Effect of Incidental Findings Information on Lung Cancer Screening Intent: a Randomized Controlled Trial

Lung cancer screening completion among patients using decision aids: a systematic review and meta-analysis

PURPOSE

Utilization of lung cancer screening (LCS) among eligible patients remains low at 16% in 2022. In this systematic review and meta-analysis we assessed the (a) LCS completion rate, and (b) intention to complete LCS, among patients who receive patient decision aids (PDAs).

METHODS

PubMed, Cochrane, Scopus, CINAHL, and Web of Science were searched for articles published in English between 1 January 2011, and 28 February 2023. Two independent reviewers selected randomized controlled trials and prospective cohort studies that reported PDA interventions targeting either LCS completion rate or intention to complete LCS. Quality appraisal and data extraction were performed independently by 2 reviewers using the National Heart, Lung, and Blood Institute quality assessment tool. A random-effects model meta-analysis was performed. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines.

RESULTS

Thirteen studies with 2,277 total participants (51.5% male) were included. The pooled LCS completion rate across all follow-up periods (range, 1-6 months) was 40% (95% confidence interval [CI], 15-65%) with an I2 of 97% for heterogeneity. Pooled intention to complete LCS among patients who received PDA across all follow-up periods (same day to 3 months) was 57% (95% CI, 34% to 80%) with significant heterogeneity (I2) of 96% (p < 0.0001). No publication bias was identified.

CONCLUSIONS

LCS completion and intention to complete LCS among patients who use PDAs is high. Our findings support the need to implement PDAs in clinical practice which could further facilitate shared decision-making and improve LCS uptake among eligible patients.

A Scoping Review of Risk Presentation in Patient Decision Aids: Communicating Risk in Imaging

PURPOSE

Best practices exist for communicating medical information to patients, but there is less emphasis on methods to communicate risks, especially in medical imaging. The authors conducted a scoping review of patient decision aids in medical imaging and characterized the presentation methods of imaging risks.

METHODS

Embase, MEDLINE, CINAHL, and PsychINFO were searched to identify studies involving patient decision aids used in diagnostic imaging that communicated the risks. Study characteristics included the number and types of risks included, as well as the presentation type and how the probability of risks were communicated.

RESULTS

The final study included 46 articles encompassing 27 distinct patient decision aids. Mammography was the most common imaging scenario (22 of 46), followed by lung cancer screening (18 of 46), traumatic brain injury (5 of 46), and urolithiasis (1 of 46). All patient decision aids included risks associated with imaging, but the number of risk types varied from two to nine (mean, 4 ± 2). Twelve risks were identified across the 27 decision aids, but no single study included all risks. Overall, most risks (65%) were communicated with text, and the presentation mode varied by type of risk. False-positive risks were most commonly communicated using a visual format, whereas radiation risk was most commonly communicated using text format.

CONCLUSIONS

There was no consistent manner of communicating risk to patients, and visual methods such as icon arrays were not consistently used. The variability of both included risks and the risk presentation modes in the patient decision aids may affect decision making, especially among patients and caregivers with lower health literacy and numeracy.

Digital Interventions to Support Lung Cancer Screening: A Systematic Review

INTRODUCTION

Lung cancer remains a leading cause of cancer-related deaths globally. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce lung cancer mortality, but its adoption in the U.S. has been limited. Digital interventions have the potential to improve uptake of LCS. This systematic review aims to summarize the evidence for the effectiveness of digital interventions in promoting LCS.

METHODS

A systematic search of three electronic databases (PubMed, Embase, and Medline) was conducted to identify studies published between January 2014 and May 2023. Studies were reviewed and abstracted between February 2023 and July 2023. Outcomes related to knowledge, decision-making and screening were measured. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools.

RESULTS

Of 1,979 screened articles, 30 studies were included in this review. Digital interventions evaluated included decision aids (n=20), electronic health record (EHR)-based interventions (n=7), social media campaigns and mobile applications (n=3). Decision aids were the most commonly studied digital interventions, with most studies showing improved knowledge (13/13) and reduced decisional conflict (7/9) but most did not show a substantial change in screening use. Fewer studies tested clinician-facing or multi-level interventions.

DISCUSSION

Digital interventions, particularly decision aids, have shown promise in improving knowledge and the quality of decision-making around LCS. However, few interventions have been shown to substantially alter screening behavior and few clinician-facing or multi-level interventions have been rigorously tested. Further research is needed to develop effective tools for engaging patients in LCS, to compare the efficacy of different interventions, and evaluate implementation strategies in diverse healthcare settings.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Effect of a Peer Comparison and Educational Intervention on Medical Test Conversation Quality: A Randomized Clinical Trial

Importance

Medical test overuse and resulting care cascades represent a costly, intractable problem associated with inadequate patient-clinician communication. One possible solution with potential for broader benefits is priming routine, high-quality medical test conversations.

Objective

To assess if a peer comparison and educational intervention for physicians and patients improved medical test conversations during annual visits.

Design, Setting, and Participants

Randomized clinical trial and qualitative evaluation at an academic medical center conducted May 2021 to October 2022. Twenty primary care physicians (PCPs) were matched-pair randomized. For each physician, at least 10 patients with scheduled visits were enrolled. Data were analyzed from December 2022 to September 2023.

Interventions

In the intervention group, physicians received previsit emails that compared their low-value testing rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received previsit educational materials via email and text message. Control group physicians and patients received general previsit preparation tips.

Main outcomes and measures

The primary patient outcome was the Shared Decision-Making Process survey (SDMP) score. Secondary patient outcomes included medical test knowledge and presence of test conversation. Outcomes were compared using linear regression models adjusted for patient age, gender, race and ethnicity, and education. Poststudy interviews with intervention group physicians and patients were also conducted.

Results

There were 166 intervention group patients and 148 control group patients (mean [SD] patient age, 50.2 [15.3] years; 210 [66.9%] female; 246 [78.3%] non-Hispanic White). Most patients discussed at least 1 test with their physician (95.4% for intervention group; 98.3% for control group; difference, -2.9 percentage points; 95% CI, -7.0 to 1.2 percentage points). There were no statistically significant differences in SDMP scores (2.11 out of 4 for intervention group; 1.97 for control group; difference, 0.14; 95% CI, -0.25 to 0.54) and knowledge scores (2.74 vs 2.54 out of 4; difference, 0.19; 95% CI, -0.05 to 0.43). In poststudy interviews with 3 physicians and 16 patients, some physicians said the emails helped them reexamine their testing approach while others noted competing demands. Most patients said they trusted their physicians' advice even when inconsistent with educational materials.

Conclusions and Relevance

In this randomized clinical trial of a physician-facing and patient-facing peer comparison and educational intervention, there was no significant improvement in medical test conversation quality during annual visits. These results suggest that future interventions to improve conversations and reduce overuse and cascades should further address physician adoption barriers and leverage patient-clinician relationships.

Trial Registration

ClinicalTrials.gov Identifier: NCT04902664.