Effectiveness of the DECIDE Interventions on Shared Decision Making and Perceived Quality of Care in Behavioral Health With Multicultural Patients A Randomized Clinical Trial
Effectiveness of the DECIDE Interventions on Shared Decision Making and Perceived Quality of Care in Behavioral Health With Multicultural Patients A Randomized Clinical Trial
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DOI：
10.1001/jamapsychiatry.2017.4585
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发表时间：
2018-04-01
期刊：
影响因子：
25.8
通讯作者：
Shrout, Patrick E.
中科院分区：
文献类型：
--
作者：
Alegria, Margarita;Nakash, Ora;Shrout, Patrick E.
重要性少数随机临床试验已经进行了与种族/少数民族，以提高共同决策（SDM）和质量的care. ObjectiveTo测试的有效性，病人和临床医生的干预措施，以提高SDM和质量的护理之间的种族/种族多样化的样本。和参与者这项跨水平2 x 2随机临床试验包括2级临床医生和患者（嵌套在临床医生中）来自马萨诸塞州13家行为健康诊所的1级。在每个研究中心以1：1的比例随机选择临床医生和患者，每个2人区组。从2013年9月1日开始招募临床医生;从2013年11月3日开始招募患者。最终数据于2016年9月30日收集。数据进行分析的基础上意向treat.INTERVENTIONS临床干预包括一个研讨会和多达6个辅导电话，以促进沟通和治疗联盟，以提高SDM。3个会话的患者干预旨在改善SDM和护理质量。主要结果和措施SDM由盲编码器根据临床记录、患者对SDM和护理质量的感知以及临床医生对SDM的感知进行评估。（67.9%）为女性，100例（32.1%）为男性;平均（SD）年龄为44.0（15.0）岁。在74名随机化临床医生中，56名（75.7%）为女性，18名（4.3%）为男性;平均（SD）年龄为39.8（12.5）岁。患者-临床医生对被分配到以下4个设计组之一：对照条件下的患者和临床医生（n = 72）、对照条件下的患者和临床医生（n = 68）、对照条件下的患者和临床医生（n = 83）或干预条件下的患者和临床医生（n = 89）。对所有配对进行分析。临床医生干预显著增加了SDM，如盲法编码者使用12项观察患者参与共享决策工具（B = 4.52; SE = 2.17; P = 0.04; Cohen d = 0.29）评定的，但不是由临床医生或患者评估的。更多的临床医生指导课程（剂量）与由盲法编码者评定的SDM增加显著相关（B = 12.01; SE = 3.72; P = 0.001; Cohen d = 0.78）。患者干预显著提高了患者感知的护理质量（B = 2.27; SE = 1.16; P = 0.05; Cohen d = 0.19）。有一个显着的患者和临床医生的剂量（B = 7.40; SE = 3.56; P = 0.04;科恩d = 0.62）之间的相互作用，最大的好处时，都获得了推荐dose.Conclusions和相关性的临床医生的干预可以改善SDM与少数人群，和患者的干预可以增加患者报告的护理质量。
IMPORTANCE Few randomized clinical trials have been conducted with ethnic/racial minorities to improve shared decision making (SDM) and quality of care.OBJECTIVE To test the effectiveness of patient and clinician interventions to improve SDM and quality of care among an ethnically/racially diverse sample.DESIGN, SETTING, AND PARTICIPANTS This cross-level 2 x 2 randomized clinical trial included clinicians at level 2 and patients (nested within clinicians) at level 1 from 13 Massachusetts behavioral health clinics. Clinicians and patients were randomly selected at each site in a 1:1 ratio for each 2-person block. Clinicians were recruited starting September 1, 2013; patients, starting November 3, 2013. Final data were collected on September 30, 2016. Data were analyzed based on intention to treat.INTERVENTIONS The clinician intervention consisted of a workshop and as many as 6 coaching telephone calls to promote communication and therapeutic alliance to improve SDM. The 3-session patient intervention sought to improve SDM and quality of care.MAIN OUTCOMES AND MEASURES The SDM was assessed by a blinded coder based on clinical recordings, patient perception of SDM and quality of care, and clinician perception of SDM.RESULTS Of 312 randomized patients, 212 (67.9%) were female and 100 (32.1%) were male; mean (SD) age was 44.0 (15.0) years. Of 74 randomized clinicians, 56 (75.7%) were female and 18 (4.3%) were male; mean (SD) age was 39.8 (12.5) years. Patient-clinician pairs were assigned to 1 of the following 4 design arms: patient and clinician in the control condition (n = 72), patient in intervention and clinician in the control condition (n = 68), patient in the control condition and clinician in intervention (n = 83), or patient and clinician in intervention (n = 89). All pairs underwent analysis. The clinician intervention significantly increased SDM as rated by blinded coders using the 12-item Observing Patient Involvement in Shared Decision Making instrument (b = 4.52; SE = 2.17; P = .04; Cohen d = 0.29) but not as assessed by clinician or patient. More clinician coaching sessions (dosage) were significantly associated with increased SDM as rated by blinded coders (b = 12.01; SE = 3.72; P = .001; Cohen d = 0.78). The patient intervention significantly increased patient-perceived quality of care (b = 2.27; SE = 1.16; P = .05; Cohen d = 0.19). There was a significant interaction between patient and clinician dosage (b = 7.40; SE = 3.56; P = .04; Cohen d = 0.62), with the greatest benefit when both obtained the recommended dosage.CONCLUSIONS AND RELEVANCE The clinician intervention could improve SDM with minority populations, and the patient intervention could augment patient-reported quality of care.