Schuttner Linnaea, Hockett Sherlock Stacey, Simons Carol, Ralston James D, Rosland Ann-Marie, Nelson Karin, Lee Jennifer R, Sayre George
Health Services Research & Development, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, Washington, 98108, USA.
Department of Medicine, University of Washington, Seattle, WA, USA.
BMC Prim Care. 2022 Feb 5;23(1):25. doi: 10.1186/s12875-022-01633-x.
Patients with multiple chronic conditions (multimorbidity) and additional psychosocial complexity are at higher risk of adverse outcomes. Establishing treatment or care plans for these patients must account for their disease interactions, finite self-management abilities, and even conflicting treatment recommendations from clinical practice guidelines. Despite existing insight into how primary care physicians (PCPs) approach care decisions for their patients in general, less is known about how PCPs make care planning decisions for more complex populations particularly within a medical home setting. We therefore sought to describe factors affecting physician decision-making when care planning for complex patients with multimorbidity within the team-based, patient-centered medical home setting in the integrated healthcare system of the U.S. Department of Veterans Affairs, the Veterans Health Administration (VHA).
This was a qualitative study involving semi-structured telephone interviews with PCPs working > 40% time in VHA clinics. Interviews were conducted from April to July, 2020. Content was analyzed with deductive and inductive thematic analysis.
23 physicians participated in interviews; most were MDs (n = 21) and worked in hospital-affiliated clinics (n = 14) across all regions of the VHA's national clinic network. We found internal, external, and relationship-based factors, with developed subthemes describing factors affecting decision-making for complex patients with multimorbidity. Physicians described tailoring decisions to individual patients; making decisions in keeping with an underlying internal style or habit; working towards an overarching goal for care; considering impacts from patient access and resources on care plans; deciding within boundaries provided by organizational structures; collaborating on care plans with their care team; and impacts on decisions from their own emotions and relationship with patient.
PCPs described internal, external, and relationship-based factors that affected their care planning for high-risk and complex patients with multimorbidity in the VHA. Findings offer useful strategies employed by physicians to effectively conduct care planning for complex patients in a medical home setting, such as delegation of follow-up within multidisciplinary care teams, optimizing visit time vs frequency, and deliberate investment in patient-centered relationship building to gain buy-in to care plans.
患有多种慢性病（共病）且伴有额外心理社会复杂性的患者出现不良后果的风险更高。为这些患者制定治疗或护理计划时，必须考虑到他们疾病之间的相互作用、有限的自我管理能力，甚至临床实践指南中相互冲突的治疗建议。尽管目前已经了解初级保健医生（PCP）总体上如何为患者做出护理决策，但对于初级保健医生如何为更复杂的人群制定护理计划，尤其是在医疗之家环境中，了解较少。因此，我们试图描述在美国退伍军人事务部（VHA）综合医疗系统中，基于团队、以患者为中心的医疗之家环境下，为患有共病的复杂患者进行护理计划时影响医生决策的因素。
这是一项定性研究，对在VHA诊所工作时间超过40%的初级保健医生进行半结构化电话访谈。访谈于2020年4月至7月进行。采用演绎和归纳主题分析法对内容进行分析。
23名医生参与了访谈；大多数是医学博士（n = 21），在VHA全国诊所网络的所有地区的医院附属诊所工作（n = 14）。我们发现了内部、外部和基于关系的因素，并有已形成的子主题描述了影响患有共病的复杂患者决策的因素。医生们描述了根据个体患者情况量身定制决策；按照潜在的内部风格或习惯做出决策；朝着总体护理目标努力；考虑患者就医机会和资源对护理计划的影响；在组织结构规定的范围内做出决策；与护理团队就护理计划进行协作；以及自身情绪和与患者的关系对决策的影响。
初级保健医生描述了影响他们在VHA中为患有共病的高危和复杂患者进行护理计划的内部、外部和基于关系的因素。研究结果提供了医生在医疗之家环境中为复杂患者有效进行护理计划所采用的有用策略，例如在多学科护理团队中委托进行随访、优化就诊时间与频率，以及有意识地投入以建立以患者为中心的关系，从而使患者接受护理计划。
