Informed decision making in outpatient practice - Time to get back to basics
Informed decision making in outpatient practice - Time to get back to basics
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DOI：
10.1001/jama.282.24.2313
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发表时间：
1999-12-22
影响因子：
120.7
通讯作者：
Levinson, W
中科院分区：
文献类型：
--
作者：
Braddock, CH;Edwards, KA;Levinson, W
背景许多临床医生呼吁加强对患者在临床决策中的作用的重视。目的描述初级保健内科医生和外科医生常规办公室访问中知情决策的性质和完整性。设计对1993年期间录音办公室访问的横断面描述性评估，背景和参与者59名初级保健医生(普通内科医生和家庭医生)和65名普通外科医生和整形外科医生共1057次会面；从每个医生的社区私人办公室招募2到12名患者。主要结果指标录音的医患讨论分析知情决策的要素，使用随决策复杂程度的不同而变化的标准：基本(如实验室测试)、中间(如新药)或复杂(如程序)，基本决定的标准包括对决定性质的讨论并要求患者表达偏好；其他类别的标准逐渐严格，结果1057次录音会面包含3552个临床决定。总体而言，9.0%的决策符合我们对知情决策完整性的定义，基本决策通常是完全知情的(17.2%)，而没有中间决策是完全知情的，只有1个(0.5%)复杂决策完全知情。在知情决策的要素中，对干预性质的讨论最多(71%)，对患者理解的评估最少(1.5%)。结论这一群体的初级保健内科医生和外科医生的知情决策往往是不完整的。即使对知情决策的标准进行了调整，以期对复杂性较低的决策进行较广泛的讨论，但这一缺陷仍然存在。这些发现表明，需要努力鼓励在临床实践中做出明智的决策。
Context Many clinicians have called for an increased emphasis on the patient's role in clinical decision making. However, little is known about the extent to which physicians foster patient involvement in decision making, particularly in routine office practice.Objective To characterize the nature and completeness of informed decision making in routine office visits of both primary care physicians and surgeons.Design Cross-sectional descriptive evaluation of audiotaped office visits during 1993,Setting and Participants A total of 1057 encounters among 59 primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons; 2 to 12 patients were recruited from each physician's community-based private office.Main Outcome Measures Analysis of audiotaped patient-physician discussions for elements of informed decision making, using criteria that varied with the level of decision complexity: basic (eg, laboratory test), intermediate (eg, new medication), or complex (eg, procedure), Criteria for basic decisions included discussion of the nature of the decision and asking the patient to voice a preference; other categories had criteria that were progressively more stringent,Results The 1057 audiotaped encounters contained 3552 clinical decisions. Overall, 9.0% of decisions met our definition of completeness for informed decision making, Basic decisions were most often completely informed (17.2%), while no intermediate decisions were completely informed, and only 1 (0.5%) complex decision was completely informed. Among the elements of informed decision making, discussion of the nature of the intervention occurred most frequently (71%) and assessment of patient understanding least frequently (1.5%).Conclusions Informed decision making among this group of primary care physicians and surgeons was often incomplete. This deficit was present even when criteria for informed decision making were tailored to expect less extensive discussion for decisions of lower complexity. These findings signal the need for efforts to encourage informed decision making in clinical practice.