Boston University Medical Center, Boston, Massachusetts, United States ; firstname.lastname@example.org.
Brown University, 6752, Division of Pulmonary, Critical Care, and Sleep Medicine, Providence, Rhode Island, United States ; email@example.com.
Kaiser Permanente Southern California, Research and Evaluation , 100 S. Los Robles Ave. , Suite 304 , Pasadena, California, United States , 91101 ; firstname.lastname@example.org.
Portland VA Medical Center, Health Services Research & Development , 3710 SW US Veterans Hospital Rd. , Portland, Oregon, United States , 97239.
Oregon Health & Sciences University, Division of Pulmonary and Critical Care Medicine ; email@example.com.
The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, United States ; Steven.Woloshin@Dartmouth.edu.
The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, United States ; Lisa.Schwartz@Dartmouth.edu.
Edith Nourse Rogers Memorial Veterans Hospital, 20024, Center for Healthcare Organization & Implementation Research, Bedford, Massachusetts, United States , 01730-1198.
Boston University School of Medicine, 12259, The Pulmonary Center, Boston, Massachusetts, United States , 02118 ; firstname.lastname@example.org.
Guidelines for pulmonary nodule evaluation suggest a variety of strategies, reflecting the lack of high-quality evidence demonstrating the superiority of any one approach. It is unclear whether clinicians agree that multiple management options are appropriate at different levels of risk and whether this impacts their decision-making approaches with patients.
To assess clinicians' perceptions of the appropriateness of various diagnostic strategies, approach to decision-making, and perceived clinical equipoise in pulmonary nodule evaluation.
We developed and administered a web-based survey in March and April, 2014 to clinician members of the American Thoracic Society (ATS). The primary outcome was perceived appropriateness of pulmonary nodule evaluation strategies in three clinical vignettes with different malignancy risk. We compared responses to guideline recommendations and analyzed clinician characteristics associated with a reported shared decision-making approach. We also assessed clinicians' likelihood to enroll patients in hypothetical randomized trials comparing nodule evaluation strategies.
Of 5872 ATS members emailed, 1444 opened the email and 428 eligible clinicians participated in the survey (response rate 30.0% among those who opened the invitation, 7% overall). The mean number of options considered appropriate increased with pre-test probability of cancer, ranging from 1.8 (SD 1.2) for the low-risk case to 3.5 (1.1) for the high-risk case (p<0.0001). As recommended by guidelines, the proportion that deemed surgical resection as an appropriate option also increased with cancer risk (p<0.0001). Half of clinicians (50.4%) reported engaging in shared decision-making with patients for pulmonary nodule management; this was more commonly reported by clinicians with more years of experience (p=0.01) and those who reported greater comfort in managing pulmonary nodules (p=0.005). Although half (49.9%) deemed the evidence for pulmonary nodule evaluation to be strong, most clinicians were willing to enroll patients in randomized trials to compare nodule management strategies in all risk categories (low-risk: 87.6%, moderate-risk: 89.7%, high-risk: 63.0%).
Consistent with guideline recommendations, clinicians embrace multiple options for pulmonary nodule evaluation and many are open to shared decision-making. Clinicians support the need for randomized clinical trials to strengthen the evidence for nodule evaluation, which will further improve decision-making.