提供者與病患之間的溝通在全膝置換術上經常不一致


  January 15, 2009 — 一項發表在關節炎照護與研究期刊上的研究結果顯示,即使在診間溝通過後,健康照護提供者與病患之間在關於全膝置換術(TKR)之間的想法經常是不一致的。根據德州休士頓貝勒醫學院的Richard L. Street博士表示,鼓勵病患參與建立夥伴關係技巧,可以改善提供者與病患之間溝通的品質,且具有改善預後的潛質。
  
  研究者們寫到,提供者在提供臨床資訊、發現病患的看法與所關心的事情上,可以做得更廣泛且更容易理解,而這些需要更多的研究。
  
  這項研究是根據提供者與病患在診間諮詢TKR需求前與後填寫的問卷,以及提供者/病患見面時的溝通行為錄音。最後的樣本數目包括27位健康照護提供者(其中有5位醫師、17位男性住院醫師、與5位醫師助理),以及74位病患。
  
  提供者與病患之間的意見一致性,在病患是否應該接受TKR上是中等到不佳的,包括病患的骨關節炎嚴重度,以及對TKR期望的好處與風險。大約每5次訪談中有1次,提供者與病患對是否應該建議進行TKR的反應不一。提供者與病患對於TKR的好處以及讓病患接受TKR的重要性反應是更一致的。然而,提供者們評估病患骨關節炎嚴重度比病患自行認知的輕,且提供者們一般而言對於手術併發症較不擔心。
  
  提供者與病患對於手術擔憂的差異,在病患參與度較低、非裔族群、以及對他們的醫師較不信任時較為顯著。有關於可以改善提供者與病患之間的一致性方面,包括病患主動參與、建立與提供者的夥伴關係、以及病患有關於提供者告知資訊能力的認知。作者們表示,雖然提供者與研究中的病患可能已經討論到手術的過程,以及其預期帶來的好處,但他們可能沒有與病患討論太多有關TKR的需求。
  
  這項研究的限制包括,樣本數目太小與女性參與者人數較少,使得統計力量有限。有3次訪談是被排除的,因為大部分是由病患的陪伴者主導談話。研究者們表示,未來的研究應該檢驗陪伴者在訪談中所扮演的角色,因為他們經常作為病患的代理或是主張。再來,作者認為未來的研究應該區分提供者與病患之間的真正的溝通不良,以及誤解,而非意見相左。
  
  在這項研究中,病患與提供者在對於TKR的需求、風險與好處之間的看法經常不同。病患主動參與在提供者-病患之間有關手術擔憂的一致性認知是有幫助的,或許是因為提供者對於病患的想法瞭解得更多,研究者的結論是,雖然他們附帶表示需要更多的研究來告訴我們,提供者要如何更全面地提供容易理解的臨床資訊,且進一步了解病患的想法與擔憂。
  
  這項研究由健康照護研究與品質署的消除人種與種族差異行動卓越中心、以及國家少數民族健康與健康差異中心、休士頓VA健康照護研究與卓越發展中心贊助。資深作者Maria E. Suarez-Almazor醫師表示接受來自Bristol-Myers Squibb發言事務處的顧問費、演講費、以及/或是謝禮(少於1萬美金)。

Provider-Patient Communication Often Discordant Regarding Total Knee Replacement

By Alice Goodman
Medscape Medical News

January 15, 2009 — Healthcare providers and patients often have different ideas about the need for total knee replacement (TKR), even after an office consultation, according to a study in the January 15 issue of Arthritis Care and Research. Encouraging patient participation with partnership-building skills can improve the quality of provider-patient communication and has the potential to improve outcomes, according to Richard L. Street, Jr, PhD, from the Baylor College of Medicine, Houston, Texas, and colleagues.

"More research is needed on how providers can be both comprehensive and comprehensible in the provision of clinical information and in discovering the patient's beliefs and concerns," the researchers write.

The study was based on questionnaire responses from providers and patients at baseline and after an office consultation on the need for TKR, as well as on coded audiotranscripts of communication behaviors in the provider/patient encounter. The final sample consisted of responses from 27 healthcare providers (5 physicians, 17 medical residents, and 5 physician assistants) and 74 patients.

Provider-patient agreement was modest to poor on issues related to whether the patient should have TKR, including the severity of the patient's osteoarthritis and the expected benefits and risks for TKR. In about 1 of every 5 encounters, providers' and patients' responses differed on whether TKR was even recommended. Providers' and patients' responses were more concordant on the benefits of TKR and the importance of having the patient undergo TKR. However, providers generally viewed the severity of osteoarthritis as less severe than patients did, and providers generally expressed less concern about surgical complications.

Differences between provider and patient concerns about surgery were magnified when patients were less participatory, black, and expressed lower trust in their physicians. Aspects of communication that could improve provider-patient concordance include more active patient participation, provider partnership building, and patient perceptions about the provider's ability to impart information. The authors suggest that although providers and patients in this study may have discussed the nature of surgery and its expected benefits, they may not have had adequate conversations about the patient's need for TKR.

Limitations of the study include its small sample size and a low number of women participants, resulting in limited statistical power. Three consultations were excluded because the patient's companion did most of the talking. The researchers suggest that future studies should examine the role of companions in consultations, because they often serve as patients' surrogates or advocates. Also, the authors say that future research should distinguish between genuine miscommunication and misunderstanding between providers and patients as opposed to differences of opinion.

In this study, "patients and providers often differed in their beliefs about the need for, risks of, and benefits of TKR. Active patient participation contributed to greater provider-patient agreement on concerns about surgery, perhaps because the provider gained a better understanding of the patients perspective.," the investigators conclude, although they add that "[m]ore research is needed on how providers can be both comprehensive and comprehensible in the provision of clinical information and in discovering patients beliefs and concerns."

The study was supported in part by the Excellence Centers to Eliminate Ethnic and Racial Disparities initiative of the Agency for Healthcare Research and Quality and by grants from the National Center for Minority Health and Health Disparities and the Houston VA Health Services Research and Development Center of Excellence. Senior author Maria E. Suarez-Almazor, MD, has received consultancies, speaking fees, and/or honoraria (less than $10,000) from the Bristol-Myers Squibb speakers bureau.

Arthritis Care Res. 2009;61:100–107.

    
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