Braddock Clarence, Hudak Pamela L, Feldman Jacob J, Bereknyei Sylvia, Frankel Richard M, Levinson Wendy
Stanford University School of Medicine, 251 Campus Drive, MC 5475, Stanford, CA 94305-5475, USA.
J Bone Joint Surg Am. 2008 Sep;90(9):1830-8. doi: 10.2106/JBJS.G.00840.
Informed decision-making has been widely promoted in several medical settings, but little is known about the actual practice in orthopaedic surgery and there are no clear guidelines on how to improve the process in this setting. This study was designed to explore the quality of informed decision-making in orthopaedic practice and to identify excellent time-efficient examples with older patients.
We recruited orthopaedic surgeons, and patients sixty years of age or older, in a Midwestern metropolitan area for a descriptive study performed through the analysis of audiotaped physician-patient interviews. We used a valid and reliable measure to assess the elements of informed decision-making. These included discussions of the nature of the decision, the patient's role, alternatives, pros and cons, and uncertainties; assessment of the patient's understanding and his or her desire to receive input from others; and exploration of the patient's preferences and the impact on the patient's daily life. The audiotapes were scored with regard to whether there was a complete discussion of each informed-decision-making element (an IDM-18 score of 2) or a partial discussion of each element (an IDM-18 score of 1) as well as with a more pragmatic metric (the IDM-Min score), reflecting whether there was any discussion of the patient's role or preference and of the nature of the decision. The visit duration was studied in relation to the extent of the informed decision-making, and excellent time-efficient examples were sought.
There were 141 informed-decision-making discussions about surgery, including knee and hip replacement as well as wrist/hand, shoulder, and arthroscopic surgery. Surgeons frequently discussed the nature of the decision (92% of the time), alternatives (62%), and risks and benefits (59%); they rarely discussed the patient's role (14%) or assessed the patient's understanding (12%). The IDM-18 scores of the 141 discussions averaged 5.9 (range, 0 to 15; 95% confidence interval, 5.4 to 6.5). Fifty-seven percent of the discussions met the IDM-Min criteria. The median duration of the visits was sixteen minutes; the extent of informed decision-making had only a modest relationship with the visit duration. Time-efficient strategies that were identified included use of scenarios to illustrate distinct choices, encouraging patient input, and addressing primary concerns rather than lengthy recitations of pros and cons.
In this study, which we believe is the first to focus on informed decision-making in orthopaedic surgical practice, we found opportunities for improvement but we also found that excellent informed decision-making is feasible and can be accomplished in a time-efficient manner.
知情决策在多种医疗环境中得到广泛推广，但对于骨科手术中的实际操作了解甚少，且对于如何在该环境中改进这一过程也没有明确的指导方针。本研究旨在探讨骨科实践中知情决策的质量，并识别针对老年患者的高效优质范例。
我们在中西部一个大都市地区招募了骨科医生和60岁及以上的患者，通过分析医患访谈录音进行描述性研究。我们使用一种有效且可靠的方法来评估知情决策的要素。这些要素包括对决策性质、患者角色、替代方案、利弊和不确定性的讨论；对患者理解程度以及其接受他人意见意愿的评估；以及对患者偏好及其对患者日常生活影响的探索。根据是否对每个知情决策要素进行了完整讨论（IDM - 18评分为2）或部分讨论（IDM - 18评分为1），以及一个更实用的指标（IDM - Min评分）对录音进行评分，该指标反映是否讨论了患者的角色或偏好以及决策的性质。研究了就诊时间与知情决策程度的关系，并寻找高效优质的范例。
共有141次关于手术的知情决策讨论，包括膝关节和髋关节置换以及手腕/手部、肩部和关节镜手术。外科医生经常讨论决策的性质（92%的时间）、替代方案（62%）和风险与益处（59%）；他们很少讨论患者的角色（14%）或评估患者的理解程度（12%）。141次讨论的IDM - 18评分平均为5.9（范围为0至15；95%置信区间为5.4至6.5）。57%的讨论符合IDM - Min标准。就诊的中位时间为16分钟；知情决策的程度与就诊时间仅有适度的关系。确定的高效策略包括使用情景来说明不同的选择、鼓励患者发表意见以及关注主要问题而非冗长地列举利弊。
在我们认为是首个关注骨科手术实践中知情决策的研究中，我们发现了改进的机会，但也发现优质的知情决策是可行的，并且可以高效完成。
