Nathan Karthik, Uzosike Maechi, Sanchez Uriel, Karius Alexander, Leyden Jacinta, Segovia Nicole, Eppler Sara, Hastings Katherine G, Kamal Robin, Frick Steven
Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA.
Int J Qual Health Care. 2020 Dec 15;32(10):658-662. doi: 10.1093/intqhc/mzaa119.
Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision-making, national guidelines and clinical pathways for many conditions in pediatric orthopedic surgery are limited. This study investigated decision-making rationale and quantified the evidence supporting decisions made by pediatric orthopedic surgeons in an outpatient clinic.
DESIGN/SETTING/PARTICIPANTS/INTERVENTION(S)/MAIN OUTCOME MEASURE(S): We recorded decisions made by eight pediatric orthopedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. 'Experience/anecdote,' 'First principles,' 'Trained to do it,' 'Arbitrary/instinct,' 'General study,' 'Specific study').
Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were 'First principles' (n = 310, 27.0%) and 'Experience/anecdote' (n = 253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. As high as 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions.
With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence and help create clinical care pathways in pediatric orthopedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools and aids could also be implemented to guide these decisions.
确定基于高质量证据做出决策的时间和频率，可为循证治疗计划和护理路径的制定提供依据，而这些已被证明可提高护理质量和患者安全。指导小儿骨科手术中多种病症决策的证据、国家指南和临床路径有限。本研究调查了决策依据，并对小儿骨科门诊外科医生所做决策的支持证据进行了量化。
设计/地点/参与者/干预措施/主要结局指标：我们记录了八名小儿骨科门诊外科医生所做的决策以及医生报告的决策依据。外科医生将每个决策的依据归类为12种可能性中的一种或多种组合（例如“经验/轶事”、“第一原理”、“经培训执行”、“随意/本能”、“一般研究”、“具体研究”）。
在总共1150项决策中，最常见的决策是随访安排，其次是支具处方/拆除。最常见的决策依据是“第一原理”（n = 310，27.0%）和“经验/轶事”（n = 253，22.0%）。只有17.8%的决策归因于科学研究，其中7.3%基于针对该决策的研究。高达34.6%的手术干预决策基于科学研究，而只有10.4%的随访安排决策考虑了研究因素。决策类别与科学研究依据显著相关：手术干预和药物处方决策比所有其他决策更有可能基于科学研究。
随着对高价值、循证护理的日益重视，了解医生决策背后的依据可以对医生进行教育，识别缺乏支持证据的常见决策，并有助于创建小儿骨科手术的临床护理路径。基于证据或外科医生之间共识的决策可为路径和国家指南提供信息，从而最大限度地减少不必要的护理差异和浪费。还可以实施决策支持工具和辅助手段来指导这些决策。
