Drewelow Eva, Santos Sara, Hornung Anne, Altiner Attila, Löffler Christin, Pentzek Michael, Wilm Stefan, Löscher Susanne, Wollny Anja
Institut für Allgemeinmedizin, Universitätsmedizin Rostock, Rostock, Deutschland.
Institut für Allgemeinmedizin (ifam), Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland.
Z Evid Fortbild Qual Gesundhwes. 2018 Nov;137-138:36-41. doi: 10.1016/j.zefq.2018.07.008. Epub 2018 Sep 1.
In the last 20 years, patient involvement in clinical decision-making has continuously gained traction in scientific and clinical (including general practice, GP) discussions. Patients with chronic conditions in particular may benefit from active involvement. Referring to existing studies on shared decision making and regional differences; patients with poorly controlled diabetes mellitus type 2 (DM2) were used as an example to investigate the perceived involvement during clinical decision making in general practice. Differences in treatment options based on the patients' place of residence (East- and West Germany) were compared.
501 West- (North-Rhine-Westphalia, NRW) and 338 East-German (Mecklenburg-Western Pomerania, MWP) patients with DM2 and HbA levels≥8.0 were assessed during the cluster-randomised controlled trial DEBATE, which was conducted between 2011 and 2012. The questionnaire to measure participatory decision making (Q-PDM) was used in order to provide an estimate of their involvement in clinical decision making processes, and baseline data was analysed before intervention. The standardised Q-PDM summed value was compared among the different subgroups (i. e., place of residence, age, sex) using bivariate group analyses (t tests), and a multivariate regression analysis was conducted.
Patients living in the MWP region perceived a higher level of involvement in GP decision making than NRW residents. Younger patients with DM2 showed higher Q-PDM summed values than older patients. When all variables, including 'GP practice' (number of patients per GP/cluster), were considered together in the multivariate regression analysis, the place of residence would no longer show an independent effect on perceived decision making. The expected difference between MWP and NRW (i. e. East/West Germany) could not be confirmed, while a significant difference remained with regard to age. Education, population density, sex and marital status did not show any relevant differences.
Patient age remains an important factor influencing the perceived involvement in joint decision making and should be taken into account while implementing clinical decision making processes in the future. It is possible that patients of different age and with different chronic diseases may need different decision support offerings (e. g., educational videos, booklets or computer-based decision aids). Trainings in communication skills or in the implementation of patient-centred communication might be effective on the GP level to reduce possible barriers to shared decision making.
在过去20年里，患者参与临床决策在科学和临床（包括全科医疗，GP）讨论中越来越受到关注。患有慢性病的患者尤其可能从积极参与中受益。参考关于共同决策和地区差异的现有研究，以2型糖尿病（DM2）控制不佳的患者为例，调查全科医疗中临床决策过程中患者的参与感。比较了基于患者居住地（德国东部和西部）的治疗方案差异。
在2011年至2012年进行的整群随机对照试验DEBATE中，对501名西德（北莱茵 - 威斯特法伦州，NRW）和338名东德（梅克伦堡 - 前波美拉尼亚州，MWP）的DM2患者且糖化血红蛋白（HbA）水平≥8.0进行了评估。使用测量参与式决策的问卷（Q - PDM）来估计他们在临床决策过程中的参与程度，并在干预前分析基线数据。使用双变量组分析（t检验）比较不同亚组（即居住地、年龄、性别）之间标准化的Q - PDM总和值，并进行多变量回归分析。
居住在MWP地区的患者认为在全科医生决策中的参与程度高于NRW居民。年轻的DM2患者的Q - PDM总和值高于老年患者。在多变量回归分析中，当将所有变量，包括“全科医疗实践”（每个全科医生/群组的患者数量）一起考虑时，居住地对感知决策不再显示独立影响。MWP和NRW（即德国东部/西部）之间预期的差异无法得到证实，而年龄方面仍存在显著差异。教育程度、人口密度、性别和婚姻状况没有显示出任何相关差异。
患者年龄仍然是影响共同决策中感知参与程度的重要因素，未来在实施临床决策过程时应予以考虑。不同年龄和患有不同慢性病的患者可能需要不同的决策支持服务（例如，教育视频、手册或基于计算机辅助决策工具）。在全科医生层面，沟通技能培训或以患者为中心的沟通实施培训可能有效地减少共同决策的潜在障碍。
