醫病共享決策於Guillain-Barre’氏症候群病人

Shared Decision Making for Patients with Guillain-Barre' Syndrome

Guillain-Barre'氏症候群（Guillain-Barre’s syndrome, GBS）在急性期的病程發展快速，醫療人員須盡早與病人討論，從血漿置換術及靜脈注射免疫球蛋白二種治療方式中作選擇，以減緩疾病惡化及提升病人的預後。本文旨在運用實證實務與醫病共享決策，以解決GBS病人治療選擇問題。以實證實務步驟，先形成臨床問題（PICO,即patient, intervention, comparison, and outcome）問題後，再進行文獻搜尋與評讀，評讀結果顯示，血漿置換術與靜脈注射免疫球蛋白二種治療方式，對於GBS失能程度和不良事件發生率無顯著性差異，因此在實證運用階段採用醫病共享決策，依據文獻結果製作決策輔助工具，並於2020年6月至12月，在北部某醫學中心神經內科病房，進行實證實務運用，並針對失能程度、不良事件、病人舒適度、住院天數及醫療花費進行成效評量。結果共有42位GBS病人參與，其中有14位病人選擇注射人類免疫球蛋白、28位選擇血漿置換術，結果顯示選擇注射免疫球蛋白的病人，在失能程度及不良事件上，兩者無顯著差異（p>0.05），然而在舒適度、住院天數、及發生不良事件後的醫療花費成效上，注射免疫球蛋白的病人顯著優於血漿置換術者（p<0.05）。本文提出一個透過實證實務合併醫病共享決策的方式，進行臨床實務運用經驗，作為臨床實務運用參考。建議未來研究可針對GBS病人治療舒適度、不良事件醫療花費進行大樣本探討，以提供更多實證結果，供臨床實務參考。

Guillain-BarréSyndrome (GBS) manifests with a rapid progression during the acute phase, an early decision is required to be made regarding the treatments between plasma exchange (PE) and intravenous immunoglobulin (IVIG) in order for the reduction in disease exacerbation and improvement of patient prognosis. This study aims to apply evidence-based practice with shared decision-making (SDM) to address the treatment selection dilemma in GBS patients. Employing evidence-based practice process, we formulated a clinical question with PICO, followed by a comprehensive literature search and critical appraisal. After appraisal, it is revealed no statistical significance was found between PE and IVIG for the disability progression and adverse event incidence in GBS. Therefore, SDM was employed during the application phase of evidence-based practices, and a patient decision aid based on literature was developed. From June to December 2020, this study was implemented in a neurology ward of a medical center in northern Taiwan. Outcome measures were conducted with disability progression, adverse events, patient comfort level, length of hospitalization, and associated healthcare expenditures. A total of 42 GBS patients participated, with 14 with IVIG and 28 with PE. Findings revealed no significance in disability progression and adverse event between patients with the two treatments (p > 0.05). However, in terms of patient comfort levels, duration of hospitalization, and cost of adverse events patients, IVIG demonstrated a significant advantage over PE (p < 0.05). This study proposes an integration of evidence-based practices with shared decision-making for practical clinical implementation, serving as a clinical reference. It is suggested that future research endeavors should focus on comprehensive exploration of patient comfort, and healthcare expenditures in a larger GBS patient research, contributing further empirical evidence for clinical decision-making.