Some examples of shared decision making for lung cancer screening and draft requirements

1. Shared Decision Making Aid
for Lung Cancer Screening
Discussion

2. Elements of shared decision making
• Understands the risk or seriousness of the disease or
condition
• Understands the preventive service, including the risks,
benefits, alternatives and uncertainties
• Have weighed his/her values regarding the potential
harms and benefits associated with the service
• Have engaged in decision-making at a level he or she
desires and feels comfortable
Sheridan SL, Harris RP, Woolf SH. Shared Decision making about screening and chemoprevention, a suggested approach from
the U.S. Preventive Services Task Force. American journal of preventive medicine. 2004;26(1):55-56

3. CMS Draft Recommendation Requirements
A lung cancer screening counseling and shared decision making visit includes the
following elements (and is appropriately documented in the beneficiary’s medical
records):
◦Determination of beneficiary eligibility including age, absence of signs or symptoms of
lung disease, a specific calculation of cigarette smoking pack-years; and if a former
smoker, the number of years since quitting;
◦Shared decision making, including the use of one or more decision aids, to include
benefits, harms, follow-up diagnostic testing, over-diagnosis, false positive rate, and total
radiation exposure;
◦Counseling on the importance of adherence to annual LDCT lung cancer screening,
impact of comorbidities and ability or willingness to undergo diagnosis and treatment;
◦Counseling on the importance of maintaining cigarette smoking abstinence if former
smoker, or smoking cessation if current smoker and, if appropriate, offering additional
Medicare-covered tobacco cessation counseling services; and
◦If appropriate, the furnishing of a written order for lung cancer screening with LDCT.
Written orders for both initial and subsequent LDCT lung cancer screenings must contain
the following information, which must also be documented in the beneficiaries’ medical
records:
Beneficiary date of birth,
Actual pack-year smoking history (number);
Current smoking status, and for former smokers, the number of years since quitting smoking;
Statement that the beneficiary is asymptomatic; and
NPI of the ordering practitioner.

4. Implementation possibilities and challenges would benefit
from pilot program approach to development and
evaluation
• Some studies show distributing the decision aide prior to the
shared discussion is most effective
• Variations in health literacy (and patient activation) levels may
necessitate diverse approaches (multiple messaging and
distribution channels)
• Not all physicians comfortable or competent in SDM.

5. Examples of Shared Decision Aides

6. Examples of Shared Decision Aides – Cancer Treatment
Centers of America – pages 1-3

7. Examples of Shared Decision AidesCancer Treatment
Centers of America – pages 4 and 5

8. Examples of Shared Decision Aides – 40 Page Patient
Pre-discussion booklet for FOBT Screening (low health
literacy population)

9. Draft Requirements
• Automatically generate electronic physician order
• Shared decision discussion and outcome recorded in the patient
EMR
• “proof” each required element covered during the discussion
• Automatically populate the appropriate data elements into the
national screening registry “data set”
• “Modular” Design implementable in various media and distribution
channels – print, video, internet
• Modules can be combined in any order and used individually as
appropriate.
• Allows for re-use of modules in other health care settings and
generic health care discussions
• patient eligibility module at lung cancer screening site
• smoking cessation module during any health care provider patient visit

10. Shared Decision Aid for Lung Cancer Screening – Modules
• Patient Risk Module: Discuss lung cancer epidemiology (e.g. risk in targeted population, five
year survival rates, general risks for lung cancer). The individual risk discussion should include
all known risks regardless of whether they are included in the recommended to screen criteria;
age, pack years smoking history – convert other tobacco use into equivalent pack years, years
since quit if former smoker, history of cancer, family history of cancer, exposure to radon,
asbestos, arsenic, cadmium, chromium, diesel fumes, nickel, silica, second hand smoke, air
pollution, and/or cooking fires (if grew up in developing countries). Consider using Tammemagi
risk model for specific risk calculation
• Eligibility Module: Assess eligibility for USPSTF or CMS criteria as appropriate including patient
being asymptomatic.
• Lung Cancer Screening Discussion Module:. Define a low dose CT scan, discuss the NLST
process and results. Discuss benefits, harms, follow-up diagnostic testing, over-diagnosis, false
positive rate, and total radiation exposure. Describe the process the patient would experience
from decision to screen through follow-up for various CT scan result scenarios.
• Patient Preference and Decision Module: Counseling on the importance of adherence to
annual LDCT lung cancer screening, impact of patient comorbidities and patient ability or
willingness to undergo diagnosis and treatment. Discussion of patient preference, willingness
and desire to comply with screening follow-up and recurrent annual screening during eligibility
period (i.e. age and time since quit smoking).
• Smoking Cessation Module: Counseling on the importance of maintaining cigarette smoking
abstinence or smoking cessation if current smoker. Use the 2008 Clinical Practice Guideline 5
key steps for smoking intervention.