Program Profile

Implementing a Telehealth Shared Counseling and Decision-Making Visit for Lung Cancer Screening in a Veterans Affairs Medical Center

Fed Pract. 2023 August;40(3):S83-S90 | doi:10.12788/fp.0403

References

1. Zullig LL, Jackson GL, Dorn RA, et al. Cancer incidence among patients of the U.S. Veterans Affairs Health Care System. Mil Med. 2012;177(6):693-701. doi:10.7205/milmed-d-11-00434

2. Hoffman RM, Atallah RP, Struble RD, Badgett RG. Lung cancer screening with low-dose CT: a meta-analysis. J Gen Intern Med. 2020;35(10):3015-3025. doi:10.1007/s11606-020-05951-7

3. National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. doi:10.1056/NEJMoa1102873

4. Moyer VA, US Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-338. doi:10.7326/M13-2771

5. Maurice NM, Tanner NT. Lung cancer screening at the VA: past, present and future. Semin Oncol. 2022;S0093-7754(22)00041-0. doi:10.1053/j.seminoncol.2022.06.001

6. Centers for Medicare & Medicaid Services. Screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N). Published 2015. Accessed July 10, 2023. http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274

7. Centers for Medicare & Medicaid Services. Screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439R). Published 2022. Accessed July 10, 2023. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=304

8. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; National Cancer Policy Forum. Implementation of Lung Cancer Screening: Proceedings of a Workshop. The National Academies Press; November 17, 2016. doi:10.172216/23680

9. Bernstein E, Bade BC, Akgün KM, Rose MG, Cain HC. Barriers and facilitators to lung cancer screening and follow-up. Semin Oncol. 2022;S0093-7754(22)00058-6. doi:10.1053/j.seminoncol.2022.07.004

10. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117

11. Kinsinger LS, Atkins D, Provenzale D, Anderson C, Petzel R. Implementation of a new screening recommendation in health care: the Veterans Health Administration’s approach to lung cancer screening. Ann Intern Med. 2014;161(8):597-598. doi:10.7326/M14-1070

12. Lowenstein LM, Godoy MCB, Erasmus JJ, et al. Implementing decision coaching for lung cancer screening in the low-dose computed tomography setting. JCO Oncol Pract. 2020;16(8):e703-e725. doi:10.1200/JOP.19.00453

13. American College of Radiology Committee on Lung-RADS. Lung-RADS assessment categories 2022. Published November 2022. Accessed July 3, 2023. https://www.acr.org/-/media/ACR/Files/RADS/Lung-RADS/Lung-RADS-2022.pdf

14. Lowenstein LM, Richards VF, Leal VB, et al. A brief measure of smokers’ knowledge of lung cancer screening with low-dose computed tomography. Prev Med Rep. 2016;4:351-356. doi:10.1016/j.pmedr.2016.07.008

15. Elwyn G, Barr PJ, Grande SW, Thompson R, Walsh T, Ozanne EM. Developing CollaboRATE: a fast and frugal patient-reported measure of shared decision making in clinical encounters. Patient Educ Couns. 2013;93(1):102-107. doi:10.1016/j.pec.2013.05.009

16. Barr PJ, Thompson R, Walsh T, Grande SW, Ozanne EM, Elwyn G. The psychometric properties of CollaboRATE: a fast and frugal patient-reported measure of the shared decision-making process. J Med Internet Res. 2014;16(1):e2. doi:10.2196/jmir.3085

17. Légaré F, Kearing S, Clay K, et al. Are you SURE?: Assessing patient decisional conflict with a 4-item screening test. Can Fam Physician. 2010;56(8):e308-e314.

18. MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology. 2017;284(1):228-243. doi:10.1148/radiol.2017161659

19. Wiener RS, Koppelman E, Bolton R, et al. Patient and clinician perspectives on shared decision-making in early adopting lung cancer screening programs: a qualitative study. J Gen Intern Med. 2018;33(7):1035-1042. doi:10.1007/s11606-018-4350-9

20. Zeliadt SB, Heffner JL, Sayre G, et al. Attitudes and perceptions about smoking cessation in the context of lung cancer screening. JAMA Intern Med. 2015;175(9):1530-1537. doi:10.1001/jamainternmed.2015.3558

21. Mazzone PJ, White CS, Kazerooni EA, Smith RA, Thomson CC. Proposed quality metrics for lung cancer screening programs: a National Lung Cancer Roundtable Project. Chest. 2021;160(1):368-378. doi:10.1016/j.chest.2021.01.063

22. Mazzone PJ, Tenenbaum A, Seeley M, et al. Impact of a lung cancer screening counseling and shared decision-making visit. Chest. 2017;151(3):572-578. doi:10.1016/j.chest.2016.10.027

23. Reuland DS, Cubillos L, Brenner AT, Harris RP, Minish B, Pignone MP. A pre-post study testing a lung cancer screening decision aid in primary care. BMC Med Inform Decis Mak. 2018;18(1):5. doi:10.1186/s12911-018-0582-1

24. Dharod A, Bellinger C, Foley K, Case LD, Miller D. The reach and feasibility of an interactive lung cancer screening decision aid delivered by patient portal. Appl Clin Inform. 2019;10(1):19-27. doi:10.1055/s-0038-1676807

25. Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4:CD001431. doi:10.1002/14651858.CD001431.pub5

26. Tanner NT, Banas E, Yeager D, Dai L, Hughes Halbert C, Silvestri GA. In-person and telephonic shared decision-making visits for people considering lung cancer screening: an assessment of decision quality. Chest. 2019;155(1):236-238. doi:10.1016/j.chest.2018.07.046

Evaluating Shared Decision Making

We audio taped and transcribed randomly selected SDM encounters to assess fidelity with the 2016 CMS required discussion elements for counseling about lung cancer, including the benefit of reducing lung cancer mortality; the potential for harms from false alarms, incidental findings, overdiagnosis, and radiation exposure; the need for annual screening; the importance of smoking cessation; and the possibility of undergoing follow-up testing and diagnostic procedures. An investigator coded the transcripts to assess for the presence of each required element and scored the encounter from 0 to 7.

We also surveyed veterans completing SDM, using a convenience sampling strategy to evaluate knowledge, the quality of the SDM process, and decisional conflict. Initially, we sent mailed surveys to subjects to be completed 1 week after the SDM visit. To increase the response rate, we subsequently called patients to complete the surveys by telephone 1 week after the SDM visit.

We used the validated LCS-12 knowledge measure to assess awareness of lung cancer risks, screening eligibility, and the benefits and harms of screening.¹⁴ We evaluated the quality of the SDM visit by using the 3-item CollaboRATE scale (Table 1).¹⁵

The response items were scored on a 9-point Likert scale (0, no effort; 9, every effort). The CollaboRATE developers recommend reporting the top score (ie, the proportion of subjects whose response to all 3 questions was 9).¹⁶ We used the 4-item SURE scale to assess decisional conflict, a measure of uncertainty about choosing an option.¹⁷ A yes response received 1 point; patients with scores of 4 were considered to have no decisional conflict.

The NPC also took field notes during interviews to help identify additional SDM issues. After each call, the NPC noted her impressions of the veteran’s engagement with SDM and understanding of the screening issues.

Clinical Outcomes

We used the screening dashboard and CPRS to track clinical outcomes, including screening uptake, referrals for tobacco cessation, appropriate (screening or diagnostic) follow-up testing, and cancer diagnoses. We used descriptive statistics to characterize demographic data and survey responses.

Initial Findings

We conducted 105 SDM telephone visits from November 2020 through July 2022 (Table 2).

We audio taped 27 encounters. Measures of SDM showed good fidelity with addressing required CMS elements. The mean number of elements addressed was 6.2 of 7. Reduction in lung cancer mortality was the issue least likely to be addressed (59%).

We surveyed 47 of the veterans completing SDM visits (45%) and received 37 completed surveys (79%). All respondents were male, mean age 61.9 years, 89% White, 38% married/partnered, 70% rural, 65% currently smoking, with a mean 44.8 pack-years smoking history. On average, veterans answered 6.3 (53%) of knowledge questions correctly (Table 3).

They were most likely to correctly answer questions about the harms of radiation exposure (65%), false-positive results (84%), false-negative results (78%), and overdiagnosis (86%).

Only 1 respondent (3%) correctly answered the multiple-choice question about indications for stopping screening. Two (5%) correctly answered the question on the magnitude of benefit, most overestimated or did not know. Similarly, 23 (62%) overestimated or did not know the predictive value of an abnormal scan. About two-thirds of veterans underestimated or did not know the attributable risk of lung cancer from tobacco, and about four-fifths did not know the mortality rank of lung cancer. Among the 37 respondents, 31 (84%) indicated not having any decisional conflict as defined by a score of 4 on the SURE scale.

Overall, 59% of respondents had a top box score on the CollaboRATE scale. Ratings for individual domains ranged from 65% to 73% (Table 4).

References

1. Zullig LL, Jackson GL, Dorn RA, et al. Cancer incidence among patients of the U.S. Veterans Affairs Health Care System. Mil Med. 2012;177(6):693-701. doi:10.7205/milmed-d-11-00434

2. Hoffman RM, Atallah RP, Struble RD, Badgett RG. Lung cancer screening with low-dose CT: a meta-analysis. J Gen Intern Med. 2020;35(10):3015-3025. doi:10.1007/s11606-020-05951-7

3. National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409. doi:10.1056/NEJMoa1102873

4. Moyer VA, US Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-338. doi:10.7326/M13-2771

5. Maurice NM, Tanner NT. Lung cancer screening at the VA: past, present and future. Semin Oncol. 2022;S0093-7754(22)00041-0. doi:10.1053/j.seminoncol.2022.06.001

6. Centers for Medicare & Medicaid Services. Screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N). Published 2015. Accessed July 10, 2023. http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274

7. Centers for Medicare & Medicaid Services. Screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439R). Published 2022. Accessed July 10, 2023. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=304

8. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; National Cancer Policy Forum. Implementation of Lung Cancer Screening: Proceedings of a Workshop. The National Academies Press; November 17, 2016. doi:10.172216/23680

9. Bernstein E, Bade BC, Akgün KM, Rose MG, Cain HC. Barriers and facilitators to lung cancer screening and follow-up. Semin Oncol. 2022;S0093-7754(22)00058-6. doi:10.1053/j.seminoncol.2022.07.004

10. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117

11. Kinsinger LS, Atkins D, Provenzale D, Anderson C, Petzel R. Implementation of a new screening recommendation in health care: the Veterans Health Administration’s approach to lung cancer screening. Ann Intern Med. 2014;161(8):597-598. doi:10.7326/M14-1070

12. Lowenstein LM, Godoy MCB, Erasmus JJ, et al. Implementing decision coaching for lung cancer screening in the low-dose computed tomography setting. JCO Oncol Pract. 2020;16(8):e703-e725. doi:10.1200/JOP.19.00453

13. American College of Radiology Committee on Lung-RADS. Lung-RADS assessment categories 2022. Published November 2022. Accessed July 3, 2023. https://www.acr.org/-/media/ACR/Files/RADS/Lung-RADS/Lung-RADS-2022.pdf

14. Lowenstein LM, Richards VF, Leal VB, et al. A brief measure of smokers’ knowledge of lung cancer screening with low-dose computed tomography. Prev Med Rep. 2016;4:351-356. doi:10.1016/j.pmedr.2016.07.008

15. Elwyn G, Barr PJ, Grande SW, Thompson R, Walsh T, Ozanne EM. Developing CollaboRATE: a fast and frugal patient-reported measure of shared decision making in clinical encounters. Patient Educ Couns. 2013;93(1):102-107. doi:10.1016/j.pec.2013.05.009

16. Barr PJ, Thompson R, Walsh T, Grande SW, Ozanne EM, Elwyn G. The psychometric properties of CollaboRATE: a fast and frugal patient-reported measure of the shared decision-making process. J Med Internet Res. 2014;16(1):e2. doi:10.2196/jmir.3085

17. Légaré F, Kearing S, Clay K, et al. Are you SURE?: Assessing patient decisional conflict with a 4-item screening test. Can Fam Physician. 2010;56(8):e308-e314.

18. MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology. 2017;284(1):228-243. doi:10.1148/radiol.2017161659

19. Wiener RS, Koppelman E, Bolton R, et al. Patient and clinician perspectives on shared decision-making in early adopting lung cancer screening programs: a qualitative study. J Gen Intern Med. 2018;33(7):1035-1042. doi:10.1007/s11606-018-4350-9

20. Zeliadt SB, Heffner JL, Sayre G, et al. Attitudes and perceptions about smoking cessation in the context of lung cancer screening. JAMA Intern Med. 2015;175(9):1530-1537. doi:10.1001/jamainternmed.2015.3558

21. Mazzone PJ, White CS, Kazerooni EA, Smith RA, Thomson CC. Proposed quality metrics for lung cancer screening programs: a National Lung Cancer Roundtable Project. Chest. 2021;160(1):368-378. doi:10.1016/j.chest.2021.01.063

22. Mazzone PJ, Tenenbaum A, Seeley M, et al. Impact of a lung cancer screening counseling and shared decision-making visit. Chest. 2017;151(3):572-578. doi:10.1016/j.chest.2016.10.027

23. Reuland DS, Cubillos L, Brenner AT, Harris RP, Minish B, Pignone MP. A pre-post study testing a lung cancer screening decision aid in primary care. BMC Med Inform Decis Mak. 2018;18(1):5. doi:10.1186/s12911-018-0582-1

24. Dharod A, Bellinger C, Foley K, Case LD, Miller D. The reach and feasibility of an interactive lung cancer screening decision aid delivered by patient portal. Appl Clin Inform. 2019;10(1):19-27. doi:10.1055/s-0038-1676807

25. Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4:CD001431. doi:10.1002/14651858.CD001431.pub5

26. Tanner NT, Banas E, Yeager D, Dai L, Hughes Halbert C, Silvestri GA. In-person and telephonic shared decision-making visits for people considering lung cancer screening: an assessment of decision quality. Chest. 2019;155(1):236-238. doi:10.1016/j.chest.2018.07.046

	These patients have a cytologically confirmed pleural or pericardial effusion
	This stage usually involves disease that has spread outside the hemithorax
	Patients have disease that is safely within one radiation field
	A and B

Implementing a Telehealth Shared Counseling and Decision-Making Visit for Lung Cancer Screening in a Veterans Affairs Medical Center

References

Recommended Reading

Clinical Topics

Digital Edition

Multimedia

Conference Coverage

Implementing a Telehealth Shared Counseling and Decision-Making Visit for Lung Cancer Screening in a Veterans Affairs Medical Center

References

Evaluating Shared Decision Making

Clinical Outcomes

Initial Findings

Pages

Recommended Reading

Clinical Topics

Digital Edition

Multimedia

Conference Coverage