Department of Surgery, University of California Davis, Davis, California, USA.
Department of Health Research Methods, Evidence and Impact McMaster University, Hamilton, Ontario, Canada.
Heart. 2019 May;105(10):749-754. doi: 10.1136/heartjnl-2018-314339. Epub 2019 Jan 12.
Healthcare costs are increasing in the USA and Canada and a substantial portion of health spending is devoted to services that do not improve health outcomes. Efforts to reduce waste by adopting evidence-based clinical practice guideline recommendations have had limited success. We sought insight into improving health system efficiency through understanding cardiologists' perceptions of factors that influence clinical decision-making.
In this descriptive qualitative study, we conducted in-depth interviews with 18 American and 3 Canadian cardiologists. We used conventional content analysis including inductive and deductive approaches for data analysis and mapped findings to the ecological systems framework.
Physicians reported that major determinants of practice included interpersonal interactions with peers, patients and administrators; financial incentives and system factors. Patients' insurance status represented an important consideration for some cardiologists. Other major influences included time constraints, fear of litigation (less prominent in Canada), a sense that their obligation was never to miss any underlying pathology, and patient demands. The need to bring income into their health system influenced American cardiologists' practice; personal income implications influenced Canadian cardiologists' practice. Cardiologists reported that knowledge limitations and logistical challenges limit their ability to assist patients with cost considerations. All these considerations were more influential than guidelines; some cardiologists expressed a high level of scepticism regarding guidelines.
Clinical decision-making by cardiologists is shaped by individual, interpersonal, organisational, environmental, financial and sociopolitical influences and only to a limited extent by guideline recommendations. Successful strategies to achieve efficient, evidence-based care will require addressing socioecological influences on decision-making.
美国和加拿大的医疗保健成本不断增加，大量卫生支出用于无法改善健康结果的服务。通过采用基于证据的临床实践指南建议来减少浪费的努力收效甚微。我们试图通过了解影响临床决策的因素来提高卫生系统的效率。
在这项描述性定性研究中，我们对 18 名美国和 3 名加拿大心脏病专家进行了深入访谈。我们使用常规内容分析法，包括归纳法和演绎法进行数据分析，并将研究结果映射到生态系统框架中。
医生报告说，实践的主要决定因素包括与同行、患者和管理人员的人际互动；经济激励和系统因素。一些心脏病专家认为患者的保险状况是一个重要的考虑因素。其他主要影响因素包括时间限制、对诉讼的恐惧（在加拿大不太突出）、认为自己的义务永远不能错过任何潜在的病理，以及患者的需求。将收入纳入其卫生系统的需求影响了美国心脏病专家的实践；个人收入的影响影响了加拿大心脏病专家的实践。心脏病专家报告说，知识限制和后勤挑战限制了他们帮助患者考虑成本的能力。所有这些考虑因素都比指南更有影响力；一些心脏病专家对指南表示高度怀疑。
心脏病专家的临床决策受到个人、人际、组织、环境、财务和社会政治因素的影响，而仅受到指南建议的有限影响。要实现高效、基于证据的护理，成功的策略需要解决决策中的社会生态影响。
