Department of Public Health, University of Oxford, UK.
J Health Serv Res Policy. 2013 Jul;18(3):160-6. doi: 10.1177/1355819613480142. Epub 2013 Jun 18.
To examine the challenges to using systematic review evidence to develop guidance for decommissioning ineffective health services, and the problems experienced by clinicians and commissioners when they attempt to implement the evidence from this guidance.
Interviews with 23 clinicians and 15 commissioners from nine commissioning organizations (Primary Care Trusts) in the south of England.
Participants identified generic and intervention-specific barriers to using systematic review evidence to develop and implement decommissioning. Generic barriers included: contradictions within the health care system arising from policy; managing a high volume of evidence; difficulty in applying the evidence to the local context; and patient or parent expectations. Intervention-specific factors included: the influence of industry; an absence of systems for monitoring local implementation of guidance; and the availability of different codes for the same procedure which made monitoring some practices unreliable.
The micro practices of commissioners are shaped by the wider system of health policy, the knowledge producing and delivery agencies associated with health care, and power dynamics within the health care system. If decommissioning is to be guided by evidence, then adequate resources to support the process are necessary. This includes long-term engagement of clinicians, providing alternatives to the decommissioned activity and tackling perverse incentives. An important precursor to decommissioning is obtaining data on the nature and extent of current clinical practice and using these data to monitor variation in the implementation of guidance.
探讨在淘汰无效卫生服务的指南制定过程中应用系统评价证据所面临的挑战，以及临床医生和决策者在尝试应用该指南证据时所遇到的问题。
对来自英格兰南部 9 家委托组织（初级保健信托）的 23 名临床医生和 15 名决策者进行了访谈。
参与者确定了在使用系统评价证据制定和实施淘汰时存在的一般障碍和干预措施特定障碍。一般障碍包括：政策导致医疗体系内部的矛盾；管理大量证据；将证据应用于当地情况的困难；以及患者或家长的期望。干预措施特定因素包括：行业的影响；缺乏监测指南在当地实施情况的系统；以及同一程序存在不同的代码，使得对某些实践的监测不可靠。
决策者的微观实践受到卫生政策的广泛体系、与医疗保健相关的知识产生和提供机构以及医疗体系内部的权力动态的影响。如果要根据证据来指导淘汰，那么就需要有足够的资源来支持这一过程。这包括临床医生的长期参与，为被淘汰的活动提供替代方案，并解决不当激励问题。淘汰之前的一个重要前提是获取有关当前临床实践性质和范围的数据，并利用这些数据监测指南实施情况的变化。
