Stamm Andrew W, Banerji John S, Wolff Erika M, Slee April, Akapame Sydney, Dahl Kathryn, Massman I I I John D, Soung Michael C, Pittenger Kim R, Corman John M
Virginia Mason, Section of Urology and Renal Transplantation, Seattle, Washington, USA.
Can J Urol. 2017 Aug;24(4):8910-8917.
Shared decision making (SDM) is widely encouraged by both the American Urological Association and Choosing Wisely for prostate cancer screening. Implementation of SDM is challenging secondary to time constraints and competing patient priorities. One strategy to mitigate the difficulties in implementing SDM is to utilize a decision aid (DA). Here we evaluate whether a DA improves a patient's prostate cancer knowledge and affects prostate-specific antigen (PSA) screening rates.
Patients were randomized to usual care (UC), DA, or DA + SDM. Perception of quality of care was measured using the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Outcomes were stratified by long term provider relationship (LTPR, > 3 years) versus short term provider relationship (STPR, < 3 years). Knowledge of prostate cancer screening and the decision regarding screening were assessed. Groups were compared using ANOVA and logistic regression models.
A total of 329 patients were randomized. Patients in the DA + SDM arm were significantly more likely to report discussing the implication of screening (33% DA + SDM, 22% UC, 16% DA, p = 0.0292) and answered significantly more knowledge questions correctly compared to the UC arm (5.03 versus 4.46, p = 0.046). However, those in the DA arm were significantly less likely to report that they always felt encouraged to discuss all health concerns (72% DA, 78% DA + SDM, 87% UC, p = 0.0285). Interestingly, STPR patients in the DA arm were significantly more likely to undergo PSA-based prostate cancer screening (41%) than the UC arm (8%, p = 0.019). This effect was not observed in the LTPR group.
Providing patients a DA without a personal interaction resulted in a greater chance of undergoing PSA-based screening without improving knowledge about screening or understanding of the consequences of this decision. This effect was exacerbated by a shorter term provider relationship. With complex issues such as the decision to pursue PSA-based prostate cancer screening, tools cannot substitute for direct interaction with a trusted provider.
美国泌尿外科学会和“明智选择”组织都广泛鼓励在前列腺癌筛查中采用共同决策（SDM）。由于时间限制和患者的其他优先事项，实施共同决策具有挑战性。减轻实施共同决策困难的一种策略是使用决策辅助工具（DA）。在此，我们评估决策辅助工具是否能提高患者对前列腺癌的了解并影响前列腺特异性抗原（PSA）筛查率。
患者被随机分为常规护理（UC）组、决策辅助工具组或决策辅助工具+共同决策组。使用医疗服务提供者和系统消费者评估（CAHPS）调查来衡量对医疗质量的感知。结果按长期医患关系（LTPR，>3年）与短期医患关系（STPR，<3年）进行分层。评估前列腺癌筛查知识以及关于筛查的决策。使用方差分析和逻辑回归模型对各组进行比较。
总共329名患者被随机分组。与常规护理组相比，决策辅助工具+共同决策组的患者更有可能报告讨论了筛查的影响（决策辅助工具+共同决策组为33%，常规护理组为22%，决策辅助工具组为16%，p = 0.0292），并且正确回答的知识问题显著更多（分别为5.03和4.46，p = 0.046）。然而，决策辅助工具组的患者报告他们总是感到被鼓励讨论所有健康问题的可能性显著更低（决策辅助工具组为72%，决策辅助工具+共同决策组为78%，常规护理组为87%，p = 0.0285）。有趣的是，决策辅助工具组中的短期医患关系患者进行基于PSA的前列腺癌筛查的可能性（41%）显著高于常规护理组（8%，p = 0.019）。在长期医患关系组中未观察到这种效果。
在没有人际互动的情况下为患者提供决策辅助工具，会增加进行基于PSA筛查的可能性，但不会提高对筛查的了解或对该决策后果的理解。短期医患关系会加剧这种影响。对于像是否进行基于PSA的前列腺癌筛查这样的复杂问题，工具无法替代与可信赖的医疗服务提供者的直接互动。
