当指南不具有指导作用时：基于临床实践指南的管理决策中患者背景的影响。
When guidelines don't guide: the effect of patient context on management decisions based on clinical practice guidelines.
机构信息
Dr. Mercuri is a postdoctoral research fellow, Department of Medicine, Division of Cardiology, Columbia University, New York, New York. Dr. Sherbino is emergency medicine physician and associate professor, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. Dr. Sedran is emergency medicine physician and associate professor, Department of Medicine, Division of Emergency Medicine, Western University, London, Ontario, Canada. Dr. Frank is associate director, Office of Education, Royal College of Physicians and Surgeons of Canada, and director of education and associate professor, Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada. Dr. Gafni is professor, Department of Clinical Epidemiology and Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada. Dr. Norman is professor, Department of Clinical Epidemiology and Biostatistics, Program for Educational Research and Development, McMaster University, Hamilton, Ontario, Canada.
出版信息
Acad Med. 2015 Feb;90(2):191-6. doi: 10.1097/ACM.0000000000000542.
PURPOSE
This study examines the influence of patient social context on physicians' adherence to clinical practice guidelines (CPGs).
METHOD
Expert emergency medicine (EM) physicians and novice physicians (EM residents) were surveyed using an Internet-based program between January and July of 2013. Participants were presented clinical cases and were asked to indicate if they would order or prescribe a specified test or treatment. Cases were chosen from four domains where CPGs exist, and were constructed to include or exclude a "context variable" (CV). Both expert and novice physicians' CPG adherence rate in the CV condition was compared with that in the no CV condition. The CPG adherence rates in CV and no CV conditions were also compared between expert and novice EM physicians.
RESULTS
Expert EM physicians (n = 28) were less likely to adhere to CPGs in the CV condition compared with the no CV condition (56% versus 80%, respectively; odds ratio [OR] = 0.32, 95% confidence interval [CI]: 0.17-0.53, P < .001). Experts were less likely to adhere to CPGs in the CV condition when compared with novice physicians (n = 28) (56% versus 67%; OR = 0.62, 95% CI: 0.39-1.0, P = .039). Expert and novice EM physicians did not differ in their adherence to CPGs in the no CV condition.
CONCLUSIONS
Participants were sensitive to both the best clinical evidence of benefit, as recommended by CPGs, and patient context when determining how care should be managed.
目的
本研究考察了患者社会背景对医生遵循临床实践指南（CPG）的影响。
方法
2013 年 1 月至 7 月，通过互联网程序对专家急诊医学（EM）医生和新手医生（EM 住院医师）进行了调查。参与者被提供临床病例，并被要求表示是否会开或开特定的检查或治疗。病例选自存在 CPG 的四个领域，并构建为包含或排除“背景变量”（CV）。比较专家和新手 EM 医生在 CV 条件和无 CV 条件下的 CPG 依从率。还比较了 CV 和无 CV 条件下专家和新手 EM 医生的 CPG 依从率。
结果
与无 CV 条件相比，专家 EM 医生（n=28）在 CV 条件下更不可能遵循 CPG（分别为 56%和 80%；优势比[OR]=0.32，95%置信区间[CI]：0.17-0.53，P<0.001）。与新手医生（n=28）相比，专家在 CV 条件下更不可能遵循 CPG（56%比 67%；OR=0.62，95%CI：0.39-1.0，P=0.039）。专家和新手 EM 医生在无 CV 条件下对 CPG 的依从性没有差异。
结论
参与者在确定应如何管理护理时，对 CPG 推荐的最佳临床获益证据和患者背景都很敏感。
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