他汀类药物用于多病共存患者的一级预防：开处方还是不开处方？对全科医生决策过程的定性分析

Statins for primary prevention in multimorbid patients: to prescribe or not to prescribe? A qualitative analysis of general practitioners' decision-making processes.

作者信息

Onaisi Racha, Bezzazi Anaïs, Berthouin Thomas, Boulet Justine, Hasselgard-Rowe Jennifer, Maisonneuve Hubert

机构信息

Department of General Practice, University of Bordeaux, F-33000 Bordeaux, France.

University College of General Medicine, University Claude Bernard Lyon 1, Lyon, France.

出版信息

Fam Pract. 2025 Apr 12;42(3). doi: 10.1093/fampra/cmad068.

DOI:10.1093/fampra/cmad068

PMID:37463339

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC12014902/

Abstract

INTRODUCTION

A better understanding of the determinants involved in general practitioners' (GPs) decision-making processes when it comes to prescribing statins as primary prevention in patients with multimorbidity could provide insights for improving implementation of primary prevention guidelines.

METHODS

We conducted a qualitative study using a deductive framework-based and inductive analysis of GPs' semi-structured interviews verbatim, from which expertise profiles of prescribers were also drawn. The analytical framework was built from a pragmatic synthesis of the evidence-based medicine, Modelling using Typified Objects (MOT) model of clinical reasoning processes, Theoretical Domains Framework, and shared decision-making frameworks.

RESULTS

Fifteen GPs were interviewed between June 2019 and January 2020. Diabetes seemed to represent a specific motivation for deciding about statin prescription for primary prevention purposes; and in situations of multimorbidity, GPs differentiated between cardiovascular and non-cardiovascular multimorbidity. Expert prescribers seemed to have integrated the utilisation of cardiovascular risk calculation scores throughout their practice, whereas non-expert prescribers considered them difficult to interpret and preferred using more of a "rule of thumb" process. One interviewee used the risk calculation score as a support for discussing statin prescription with the patient.

CONCLUSION

Our results shed light on the reasons why statins remain under-prescribed for primary prevention and why non-diabetic multimorbid patients have even lower odds of being prescribed a statin. They call for a change in the use of risk assessment scores, by placing them as decision aids, to support and improve personalised shared decision-making discussions as an efficient approach to improve the implementation of recommendations about statins for primary prevention.

摘要

引言

在为患有多种疾病的患者开具他汀类药物进行一级预防时，更好地理解全科医生（GP）决策过程中的影响因素，可为改进一级预防指南的实施提供见解。

方法

我们进行了一项定性研究，采用基于演绎框架和归纳分析的方法，逐字记录全科医生的半结构化访谈内容，并从中得出开药者的专业特征。分析框架是基于循证医学、临床推理过程的典型对象建模（MOT）模型、理论领域框架和共同决策框架的实用综合构建而成。

结果

在2019年6月至2020年1月期间，对15名全科医生进行了访谈。糖尿病似乎是决定开具他汀类药物进行一级预防的一个特殊动机；在患有多种疾病的情况下，全科医生区分了心血管疾病合并症和非心血管疾病合并症。专家开药者似乎在整个实践中都综合运用了心血管风险计算评分，而非专家开药者认为这些评分难以解读，更喜欢采用更多的“经验法则”方法。一名受访者将风险计算评分用作与患者讨论他汀类药物处方的依据。