肺がんスクリーニング開始時の「共同意思決定」ガイドライン、まったく遵守されておらず（JAMA）
Evaluating Shared Decision Making for Lung Cancer Screening
Alison T. Brenner, PhD, MPH1,2; Teri L. Malo, PhD, MPH2; Marjorie Margolis, MSPH3; et al, JAMA, August 13, 2018
Alison T. Brenner, PhD, MPH1,2; Teri L. Malo, PhD, MPH2; Marjorie Margolis, MSPH3; et al, JAMA, August 13, 2018
Importance The US Preventive Services Task Force recommends that shared decision making (SDM) involving a thorough discussion of benefits and harms should occur between clinicians and patients before initiating lung cancer screening (LCS) with low-dose computed tomography. The Centers for Medicare & Medicaid Services require an SDM visit using a decision aid as a prerequisite for LCS coverage. However, little is known about how SDM about LCS occurs in practice.
Objective To assess the quality of SDM about the initiation of LCS in clinical practice.
Design, Setting, and Participants A qualitative content analysis was performed of transcribed conversations between primary care or pulmonary care physicians and 14 patients presumed to be eligible for LCS, recorded between April 1, 2014, and March 1, 2018, that were identified within a large database.
Main Outcomes and Measures Independent observer ratings of communication behaviors of physicians using the OPTION (Observing Patient Involvement in Decision Making) scale, a validated 12-item measure of SDM (total score, 0-100 points, where 0 indicates no evidence of SDM and 100 indicates evidence of SDM at the highest skill level); time spent discussing LCS during visits; and evidence of decision aid use.
Results A total of 14 conversations about initiating LCS were identified; 9 patients were women, and 5 patients were men; the mean (SD) patient age was 63.9 (5.1) years; 7 patients had Medicare, and 8 patients were current smokers. Half the conversations were conducted by primary care physicians. The mean total OPTION score for the 14 LCS conversations was 6 on a scale of 0 to 100 (range, 0-17). None of the conversations met the minimum skill criteria for 8 of the 12 SDM behaviors. Physicians universally recommended LCS. Discussion of harms (such as false positives and their sequelae or overdiagnosis) was virtually absent. The mean total visit length of a discussion was 13:07 minutes (range, 3:48-27:09 minutes). The mean time spent discussing LCS was 0:59 minute (range, 0:16-2:19 minutes), or 8% of the total visit time (range, 1%-18%). There was no evidence that decision aids or other patient education materials for LCS were used.
Conclusions and Relevance In this small sample of recorded encounters about initiating LCS, the observed quality of SDM was poor and explanation of potential harms of screening was virtually nonexistent. Time spent discussing LCS was minimal, and there was no evidence that decision aids were used. Although these findings are preliminary, they raise concerns that SDM for LCS in practice may be far from what is intended by guidelines.
Objective To assess the quality of SDM about the initiation of LCS in clinical practice.
Design, Setting, and Participants A qualitative content analysis was performed of transcribed conversations between primary care or pulmonary care physicians and 14 patients presumed to be eligible for LCS, recorded between April 1, 2014, and March 1, 2018, that were identified within a large database.
Main Outcomes and Measures Independent observer ratings of communication behaviors of physicians using the OPTION (Observing Patient Involvement in Decision Making) scale, a validated 12-item measure of SDM (total score, 0-100 points, where 0 indicates no evidence of SDM and 100 indicates evidence of SDM at the highest skill level); time spent discussing LCS during visits; and evidence of decision aid use.
Results A total of 14 conversations about initiating LCS were identified; 9 patients were women, and 5 patients were men; the mean (SD) patient age was 63.9 (5.1) years; 7 patients had Medicare, and 8 patients were current smokers. Half the conversations were conducted by primary care physicians. The mean total OPTION score for the 14 LCS conversations was 6 on a scale of 0 to 100 (range, 0-17). None of the conversations met the minimum skill criteria for 8 of the 12 SDM behaviors. Physicians universally recommended LCS. Discussion of harms (such as false positives and their sequelae or overdiagnosis) was virtually absent. The mean total visit length of a discussion was 13:07 minutes (range, 3:48-27:09 minutes). The mean time spent discussing LCS was 0:59 minute (range, 0:16-2:19 minutes), or 8% of the total visit time (range, 1%-18%). There was no evidence that decision aids or other patient education materials for LCS were used.
Conclusions and Relevance In this small sample of recorded encounters about initiating LCS, the observed quality of SDM was poor and explanation of potential harms of screening was virtually nonexistent. Time spent discussing LCS was minimal, and there was no evidence that decision aids were used. Although these findings are preliminary, they raise concerns that SDM for LCS in practice may be far from what is intended by guidelines.
肺がんの断層写真によるスクリーニング（LCS）を始めるにあたっては、
医師と患者の間で利益と危害リスクについての話し合いを含めた
Shared Decision Making（共同意思決定）が基本とされており、
メディケア、メディケイドの支給条件ともなっているが、
実態は長らく不明だった。
医師と患者の間で利益と危害リスクについての話し合いを含めた
Shared Decision Making（共同意思決定）が基本とされており、
メディケア、メディケイドの支給条件ともなっているが、
実態は長らく不明だった。
そこで、2014年4月1日から2018年3月1日までの期間、
著者らがプライマリケア医または肺疾患の専門医とLCS適用とみられる患者との
やりとりを意思決定にかかわる患者の観察指標（OPTION）を用いて観察分析したところ、
著者らがプライマリケア医または肺疾患の専門医とLCS適用とみられる患者との
やりとりを意思決定にかかわる患者の観察指標（OPTION）を用いて観察分析したところ、
14の会話において医師は全員がLCSを進めていたが
危害リスクの説明は事実上まったくなく、
LCSについての話し合い（discussion）に費やされた時間の中間値は0.59分。
危害リスクの説明は事実上まったくなく、
LCSについての話し合い（discussion）に費やされた時間の中間値は0.59分。
意思決定ツールやその多の患者教育マテリアルが使用されたエビデンスも皆無。
結論は、
