影响临床预防指南变更采纳的因素。
Factors Influencing Uptake of Changes to Clinical Preventive Guidelines.
机构信息
From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (VJ, EMB, AHK); Department of Family Medicine, Oregon Health Sciences University, Portland, OR (JH); Oregon Community Health Information Network (OCHIN), Portland OR (JH).
出版信息
J Am Board Fam Med. 2020 Mar-Apr;33(2):271-278. doi: 10.3122/jabfm.2020.02.190146.
BACKGROUND
Despite widespread recognition that adherence to clinical preventive guidelines improves patient outcomes, clinicians struggle to implement guideline changes in a timely manner. Multiple factors influence guideline adoption and effective implementation. However, few studies evaluate their collective and inter-related effects. This qualitative study provides a comprehensive picture of the interplay between multiple factors on uptake of new or changed preventive guidelines.
METHODS
Semistructured interviews conducted in 2018 with a diverse sample of clinicians and practice leaders sought to understand patient, clinician, practice, health system, environment, and guideline factors of influence. An immersion-crystallization approach was used to identify emergent themes.
RESULTS
Interviewees expressed motivation to adhere to guidelines but also valued sharing decisions with patients. Personal biases and fears affected both clinician and patient guideline adoption. Practices facilitated implementation through workflow optimization and encouraging a culture of evidence-based practice while a key health system function was to maintain electronic health record alerts. More traditional environmental factors, such as insurance coverage or transportation, were less of a barrier to guideline adoption and implementation than the influence of media and specialists. Various specific guideline characteristics also affected ease of adoption and implementation. Different settings expressed greater health system, practice, or clinician-centric approaches to guideline implementation.
CONCLUSIONS
Guideline uptake is influenced by a complex interplay of multiple levels of factors including the patient, clinician, practice, health system, environment, and guideline levels. Comprehensively understanding all levels of influence for each specific clinical setting may help to determine the optimal intervention(s) for improving uptake of evidence-based guidelines.
背景
尽管普遍认识到遵循临床预防指南可以改善患者的治疗效果，但临床医生仍难以及时实施指南的改变。多种因素影响指南的采用和有效实施。然而，很少有研究评估它们的综合和相互关联的影响。这项定性研究全面描绘了在采用新的或改变的预防指南时，多种因素之间的相互作用。
方法
2018 年对来自不同临床医生和实践领导的多样化样本进行了半结构式访谈，旨在了解患者、临床医生、实践、卫生系统、环境和指南影响因素。采用沉浸-结晶方法识别出出现的主题。
结果
受访者表示愿意遵守指南，但也重视与患者共同决策。个人偏见和恐惧会影响临床医生和患者对指南的采用。实践通过优化工作流程和鼓励基于证据的实践文化来促进实施，而卫生系统的一个关键功能是维护电子健康记录提醒。更传统的环境因素，如保险覆盖范围或交通，对指南的采用和实施的阻碍程度不如媒体和专家的影响大。各种具体的指南特征也影响了采用和实施的难易程度。不同的环境表达了对指南实施更具卫生系统、实践或临床医生为中心的方法。
结论
指南的采用受到多种因素的复杂相互作用的影响，包括患者、临床医生、实践、卫生系统、环境和指南层面。全面了解每个特定临床环境的所有影响因素，可能有助于确定改善基于证据的指南采用的最佳干预措施。
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