Tietbohl Caroline K, Rendle Katharine A S, Halley Meghan C, May Suepattra G, Lin Grace A, Frosch Dominick L
University of California, Los Angeles, Los Angeles, CA, USA (CKT, DLF)
Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA (CKT, KASR, MCH, SGM, DLF)
Med Decis Making. 2015 Nov;35(8):987-98. doi: 10.1177/0272989X15602886. Epub 2015 Aug 27.
The benefits of patient decision support interventions (DESIs) have been well documented. However, DESIs remain difficult to incorporate into clinical practice. Relational coordination (RC) has been shown to improve performance and quality of care in health care settings. This study aims to demonstrate how applying RC theory to DESI implementation could elucidate underlying issues limiting widespread uptake.
Five primary care clinics in Northern California participated in a DESI implementation project. We used a deductive thematic approach guided by behaviors outlined in RC theory to analyze qualitative data collected from ethnographic field notes documenting the implementation process and focus groups with health care professionals. We then systematically compared the qualitative findings with quantitative DESI distribution data.
Based on DESI distribution rates, clinics were placed into 3 performance categories: high, middle, and low. Qualitative data illustrated how each clinic's performance related to RC behaviors. Consistent with RC theory, the high-performing clinic exhibited frequent, timely, and accurate communication and positive working relationships. The 3 middle-performing clinics exhibited high-quality communication within physician-staff teams but limited communication regarding DESI implementation across the clinic. The lowest-performing clinic was characterized by contentious relationships and inadequate communication.
Limitations of the study include nonrandom selection of clinics and limited geographic diversity. In addition, ethnographic data collected documented only DESI implementation practices and not larger staff interactions contributing to RC.
These findings suggest that a high level of RC within clinical settings may be a key component and facilitator of successful DESI implementation. Future attempts to integrate DESIs into clinical practice should consider incorporating interventions designed to increase positive RC behaviors as a potential means to improve uptake.
患者决策支持干预措施（DESIs）的益处已有充分记录。然而，DESIs仍难以融入临床实践。关系协调（RC）已被证明可提高医疗环境中的绩效和护理质量。本研究旨在证明将RC理论应用于DESI实施如何能够阐明限制其广泛采用的潜在问题。
北加利福尼亚的五家初级保健诊所参与了一个DESI实施项目。我们采用了一种由RC理论中概述的行为所指导的演绎主题方法，来分析从人种志实地记录中收集的定性数据，这些记录记录了实施过程以及与医疗保健专业人员的焦点小组讨论。然后，我们系统地将定性研究结果与定量的DESI分布数据进行了比较。
根据DESI分布率，诊所被分为三个绩效类别：高、中、低。定性数据说明了每个诊所的绩效与RC行为之间的关系。与RC理论一致，高绩效诊所表现出频繁、及时和准确的沟通以及积极的工作关系。三家中等绩效诊所在内科医生-工作人员团队内部表现出高质量的沟通，但在整个诊所内关于DESI实施的沟通有限。绩效最差的诊所的特点是关系紧张和沟通不足。
该研究的局限性包括诊所的非随机选择和有限的地理多样性。此外，收集的人种志数据仅记录了DESI实施实践，而没有记录对RC有贡献的更大规模的工作人员互动。
这些发现表明，临床环境中的高水平RC可能是成功实施DESI的关键组成部分和促进因素。未来将DESIs整合到临床实践中的尝试应考虑纳入旨在增加积极RC行为的干预措施，作为提高采用率的潜在手段。
