本帖最後由 yanjw2000 於 2009-10-20 16:12 編輯
作者：Nick Mulcahy
出處：WebMD醫學新聞
September 29, 2009 — 根據一項針對美國40歲以上男性進行的調查，接受攝護腺特異抗原（PSA）檢查攝護腺癌的男性，有30%他們的醫師並沒有和他們進行討論。
這篇新文獻發表於9月28日內科醫學誌（Archives of Internal Medicine），作者們寫到，這項發現是令人不安的。
在隨後的主編評論中指出，這項發現並不令人意外。
來自里奇蒙維吉尼亞自治區大學的主編Steven H. Woolf醫師與Alex Krist醫師寫到，現今的執業環境對偏好討論而非只是在PSA檢驗單上打勾的臨床醫師與病患沒有太多的激勵或是支持工具。
主編們表示，理想地，健康照護提供者與病患共同做出決定是否要進行PSA檢驗。
為了讓共同做出決定是否要進行PSA檢驗能夠在美國各地廣泛推廣，Woolf醫師與Krist醫師寫到，需要許多條件：要給付所花費的時間、侵權改革以保護告知選擇的臨床醫師、以及一連串有關攝護腺癌篩檢，來自公共衛生社群更平衡的訊息。
在這項調查中，僅有20%的回應者表示他們有與其健康照護提供者討論PSA的好處與壞處，且若是他們要進行這些檢驗，有獲得意見徵詢。主要研究作者Richard M. Hoffman醫師向Medscape腫瘤學表示，這是最低程度必須的。Hoffman醫師是新墨西哥阿布奎基墨菲VA醫學中心的一位內科醫師。
Hoffman醫師也指出，調查回應高估了罹癌與死於癌症的風險以及PSA的正確性。
【廣泛討論之外是否有替代方法】
這項研究是根據一項稱為國家醫療決策調查的全國性電話訪查，研究中包括3,010位成人，有375位在過去兩年內接受PSA檢驗或與醫師討論的男性。
Hoffman醫師與他的共同作者們寫到，在240位進行PSA檢驗的男性中，健康照護提供者的建議與資訊強烈地影響治療決策。
他們寫到，健康照護者的建議（勝算比為2.67[95%信賴區間為1.08-6.58]）是唯一與檢驗有關的討論特色。
Hoffman醫師與其共同作者們表示，值得注意的，健康照護提供者強調71.4%討論強調檢驗的好處，但是很少提到壞處（32%）。
Hofflman醫師表示，偏差與偏頗是這些PSA討論進行的兩個缺點。這些經常發生，對於初級照護提供者的需求是顯著的。
他指出，初級照護並沒有共同做出決定。時間非常有限。
有什麼替代選擇嗎？Hoffman醫師表示，有，決策輔助工具。這些是書面或視聽工具，可以協助病患面對一個以上合理的臨床處理策略。作者們表示，有趣地是，在其他研究中，這些輔助工具一致地顯示知識的增長與降低對檢驗的意願有關。
Hoffman醫師表示，他與麻州波士頓告知醫療決策非營利基金會合作，並接受部分薪資贊助。Hoffman醫師是基金會攝護腺癌篩檢與治療協助的醫療主編。
他表示，目前，華盛頓州已經資助一項使用決策輔助工具於攝護腺與大腸癌篩檢的示範計劃。
Hoffman醫師表示，我們並沒有很多工具，這些輔助工具看起來似乎是合理的。他指出，臨床工具的應用仍處於嬰兒期。
One Third of Men Undergo PSA Test Without Discussion, Survey Says
By Nick Mulcahy
Medscape Medical News
September 29, 2009 — Thirty percent of men underwent prostate-specific antigen (PSA) testing for prostate cancer without their doctor first discussing the test with them, according to data from a survey of American men 40 years and older.
The finding is "disconcerting," write the authors of a new paper on the survey published in the September 28 issue of the Archives of Internal Medicine.
The finding is not surprising, suggests an accompanying editorial.
"Today's practice environment presents few incentives or support tools for those clinicians and patients who prefer a discussion rather than simply marking a checkbox for PSA on a laboratory requisition form," write editorialists Steven H. Woolf, MD, MPH, and Alex Krist, MD, MPH, from Virginia Commonwealth University in Richmond.
Ideally, shared decision-making between a healthcare provider and patient should take place with PSA testing, the editorialists note.
For shared decision-making about PSA testing to take place broadly in the United States, write Drs. Woolf and Krist, many things would be needed: reimbursement for the time, tort reforms to protect clinicians who present informed choice, and a more balanced set of messages about prostate cancer screening from the public health community.
In the survey, only 20% of the respondents indicated that they had discussed the pros and cons of PSA testing with their healthcare provider and that they were asked if they wanted to have the test done. "This is what is needed — at a minimum," lead study author Richard M. Hoffman, MD, MPH, told Medscape Oncology. He is an internist at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico.
Dr. Hoffman also noted that the survey respondents "way overestimated" the risk of getting cancer and dying from cancer, and the accuracy of PSA.
What is the Alternative to Extensive Discussion?
The study is derived from a telephone survey of a national sample, known as the National Survey of Medical Decisions, which was conducted among 3010 adults, including 375 men who had either undergone a PSA test or discussed one with their doctor in the previous 2 years.
Recommendations and information from the healthcare provider strongly influenced testing decisions by the 240 men who went on to get the PSA test, write Dr. Hoffman and his coauthors.
A healthcare provider recommendation (odds ratio, 2.67; 95% confidence interval, 1.08?- 6.58) was the only "discussion characteristic" associated with testing, they write.
Notably, the healthcare providers "emphasized the pros of testing in 71.4% of discussions but infrequently addressed the cons (32%)" note Dr. Hoffman and his coauthors.
Inaccuracy and imbalance are 2 of the shortcomings in how these PSA discussions take place. That they sometimes take place at all — given all of the demands on primary care providers — is remarkable, suggested Dr. Hoffman.
"Shared decision-making isn't going to happen in primary care. There is no time for it," he said.
What can work instead? Decision aids, said Dr. Hoffman. They are written or audiovisual tools that help patients when "there is more than 1 reasonable strategy for clinical management." Interestingly, in other studies, the aids have "consistently shown that enhanced knowledge is associated with decreased interest in testing," note the authors.
Dr. Hoffman disclosed that he works with and receives partial salary support from the not-for-profit Foundation for Informed Medical Decision Making, in Boston, Massachusetts. Dr. Hoffman is the medical editor of the Foundation's aids for prostate cancer screening and treatment.
Currently, the state of Washington has funded a demonstration project using decision aids for prostate and colorectal cancer screenings, he noted.
As sensible as the aids seem, "there aren't many of them," Dr. Hoffman noted, saying that they are in their "infancy as a clinical tool."
Arch Intern Med. 2009;169:1557-1559, 1611-1618. |
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