A nearly 10-year-old Medicare policy that was enacted to encourage the use of lung cancer screening in patients with comorbidities needs major changes to improve patient-provider shared decision making and eliminate patient selection bias for these procedures. This, according to a study published today in the Annals of Family Medicine, from researchers at Mount Sinai Health.
According to their findings, the investigators say that policy was intended to incorporate a patient’s complete health history with the understanding that smokers have increased risk not just of lung cancer, but other health conditions such as cardiovascular disease, cerebrovascular disease, and obstructive pulmonary disease related to their tobacco use. However, the policy lacks evidence-based information, which is confusing for physicians, and may actually be undermining the purpose for which it was created.
While the policy required counseling on the importance of adherence to annual lung cancer screening—impact of comorbidities and the ability or willingness to undergo diagnosis and treatment—it did not address the increasing prevalence of comorbidities, nor did it provide guidance on how to assess the impact of comorbidities on screening, diagnosis, and treatment.
“The policy was added in 2015 for a well-intentioned reason, but unfortunately it’s caused a great deal of confusion over patient eligibility and may contribute to ambivalence among primary care physicians when it comes to recommending lung cancer screening to patients with complex comorbidities,” said lead study author Minal Kale, MD, associate professor of medicine at the Icahn School of Medicine at Mount Sinai. “Our study found that primary care physicians’ approach reflects a dearth of evidence-based guidance for lung cancer screening shared decision-making in patients with complex comorbidities.”
To better understand how primary care physicians factor comorbidities into their evaluation of the benefits and risks of cancer screening for specific patients and the process of shared decision making, the Mount Sinai team conducted videoconference interviews with 15 primary care physicians from internal medicine practices affiliated with Mount Sinai. The 45-minute interviews revealed that physicians are predisposed to making subjective clinical decisions based on whether they believe a patient is a good candidate for screening instead of consulting with a patient to make a shared decision.
“Patients perceived as likely to adhere to treatment recommendations and as having a high quality of life were more likely to be advised to undertake lung cancer screening, as opposed to those who had previously expressed frustration or dissatisfaction with their state of health and well-being,” said Juan Wisnivesky, MD, DrPH, chief of the division of internal medicine at Icahn Mount Sinai, and co-author of the study. “Other patient characteristics shown by the study to influence physician judgments include life expectancy, presence of a support system, and expectations of and attitudes toward medical care.”
The Mount Sinai team recommends that more research is needed to better understand the impact of comorbidities on lung cancer screening and its benefits—and appropriate clinical actions—in order to address the patient selection bias revealed by their research.
Kale highlighted that the complicated recommendations currently in place create confusion and uncertainty among treating physicians and that new streamline and clearer guidelines could improve the rate of adoption of lung cancer screening among this vulnerable patient population.
