“都是为了钱？”一项定性访谈研究，考察了在美国促进或阻碍癌症护理中共同决策的组织和系统层面的特征。
"All about the money?" A qualitative interview study examining organizational- and system-level characteristics that promote or hinder shared decision-making in cancer care in the United States.
机构信息
Dartmouth College, The Dartmouth Institute for Health Policy & Clinical Practice, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH, 03756, USA.
Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, W26, 20246, Hamburg, Germany.
出版信息
Implement Sci. 2020 Sep 21;15(1):81. doi: 10.1186/s13012-020-01042-7.
BACKGROUND
Despite decades of ethical, empirical, and policy support, shared decision-making (SDM) has failed to become standard practice in US cancer care. Organizational and health system characteristics appear to contribute to the difficulties in implementing SDM in routine care. However, little is known about the relevance of the different characteristics in specific healthcare settings. The aim of the study was to explore how organizational and health system characteristics affect SDM implementation in US cancer care.
METHODS
We conducted semi-structured interviews with diverse cancer care stakeholders in the USA. Of the 36 invited, 30 (83%) participants consented to interview. We used conventional content analysis to analyze transcript content.
RESULTS
The dominant theme in the data obtained was that concerns regarding a lack of revenue generation, or indeed, the likely loss of revenue, were a major barrier preventing implementation of SDM. Many other factors were prominent as well, but the view that SDM might impair organizational or individual profit margins and reduce the income of some health professionals was widespread. On the organizational level, having leadership support for SDM and multidisciplinary teams were viewed as critical to implementation. On the health system level, views diverged on whether embedding tools into electronic health records (EHRs), making SDM a criterion for accreditation and certification, and enacting legislation could promote SDM implementation.
CONCLUSION
Cancer care in the USA has currently limited room for SDM and is prone to paying lip service to the idea. Implementation efforts in US cancer care need to go further than interventions that target only the clinician-patient level. On a policy level, SDM could be included in alternative payment models. However, its implementation would need to be thoroughly assessed in order to prevent further misdirected incentivization through box ticking.
背景
尽管几十年来在伦理、实证和政策方面得到支持，共同决策（SDM）仍未能成为美国癌症护理的标准实践。组织和卫生系统特征似乎对在常规护理中实施 SDM 造成了困难。然而，对于不同特征在特定医疗保健环境中的相关性知之甚少。本研究旨在探讨组织和卫生系统特征如何影响美国癌症护理中的 SDM 实施。
方法
我们对美国癌症护理的不同利益相关者进行了半结构化访谈。在邀请的 36 人中，有 30 人（83%）同意接受采访。我们使用常规内容分析来分析转录内容。
结果
数据中占主导地位的主题是，对缺乏创收或实际上可能损失收入的担忧是阻止实施 SDM 的主要障碍。许多其他因素也很突出，但认为 SDM 可能损害组织或个人的利润率并减少一些卫生专业人员收入的观点很普遍。在组织层面上，领导层对 SDM 和多学科团队的支持被视为实施的关键。在卫生系统层面上，对于将工具嵌入电子健康记录（EHRs）、将 SDM 作为认证和认证标准以及制定立法是否可以促进 SDM 实施存在分歧。
结论
美国的癌症护理目前对 SDM 的空间有限，并且倾向于口头上支持这一理念。美国癌症护理的实施工作需要不仅仅针对临床医生-患者层面的干预措施。在政策层面上，SDM 可以纳入替代支付模式。然而，为了防止通过勾选框进一步误导激励，其实施需要进行彻底评估。
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