Opportunities for addressing gaps in primary care shared decision-making with technology: a mixed-methods needs assessment
Opportunities for addressing gaps in primary care shared decision-making with technology: a mixed-methods needs assessment
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DOI：
10.1093/jamiaopen/ooz027
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发表时间：
2019-12-01
期刊：
影响因子：
2.1
通讯作者：
Melnick，Edward R.
中科院分区：
文献类型：
--
作者：
Misra，Anjali J.;Ong，Shawn Y.;Melnick，Edward R.
目的分析共享决策(SDM)在初级保健中的当前做法，并对信息技术(IT)干预的作用进行需求评估。材料与方法一项混合方法研究分三个阶段进行：(1)临床接触的人种学观察；(2)患者访谈；(3)医生访谈。使用经过验证的选项量表来衡量SDM。半结构化访谈遵循的是访谈指南(由我们的多学科团队开发)，其中包括传统的决策冲突量表和共享决策问卷。现场笔记由两名审查者在Dedoos中独立编码和分析。结果在3种不同的实践中观察到24次患者接触，平均选项得分为57.2(0-100分；95%可信区间[CI]，51.8-62.6)。22名患者和8名医生进行了访谈，直到达到主题饱和。科恩的卡帕，测量编码者协议，是0.42。患者的领域包括：建立信任、他人的影响、灵活性、挫折感、价值观和偏好。医生领域包括挫折、技术(关注、现有用途和愿望)和决策(当前使用的方法、挑战和患者的理解)。讨论由于观察到的SDM较低，基于得分较低的特定选项项目，存在多种技术增强SDM的机会，包括：(1)检查患者的首选信息格式，(2)询问患者在决策中的首选参与程度，以及(3)提供推迟决策的机会。根据访谈的数据，患者和医生重视信息交换，并对加强护理选择沟通的技术持开放态度。结论未来的初级保健IT平台应该优先考虑确定的3个量化差距，以改善医患沟通和关系。此外，SDM工具应该寻求标准化决策中的常见工作流程步骤，并重点关注在日常初级保健中更多地采用有效的SDM工具的障碍。
ObjectivesTo analyze current practices in shared decision-making (SDM) in primary care and perform a needs assessment for the role of information technology (IT) interventions.Materials and MethodsA mixed-methods study was conducted in three phases: (1) ethnographic observation of clinical encounters, (2) patient interviews, and (3) physician interviews. SDM was measured using the validated OPTION scale. Semistructured interviews followed an interview guide (developed by our multidisciplinary team) informed by the Traditional Decision Conflict Scale and Shared Decision Making Questionnaire. Field notes were independently coded and analyzed by two reviewers in Dedoose.ResultsTwenty-four patient encounters were observed in 3 diverse practices with an average OPTION score of 57.2 (0–100 scale; 95% confidence interval [CI], 51.8–62.6). Twenty-two patient and 8 physician interviews were conducted until thematic saturation was achieved. Cohen’s kappa, measuring coder agreement, was 0.42. Patient domains were: establishing trust, influence of others, flexibility, frustrations, values, and preferences. Physician domains included frustrations, technology (concerns, existing use, and desires), and decision making (current methods used, challenges, and patients’ understanding).DiscussionGiven low SDM observed, multiple opportunities for technology to enhance SDM exist based on specific OPTION items that received lower scores, including: (1) checking the patient’s preferred information format, (2) asking the patient's preferred level of involvement in decision making, and (3) providing an opportunity for deferring a decision. Based on data from interviews, patients and physicians value information exchange and are open to technologies that enhance communication of care options.ConclusionFuture primary care IT platforms should prioritize the 3 quantitative gaps identified to improve physician–patient communication and relationships. Additionally, SDM tools should seek to standardize common workflow steps across decisions and focus on barriers to increasing adoption of effective SDM tools into routine primary care.