我国医患共同决策问题及优化路径

随着公民权利意识的增强和健康需求的提升，以患者为中心的医患共同决策模式日益受到医疗领域的关注。域外研究和实践经验表明，医患共同决策可以有效改善医患关系、缓和医患矛盾。我国医患共同决策研究起步较晚，对其进行系统研究是必须面对的课题。从医患共同决策的概念、界定入手，阅读并梳理国内外相关文献，检索英国国家医疗服务网站及国内网站，分析我国面临的问题，并介绍英国医患共同决策的实践经验，以期为我国医患共同决策的理论研究和优化路径提供有益参考。     

药物涂层支架技术临床应用中的患者参与决策研究

目的:研究药物涂层支架技术临床应用中的患者参与决策现况,分析患者在治疗决策中的参与及其对患者技术使用行为的影响,为相关理论研究和临床实践提供参考。方法:采用横断面设计和多阶段分层抽样方法,选取上海市、福建省、四川省医院心内科冠心病患者进行问卷调查。结果:冠心病患者参与决策量表总得分为32.93±8.235,聚类分析显示92位(61.33%)患者量表得分为"较高";患者量表得分对患者治疗技术选择有显著影响(P0.05),对患者决策满意度有显著影响(P0.05),患者决策满意度对患者治疗技术选择也有显著影响(P0.05),此三者间两两相关。结论:冠心病患者多偏好医患共同决策,但其参与决策的实际程度仍有待提高;患者参与决策正向影响冠心病患者决策满意度,并影响患者是否选择应用药物支架;应当鼓励医患共同决策模式,提升患者满意度并改善医患关系;建议加强技术全方位监督管理,促进药物支架技术的适宜推广。     

基于行为经济学理论的医患关系与医生决策行为研究

通过梳理医患关系与医生决策行为相关的行为经济学理论,构建医疗纠纷背景下基于损失厌恶、易得性直觉推断、框架效应等理论的医生决策行为模型。目的在于理解医生决策过程的各个环节、存在的偏好以及由于行为偏差而造成的社会福利损失;解释医疗纠纷对医生决策行为的影响;为提高医疗服务质量,避免医疗资源浪费,降低非必要卫生支出提供理论依据。     

基于医患偏好差异的治疗方案决策模型

文章针对医生、患者等对治疗方案的疗效和风险等存在不同的偏好,难以达成一致的治疗决策,提出了一种基于离散选择实验（DCE）和逼近理想解法（TOPSIS）的治疗方案选择方法。在应用离散选择实验调查患者及医生的偏好基础上,引入逼近理想解法对各种治疗方案进行定量评价。最后,以转移性肾细胞癌的靶向治疗为例说明该方法的具体应用,并比较了医生决策、患者决策、医患共同参与决策等不同决策方式下各治疗方案的评价排序,为临床决策制定提供参考意见。     

住院患者对医生的信任水平及自我效能与医疗决策行为的关系研究——以医患互动为中介

目的：通过调查杭州市住院患者参与医疗决策行为现状,分析其主要影响因素和机制,为提高杭州市住院患者参与医疗决策积极性、有效性提出建议。方法：采用分层随机抽样的方法,参考成熟量表后自行设计的调查问卷,对杭州市二、三级医院的750名住院患者进行调查;用结构方程模型分析住院患者对医生的信任水平、参与决策自我效能、医患互动与其参与医疗决策行为的作用机制。结果：不同家庭月收入、住院科室、过去一年住院次数、本次入院决策方案制定方式的患者参与医疗决策行为得分有显著性差异(均P＜0.05)。患者参与医疗决策行为与其对医生的信任水平呈负相关;与其自我效能和医患互动呈正相关(P＜0.01)。患者对医生的信任水平和自我效能直接影响患者参与医疗决策行为,直接效应值分别为-0.373、0.358(P<0.001);医患互动在对医生的信任水平、自我效能与患者参与医疗决策行为之间的关系中起较显著的中介作用,中介效应值分别为-0.089、0.328(P<0.001)。结论：医患互动的中介效应可以促进患者参与医疗决策行为的积极性和有效性,医疗卫生机构应以患者为中心,优化住院患者参与医疗决策的途径,加强对医务人员医患互动能力和意识的培训,切实提高患者参与医疗决策行为的主动性和有效性。     

医患共同决策影响因素及对患者结果的影响

文章从医患共同决策的相关研究趋势与评价工具、医患共同决策相关影响因素以及医患共同决策对患者结果的影响等方面进行了综述,以期为后期理论研究和临床实践提供参考。     

基于患者偏好的医患知识转移策略探讨

医患知识转移在医疗服务巾起到重要的作用.通过对患者的基本特征和偏好特点进行实证调查,以信息偏好、决策偏好、感知疾病严重程度和参考群体影响这4个影响因素作为标准,将被调查患者分为6类,即矛盾型、完全被动型、自我型、决策偏好型、完全平等型和积极型.并依据每种类型的偏好特点提出不同的医患知识转移策略,为医护人员进行有效的医患沟通提供参考.     

医患关系现状及医患关系紧张原因分析——以大连市为例

目的 了解当前医患关系现状并分析医患关系紧张的原因,为构建和谐医患关系提供依据.方法 在大连市随机选取8家医院,对其中890名医生及1120名患者进行问卷调查,采用卡方检验、Logistic回归分析进行数据分析.结果 被调查医生和患者中分别有85.11%和39.26%的人认为目前医患关系有点紧张或很紧张,且差异有统计学意义(P<0.05).同时医生和患者认为医患关系紧张的原因不同(P<0.05),医生认为的医患关系紧张的3个最主要原因是媒体舆论的负面报道、患者期望太高和现行医疗体制不合理;而患方则认为挂号难排队久流程繁琐、看病太贵和部分医生水平不高是引起医患关系紧张的最主要因素.结论 目前医患关系总体是紧张的,医生和患者对医患关系的评价和对造成医患关系紧张原因的认识存在差异.     

武汉地区三级甲等医院医患双方对医患关系认识的调查分析

目的：了解武汉地区三甲医院医患双方对医患关系现状的认知差异,分析医患关系的影响因素,促进和谐医患关系的建立。方法采取整群随机抽样方法,对武汉市2家三甲医院的760名医护人员和752名患者进行问卷调查。结果医患双方对医患关系现状和发展前景、医患关系双主体及医患关系的影响因素等方面均存在认知上的差异(P <0.01)。医护人员对医患关系现状及发展前景的认知较患者悲观,患者认为医方因素对医患关系影响最大,而医护人员认为社会和患方因素是影响医患关系的主要原因。结论加强医患双方的有效沟通和交流、互相理解和体谅、缩小医患双方的认知差异等是构建和谐医患关系的重要手段。     

患者对医患共享决策和医疗价值的感知分析

目的 分析上海市公立医疗机构门诊和住院患者对医患共享决策和医疗价值的感知。方法 通过对2022年和2021年上海市公立医疗机构门诊和住院患者的问卷调查，分析患者对医患共享决策和医疗价值的感知，并采用多层广义线性混合模型分析影响患者对医患共享决策和医疗价值评价的因素。结果 2022年和2021年，上海市公立医疗机构门诊患者相比于医疗服务的医疗费用合理性评分均值分别为4.79分和4.71分，住院患者对医患共享决策和医疗价值总体评分均值分别为4.46分和4.50分。但2022年81.87%和80.55%的住院患者认为自费外购药物或器械会增加医疗不便和经济负担，比2021年（74.85%和72.43%）显著增加。此外，多层广义线性混合模型分析显示，患者对医患共享决策和医疗价值的感知受患者社会人口特征、健康状况、门诊就诊时间和诊疗状况等因素影响。结论 医疗服务的提供不能忽略患者的社会属性，应更多考虑患者的期望与偏好，以体现高质量发展和价值竞争的核心。     

我国医学新技术临床应用中医患沟通与决策模式探讨

目的分析我国医学新技术临床应用中的医患沟通现况及决策模式,为相关研究和临床实践提供参考。 方法针对高通量基因测序、药物涂层支架两项具体新技术,采用横断面设计和多阶段分层抽样方法,对上海市、福建省、四川省19家医院的患者及医生进行调查。结果共调查了5城市19家医院的950位患者（心内科178位,妇产科233位,其他科室554位）和908位医生（心内科158位,妇产科177位,其他科室556位）;54.9%~63.5%患者会主动向医生表达诉求,52.8%~58.9%得到医生回应;85.3%~96.7%医生会征     

Observing decision‐making in the general practice consultation: who makes which decisions?

OBJECTIVE: To investigate opportunities for, and types of decision making in the general practice (primary care) consultation, and examine differences in skills of those doctors who are successful at meeting their patients' preferences and those who are less successful. DESIGN: Observation study of doctor-patient consultations in general practice. PARTICIPANTS: Patients attending for routine appointments in 12 general practice surgeries across Oxfordshire. METHODS: A total of 212 doctor-patient consultations were video-recorded. The patients involved completed a questionnaire to elicit their perceptions of how decisions were made. The video-taped recordings were coded with a new instrument, the Evidence Based Patient Choice Instrument (EBPCI), to classify the number and type of decision-making opportunities arising during each consultation. A total of 149 recordings were coded using the Oxbridge Rating Scale to assess the doctors' consultation styles. RESULTS: There was a range of decision-making opportunities in addition to those involving medical treatment. With the exception of 'fitness for work', decisions were generally 'doctor led'. There was only moderate agreement between patient perceptions of their level of involvement in decision making and the objective ratings using the EBPCI. There was wide variation in the ability of doctors to meet their patients' preferences for involvement. CONCLUSIONS: There are many decisions made in primary care consultations, in addition to those about medical treatments, in which patients could be involved to a greater extent than they currently are. Some doctors are significantly better than others at meeting different patients' preferences for their decision-making role. Patients' perceptions of shared decision making appears to be influenced by the doctors' general consultation skills.     

Shared decision making in breast cancer patients--qualitative study on mutual decision making in breast cancer in a university hospital

This qualitative study examines doctor-patient interactions and interviews with breast cancer patients referring to shared decision making. The interviews have been evaluated according to the method of grounded theory. Videos of doctor-patient interactions show information and discussions on therapy planning. Breast cancer is a serious, in many cases life-threatening disease. The primary therapy is characterised by confrontation with the diagnosis, fear and hope of the patients and the subsequent treatment. Central themes of the article are the context and implicit assumptions of doctors influencing the shared decision making approach.     

Variation in practice: a questionnaire survey of how congruence in attitudes between doctors and patients influences referral decisions.

BACKGROUND: There is a well-known and partly unexplained variation in referral rates among general practitioners (GPs). GPs who are positive toward shared decision making refer less to secondary care, but how congruence in attitudes between doctors and patients influences referral rates has not been investigated. In this study, the authors analyze whether congruence in attitudes between the GP and patients toward shared decision making affects the GP's referral rate. METHODS: Questionnaire survey was distributed by 56 Norwegian GPs, each to 50 consulting patients. The level of congruence in attitudes toward shared decision making of GPs and corresponding patients was measured by the Patient-Practitioner Orientation Scale. The survey also included self-reported referral rates. RESULTS: In total, 1268 patients (45%) returned the questionnaires. Respondents were eliminated if they did not fully answer the questionnaire, resulting in a working sample of 835 patients. The authors found that congruence of attitudes toward shared decision making between the GP and patients had a negative effect on referral rate. CONCLUSION: In this study, congruence of attitudes toward shared decision making between GPs and patients influences referral decisions, indicating that matching attitudes may enhance the effort to solve the medical problem within the GPs' practice (i.e., doctor-patient interaction explains some of the variation in practice). The study supports the policy argument that, if possible, health authorities should enhance the possibilities for patients to choose a GP of matching attitudes.     

医患共享决策模式构建

医患共享决策模式实践对于推进循证医学和精准医学具有重要意义。在对比分析欧美地区及我国台湾地区医患共享决策模式研究进展及应用现状基础上，以我国台湾地区医患共享决策模式为基础，建立了兼具理论性与实践性的医患共享决策模式。经应用评价，该模式具有可行性，能够促进决策，提升患者体验，缩短平均住院日。但模式还需在决策辅助工具呈现形式与管理方式、病种审议及评价指标等方面持续优化。     

医患共同决策的研究现状及展望

医患共同决策(Shared Decision Making,SDM)过程中,医生从疾病的最佳方案考虑,患者从最适合自己的诊疗方式考虑,最终制定的个性化诊疗方案能最大限度地满足患者疾病、社会心理、经济等各方面的需求,把患者作为一个整体纳入到诊疗方案当中,而不仅仅是针对疾病本身,对医务工作者除专业技术外又提出了更高的要求。对国内外的医患共同决策进行了文献检索和综述,并探讨了在我国的应用展望,拟对医患共同决策在我国落地提供借鉴和参考。     

修复性正义对我国医疗纠纷处理方式的启示

医疗纠纷发生后的患者、家属及医疗人员都可能会受到伤害,此时医患双方都需要通过修复的平台促进了解与体谅从而让伤害得以复原。修复式正义的基本目标在于平衡医患双方及社会利益,修复纠纷双方紧张的关系,努力促成多元关系社群的动态和谐。在医疗纠纷处理中运用修复式实践模式可以纠正现有处理方式在处理理念,处理效果和处理方式等多方面的局限性。修复性正义对我国医疗纠纷处理的理念及路径具有重要启示,如提供医疗事故风险救济或补偿方式,建立有利于医患沟通的对话平台推动医患共享决策模式以提升沟通品质、整体化处理医疗纠纷的思路和关怀小组积极介入协调医疗纠纷。     

What are the ingredients for a successful evidence-based patient choice consultation?: A qualitative study

The evidence-based patient choice (EBPC) approach is one of a number of newly emerging templates for medical encounters that advocate evidence-informed choice and shared decision-making. These models emphasise respect for patient preferences for involvement in health care decisions and advocate the sharing of good quality evidence-based information. In the medical consultation EBPC involves providing patients with evidence-based information in a way that facilitates their ability to make choices or decisions about their health care. Whereas the key principles of shared decision-making have been conceptualised, so far, no qualitative investigations have been undertaken to establish the key components of an EBPC consultation. Therefore, a series of semi-structured interviews were carried out with key informants to identify the elements and skills required for a successful EBPC consultation to occur. The interviews were conducted with purposively selected UK general practitioners (n=11), hospital doctors (n=10), practice nurses (n=5), academics (n=11) and lay people (n=8). Qualitative analysis of participants' responses was conducted using the constant comparative method. Six main themes emerged from the data, these were research evidence/medical information, the doctor-patient relationship, patient perspectives, decision-making processes, time issues and establishing the patient's problem. All respondents placed importance on doctors and patients being well informed and appraised of the latest available medical evidence. There was a general view that evidence-based information regarding diagnosis and treatment options should be shared with patients during a consultation. However, there were no suggestions as to how this might be achieved in practice. Participants' opinions relating to which model of decision-making should be adopted ranged from favouring an informed choice model, to the view that decision-making should be shared equally. Similarly, there was no clear view on how much guidance a doctor should offer a patient during decision-making concerning the most appropriate treatment option for that patient.     

Shared decision-making in medical practice--patient-centred communication skills

Most patients (70%) want to participate actively in important healthcare decisions, the rest (30%) prefer the doctor to make the decision for them. Shared decision-making provides more patient satisfaction, a better quality of life and contributes to a better doctor-patient relationship. Patients making their own decision generally make a well considered and medically sensible choice. In shared decision-making the doctor asks many open questions, gives and requests much information, asks if the patient wishes to participate in the decision-making and explicitly takes into account patient circumstances and preferences. Shared decision-making should remain an individual choice and should not become a new dogma.