Department of Psychiatry II,Ulm University,Günzburg,Germany.
Institute of Epidemiology and Medical Biometry,Ulm University,Ulm,Germany.
Epidemiol Psychiatr Sci. 2016 Feb;25(1):69-79. doi: 10.1017/S204579601400078X. Epub 2015 Jan 20.
Shared decision making has been advocated as a means to improve patient-orientation and quality of health care. There is a lack of knowledge on clinical decision making and its relation to outcome in the routine treatment of people with severe mental illness. This study examined preferred and experienced clinical decision making from the perspectives of patients and staff, and how these affect treatment outcome.
"Clinical Decision Making and Outcome in Routine Care for People with Severe Mental Illness" (CEDAR; ISRCTN75841675) is a naturalistic prospective observational study with bimonthly assessments during a 12-month observation period. Between November 2009 and December 2010, adults with severe mental illness were consecutively recruited from caseloads of community mental health services at the six study sites (Ulm, Germany; London, UK; Naples, Italy; Debrecen, Hungary; Aalborg, Denmark; and Zurich, Switzerland). Clinical decision making was assessed using two instruments which both have parallel patient and staff versions: (a) The Clinical Decision Making Style Scale (CDMS) measured preferences for decision making at baseline; and (b) the Clinical Decision Making Involvement and Satisfaction Scale (CDIS) measured involvement and satisfaction with a specific decision at all time points. Primary outcome was patient-rated unmet needs measured with the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS). Mixed-effects multinomial regression was used to examine differences and course over time in involvement in and satisfaction with actual decision making. The effect of clinical decision making on the primary outcome was examined using hierarchical linear modelling controlling for covariates (study centre, patient age, duration of illness, and diagnosis). Analysis were also controlled for nesting of patients within staff.
Of 708 individuals approached, 588 adults with severe mental illness (52% female, mean age = 41.7) gave informed consent. Paired staff participants (N = 213) were 61.8% female and 46.0 years old on average. Shared decision making was preferred by patients (χ 2 = 135.08; p < 0.001) and staff (χ 2 = 368.17; p < 0.001). Decision making style of staff significantly affected unmet needs over time, with unmet needs decreasing more in patients whose clinicians preferred active to passive (-0.406 unmet needs per two months, p = 0.007) or shared (-0.303 unmet needs per two months, p = 0.015) decision making.
Decision making style of staff is a prime candidate for the development of targeted intervention. If proven effective in future trials, this would pave the ground for a shift from shared to active involvement of patients including changes to professional socialization through training in principles of active decision making.
共同决策被提倡作为改善以患者为中心和医疗保健质量的一种手段。在严重精神疾病患者的常规治疗中，临床决策及其与结果的关系方面的知识还很匮乏。本研究从患者和工作人员的角度考察了他们所偏好的和经历过的临床决策，并探讨了这些决策如何影响治疗结果。
“严重精神疾病患者常规治疗中的临床决策和结果（CEDAR；ISRCTN75841675）”是一项自然主义的前瞻性观察研究，在 12 个月的观察期内每两个月评估一次。从 2009 年 11 月至 2010 年 12 月，连续从六个研究地点（德国乌尔姆、英国伦敦、意大利那不勒斯、匈牙利德布勒森、丹麦奥尔堡和瑞士苏黎世）的社区精神卫生服务的患者中招募患有严重精神疾病的成年人。使用两种具有平行患者和工作人员版本的工具评估临床决策：（a）临床决策风格量表（CDMS），在基线时测量对决策的偏好；和（b）临床决策参与和满意度量表（CDIS），在所有时间点测量对特定决策的参与度和满意度。主要结局是患者使用 Camberwell 需求评估简表（CANSAS）评估的未满足需求。采用混合效应多项逻辑回归分析评估实际决策中的参与度和满意度的差异和随时间的变化。使用分层线性建模控制协变量（研究中心、患者年龄、疾病持续时间和诊断），检验临床决策对主要结局的影响。分析还控制了工作人员内患者的嵌套。
在接触的 708 个人中，588 名患有严重精神疾病的成年人（52%为女性，平均年龄为 41.7 岁）表示同意。配对的工作人员参与者（N=213）中，61.8%为女性，平均年龄为 46.0 岁。患者（χ2=135.08；p<0.001）和工作人员（χ2=368.17；p<0.001）都更喜欢共同决策。工作人员的决策风格显著影响了随时间的未满足需求，与偏好被动或共同决策的患者相比，其未满足需求减少得更多（每两个月增加 0.406 个未满足需求，p=0.007）或共享（每两个月增加 0.303 个未满足需求，p=0.015）。
工作人员的决策风格是有针对性干预措施的重要候选因素。如果在未来的试验中被证明有效，这将为患者从共同参与转变为积极参与铺平道路，包括通过培训积极决策原则来改变专业人员的社会化。
