Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, 750 N Lakeshore Dr. 10th Floor, Chicago, IL, 60611, USA.
Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA.
BMC Fam Pract. 2021 May 15;22(1):95. doi: 10.1186/s12875-021-01440-w.
The objective is to understand why physicians order tests or treatments in older adults contrary to published recommendations.
Participants: Physicians above the median for ≥ 1 measures of overuse representing 3 Choosing Wisely topics.
Participants evaluated decisions in a semi-structured interview regarding: 1) Screening men aged ≥ 76 with prostate specific antigen 2) Ordering urine studies in women ≥ 65 without symptoms 3) Overtreating adults aged ≥ 75 with insulin or oral hypoglycemic medications. Two investigators independently coded transcripts using qualitative analysis.
Nineteen interviews were conducted across the three topics resulting in four themes. First, physicians were aware and knowledgeable of guidelines. Second, perceived patient preference towards overuse influenced physician action even when physicians felt strongly that testing was not indicated. Third, physicians overestimated benefits of a test and underemphasized potential harms. Fourth, physicians were resistant to change when patients appeared to be doing well.
Though physicians expressed awareness to avoid overuse, deference to patient preferences and the tendency to distort the chance of benefit over harm influenced decisions to order testing. Approaches for decreasing unnecessary testing must account for perceived patient preferences, make the potential harms of overtesting salient, and address clinical inertia among patients who appear to be doing well.
本研究旨在了解为什么医生会违背已发表的建议，为老年人开出与建议不符的检查或治疗方案。
参与者：在 3 个“明智选择”主题中，至少有 1 项过度医疗指标高于中位数的医生。
参与者在半结构化访谈中评估了以下决策：1）对年龄≥76 岁的男性进行前列腺特异性抗原筛查；2）对无相关症状的年龄≥65 岁女性进行尿液检查；3）对年龄≥75 岁的成年人过度使用胰岛素或口服降糖药物。两名研究人员使用定性分析方法独立对转录本进行编码。
在三个主题中进行了 19 次访谈，得出了四个主题。首先，医生了解并熟知指南。其次，即使医生强烈认为不需要进行检查，但他们认为患者有过度医疗的偏好，这会影响医生的决策。第三，医生高估了检查的益处，而低估了潜在的危害。第四，当患者看起来病情良好时，医生会抗拒改变。
尽管医生表示希望避免过度医疗，但对患者偏好的尊重以及对获益与危害的可能性的扭曲会影响他们进行检查的决策。减少不必要检查的方法必须考虑到患者的偏好，使过度检查的潜在危害凸显，并解决那些看起来病情良好的患者的临床惰性问题。
