某醫學中心導入醫病共享決策模式於冠狀動脈疾病之實務經驗

The practical experience of introducing shared decision making for patients with coronary artery disease in a medical center

「醫病共享決策」是醫療團隊與病人透過溝通對話，對於醫療診斷或處置的選項進行選擇的過程，強調雙方的互動以及意見投入，以達到決策之目的。醫病共享決策在國外推動多年，但近兩年才在台灣大力推廣，在原本就忙碌的醫療環境中，要推動醫病共享決策仍是相當大的挑戰，因此，測試其可行性與效用是在未來推行前的重要工作。心臟病位居台灣十大死因之第二位，其中冠狀動脈心臟病為常見原因之一，現行冠狀動脈心臟病的治療有好幾種方式。本研究之目的在於發展冠狀動脈疾病治療的決策輔助工具，並評估病人使用的經驗。這是一個橫斷性研究，在北部一醫學中心之心血管中心進行，由該中心之醫療團隊以及該院的品質管理中心共同發展一份決策輔助工具以及介紹醫病共享決策觀念之影片，邀請9位臨床醫師參與，在進行心血管疾病處置前，給予病人決策輔助工具與影片，並利用問卷調查了解其使用經驗。共有31位心血管中心病人完成問卷，研究結果顯示病人對於「輔助工具有助瞭解目前面對各種醫療選項時最在意的事」，以及「輔助工具協助做出最適合的醫療選擇」相當滿意，且輔助工具使用前後焦慮程度顯著降低(2.7±0.7vs.2.2±0.5,p=<0.001).。醫病共享決策在臺灣仍屬新觀念，本先驅研究顯示病人使用的正向經驗，且可以降低焦慮，未來應該朝向醫護團隊的經驗調查、溝通效度評估以及對預後改善成效等方向繼續研究。

Shared decision making (SDM) is the conversation between patients and the health professionals when a choice has to be made for medical diagnosis or intervention. It emphasizes the interactive process and the contribution of opinions from both patients (and/or families) and physicians to reach the final decision. SDM had been promoted in developed countries for years, but introduced into the medical society in Taiwan not until recent 2 years. It is a big challenge to adapt SDM in concerns of the busy schedules of medical practice in Taiwan. Therefore, it is important to test the feasibility and efficacy of the process before further implementation. Heart disease is the second leading cause of death in Taiwan and coronary artery disease (CAD) is one of the most frequent heart diseases. Several options are available for the treatment. The purpose of this study is to develop decision aids for CAD treatment based on the concept of SDM and to survey the patient experience. This was a cross-sectional study conducted in the Cardiovascular Center of a University hospital in Taiwan. A decision aid for CAD was developed through the cooperation among staffs from the Cardiovascular Center and Center for Quality Management. Then it was used in clinical practice and 9 physicians were invited to use the decision aid in the process of SDM when a treatment decision had to be made for CAD. Meanwhile, the patients´ experience of using the decision aid and participating in the SDM process was surveyed. Thirty-one questionnaires were completed. The patients had high rating about the decision aids and SDM process. And after using the decision aids, the anxiety of the subjects significantly decreased(2.7±0.7 vs. 2.2±0.5, p = <0.001 by paired test). SDM is a relatively new concept in Taiwan and its clinical application faces great challenge. The pilot testing showed positive patient experience with the decision aids, which also reduce the anxiety. Further evaluation on medical staffs´ experience, communication efficacy or even outcome should be evaluated.