质量与结果框架如何塑造初级保健审查咨询：一项纵向定性研究。
How QOF is shaping primary care review consultations: a longitudinal qualitative study.
机构信息
General Practice Research, Research Institute, Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG, England.
出版信息
BMC Fam Pract. 2013 Jul 21;14:103. doi: 10.1186/1471-2296-14-103.
BACKGROUND
Long-term conditions (LTCs) are increasingly important determinants of quality of life and healthcare costs in populations worldwide. The Chronic Care Model and the NHS and Social Care Long Term Conditions Model highlight the use of consultations where patients are invited to attend a consultation with a primary care clinician (practice nurse or GP) to complete a review of the management of the LTC. We report a qualitative study in which we focus on the ways in which QOF (Quality and Outcomes Framework) shapes routine review consultations, and highlight the tensions exposed between patient-centred consulting and QOF-informed LTC management.
METHODS
A longitudinal qualitative study. We audio-recorded consultations of primary care practitioners with patients with LTCs. We then interviewed both patients and practitioners using tape-assisted recall. Patient participants were followed for three months during which the research team made weekly contact and invited them to complete weekly logs about their health service use. A second interview at three months was conducted with patients. Analysis of the data sets used an integrative framework approach.
RESULTS
Practitioners view consultations as a means of 'surveillance' of patients. Patients present themselves, often passively, to the practitioner for scrutiny, but leave the consultation with unmet biomedical, informational and emotional needs. Patients perceived review consultations as insignificant and irrelevant to the daily management of their LTC and future healthcare needs. Two deviant cases, where the requirements of the 'review' were subsumed to meet the patient's needs, focused on cancer and bereavement.
CONCLUSIONS
Routine review consultations in primary care focus on the biomedical agenda set by QOF where the practitioner is the expert, and the patient agenda unheard. Review consultations shape patients' expectations of future care and socialize patients into becoming passive subjects of 'surveillance'. Patient needs outside the narrow protocol of the review are made invisible by the process of review except in extreme cases such as anticipating death and bereavement. We suggest how these constraints might be overcome.
背景
长期病症（LTCs）是全世界人口生活质量和医疗保健成本的重要决定因素。慢性病护理模式和英国国民保健制度及社会保健长期病症模式强调使用会诊，邀请患者与初级保健临床医生（执业护士或全科医生）一起参加会诊，以完成对长期病症管理的审查。我们报告了一项定性研究，该研究重点关注质量和结果框架（QOF）塑造常规审查咨询的方式，并强调在以患者为中心的咨询和 QOF 知情的长期病症管理之间暴露的紧张关系。
方法
一项纵向定性研究。我们对患有长期病症的初级保健从业者的咨询进行了音频记录。然后，我们使用录音辅助回忆对患者和从业者进行了访谈。患者参与者在三个月的随访期间每周与研究团队联系，并邀请他们每周记录自己的卫生服务使用情况。在三个月时对患者进行了第二次访谈。使用综合框架方法分析数据集。
结果
从业者将咨询视为对患者进行“监视”的一种手段。患者通常被动地向从业者展示自己，但在离开咨询时，他们的生物医学、信息和情感需求未得到满足。患者认为审查咨询不重要，与他们日常管理长期病症和未来医疗保健需求无关。两个异常案例（癌症和丧亲之痛）中，审查的要求被归入以满足患者的需求，重点关注癌症和丧亲之痛。
结论
初级保健中的常规审查咨询侧重于 QOF 设定的生物医学议程，其中从业者是专家，而患者的议程未被听到。审查咨询塑造了患者对未来护理的期望，并将患者社会化成为被动的“监视”对象。审查过程中除了在预期死亡和丧亲等极端情况下，患者的审查范围之外的需求变得不可见。我们提出了如何克服这些限制的建议。
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