Implementing shared decision-making: consider all the consequences.
Implementing shared decision-making: consider all the consequences.
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DOI：
10.1186/s13012-016-0480-9
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发表时间：
2016-08-08
期刊：
影响因子：
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通讯作者：
Kobrin S
中科院分区：
文献类型：
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作者：
Elwyn G;Frosch DL;Kobrin S
共同决策是“正确”的事情的伦理论点，无论多么值得称赞，都不太可能改变医疗保健的组织方式，就像证据本身是一个不充分的因素一样：实践变化受到成本，利润率，质量和效率等因素的影响。因此，在评估共同决策等新方法时，以广泛、长期和尽可能与多个利益攸关方相关的方式将潜在后果概念化是有帮助的。然而，到目前为止，共享决策的评估指标主要集中在短期结果上，例如患者的认知或情感后果。本文的目标是假设一组更广泛的后果，适用于一个较长的时间范围内，并包括在international，团队，组织和系统层面的成果，并呼吁未来的研究，以研究这些可能的后果。到目前为止，更多的研究已经评估了患者的决策辅助工具，而不是其他方法来共同决策，测量的结果通常集中在短期的认知和情感结果，例如知识和决策冲突。从临床医生的角度来看，共享的决策过程可以被视为本质上的奖励和保护，或负担和不切实际的，但研究并没有集中在专业人士的影响，无论是积极的还是消极的。在干预水平，组，团队和微系统，潜在的长期后果可能包括一种文化的发展，审议和协作被视为指导原则，在那里病人被教导评估干预措施的价值，权衡利益与危害，并评估他们的负担，简而言之，在临床工作场所的新的社会规范。在组织层面，一致的共享决策可能会提高患者体验评估，并导致更少的投诉和法律的挑战。从长远来看，共同决策可能会导致资源利用的变化，也许会降低成本，并改变劳动力的构成。尽管逐渐转向基于价值的支付，但一些组织出于实现大量程序和联系所带来的持续收入的动机，将这视为一种负面后果。我们认为，更广泛的概念化和衡量共同决策将提供一个更实质性的证据基础，以指导实施。我们概述了一个框架，它说明了一组假设的近端，远端和远端的后果，可能会发生，如果合作和审议可以实现常规，提出充分知情的偏好为基础的患者决策可能会导致更安全，更具成本效益的医疗保健，这反过来可能会导致利用率降低和改善健康结果。
The ethical argument that shared decision-making is “the right” thing to do, however laudable, is unlikely to change how healthcare is organized, just as evidence alone will be an insufficient factor: practice change is governed by factors such as cost, profit margin, quality, and efficiency. It is helpful, therefore, when evaluating new approaches such as shared decision-making to conceptualize potential consequences in a way that is broad, long-term, and as relevant as possible to multiple stakeholders. Yet, so far, evaluation metrics for shared decision-making have been mostly focused on short-term outcomes, such as cognitive or affective consequences in patients. The goal of this article is to hypothesize a wider set of consequences, that apply over an extended time horizon, and include outcomes at interactional, team, organizational and system levels, and to call for future research to study these possible consequences. To date, many more studies have evaluated patient decision aids rather than other approaches to shared decision-making, and the outcomes measured have typically been focused on short-term cognitive and affective outcomes, for example knowledge and decisional conflict. From a clinicians perspective, the shared decision-making process could be viewed as either intrinsically rewarding and protective, or burdensome and impractical, yet studies have not focused on the impact on professionals, either positive or negative. At interactional levels, group, team, and microsystem, the potential long-term consequences could include the development of a culture where deliberation and collaboration are regarded as guiding principles, where patients are coached to assess the value of interventions, to trade-off benefits versus harms, and assess their burdens—in short, to new social norms in the clinical workplace. At organizational levels, consistent shared decision-making might boost patient experience evaluations and lead to fewer complaints and legal challenges. In the long-term, shared decision-making might lead to changes in resource utilization, perhaps to reductions in cost, and to modification of workforce composition. Despite the gradual shift to value-based payment, some organizations, motivated by continued income derived from achieving high volumes of procedures and contacts, will see this as a negative consequence. We suggest that a broader conceptualization and measurement of shared decision-making would provide a more substantive evidence base to guide implementation. We outline a framework which illustrates a hypothesized set of proximal, distal, and distant consequences that might occur if collaboration and deliberation could be achieved routinely, proposing that well-informed preference-based patient decisions might lead to safer, more cost-effective healthcare, which in turn might result in reduced utilization rates and improved health outcomes.