冠心病诊疗中患者决策辅助工具干预效果的系统评价

doi:10.12114/j.issn.1007-9572.2021.01.042

摘要/Abstract

摘要： 背景患者决策辅助工具（DA）被认为是实现医患共同决策的重要工具，然而在冠心病的诊断和治疗中其干预效果并不明朗。目的评价DA在冠心病诊疗中的应用效果。方法计算机检索PubMed、Web of Science、EMBase、The Cochrane Library数据库，采用主题词和自由词构造检索式，检索自建库至2021年3月发表的使用DA对冠心病患者进行干预的研究文献。依据Cochrane偏倚风险评估工具（RoB2版）进行文献质量评价，提取数据，总结DA的干预效果。结果共纳入文献6篇，文献质量总体中等。4篇文献为近5年研究；5项研究主要来自美国；3项研究为冠心病的治疗方式，3项研究为疑似冠心病的胸痛诊断筛查。结果显示：（1）在6项研究中，2项改变了患者的决策行为，6项提高了患者知识水平，3项降低了患者的决策冲突，2项提高了患者的决策参与程度；（2）DA多以网页版的形式为主，内容包括冠心病相关的信息支持、澄清方案利弊、患者价值判断。结论在冠心病诊疗中，DA的干预效果具有一定局限性，但其在临床仍具有广阔的应用前景。未来应该加强对临床医生的培训，设计出符合患者特征和中国文化背景的决策辅助工具，以促进其临床应用。

关键词: 冠心病, 心血管疾病, 医患共同决策, 共同决策, 决策支持技术, 患者决策辅助工具, 系统综述

Abstract: Background

Patient decision aid is recognized as an essential tool for shared-decision making. However, it is not clear that its role in shared-decision making in the diagnosis and treatment of coronary artery disease (CAD) .

Objective

To assess the effect of patient decision aids in the diagnosis and treatment of CAD using a systematic review.

Methods

Databases of PubMed, Web of Science, EMBase and The Cochrane Library were searched from inception to March 2021 for randomized trials assessing the effect of patient decision aids used in the diagnosis and treatment of CAD patients using a type of searching algorithm consisting of subject headings and free words. The Cochrane risk-of-bias tool for randomized trials (RoB2) was used for assessing risk of bias. Data were extracted, and effects of patient decision aids were summarized.

Results

A total of six randomized trials were included, and their qualities were moderate on the whole. Four were published within the past five years; five were conducted in the United States; three focus on the treatment of CAD and another three are about chest pain assessment due to suspected CAD. The effects of patient decision aids were summarized as follows: (1) With the support of a patient decision aid, patients obtained changes in their decision-making behaviors (two studies) , increased CAD-related knowledge (all studies) , reduced decisional conflicts (three studies) , and higher rate of attending decision-making (two studies) . (2) Most of the patient decision aids are web-based, and their contents mainly include information related to CAD, clarifying the pros and cons of treatment schemes for CAD, and personal risk assessments.

Conclusion

The effects of patient decision aids are limited in the diagnosis and treatment of CAD, yet they have broad prospect in clinical practice. To promote their application in China, it is suggested to strengthen relevant trainings for clinicians to develop patient decision aids in line with features of Chinese culture and patients.

Key words: Coronary disease, Cardiovascular diseases, Shared decision making, Decision making, shared, Decision support techniques, Patient decision aids, Systematic review

中图分类号:

R541.4

高川,高莹,周俞余,等. 冠心病诊疗中患者决策辅助工具干预效果的系统评价[J]. 中国全科医学, 2022, 25(05): 530-534. DOI: 10.12114/j.issn.1007-9572.2021.01.042.

GAO Chuan, GAO Ying, ZHOU Yuyu, GUO Xufang, HE Zhong.

Effect of Patient Decision Aids in the Diagnosis and Treatment of Coronary Artery Disease：a Systematic Review [J]. Chinese General Practice, 2022, 25(05): 530-534.

图/表 4

参考文献 32

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作者	国家	发表年份	研究类型	决策问题	样本量（干预组/对照组）	干预措施	对照措施	随访时间	结局指标
MORGAN等^[11]	加拿大	2000年	RCT	缺血性心脏病治疗方式	187（90/97）	IHD SDP +健康教育手册	健康教育手册	6个月	临床结局、知识水平、决策行为、决策满意度
HESS等^[12]	美国	2012年	RCT	低风险胸痛检查	204（101/103）	CPC DA	常规治疗	1个月	临床结局、知识水平、决策行为、决策冲突、医患信任、决策参与程度
COYLEWRIGHT等^[13]	美国	2016年	RCT	PCI和OMT选择	124（65/59）	PCI Choice Decision Aid	常规治疗	3个月	知识水平、决策冲突、决策参与程度
HESS等^[14]	美国	2012年	多中心RCT	低风险胸痛检查	898（451/447）	CPC DA	常规治疗	1个月	临床结局、知识水平、决策行为、决策冲突、决策参与程度、医患信任
CASE等^[15]^a	美国	2019年	RCT	疑似CAD风险评估	90（50/49）	DA	常规治疗	-	知识水平、决策冲突
DOLL等^[16]^a	美国	2019年	整群RCT	冠心病治疗方式选择	203（103/100）	DA	常规治疗	1个月	知识水平、决策冲突、决策偏好、治疗偏好

作者	国家	发表年份	研究类型	决策问题	样本量（干预组/对照组）	干预措施	对照措施	随访时间	结局指标
MORGAN等^[11]	加拿大	2000年	RCT	缺血性心脏病治疗方式	187（90/97）	IHD SDP +健康教育手册	健康教育手册	6个月	临床结局、知识水平、决策行为、决策满意度
HESS等^[12]	美国	2012年	RCT	低风险胸痛检查	204（101/103）	CPC DA	常规治疗	1个月	临床结局、知识水平、决策行为、决策冲突、医患信任、决策参与程度
COYLEWRIGHT等^[13]	美国	2016年	RCT	PCI和OMT选择	124（65/59）	PCI Choice Decision Aid	常规治疗	3个月	知识水平、决策冲突、决策参与程度
HESS等^[14]	美国	2012年	多中心RCT	低风险胸痛检查	898（451/447）	CPC DA	常规治疗	1个月	临床结局、知识水平、决策行为、决策冲突、决策参与程度、医患信任
CASE等^[15]^a	美国	2019年	RCT	疑似CAD风险评估	90（50/49）	DA	常规治疗	-	知识水平、决策冲突
DOLL等^[16]^a	美国	2019年	整群RCT	冠心病治疗方式选择	203（103/100）	DA	常规治疗	1个月	知识水平、决策冲突、决策偏好、治疗偏好

作者	1	2	3	4	5	6	质量等级
MORGAN等^[11]	A	C	C	C	A	-	C
HESS等^[12]	A	A	A	A	A	-	A
COYLEWRIGHT等^[13]	A	A	A	A	A	-	A
HESS等^[14]	A	A	A	A	B	-	B
CASE等^[15]	A	C	C	A	A	-	C
DOLL等^[16]	A	A	A	A	C	A	C

作者	1	2	3	4	5	6	质量等级
MORGAN等^[11]	A	C	C	C	A	-	C
HESS等^[12]	A	A	A	A	A	-	A
COYLEWRIGHT等^[13]	A	A	A	A	A	-	A
HESS等^[14]	A	A	A	A	B	-	B
CASE等^[15]	A	C	C	A	A	-	C
DOLL等^[16]	A	A	A	A	C	A	C

作者	工具形式	工具载体	内容形式	主要内容
MORGAN等^[11]	交互式视频	光碟	视频	OMT、PCI、CABG治疗的利弊，以及个体不同治疗方式的风险估计
HESS等^[12,14]	网页	平板	文字、图片、视频	胸痛诊断和筛查项目的基本知识：包括心电图、肌钙蛋白、心脏负荷试验，45 d内ACS验前概率，后续可供选择项目
COYLEWRIGHT等^[13]	纸质手册	纸张	文字、图片	PCI和OMT的利弊和风险概率
CASE等^[15]	网页	台式机、笔记本、平板、iPad	文字、图片、视频	CAD疾病相关知识，CAD筛查诊断及治疗方式，风险利弊，个人风险评估
DOLL等^[16]	网页/纸质副本	平板/纸张	文字、图片（视频）	CAD疾病相关知识，不同的治疗方式，每种治疗方式的风险利弊