Elston Lafata Jennifer, Brown Richard F, Pignone Michael P, Ratliff Scott, Shay L Aubree
Massey Cancer Center and Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA (JEL, RFB).
Division of General Medicine and UNC Institute for Healthcare Quality Improvement, School of Medicine, University of North Carolina, Chapel Hill, NC, USA (MPP).
Med Decis Making. 2017 Jan;37(1):70-78. doi: 10.1177/0272989X16660547. Epub 2016 Jul 18.
Despite its widespread advocacy, shared decision making (SDM) is not routinely used for cancer screening. To better understand the implementation barriers, we describe primary care physicians' (PCPs') support for SDM across diverse cancer screening contexts.
Surveys were mailed to a random sample of USA-based PCPs. Using multivariable logistic regression analyses, we tested for associations of PCPs' support of SDM with the US Preventive Service Task Force (USPSTF) assigned recommendation grade, assessed whether the decision pertained to not screening older patients, and the PCPs' autonomous v. controlled motivation-orientation for using SDM.
PCPs (n = 278) were, on average, aged 52 years, 38% female, and 69% white. Of these, 79% endorsed discussing screening benefits as very important to SDM; 64% for discussing risks; and 31% for agreeing with patient's opinion. PCPs were most likely to rate SDM as very important for colorectal cancer screening in adults aged 50-75 years (69%), and least likely for colorectal cancer screening in adults aged >85 years (34%). Regression results indicated the importance of PCPs' having autonomous or self-determined reasons for engaging in SDM (e.g., believing in the benefits of SDM) (OR = 2.29, 95% CI, 1.87 to 2.79). PCPs' support for SDM varied by USPSTF recommendation grade (overall contrast, X = 14.7; P = 0.0054), with support greatest for A-Grade recommendations. Support for SDM was lower in contexts where decisions pertained to not screening older patients (OR = 0.45, 95% CI, 0.35 to 0.56).
It is unknown whether PCPs' perceptions of the importance of SDM behaviors differs with specific screening decisions or the potential limited ability to generalize findings.
Our results highlight the need to document SDM benefits and consider the specific contextual challenges, such as the level of uncertainty or whether evidence supports recommending/not recommending screening, when implementing SDM across an array of cancer screening contexts.
尽管共同决策（SDM）得到广泛倡导，但在癌症筛查中并未常规使用。为了更好地理解实施障碍，我们描述了初级保健医生（PCP）在不同癌症筛查背景下对SDM的支持情况。
向美国的PCP随机样本邮寄调查问卷。使用多变量逻辑回归分析，我们测试了PCP对SDM的支持与美国预防服务工作组（USPSTF）指定的推荐等级之间的关联，评估了该决策是否涉及不筛查老年患者，以及PCP使用SDM的自主与受控动机导向。
PCP（n = 278）平均年龄为52岁，女性占38%，白人占69%。其中，79%的人认可讨论筛查益处对SDM非常重要；64%认可讨论风险；31%认可同意患者的意见。PCP最有可能将SDM评为对50 - 75岁成年人的结直肠癌筛查非常重要（69%），而对85岁以上成年人的结直肠癌筛查可能性最小（34%）。回归结果表明PCP参与SDM具有自主或自我决定的原因（例如，相信SDM的益处）很重要（OR = 2.29，95% CI，1.87至2.79）。PCP对SDM的支持因USPSTF推荐等级而异（总体对比，X = 14.7；P = 0.0054），对A级推荐的支持最大。在决策涉及不筛查老年患者的情况下，对SDM的支持较低（OR = 0.45，95% CI，0.35至0.56）。
尚不清楚PCP对SDM行为重要性的认知是否因具体筛查决策而异，或者研究结果的潜在推广能力是否有限。
我们的结果强调了记录SDM益处的必要性，并在一系列癌症筛查背景下实施SDM时考虑特定的背景挑战，例如不确定性水平或证据是否支持推荐/不推荐筛查。
