal of this proposal was to better understand facilitators and barriers to informed decision making for LC screening among Veterans. Evidence has shown that shared decision making interventions enhance informed decision making and reduce health inequalities. This study found that Veterans are making informed decisions within the current constructs of lung cancer screening within the VA. The majority of participants were satisfied with their decision and felt strongly that the decision aid along with the shared decision making phone call from the nurse coordinator were helpful in improving knowledge about lung screening and in the decision process.
These findings are impactful in that they provide information on how to offer Veterans LC screening effectively in ways that Veterans understand the benefits, limitations and risks of screening and ultimately make an informed and patient-centered decision about screening. The findings will benefit other VAMCs as they start to implement lung cancer screening.
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