加拿大和美国特别工作组建议不要对40-49岁的女性进行常规乳房X线照相术筛查,因为其平均患乳腺癌的风险大于益处。两者都建议根据女性对潜在筛查益处和危害的相对价值做出个性化决定。基于人群的数据显示,在调整社会人口统计学因素后,该年龄组的初级保健专业人员(PCP)乳房X线照相术率有所不同。强调需要探索PCP筛查观点,以及这如何影响临床行为。这项研究的结果将为干预措施提供信息,这些干预措施可以改善该年龄组的指南一致性乳房筛查。
对安大略省的PCP进行了定性半结构化访谈,加拿大。使用理论领域框架(TDF)进行访谈,以探索乳腺癌筛查最佳实践行为的决定因素:(1)风险评估;(2)关于益处和危害的讨论;(3)转诊筛查。
对访谈进行转录和迭代分析直至饱和。转录本通过行为和TDF域演绎编码。不符合TDF代码的数据被感应编码。研究小组反复开会,以确定影响筛查行为或成为筛查行为重要后果的潜在主题。针对进一步的数据对主题进行了测试,不确定的案件,和不同的PCP人口统计学。
18位医生接受了采访。公认的准则清晰度主题(准则一致性做法缺乏清晰度)影响了所有行为,并缓和了风险评估和讨论的发生程度。许多人不知道风险评估是如何纳入指南的,和/或没有意识到共享护理讨论是指南一致的。当PCP对危害的了解较低和/或由于先前的临床经验而感到后悔(TDF领域:情绪)时,发生了患者偏好的延迟(筛查转诊而没有对益处和危害的完整讨论)。年长的提供者描述了患者的影响影响他们的决定和在加拿大以外接受培训的医生,在资源较高的地区实习,和女医生描述说,受到有关筛查益处后果的信念的影响。
感知到的指南清晰度是医生行为的重要驱动因素。改善指南协调护理应从澄清指南本身开始。此后,有针对性的策略包括培养识别和克服情感因素的技能以及对循证筛查讨论很重要的沟通技巧.
Canadian and US Task Forces recommend against routine mammography screening for women age 40-49 at average breast cancer risk as harms outweigh benefits. Both suggest individualized decisions based on the relative value women place on potential screening benefits and harms. Population-based data reveal variation in primary care professionals (PCPs) mammography rates in this age group after adjusting for sociodemographic factors, highlighting the need to explore PCP screening perspectives and how this informs clinical behaviours. Results from this study will inform interventions that can improve guideline concordant breast screening for this age group.
Qualitative semi-structured interviews were performed with PCPs in Ontario, Canada. Interviews were structured using the theoretical domains framework (TDF) to explore determinants of breast cancer screening best-practice behaviours: (1) risk assessment; (2) discussion regarding benefits and harms; and (3) referral for screening.
Interviews were transcribed and analyzed iteratively until saturation. Transcripts were coded deductively by behaviour and TDF domain. Data that did not fit within a TDF code were coded inductively. The research team met repeatedly to identify potential themes that influenced or were important consequences of the screening behaviours. The themes were tested against further data, disconfirming cases, and different PCP demographics.
Eighteen physicians were interviewed. The theme of perceived
guideline clarity (a lack of clarity on
guideline-concordant practices) influenced all behaviours and moderated the extent to which the risk assessment and discussion occurred. Many were unaware of how risk-assessment factored into the
guidelines and/or did not perceive that a shared-care discussion was
guideline-concordant. Deferral to patient preference (screening referral without a complete discussion of benefits and harms) occurred when the PCPs had low knowledge regarding harms and/or if they experienced regret (TDF domain: emotion) resulting from prior clinical experiences. Older providers described patient\'s influence impacting their decisions and physicians trained outside Canada, practicing in higher-resourced areas, and female physicians described being influenced by beliefs about consequences of benefits of screening.
Perceived
guideline clarity is an important driver of physician behaviour. Improving
guideline concordant care should start by clarifying the
guideline itself. Thereafter, targeted strategies include building skills in identifying and overcoming emotional factors and communication skills important for evidence-based screening discussions.