title: Clinical Equipoise and Shared Decision-making in Pulmonary Nodule Management. A Survey of American Thoracic Society Clinicians.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  To assess clinicians' perceptions of the appropriateness of various diagnostic strategies, approach to decision-making, and perceived clinical equipoise in pulmonary nodule evaluation.
  
  
  METHODS
  We developed and administered a web-based survey in March and April, 2014 to clinician members of the American Thoracic Society. 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.
  
  
  RESULTS
  Of 5,872 American Thoracic Society members e-mailed, 1,444 opened the e-mail 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 pretest 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). One-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 one-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%).
  
  
  CONCLUSIONS
  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.
authors.affiliation: 1 Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Iaccarino
authors.affiliation: 2 Division of Pulmonary, Critical Care, and Sleep Medicine, Brown University, Providence, Rhode Island.
authors.forename: James
authors.initials: J
authors.lastname: Simmons
authors.affiliation: 3 Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
authors.affiliation: 4 Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon.|5 Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Slatore
authors.affiliation: 6 Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and.
authors.forename: Steven
authors.initials: S
authors.lastname: Woloshin
authors.affiliation: 6 Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Schwartz
authors.affiliation: 1 Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts.|7 Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts.
authors.forename: Renda Soylemez
authors.initials: RS
authors.lastname: Wiener
mesh_terms: D001291:Attitude of Health Personnel; D001999:Bronchoscopy; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D055613:Multiple Pulmonary Nodules / Q000175:diagnosis / Q000473:pathology / Q000628:therapy*; D015999:Multivariate Analysis; D049268:Positron-Emission Tomography; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D016032:Randomized Controlled Trials as Topic; D012044:Regression Analysis; D018570:Risk Assessment; D011795:Surveys and Questionnaires; D014057:Tomography, X-Ray Computed; D014481:United States
keywords: guideline adherence; pulmonary nodules; shared decision-making; surveys and questionnaires