Why Aren’t Medicare Enrollees Participating in Decision Making Sessions Prior to Lung Cancer Screening?

A surprisingly low percentage of Medicare enrollees who undergo low-dose computed tomography (LDCT) screening for lung cancer participate in a shared decision-making (SDM) session prior to the screening, in spite of a reimbursement requirement to do so, according to a new analysis. Among those who do have an SDM session, a high percentage opt to avoid the screening.

The Centers for Medicare & Medicaid Services (CMS) approved reimbursements for LDCT screening in 2015. The screening was approved for individuals aged 55 to 77 years, with at least a 30 pack-year history of smoking, and it included a requirement for a separate SDM session before LDCT screening. “This visit had several components, including use of a decision aid and counseling on tobacco abstinence,” wrote study authors led by James S. Goodwin, MD, of the University of Texas Medical Branch in Galveston.

The researchers used Medicare data ranging from January 1, 2015 through December 31, 2016 to determine how many enrollees who underwent LDCT actually had the SDM visit. They included two separate cohorts for 2015 (4,192,802 individuals) and 2016 (4,138,559 individuals); results of the analysis were published in JAMA Internal Medicine.

A total of 19,021 individuals underwent LDCT screening for lung cancer in 2016. Of those, only 1,719 people (9.0%) had a separate SDM visit either on the day of LDCT or in the previous 3 months. At the start of the study period, the data show an increase in SDM visits, but this eventually plateaus; before May 2016, there was an absolute increase of 1.05% per month, and after that point, there was only a 0.09% increase per month.

Several factors were associated with lower odds of having the SDM visit. These included black race vs white race, with an odds ratio (OR) of 0.76 (95% CI, 0.59–0.97); female sex, with an OR of 0.88 (95% CI, 0.79–0.98); and highest quartile of education vs lowest quartile, with an OR of 0.81 (95% CI, 0.68–0.96). There was substantial regional variation in the rate of SDM visits as well.

Among individuals who did undergo an SDM visit, a relatively large number then opted to not undergo the screening. Of 2,154 individuals who had an SDM visit from January through October 2016, 60.8% went on to undergo LDCT within the following 3 months. A multivariable analysis showed that black race, with a risk ratio of 0.81 (95% CI, 0.66–0.97), and female sex, with a risk ratio of 0.93 (95% CI, 0.86–0.99), were associated with lower LDCT use following the SDM visit.

“Several factors may contribute to this finding, including the recentness of the [SDM] mandate, lack of training in SDM, and competing priorities for clinicians,” the authors wrote, adding that SDM may have occurred as part of a separate medical encounter as well. “Inability or unwillingness to engage in SDM may contribute to the low overall use of LDCT screening and less awareness of its implications among eligible patients,” they concluded.

In an accompanying editorial, Rita F. Redberg, MD, MSc, of the University of California, San Francisco, School of Medicine, wrote that “it is likely that patients’ decisions not to undergo LDCT for lung cancer screening are driven by the high false-positive rate, high chance of incidental findings and subsequent need for invasive procedures, and small chance of benefit.” She noted that these findings are in line with previous research from the Veterans Health Administration, and the data “suggest that the current use of resources for lung cancer screening should be reexamined and efforts should be refocused on smoking cessation and smoking prevention to prevent lung cancer and improve health.”