Eshelman School of Pharmacy, Chapel Hill, NC.
Henry Ford Health System, Detroit, MI.
Chest. 2021 Jan;159(1):413-425. doi: 10.1016/j.chest.2020.07.078. Epub 2020 Aug 13.
The Centers for Medicare and Medicaid Services stipulate shared decision-making (SDM) counseling as a prerequisite to lung cancer screening (LCS) reimbursement, despite well-known challenges implementing SDM in practice.
How have health-care organizations implemented SDM for LCS?
For this qualitative study, we used data from in-depth, semistructured interviews with key informants directly involved in implementing SDM for LCS, managing SDM for LCS, or both. We identified respondents using a snowball sampling technique and used template analysis to identify and analyze responses thematically.
We interviewed 30 informants representing 23 health-care organizations located in 12 states and 4 Census regions. Respondents described two types of SDM for LCS programs: centralized models (n = 7), in which front-end practitioners (eg, primary care providers) referred patients to an LCS clinic where trained staff (eg, advanced practice nurses) delivered SDM at the time of screening, or decentralized models (n = 10), in which front-end practitioners delivered SDM before referring patients for screening. Some organizations used both models simultaneously (n = 6). Respondents discussed tradeoffs between SDM quality and access. They perceived centralized models as enhancing SDM quality, but limiting patient access to care, and vice versa. Respondents reported ongoing challenges with limited resources and budgetary constraints, ambiguity regarding what constitutes SDM, and an absence of benchmarks for evaluating SDM for LCS quality.
Those responsible for developing and managing SDM for LCS programs voiced concerns regarding both patient access and SDM quality, regardless of organizational context, or the SDM for LCS model implemented. The challenge facing these organizations, and those wanting to help patients and clinicians balance the tradeoffs inherent with LCS, is how to move beyond a check-box documentation requirement to a process that enables LCS to be offered to all high-risk patients, but used only by those who are informed and for whom screening represents a value-concordant service.
尽管在实践中实施共享决策（SDM）面临诸多挑战，医疗保险和医疗补助服务中心仍规定 SDM 咨询是肺癌筛查（LCS）报销的前提条件。
医疗机构如何实施 LCS 的 SDM？
在这项定性研究中，我们使用了与直接参与实施 LCS 的 SDM、管理 LCS 的 SDM 或两者都有参与的关键知情者进行深入半结构化访谈的数据。我们使用滚雪球抽样技术识别受访者，并使用模板分析对主题进行识别和分析。
我们采访了 30 名代表来自 12 个州和 4 个人口普查区域的 23 家医疗机构的知情者。受访者描述了两种类型的 LCS 的 SDM 项目：集中式模型（n=7），其中前端执业者（例如，初级保健提供者）将患者转介到 LCS 诊所，在那里经过培训的工作人员（例如，高级执业护士）在筛查时提供 SDM；或分散式模型（n=10），其中前端执业者在将患者转介进行筛查之前提供 SDM。一些组织同时使用这两种模式（n=6）。受访者讨论了 SDM 质量和可及性之间的权衡。他们认为集中式模型可以提高 SDM 的质量，但限制了患者获得护理的机会，反之亦然。受访者报告说，资源有限和预算限制、SDM 构成的模糊性以及缺乏评估 LCS SDM 质量的基准等方面的持续挑战。
无论组织背景或实施的 LCS 的 SDM 模型如何，负责制定和管理 LCS 的 SDM 计划的人都对患者的可及性和 SDM 的质量表示担忧。这些组织和那些希望帮助患者和临床医生平衡 LCS 固有的权衡的组织所面临的挑战是，如何超越检查框文档要求，转而采用一种能够向所有高危患者提供 LCS 但仅由知情者使用的过程，并且仅对那些认为筛查代表符合价值的服务的患者使用。
