循证医学进展:床旁循证决策

2011-12-10 姜林娣 中国医学论坛报

    现代医学治疗发展方向是,在为患者制定个体治疗方案的同时,融入患者的价值取向,让患者更多地参与疾病的诊治决策。   床旁决策现状   临床医生在评价治疗效果时常使用实验室检查(如血沉)、治疗有效率和不良事件发生率等指标。然而,一些指标(如关节疼痛评分)不能充分评价疗效,不能为临床医师和患者选择治疗方案提供直观建议。   床旁决策新方法   20世纪90年

    现代医学治疗发展方向是,在为患者制定个体治疗方案的同时,融入患者的价值取向,让患者更多地参与疾病的诊治决策。

  床旁决策现状

  临床医生在评价治疗效果时常使用实验室检查(如血沉)、治疗有效率和不良事件发生率等指标。然而,一些指标(如关节疼痛评分)不能充分评价疗效,不能为临床医师和患者选择治疗方案提供直观建议。

  床旁决策新方法

  20世纪90年代,有学者提出适合循证医学的评价指标“需要治疗的患者数”(NNT),在数值上为绝对危险度减少值倒数。NNT值越低,治疗益处越大。NNT易被医师和患者理解,利于循证医学在床旁开展。循证医学专家通过列线图,简化了NNT计算过程。

  科克伦(Cochrane)中心循证医学专家凯特(Cate)设计了一种形象的图式(Visual Rx图式),该图示采用3种颜色代表治疗效果:绿色面带笑容为不治疗可自行缓解的患者;黄色面带微笑为治疗后恢复正常的患者;红色面带痛苦表情为治疗后无缓解的患者。Visual Rx适于两分类资料,即用药和未用药两组,或A药与B药比较,是在假定治疗100例患者的基础上分析药物治疗作用和安全性,适于 Meta分析结果表达。在床旁让患者选择不同治疗方案时,Visual Rx利于患者比较各种方法利弊,以及患者对各种治疗的倾向和意愿,可减少医患沟通障碍(图)。

inserted image

  加拿大渥太华大学专家设计的“患者决策辅助包”将系统综述结果转化为患者易理解的语言,指导患者参与决策。 决策辅助包内容包括:① 明确患者自身需要决策的内容;② 决策的好处和坏处;③ 患者在考虑决策时哪些意见最重要;④ 在决定治疗时,患者还需要哪些帮助。决策辅助包帮助患者得到更多信息,并对自己的决策充满自信,整个诊治过程体现患者价值。

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    2011-12-12 xjy04
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