Evaluating Shared Decision Making for Lung Cancer ScreeningBrenner AT, Malo TL, Margolis M, et al. Evaluating Shared Decision Making for Lung Cancer Screening. JAMA internal medicine 2018;178:1311-6.
Corresponding Author: Daniel S. Reuland, MD, MPH, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, 101 EWeaver St, Campus Box7923, Carrboro, NC 2751(dreuland@med.unc.edu).IMPORTANCE 重要性
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.美国预防服务工作组建议，在开始进行肺癌筛查（LCS）和低剂量CT扫描之前，应该在临床医生和患者之间进行关于利益和危害的全面讨论下做出共同决定（SDM）。联邦医疗保险和医疗补助服务中心对SDM的审查要求，使用辅助性的决策需作为LCS覆盖的先决条件。然而，关于LCS如何在实践中发生的问题，我们知之甚少。
OBJECTIVE 目标
To assess the quality of SDM about the initiation of LCS in clinical practice.评估SDM在临床实践中启动LCS的质量。
DESIGN, SETTING, AND PARTICIPANTS 设计，设置和参与者
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.这项质量满意度分析基于初级保健医师或肺保健医生与14名被认为有资格获得LCS的患者之间进行记录的对话，记录在2014年4月1日至2018年3月1日之间，这是在一个大型数据库中发现的。
RESULTS 结果
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. 选了14个关于启动LCS的对话;9名患者为女性，5名患者为男性;平均（SD）患者年龄为63.9（5.1）岁;7个病人有医疗保险，8个病人现在吸烟。一半的谈话是由初级保健医生进行的。
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. 14个LCS对话的平均总选项得分0到100的范围内是6（ 0-17不等）。在12个SDM行为中，没有一个符合最低技能标准。医生普遍推荐LCS。关于坏处（如假阳性和后遗症或过度诊断）的讨论几乎没有出现。
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.讨论的平均总访问时间是13:07分钟（3:48-27:09分钟不等）。讨论LCS的平均时间是0:59分钟（0:16-2:19分钟不等），或8%的总访问时间（1%-18%不等）。没有证据表明使用了用于LCS的决策的辅助工具或其他患者教育材料。
CONCLUSIONS AND RELEVANCE 结论和意义
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.在这一小段关于启动LCS的记录中，观察到的SDM的质量很差，并且几乎不存在对筛查潜在危害的解释。讨论LCS的时间很少，而且没有证据表明使用了决策辅助工具。尽管这些发现只是初步的，但它们引起了人们的担忧，即在实践中，LCS的SDM可能与指南的目的相去甚远。