Gravel Karine, Légaré France, Graham Ian D
Research Centre of the Centre Hospitalier Universitaire de Québec, Québec, Canada.
Implement Sci. 2006 Aug 9;1:16. doi: 10.1186/1748-5908-1-16.
Shared decision-making is advocated because of its potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. However, current evidence suggests that shared decision-making has not yet been widely adopted by health professionals. Therefore, a systematic review was performed on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.
Covering the period from 1990 to March 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched for studies in English or French. The references from included studies also were consulted. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in their practices. Shared decision-making was defined as a joint process of decision making between health professionals and patients, or as decision support interventions including decision aids, or as the active participation of patients in decision making. No study design was excluded. Quality of the studies included was assessed independently by two of the authors. Using a pre-established taxonomy of barriers and facilitators to implementing clinical practice guidelines in practice, content analysis was performed.
Thirty-one publications covering 28 unique studies were included. Eleven studies were from the UK, eight from the USA, four from Canada, two from The Netherlands, and one from each of the following countries: France, Mexico, and Australia. Most of the studies used qualitative methods exclusively (18/28). Overall, the vast majority of participants (n = 2784) were physicians (89%). The three most often reported barriers were: time constraints (18/28), lack of applicability due to patient characteristics (12/28), and lack of applicability due to the clinical situation (12/28). The three most often reported facilitators were: provider motivation (15/28), positive impact on the clinical process (11/28), and positive impact on patient outcomes (10/28).
This systematic review reveals that interventions to foster implementation of shared decision-making in clinical practice will need to address a broad range of factors. It also reveals that on this subject there is very little known about any health professionals others than physicians. Future studies about implementation of shared decision-making should target a more diverse group of health professionals.
倡导共同决策是因为其有可能改善患者决策过程的质量，并最终改善患者的治疗结果。然而，目前的证据表明，共同决策尚未被卫生专业人员广泛采用。因此，针对卫生专业人员所认为的临床实践中实施共同决策的障碍和促进因素进行了一项系统评价。
检索1990年至2006年3月期间的PubMed、Embase、CINHAL、PsycINFO和学位论文摘要数据库，查找英文或法文研究。还查阅了纳入研究的参考文献。如果研究报告了卫生专业人员在实践中实施共同决策所感知到的障碍和促进因素，则纳入该研究。共同决策被定义为卫生专业人员与患者之间的联合决策过程，或包括决策辅助工具在内的决策支持干预措施，或患者在决策中的积极参与。不排除任何研究设计。纳入研究的质量由两位作者独立评估。使用预先建立的实践中实施临床实践指南的障碍和促进因素分类法进行内容分析。
纳入了31篇涵盖28项独特研究的出版物。11项研究来自英国，8项来自美国，4项来自加拿大，2项来自荷兰，1项分别来自以下国家：法国、墨西哥和澳大利亚。大多数研究仅使用定性方法（18/28）。总体而言，绝大多数参与者（n = 2784）是医生（89%）。最常报告的三个障碍是：时间限制（18/28）、由于患者特征而缺乏适用性（12/28）以及由于临床情况而缺乏适用性（12/28）。最常报告的三个促进因素是：提供者的积极性（15/28）、对临床过程的积极影响（11/28）以及对患者治疗结果的积极影响（10/28）。
这项系统评价表明，促进临床实践中共同决策实施的干预措施需要解决广泛的因素。它还表明，除了医生之外，对于其他卫生专业人员在这个问题上知之甚少。未来关于共同决策实施的研究应针对更多样化的卫生专业人员群体。
