Hinton Ladson, Franz Carol E, Reddy Geetha, Flores Yvette, Kravitz Richard L, Barker Judith C
Department of Psychiatry and Behavioral Sciences and Alzheimer's Disease Center, UC Davis, Sacramento, California 95817, USA.
J Gen Intern Med. 2007 Nov;22(11):1487-92. doi: 10.1007/s11606-007-0317-y. Epub 2007 Sep 7.
To examine how practice constraints contribute to barriers in the health care of persons with dementia and their families, particularly with respect to behavioral aspects of care.
Cross-sectional qualitative interview study of primary care physicians.
Physicians' offices.
Forty primary care physicians in Northern California.
Open-ended interviews lasted 30-60 minutes and were structured by an interview guide covering clinician background and practice setting, clinical care of a particular patient, and general approach to managing patients with AD or dementia. Interviews were transcribed and themes reflecting constraints of practice were identified through a systematic coding process.
Recurring themes (i.e., those present in > or = 25% of physician interviews) included insufficient time, difficulty in accessing and communicating with specialists, low reimbursement, poor connections with community social service agencies, and lack of interdisciplinary teams. Physician narratives suggest that these constraints may lead to delayed detection of behavior problems, "reactive" as opposed to proactive management of dementia, and increased reliance on pharmacological rather than psychosocial approaches.
Physicians often feel challenged in caring for dementia patients, particularly those who are more behaviorally complex, because of time and reimbursement constraints as well as other perceived barriers. Our results suggest that more effective educational interventions (for families and physicians) and broader structural changes are needed to better meet the needs of the elderly with dementia and their families now and in the future. Without these changes, dementia care is likely to continue to fall short.
探讨实践限制如何导致痴呆患者及其家庭在医疗保健方面面临障碍，尤其是在护理的行为方面。
对初级保健医生进行横断面定性访谈研究。
医生办公室。
北加利福尼亚州的40名初级保健医生。
开放式访谈持续30 - 60分钟，由一份访谈指南构建，该指南涵盖临床医生背景和实践环境、特定患者的临床护理以及管理阿尔茨海默病或痴呆患者的一般方法。访谈进行转录，并通过系统编码过程确定反映实践限制的主题。
反复出现的主题（即在≥25%的医生访谈中出现的主题）包括时间不足、与专科医生联系和沟通困难、报销费用低、与社区社会服务机构联系不佳以及缺乏跨学科团队。医生的叙述表明，这些限制可能导致行为问题检测延迟、对痴呆症的管理是“反应性的”而非主动性的，以及增加对药物治疗而非心理社会方法的依赖。
由于时间和报销限制以及其他可感知的障碍，医生在照顾痴呆患者，尤其是那些行为问题更复杂的患者时，常常感到面临挑战。我们的结果表明，需要更有效的教育干预措施（针对家庭和医生）以及更广泛的结构变革，以便更好地满足当前和未来痴呆老年患者及其家庭的需求。没有这些变革，痴呆症护理可能会继续不足。
