Why physicians favor use of percutaneous coronary intervention to medical therapy: A focus group study
Why physicians favor use of percutaneous coronary intervention to medical therapy: A focus group study
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DOI：
10.1007/s11606-008-0706-x
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发表时间：
2008-09-01
影响因子：
5.7
通讯作者：
Redberg, Rita F.
中科院分区：
文献类型：
--
作者：
Lin, Grace A.;Dudley, R. Adams;Redberg, Rita F.
背景：经皮冠状动脉介入治疗（PCI）在许多稳定的冠状动脉疾病患者中进行，尽管有证据表明与最佳药物治疗相比临床获益很少。目的：调查医生对选择性PCI的信念、实践和决策。设计：六个焦点小组，三个是初级保健医生，三个是心脏病专家。参与者使用假设的案例场景讨论PCI。使用扎根理论分析转录本，并确定了关于PCI决策途径的共同表达主题。参与者：2006年在加州Butte县、Orange县和旧金山湾区的28名初级保健医生和20名介入性和非介入性心脏病专家。结果：许多因素导致初级保健医生评估无症状或轻度症状的冠状动脉疾病患者，并将其转介给心脏病专家。筛查试验的使用往往导致额外的检查和转诊，以及担心遗漏冠状动脉狭窄，感知患者的期望和医学上的担忧。最终的结果是一个级联，这样任何阳性的测试通常都会导致导管实验室，在那里“眼狭窄反射”使得PCI几乎是确定的。结论：在稳定型冠状动脉疾病患者中广泛使用PCI——尽管有证据表明其结果与药物治疗相比几乎没有益处——可能部分是由于心理和情绪因素导致了级联效应，其中检测不可避免地导致了PCI。确定如何帮助医生更好地将循证医学纳入决策对患者的治疗结果和新技术的最佳使用具有重要意义。
BACKGROUND: Percutaneous coronary intervention (PCI) is performed in many patients with stable coronary artery disease, despite evidence of little clinical benefit over optimal medical therapy.OBJECTIVE: To examine physicians' beliefs, practices, and decision-making regarding elective PCI.DESIGN: Six focus groups, three with primary care physicians and three with cardiologists. Participants discussed PCI using hypothetical case scenarios. Transcripts were analyzed using grounded theory, and commonly expressed themes regarding the decision-making pathway to PCI were identified.PARTICIPANTS: Twenty-eight primary care physicians and 20 interventional and non-interventional cardiologists in Butte County, Orange County, and San Francisco Bay Area, California, in 2006.RESULTS: A number of factors led primary care physicians to evaluate non-symptomatic or minimally symptomatic patients for coronary artery disease and refer them to a cardiologist. The use of screening tests often led to additional testing and referral, as well as fear of missing a coronary stenosis, perceived patient expectations, and medicolegal concerns. The end result was a cascade such that any positive test would generally lead to the catheterization lab, where an "oculostenotic reflex" made PCI a virtual certainty.CONCLUSIONS: The widespread use of PCI in patients with stable coronary artery disease-despite evidence of little benefit in outcomes over medical therapy-may in part be due to psychological and emotional factors leading to a cascade effect wherein testing leads inevitably to PCI. Determining how to help physicians better incorporate evidence-based medicine into decision-making has important implications for patient outcomes and the optimal use of new technologies.