| 摘要: | 背景： 醫病共享決策為臨床醫生與病人在進行醫療決策之前，提供現有的實證醫療結果證據，結合病人自身的偏好及價值，列出病人所有可考量的檢查或治療方式，以便傳達偏好進而選出最佳的決定。下背痛已成為全球最常見的健康問題之一，即便台灣目前已有推出下背痛相關之決策輔助工具，並沒有針對下背痛族群的醫病共享決策相關研究。目的：本研究透過下背痛醫病共享決策輔助工具介入，探討醫病共享決策在下背痛病人族群的決策決定因子、過程與結果之醫療照護成效。方法： 本研究為雙盲(病人與評估者盲性)隨機對照試驗，於台北某地區教學醫院門診之骨科與復健科，招募面臨治療選項之下背痛病人，採塊狀隨機分派方式將病人分為決策輔助工具介入組與控制組，評估工具為「自我效能評估量表」、「決策參與期待量表」、「正確知識檢核」、「病人版共享決策問卷」、「決策衝突量表」、「決策滿意度問卷」、「歐式失能量表」與「歐洲五維健康量表」。以單因子共變數分析(Analysis of covariance, ANCOVA)及皮爾森卡方檢定(Pearson's chi-squared test)分析醫病共享決策介入後介入組與控制組兩組間組內之成效差異。以多元迴歸分析控制干擾因子分析介入與各面向之相關性。結果：本研究於107年10月至108年5月間，共對81位(介入組41位；控制組40位)年滿20歲因下背痛而來門診求診之病人，進行下背痛決策輔助工具之醫病共享決策介入後，透過單因子共變數分析(ANCOVA)控制就診科別後，結果顯示比一般照護模式能顯著提升決策自我效能(p=0.02)、共享決策程度(p=0.03)與決策滿意度(p=0.04)，降低決策衝突(p=0.01)；多元迴歸分析控制干擾因子後，醫病共享決策介入仍能顯著提升自我效能(p=0.04)，並降低決策衝突(p=0.02)。但在決策參與期待、正確知識檢核、共享決策程度與決策滿意度，皆無顯著差異。討論：醫病共享決策介入能不僅能顯著降低決策衝突，亦能有效提升決策自我效能、共享決策程度與決策滿意度。但在治療相關知識改善方面，與醫院一般照護模式相比，並無顯著差異。預期結果與貢獻：本研究希望透過發展下背痛決策輔助工具與醫療決策溝通模式，提升下背痛病人與醫療人員間的醫病共享決策的溝通模式(包括決定因子、決策過程與決策結果)，進而提升下背痛病人之醫療照護品質。
Background: Shared decision making (SDM) provides clinicians and patients with existing medical evidence and combines the patient's own preferences and values, as well as listing all available examinations or treatments in order to communicate preferences and help them select the best decision. Low back pain has become one of the most common health problems in the world. Even though Taiwan has already introduced some decision-making aids for low back pain, there is no research on the effectiveness of SDM intervention in patients with low back pain.
Purposes: The study explored the effectiveness of SDM intervention in SDM determinants, procedure and outcomes compared to general care among patients with low back pain.
Methods: This study was a double-blind (blindness of patients and assessors) randomized controlled trials in the Department of Orthopedics and Rehabilitation of teaching hospital in Taipei. We recruited and randomly assigned patients with low back pain into SDM intervention group and control group. The primary outcome was SDM determinant which measured by the “Decision Self-Efficacy Scale”. Secondary outcomes were the “Control Preference Scale”, the “9-item Shared Decision Making Questionnaire”, the “Decisional Conflict Scale”, the “Satisfaction with Decision Instrument”, “Oswestry Disability Index” and the “EQ-5D-5L”. Analysis of covariance (ANCOVA) and Pearson's chi-squared test were used to analyze the difference in outcomes between two groups. Multiple regression analysis was used to control the confounding factors to evaluate the effectiveness of SDM intervention.
Results: From October 2018 to May 2019, a total of 81 adult outpatients with lower back pain participated our study. After SDM intervention, decision-making self-efficacy (p=0.02), the degree of shared decision-making (p=0.03), the decision-making conflict (p=0.01) and decision-making satisfaction (p=0.04), were significantly difference with the general care by ANCOVA analyses. However, there was no significant difference in decision-making role preferences and treatment-related knowledge.
Conclusions: The SDM intervention can effectively improve decision-making self-efficacy, degree of shared decision-making and decision-making satisfaction, reduce decision-making conflicts, and achieve significant differences with the general care for patients with low back pain.
Clinical Implementation: Our study provide an evidence-based SDM intervention effectively promoting the patient-physician communication in SDM determinants, process and outcome among patients with low back pain. |
