Health Services Research & Development, VA Puget Sound Health Care System, Seattle, WA, USA.
Department of Medicine, University of Washington School of Medicine, Seattle, USA.
J Gen Intern Med. 2022 Dec;37(16):4189-4196. doi: 10.1007/s11606-022-07533-1. Epub 2022 May 23.
Patient-centered care reflecting patient preferences and needs is integral to high-quality care. Individualized care is important for psychosocially complex or high-risk patients with multiple chronic conditions (i.e., multimorbidity), given greater potential risks of interventions and reduced benefits. These patients are increasingly prevalent in primary care. Few studies have examined provision of patient-centered care from the clinician perspective, particularly from primary care physicians serving in integrated, patient-centered medical home settings within the US Veterans Health Administration.
We sought to clarify facilitators and barriers perceived by primary care physicians in the Veterans Health Administration to delivering patient-centered care for high-risk or complex patients with multimorbidity.
We conducted semi-structured telephone interviews from April to July 2020 among physicians across 20 clinical sites. Findings were analyzed with deductive content analysis based on conceptual models of patient-centeredness and hierarchical factors affecting care delivery.
Of 23 physicians interviewed, most were female (n = 14/23, 61%), serving in hospital-affiliated outpatient clinics (n = 14/23, 61%). Participants had a mean of 21 (SD = 11.3) years of experience.
Facilitators included the following: effective physician-patient communication to individualize care, prioritize among multiple needs, and elicit goals to improve patient engagement; access to care, enabled by interdisciplinary teams, and dictating personalized care planning; effortful but worthwhile care coordination and continuity; meeting complex needs through effective teamwork; and integrating medical and non-medical care aspects in recognition of patients' psychosocial contexts. Barriers included the following: intra- and interpersonal (e.g., perceived patient reluctance to engage in care); organizational (e.g., limited encounter time); and community or policy impediments (e.g., state decisional capacity laws) to patient-centered care.
Physicians perceived individual physician-patient interactions were the greatest facilitators or barriers to patient-centered care. Efforts to increase primary care patient-centeredness for complex or high-risk patients with multimorbidity could focus on targeting physician-patient communication and reducing interpersonal conflict.
以患者为中心的医疗服务体现了患者的偏好和需求，是高质量医疗服务的重要组成部分。对于患有多种慢性疾病（即多病共存）的心理社会复杂或高风险患者，由于干预的潜在风险更大，获益减少，个体化医疗服务更为重要。这些患者在初级保健中越来越普遍。很少有研究从临床医生的角度探讨以患者为中心的医疗服务的提供情况，特别是在美国退伍军人健康管理局（Veterans Health Administration，VHA）的综合以患者为中心的医疗之家环境中为多病共存的高风险或复杂患者提供服务的情况。
我们旨在明确退伍军人健康管理局的初级保健医生在为多病共存的高风险或复杂患者提供以患者为中心的医疗服务时所感知到的促进因素和障碍。
我们于 2020 年 4 月至 7 月在 20 个临床地点对医生进行了半结构化电话访谈。根据以患者为中心的概念模型和影响医疗服务提供的分层因素，对调查结果进行了演绎内容分析。
在接受采访的 23 名医生中，大多数是女性（n=14/23，61%），在医院附属门诊工作（n=14/23，61%）。参与者的平均从业年限为 21 年（SD=11.3 年）。
促进因素包括以下方面：有效的医患沟通以实现个体化医疗服务、优先考虑多种需求以及引出目标以提高患者的参与度；通过跨学科团队获得医疗服务，并决定个性化的医疗服务计划；虽然困难但有价值的医疗协调和连续性；通过有效的团队合作满足复杂需求；以及将医疗和非医疗服务方面结合起来，以认识到患者的心理社会背景。障碍包括以下方面：医患之间（例如，患者不愿意参与医疗服务）、医际之间（例如，患者不愿意参与医疗服务）的障碍；组织方面（例如，就诊时间有限）；以及社区或政策方面（例如，州决策能力法）的障碍，这些障碍都对以患者为中心的医疗服务造成了阻碍。
医生认为医患之间的互动是实现以患者为中心的医疗服务的最大促进因素或障碍。为了提高复杂或高风险的多病共存患者的初级保健以患者为中心程度，可以集中精力改善医患沟通和减少人际冲突。
