Tong Wen Ting, Lee Yew Kong, Ng Chirk Jenn, Lee Ping Yein
Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
Department of Family Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia.
Implement Sci. 2017 Mar 21;12(1):40. doi: 10.1186/s13012-017-0569-9.
Most studies on barriers and facilitators to implementation of patient decision aids (PDAs) are conducted in the west; hence, the findings may not be transferable to developing countries. This study aims to use a locally developed insulin PDA as an exemplar to explore the barriers and facilitators to implementing PDAs in Malaysia, an upper middle-income country in Asia.
Qualitative methodology was adopted. Nine in-depth interviews (IDIs) and three focus group discussions (FGDs) were conducted with policymakers (n = 6), medical officers (n = 13), diabetes educators (n = 5) and a nurse, who were involved in insulin initiation management at an academic primary care clinic. The interviews were conducted with the aid of a semi-structured interview guide based on the Theoretical Domains Framework. The interviews were audio-recorded, transcribed verbatim and analyzed using a thematic approach.
Five themes emerged, and they were lack of shared decision-making (SDM) culture, role boundary, lack of continuity of care, impact on consultation time and reminder network. Healthcare providers' (HCPs) paternalistic attitude, patients' passivity and patient trust in physicians rendered SDM challenging which affected the implementation of the PDA. Clear role boundaries between the doctors and nurses made collaborative implementation of the PDA challenging, as nurses may not view the use of insulin PDA to be part of their job scope. The lack of continuity of care might cause difficulties for doctors to follow up on insulin PDA use with their patient. While time was the most commonly cited barrier for PDA implementation, use of the PDA might reduce consultation time. A reminder network was suggested to address the issue of forgetfulness as well as to trigger interest in using the PDA. The suggested reminders were peer reminders (i.e. HCPs reminding one another to use the PDA) and system reminders (e.g. incorporating electronic medical record prompts, displaying posters/notices, making the insulin PDA available and visible in the consultation rooms).
When implementing PDAs, it is crucial to consider the healthcare culture and system, particularly in developing countries such as Malaysia where concepts of SDM and PDAs are still novel.
大多数关于患者决策辅助工具（PDA）实施障碍与促进因素的研究在西方开展；因此，研究结果可能无法应用于发展中国家。本研究旨在以当地开发的胰岛素PDA为例，探索在亚洲中高收入国家马来西亚实施PDA的障碍与促进因素。
采用定性研究方法。对参与学术初级保健诊所胰岛素起始治疗管理的政策制定者（n = 6）、医务人员（n = 13）、糖尿病教育者（n = 5）和一名护士进行了9次深度访谈（IDI）和3次焦点小组讨论（FGD）。访谈借助基于理论领域框架的半结构化访谈指南进行。访谈进行了录音，逐字转录，并采用主题分析法进行分析。
出现了五个主题，分别是缺乏共同决策（SDM）文化、角色界限、护理连续性不足、对咨询时间的影响以及提醒网络。医疗服务提供者（HCP）家长式的态度、患者的被动性以及患者对医生的信任使得SDM具有挑战性，进而影响了PDA的实施。医生和护士之间明确的角色界限使得PDA的协作实施具有挑战性，因为护士可能不认为使用胰岛素PDA是其工作范围的一部分。护理连续性不足可能导致医生难以跟进患者使用胰岛素PDA的情况。虽然时间是PDA实施中最常被提及的障碍，但使用PDA可能会减少咨询时间。建议建立一个提醒网络来解决遗忘问题，并激发对使用PDA的兴趣。建议的提醒方式包括同行提醒（即HCP相互提醒使用PDA）和系统提醒（例如纳入电子病历提示、展示海报/通知、在咨询室提供并展示胰岛素PDA）。
在实施PDA时，考虑医疗文化和系统至关重要，特别是在马来西亚等发展中国家，SDM和PDA的概念仍然很新颖。
