Rethinking fundamental assumptions: SUPPORT's implications for future reform
Rethinking fundamental assumptions: SUPPORT's implications for future reform
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DOI：
10.1111/j.1532-5415.2000.tb03135.x
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发表时间：
2000-05-01
影响因子：
6.3
通讯作者：
Tsevat, J
中科院分区：
文献类型：
--
作者：
Lynn, J;Arkes, HR;Tsevat, J
背景：支持干预是一项研究，旨在了解预后以及对结果和治疗风险的偏好，尽管有证据表明咨询和信息按计划提供，但在改变沟通、决策和治疗模式方面无效。这一卷中的前一篇论文表明，干预设计中的适度改变可能无法解释缺乏实质性效果的原因。目的：探索改善个人、患者层面的决策不是改善临终关怀的最有效策略的可能性，以及改善常规做法可能更有效的可能性。设计：这篇论文反映了我们综合支持和其他来源的发现的努力，以探索我们的概念模型，它们与数据的一致性，以及它们对变化的影响。结果：许多支持改进决策模型的假设是有问题的。此外，支助的结果表明，根据共同决策的规范模式实施有效干预可能是相当困难的。实践模式和社会期望可能对塑造患者的护理过程有很大影响。制度功能上的创新，如提高质量或改变融资激励，可能会为改革提供更有力的途径。结论：支持的干预可能没有产生影响，因为强大的心理和社会力量支撑着目前的做法。常规护理的系统层面的创新和质量的提高可能提供更强大的改进机会。
BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects.OBJECTIVE: To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective.DESIGN: This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change.RESULTS: Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform.CONCLUSIONS: SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.