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Original Research: Lung Cancer |

Pulmonologists’ Reported Use of Guidelines and Shared Decision-making in Evaluation of Pulmonary NodulesPulmonologists2019 Approach to Lung Nodules: A Qualitative Study

Renda Soylemez Wiener, MD, MPH; Christopher G. Slatore, MD; Chris Gillespie, PhD; Jack A. Clark, PhD
Author and Funding Information

From the Center for Healthcare Organization and Implementation Research (Drs Wiener, Gillespie, and Clark), Edith Nourse Rogers Memorial VA Hospital, Bedford, MA; the Pulmonary Center (Dr Wiener) and the Department of Health Policy and Management (Dr Clark), Boston University School of Public Health, Boston, MA; Health Services Research and Development (Dr Slatore), and the Section of Pulmonary and Critical Care Medicine (Dr Slatore), VA Portland Health Care System, Portland, OR; and the Division of Pulmonary and Critical Care Medicine (Dr Slatore), Department of Medicine, Oregon Health and Science University, Portland, OR.

CORRESPONDENCE TO: Renda Soylemez Wiener, MD, MPH, Pulmonary Center, Boston University School of Medicine, 72 E Concord St, R-304, Boston, MA 02118; e-mail: rwiener@bu.edu


FOR EDITORIAL COMMENT SEE PAGE 1365

SEE RELATED ARTICLES PAGES 1405 AND 1422

FUNDING/SUPPORT: This study was supported by the National Cancer Institute [K07 CA138772 to Dr Wiener] and by a Veterans Health Administration Office of Health Services Research and Development Career Development Award [CDP 11-227 to Dr Slatore]. This study was also supported by resources from the Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, and the Portland VA Medical Center, Portland, OR.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(6):1415-1421. doi:10.1378/chest.14-2941
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BACKGROUND:  Selecting a strategy (surveillance, biopsy, resection) for pulmonary nodule evaluation can be complex given the absence of high-quality data comparing strategies and the important tradeoffs among strategies. Guidelines recommend a three-step approach: (1) assess the likelihood of malignancy, (2) evaluate whether the patient is a candidate for invasive intervention, and (3) elicit the patient’s preferences and engage in shared decision-making. We sought to characterize how pulmonologists select a pulmonary nodule evaluation strategy and the extent to which they report following the guideline-recommended approach.

METHODS:  We conducted semistructured qualitative interviews with 14 pulmonologists who manage patients with pulmonary nodules at four clinical sites. Transcripts of audiorecorded interviews were analyzed using the principles of grounded theory.

RESULTS:  Pulmonologists reported consistently performing steps 1 and 2 but described diverse approaches to step 3 that ranged from always engaging the patient in decision-making to never doing so. Many described incorporating patients’ preferences only in particular circumstances, such as when the patient appeared particularly anxious or was aggressive in questioning management options. Indeed, other factors, including convenience, physician preferences, physician anxiety, malpractice concerns, and physician experience, appeared to drive decision-making as much as, if not more than, patient preferences.

CONCLUSIONS:  Although pulmonologists appear to routinely personalize pulmonary nodule evaluation strategies based on the individual patient’s risk-benefit tradeoffs, they may not consistently take patient preferences into account during the decision-making process. In the absence of high-quality evidence regarding the optimal methods of pulmonary nodule evaluation, physicians should strive to ensure that management decisions are consistent with patients’ values.


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