"Many miles to go …": a systematic review of the implementation of patient decision support interventions into routine clinical practice.
"Many miles to go …": a systematic review of the implementation of patient decision support interventions into routine clinical practice.
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DOI：
10.1186/1472-6947-13-s2-s14
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发表时间：
2013
影响因子：
3.5
通讯作者：
Frosch DL
中科院分区：
文献类型：
--
作者：
Elwyn G;Scholl I;Tietbohl C;Mann M;Edwards AG;Clay C;Légaré F;van der Weijden T;Lewis CL;Wexler RM;Frosch DL
二十年的研究已经确立了使用以患者为目标的决策支持干预措施的积极效果：患者获得知识，更好地理解概率并增加决策信心。然而，尽管他们的功效，这些决策支持干预措施在日常实践中的有效性尚未建立;广泛采用尚未发生。本综述的目的是搜索和分析已发表的同行评议研究的结果，这些研究调查了在常规临床环境中尝试实施以患者为目标的决策支持干预措施的策略或方法的成功水平。设计了一种电子检索策略，并适用于以下数据库：ASSIA、CINAHL、Embase、HMIC、Medline、Medline-in-process、OpenSIGLE、PsycINFO、Scopus、Social Services Abstracts和Web of Science。此外，我们还使用了滚雪球技术。在双重独立评估后纳入研究。经过评估，5322篇摘要产生了51篇供考虑的文章。在检查了全文后，纳入了17项研究并进行了数据提取。所有研究中使用的方法都是临床医生及其工作人员使用转诊模型，要求符合条件的患者使用决策支持。结果表明，使用该模型实施患者决策支持面临重大挑战，包括医疗保健专业人员的冷漠。这种冷漠的原因是，据报告，对决策支助干预措施的内容缺乏信心，担心既定工作流程会被打乱，最终导致组织在采用这些措施方面的惰性。现在就提出如何最好地将患者决策支持纳入常规实践的明确建议似乎还为时过早，因为使用“转诊模式”的方法始终存在困难。我们感觉到，潜在的问题，不利于使用患者的决策支持，更一般地说，限制通过共享决策，是调查和指定不足。未来的实施研究报告可以通过以下指导方针（例如SQUIRE建议）进行改进，并通过采用能够超越“障碍”和“促进者”方法的方法来更多地了解专业和组织对这些工具的抵制的性质。需要将缺乏奖励使用这些干预措施的激励措施视为一个重大障碍。
Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings. An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment. After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption. It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a ‘referral model’ consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the ‘barriers’ and ‘facilitators’ approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.