Tanner J. Caverly

Evaluation of a Personalized, Web-Based Decision Aid for Lung Cancer Screening.

INTRODUCTION Informed decision making has been highlighted as an important aspect of lung cancer screening programs. This study seeks to assess the efficacy of a web-based patient decision aid for lung cancer screening, www.shouldiscreen.com. METHODS A before-and-after study (August through December 2014) was conducted where participants navigated a web-based decision aid that provided information about low-dose computed tomography lung cancer screening. Using an established prediction model, the decision aid computed baseline lung cancer risk and an individuals chances of benefiting from, and risk of being harmed by, screening. Outcome measures included knowledge of lung cancer risk factors and lung cancer screening, decisional conflict, concordance, and acceptability of the decision aid. Data were collected from 60 participants who were current or former smokers, had no history of lung cancer, and had not received a chest computed tomographic scan in the previous year. Analysis took place in 2015. RESULTS Knowledge increased after seeing the decision aid compared with before (p<0.001), whereas the score on the Decisional Conflict Scale decreased (p<0.001). Concordance between a participants preference to screen and the U.S. Preventive Services Task Force recommendation improved after seeing the decision aid (p<0.001). Risk perceptions among the screen-ineligible group changed (n=49), contrary to those who were eligible (n=11). Ninety-seven percent of the participants reported that the decision aid was likely useful for lung cancer screening decision making. CONCLUSIONS The web-based decision aid should be a helpful resource for individuals considering lung cancer screening, as well as for practitioners and health systems with lung cancer screening programs.

Too Much Medicine Happens Too Often The Teachable Moment and a Call for Manuscripts From Clinical Trainees

A columnist at theNew York Times asked readers, “Have you experiencedtoomuchmedicine?”Shereceivedmorethan1000 responses detailing examples ranging fromunnecessary testing and hospitalizations to useless office visits and specialist referrals.1 Patients are not the only ones worried about too muchmedicine: 42%of anational sampleofprimary carephysicians believe that patients in their own practice are receiving too muchmedical care.2 Too much medicine, or overuse, occurs in at least 3 contexts: when benefits from medical care are negligible, when thepotential for harmexceeds thepotential benefit,3 orwhen a fully informed patient would decide to forego the service. Examples of overuse include overtesting (eg, routinely ordering preoperative chest x-rays; see the Perspective in this issue4) and overtreatment (eg, coronary revascularization inpatientswith stable anginanot receivingoptimalmedical therapy). Spending on overuse is thought to substantially contribute to theunsustainablegrowth inUShealthcarecosts.5 Wastefulhealthcare is estimated tocost

Development and validation of a personalized, web-based decision aid for lung cancer screening using mixed methods: a study protocol.

750billionannually,6 limiting equitable access tonecessaryhealth care6 andcrowdingout spendingonotherpriorities suchaspublichealth, education, and valuable social programs.When passed on to our patients, health care costs can be financially catastrophic.7 The costs of overuse are not measured in dollars alone. Overtesting and overtreatment expose patients to potential harmsanddownstreamcomplications8—andoften lead tonet harm.Farbeyondcostconsciousness, theethicalcase foravoiding overuse, “first, do no harm,” is a powerful appeal to our professionalism.8 All thoughtful physicians want to minimize harms fromoveruse. The challenge is recognizingwhen an intervention is likely to represent overuse.

Patient Preference in the Decision to Place Implantable Cardioverter-Defibrillators

Background The National Lung Screening Trial demonstrated that low-dose computed tomography (LDCT) screening could be an effective way to reduce lung cancer mortality. Informed decision-making in the context of lung cancer screening requires that potential screening subjects accurately recognize their own lung cancer risk, as well as the harms and benefits associated with screening, while taking into account their personal values and preferences. Objective Our objective is to develop a Web-based decision aid in accordance with the qualifying and certification criteria in the International Patient Decision Aid Standards instrument version 4.0 that will assist patients in making informed decisions with regard to lung cancer screening. Methods In “alpha” testing, a prototype of the decision aid was tested for usability with 10 potential screening participants in focus groups. Feedback was also sought from public health and health risk communication experts external to the study. Following that, improvements to the prototype were made accordingly, and “beta” testing was done in the form of a quasi-experimental design—a before-after study—with a group of 60 participants. Outcomes tested were knowledge, risk perception of lung cancer and lung cancer screening, decisional conflict, and acceptability of the decision aid as determined by means of a self-administered electronic survey. Focus groups of a subsample of survey participants will be conducted to gain further insight into usability issues. Results Alpha testing is completed. Beta testing is currently being carried out. As of 2014 December 7, 60 participants had completed the before-after study. We expect to have results by 2015 January 31. Qualitative data collection and analysis are expected to be completed by 2015 May 31. Conclusions We hypothesize that this Web-based, interactive decision aid containing personalized, graphical, and contextual information on the benefits and harms of LDCT screening will increase knowledge, reduce decisional conflict, and improve concordance between patient preferences and the current US Preventive Services Task Force’s screening guidelines.

“Due” for a Scan: Examining the Utility of Monitoring Densitometry

Randomized controlled trials demonstrate that implantable cardioverter-defibrillators (ICDs) reduce mortality in certain patients with symptomatic heart failure and no history of sudden cardiac death (SCD).1 This trial evidence has led to guidelines recommending placement of an ICD for primary SCD prevention in patients with heart failure meeting specific criteria.2 More patients are receiving ICD therapy as indications for this therapy have expanded.3 However, ICDs are associated with important risks, including short-term procedural complications, the potential for worse quality of life if shocked, and increased hospitalization rates.4,5 Not surprisingly, patient preferences around ICD therapy vary.5 Patients who are older, have multiple comorbidities, or live with a higher burden of daily symptoms may see a trade-off between sudden cardiac death and living longer.6 In some cases, a patient’s decision to forgo ICD therapy may create a conflict between the physician’s desire to do good (beneficence) and the patient’s preference (autonomy). We conducted a study to determine how physicians weigh patient preferences and the evidence of mortality benefit in their decision to recommend an ICD for primary prevention to potentially eligible patients.

Clinicians’ Perceptions of Barriers to Avoiding Inappropriate Imaging for Low Back Pain—Knowing Is Not Enough

Author Contributions: Dr Sullivan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition of data: Sullivan, O’Donoghue. Analysis and interpretation of data: Sullivan, O’Donoghue. Drafting of the manuscript: Sullivan. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Sullivan, O’Donoghue. Administrative, technical, or material support: O’Donoghue, Aikin. Study supervision: Aikin.

Confusing Relative Risk with Absolute Risk Is Associated with More Enthusiastic Beliefs about the Value of Cancer Screening

LESS IS MORE Clinicians’ Perceptions of Barriers to Avoiding Inappropriate Imaging for Low Back Pain— Knowing Is Not Enough Overuse of imaging for low back pain (LBP) is a considerable problem. Approximately 31% of lumbosacral magnetic resonance imaging (MRI) scans performed were deemed inappropriate in the Department of Veterans Affairs (VA),1 and similar rates of inappropriate MRI use have been seen outside of the VA.2 Seven Choosing Wisely (CW) campaign recommendations support not ordering imaging tests for patients with nonspecific LBP.3 Our objective was to determine what clinicians perceive to be barriers to following the CW recommendations to avoid ordering imaging tests for nonspecific LBP.

Selecting the Best Candidates for Lung Cancer Screening

Background. Reviews of how data are presented in medical literature document that the benefit from an intervention is often exaggerated relative to the harm (e.g., relative risk for benefit and absolute risk for harm). Such mismatched presentations may create unwarranted enthusiasm, especially among those who misinterpret the statistics presented. The objective was to determine whether misinterpretation of risk data predicts enthusiasm for cancer screening. Methods. The authors administered a survey with 14 items assessing beliefs about cancer screening and 6 items measuring data interpretation ability. Multiple linear regression was used to evaluate the association between data interpretation and enthusiasm for cancer screening, with adjustment for gender and year graduated from medical school. Results. Eighty-eight of 139 physicians at a state-wide professional meeting returned completed surveys (63% response rate). Lower data interpretation scores were associated with higher enthusiasm for cancer screening scores (P = 0.004) in the adjusted primary analysis. Confusing relative risk with absolute risk appeared to drive the overall association. Conclusions. Biased presentations of risk data could affect general beliefs about the value of cancer screening, especially among physicians who uncritically accept mismatched presentations of data.

Comparison of Observed Harms and Expected Mortality Benefit for Persons in the Veterans Health Affairs Lung Cancer Screening Demonstration Project

The Center for Medicare and Medicaid Services (CMS) recently decided to reimburse for annual lung cancer screening with low-dose computed tomography (LDCT) among personswhomeet the inclusioncriteria for theNationalLungCancer Screening Trial (NLST).1 Those who have smoked for more than30pack-years, continue to smoke,orquitwithin the past 15 years and are 55 to 77 years old will be eligible for free annual LDCT screening—roughly 6% of the US population older than 40 years.2 For the initial LDCT screening, a “lung cancer screening counseling and shared decision-making visit” will be required. Counseling visits will be reimbursed annually thereafter but will not be required.What considerations should be included in shared decision making? The Teachable Moment published in this issue by Schneider andArenberg3 reminds us that lung cancer screening—likemostmedicaldecision-making—isagamble; that there are good bets and bad bets—and that the odds are stacked against some people who will be eligible for LDCT screening. Thinking hard about how to optimally select people to screen is critically important as we move forward with populationbased lung cancer screening programs.

An Examination of Deintensification Recommendations in Clinical Practice Guidelines: Stepping Up or Scaling Back?

out a comparison group of individuals enrolled in traditional plans. To identify HDHP enrollees, we relied on participants’ knowledge of their deductible, because verification of insurance benefits was infeasible. Respondents were sampled from an internet survey panel and may have had different consumer characteristics than nonrespondents. There are a number of ways in which consumer behaviors could be encouraged among and made more helpful to individuals enrolled in HDHPs. Providers could help patients anticipate services that they may need in the future so that patients can try to save for them. Health systems could make prices for services available at the point of care to facilitate patient and clinician conversations about cost. Employers and insurers could go beyond disseminating price information to help patients learn how to use thisinformationinhealthcaredecisions.Sucheffortswillbecome increasingly important as enrollment in HDHPs continues to increase and could become essential if modifications to the structure or implementation of the Affordable Care Act accelerate patients’ exposure to high cost sharing.