Understanding treatment decision making in juvenile idiopathic arthritis: a qualitative assessment.
Understanding treatment decision making in juvenile idiopathic arthritis: a qualitative assessment.
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DOI：
10.1186/1546-0096-11-34
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发表时间：
2013-09-30
期刊：
影响因子：
--
通讯作者：
Morgan Dewitt E
中科院分区：
文献类型：
--
作者：
Lipstein EA;Brinkman WB;Sage J;Lannon CM;Morgan Dewitt E
幼年特发性关节炎（JIA）治疗选择的增加增加了治疗决策的复杂性。共同决策有可能帮助提供者和家庭共同努力，从一系列选择中为每位患者选择最佳选择。作为需求评估的一部分，在设计和实施共同决策干预措施之前，我们对临床医生目前在JIA中进行治疗决策的方法进行了定性评估。儿科风湿病临床医生从2个学术儿童医院附属质量改进学习网络，采用目的性和雪球抽样。半结构化访谈引出了临床医生与处方权（n = 10）如何与家庭互动，使治疗决策。采访进行了录音并逐字转录。一个多学科的研究小组使用内容分析来分析采访数据。为了验证个人访谈的数据并丰富我们的理解，我们向参加学习网络会议的儿科风湿病临床医生（n = 24，来自12家儿童医院）介绍了访谈结果。然后，我们向临床医生提出问题，以进一步确定和讨论决策过程中的变化领域。临床医生描述了一个决策过程，在这个过程中，他们，而不是家庭或其他护理团队成员，一致地启动治疗决定。向家属提供的初始治疗方案通常反映了临床医生的首选治疗方法，这些方法在临床医生之间存在差异。临床医生使用各种方法告知家庭治疗方案，并根据家庭的信息需求，理解水平或情绪（如焦虑）的看法定制信息。呈现给家庭的药物属性分为4类：益处、风险、后勤和家庭偏好。临床医生通常包括家庭成员在决定开始JIA治疗后，限制选择，以适应临床情况和临床医生自己的喜好。家庭成员的偏好被视为在症状缓解后停止治疗的决定中更不可或缺的因素。关于JIA初始治疗的决策似乎在很大程度上取决于临床医生的偏好。家庭偏好更有可能被考虑为治疗中止。存在开发、测试和实施工具的机会，以促进儿科风湿病学的共同决策。
The increase in therapeutic options for juvenile idiopathic arthritis (JIA) has added complexity to treatment decisions. Shared decision making has the potential to help providers and families work together to choose the best possible option for each patient from the array of choices. As part of a needs assessment, prior to design and implementation of shared decision making interventions, we conducted a qualitative assessment of clinicians’ current approaches to treatment decision making in JIA. Pediatric rheumatology clinicians were recruited from 2 academic children’s hospitals affiliated with a quality improvement learning network, using purposive and snowball sampling. Semi-structured interviews elicited how clinicians with prescribing authority (n = 10) interact with families to make treatment decisions. Interviews were audio-recorded and transcribed verbatim. A multi-disciplinary research team used content analysis to analyze the interview data. To validate data from individual interviews and enrich our understanding, we presented the interview results to pediatric rheumatology clinicians attending a learning network meeting (n = 24 from 12 children’s hospitals). We then asked the clinicians questions to further identify and discuss areas of variation in the decision-making processes. Clinicians described a decision-making process in which they, rather than the family or other care team members, consistently initiated treatment decisions. Initial treatment options presented to families generally reflected the clinician’s preferred treatment approaches, which differed across clinicians. Clinicians used various methods to inform families about treatment options and tailor information according to perceptions of a family’s information needs, level of comprehension or mood (e.g. anxiety). The attributes of medication presented to families fell into 4 categories: benefits, risks, logistics and family preferences. Clinicians typically included family members in the decision to initiate JIA treatment after limiting the options to fit the clinical situation and the clinician’s own preferences. Family members’ preferences were seen as more integral in the decision to stop treatment after symptom remission. Decision making about initial JIA treatment appears to be largely driven by clinician preferences. Family preferences are more likely to be considered for treatment discontinuation. Opportunities exist to develop, test, and implement tools to facilitate shared decision making in pediatric rheumatology.
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