O'Malley Ann S, Collins Anna, Contreary Kara, Rich Eugene C
Mathematica Policy Research, Washington, DC, USA.
MDM Policy Pract. 2016 Jul 25;1(1):2381468316660375. doi: 10.1177/2381468316660375. eCollection 2016 Jul-Dec.
Physicians vary widely in how they treat some health conditions, despite strong evidence favoring certain treatments over others. We examined physicians' perspectives on factors that support or hinder evidence-based decisions and the implications for delivery systems, payers, and policymakers. We used recommendations to create four clinical vignettes for common types of decisions. We conducted semi-structured interviews with 36 specialists to identify factors that support or hinder evidence-based decisions. We examined these factors using a conceptual framework that includes six levels: patients, physicians, practice sites, organizations, networks and hospital affiliations, and the local market. In this model, population characteristics and payer and regulatory factors interact to influence decisions. Patient openness to behavior modification and expectations, facilitated and hindered physicians in making evidence-based recommendations. Physicians' communication skills were the most commonly mentioned facilitator. Practice site, organization, and hospital system barriers included measures of emergency department throughput, the order in which test options are listed in electronic health records (EHR), lack of relevant decision support in EHRs, and payment incentives that maximize billing and encourage procedures rather than medical management or counseling patients on behavior change. Factors from different levels interacted to undermine evidence-based care. Most physicians received billing feedback, but quality metrics on evidence-based service use were nonexistent for the four decisions in this study. Additional research and quality improvement may help to modify delivery systems to overcome barriers at multiple levels. Enhancing provider communication skills, improving decision support in EHRs, modifying workflows, and refining the design and interpretation of some quality metrics would help, particularly if combined with concurrent payment reform to realign financial incentives across stakeholders.
尽管有强有力的证据表明某些治疗方法优于其他方法，但医生在治疗某些健康状况时的方式差异很大。我们研究了医生对支持或阻碍循证决策的因素的看法，以及这些因素对医疗服务提供系统、支付方和政策制定者的影响。我们利用相关建议为常见类型的决策创建了四个临床案例。我们对36位专家进行了半结构化访谈，以确定支持或阻碍循证决策的因素。我们使用一个包含六个层面的概念框架来研究这些因素：患者、医生、执业地点、组织、网络和医院附属关系以及当地市场。在这个模型中，人群特征以及支付方和监管因素相互作用以影响决策。患者对行为改变的接受程度和期望，既促进也阻碍了医生做出循证建议。医生的沟通技巧是最常被提及的促进因素。执业地点、组织和医院系统的障碍包括急诊科的工作效率指标、电子健康记录（EHR）中测试选项的列出顺序、EHR中缺乏相关决策支持，以及支付激励措施，这些措施使计费最大化并鼓励进行手术，而不是进行医疗管理或就行为改变对患者进行咨询。来自不同层面的因素相互作用，破坏了循证医疗。大多数医生收到了计费反馈，但本研究中的四项决策不存在基于循证服务使用情况的质量指标。进一步的研究和质量改进可能有助于调整医疗服务提供系统，以克服多个层面的障碍。提高医疗服务提供者的沟通技巧、改善EHR中的决策支持、修改工作流程以及完善一些质量指标的设计和解读将有所帮助，特别是如果与同步的支付改革相结合，以重新调整各利益相关方的财务激励措施。
