Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
J Gen Intern Med. 2013 Jun;28(6):838-44. doi: 10.1007/s11606-012-2321-0. Epub 2013 Jan 10.
Clinical practice guidelines aim to improve the health of patients by guiding individual care in clinical settings. Many guidelines specifically about health promotion or primary disease prevention are beginning to support informed patient choice, and suggest that clinicians and patients engage in shared discussions to determine how best to tailor guidelines to individuals. However, guidelines generally do not address how to translate evidence from the population to the individual in clinical practice, or how to engage patients in these discussions. In addition, they often fail to reconcile patients' preferences and social norms with best evidence. Shared decision making (SDM) is one solution to bridge guidelines about health promotion and disease prevention with clinical practice. SDM describes a collaborative process between patients and their clinicians to reach agreement about a health decision involving multiple medically appropriate treatment options. This paper discusses: 1) a brief overview of SDM; 2) the potential role of SDM in facilitating the implementation of prevention-focused practice guidelines for both preference-sensitive and effective care decisions; and 3) avenues for future empirical research to test how best to engage individual patients and clinicians in these complex discussions about prevention guidelines. We suggest that SDM can provide a structure for clinicians to discuss clinical practice guidelines with patients in a way that is evidence-based, patient-centered, and incorporates patients' preferences. In addition to providing a model for communicating about uncertainty at the individual level, SDM can provide a platform for engaging patients in a conversation. This process can help manage patients' and clinicians' expectations about health behaviors. SDM can be used even in situations with strong evidence for benefits at the level of the population, by helping patients and clinicians prioritize behaviors during time-pressured medical encounters. Involving patients in discussions could lead to improved health through better adherence to chosen options, reduced practice variation about preference-sensitive options, and improved care more broadly. However, more research is needed to determine the impact of this approach on outcomes such as morbidity and mortality.
临床实践指南旨在通过指导临床环境中的个体护理来改善患者的健康。许多专门针对健康促进或初级疾病预防的指南开始支持知情患者选择，并建议临床医生和患者进行共同讨论，以确定如何最好地将指南适用于个体。然而，指南通常没有解决如何将人群中的证据转化为临床实践中的个体，也没有解决如何让患者参与这些讨论。此外，它们往往无法调和患者的偏好和社会规范与最佳证据。共同决策 (SDM) 是将健康促进和疾病预防指南与临床实践联系起来的一种解决方案。SDM 描述了患者及其临床医生之间的协作过程，以就涉及多种医学上适当治疗选择的健康决策达成一致。本文讨论了：1) SDM 的简要概述；2) SDM 在促进侧重于预防的实践指南实施方面的潜在作用，包括对敏感偏好和有效护理决策；3) 未来实证研究的途径，以测试如何最好地让个体患者和临床医生参与这些关于预防指南的复杂讨论。我们认为，SDM 可以为临床医生提供一种结构，以基于证据、以患者为中心的方式与患者讨论临床实践指南，并纳入患者的偏好。除了为在个体层面上交流不确定性提供模型外，SDM 还可以为患者参与对话提供平台。这个过程可以帮助管理患者和临床医生对健康行为的期望。即使在人群层面上有强烈的获益证据的情况下，SDM 也可以通过帮助患者和临床医生在时间紧迫的医疗就诊期间确定行为优先级，为患者和临床医生提供帮助。让患者参与讨论可以通过更好地遵循所选选项来提高健康水平，减少对敏感偏好选项的实践差异，并更广泛地改善护理。然而，需要更多的研究来确定这种方法对发病率和死亡率等结果的影响。
