Chimonas Susan C, Diaz-MacInnis Katherine L, Lipitz-Snyderman Allison N, Barrow Brooke E, Korenstein Deborah R
Center for Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY.
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
Mayo Clin Proc Innov Qual Outcomes. 2020 Jun 5;4(3):266-275. doi: 10.1016/j.mayocpiqo.2020.01.007. eCollection 2020 Jun.
To explore how best to deimplement nonrecommended medical services, which can result in excess costs and patient harm.
We conducted telephone interviews with 15 providers at 3 health systems from June 19 to November 21, 2017. Using the case of nonrecommended imaging in patients with cancer, participants assessed the potential for 7 rationales or "arguments," each characterizing overuse in terms of a single problem type (cost or quality) and affected stakeholder group (clinicians, institutions, society, or patients), to convince colleagues to change their practices. We tested rationales for all problem-stakeholder combinations appearing in prior deimplementation studies.
Participants' views varied widely. Relatively few found cost arguments powerful, except for patients' out-of-pocket costs. Participants were divided on institution-quality and clinician-quality rationales. Patient-quality rationales resonated strongly with nearly all participants. However, a "yes, but" phenomenon emerged: after initially expressing strong support for a rationale, participants often undercut it with denials or rationalizations.
Deimplementation efforts should combine multiple rationales appealing to clinicians' diverse perspectives and priorities. In addition, efforts must consider the complex cognitive dynamics that can undercut data and reasoned argumentation.
探讨如何以最佳方式停止实施不被推荐的医疗服务，这类服务可能导致成本过高和对患者造成伤害。
2017年6月19日至11月21日，我们对3个医疗系统的15名医疗服务提供者进行了电话访谈。以癌症患者不被推荐的影像学检查为例，参与者评估了7种基本原理或“论据”的说服力，每种原理或论据均从单一问题类型（成本或质量）和受影响的利益相关者群体（临床医生、机构、社会或患者）的角度来描述医疗服务过度使用的情况，以说服同事改变他们的做法。我们对先前停止实施研究中出现的所有问题 - 利益相关者组合的基本原理进行了测试。
参与者的观点差异很大。除了患者自付费用外，相对较少有人认为成本论据有说服力。参与者对机构质量和临床医生质量的基本原理存在分歧。患者质量的基本原理几乎得到了所有参与者的强烈共鸣。然而，出现了一种“是的，但是”现象：在最初对某个基本原理表示强烈支持后，参与者往往会用否定或辩解来削弱它。
停止实施的工作应结合多种基本原理，以吸引临床医生的不同观点和优先事项。此外，工作必须考虑到可能削弱数据和合理论证的复杂认知动态。
