BMC Med Inform Decis Mak - Diagnosis and management of people with venous thromboembolism and advanced cancer: how do doctors decide? A qualitative study.

Tópicos

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Resumo

CKGROUND: The treatment of cancer associated thrombosis (CAT) is well established, with level 1A evidence to support the recommendation of a low molecular weight heparin (LMWH) by daily injection for 3-6 months. However, registry data suggest compliance to clinical guidelines is poor. Clinicians face particular challenges in treating CAT in advanced cancer patients due to shorter life expectancy, increased bleeding risk and concerns that self injection may be too burdensome. For these reasons decision making around the diagnosis and management of CAT in people with advanced cancer, can be complex, and should focus on its likely net benefit for the patient. We explored factors that influence doctors' decision making in this situation and sought to gain an understanding of the barriers and facilitators to the application of best practice.METHODS: Think aloud exercises using standardised case scenarios, and individual in depth interviews were conducted. All were transcribed. The think aloud exercises were analysed using Protocol Analysis and the interviews using Framework Analysis.PARTICIPANTS: 46 participants took part in the think aloud exercises and 45 participants were interviewed in depth. Each group included oncologists, palliative physicians and general practitioners and included both senior doctors and those in training.SETTING: Two Strategic Health Authority regions, one in the north of England and one in Wales.RESULTS: The following key issues arose from the data synthesis: the importance of patient prognosis; the concept of "appropriateness"; "benefits and burdens" of diagnosis and treatment; LMWH or warfarin for treatment and sources of information which changed practice. Although interlinked, they do describe distinct aspects of the factors that influence doctors in their decisions in this area.CONCLUSIONS: The above factors are issues doctors take into account when deciding whether to send a patient to hospital for investigation or to anticoagulate a patient with confirmed or suspected VTE. Many factors interweave and are themselves influenced by and dependent on each other. It is only after all are taken into account that the doctor arrives at the point of referring the patient for investigation. Some factors including logistic and organisational issues appeared to influence whether a patient would be investigated or treated with LMWH for a confirmed VTE. It is important that services are optimised to ensure that these do not hinder the appropriate investigation and management of individual patients.

Resumo Limpo

ckground treatment cancer associ thrombosi cat well establish level evid support recommend low molecular weight heparin lmwh daili inject month howev registri data suggest complianc clinic guidelin poor clinician face particular challeng treat cat advanc cancer patient due shorter life expect increas bleed risk concern self inject may burdensom reason decis make around diagnosi manag cat peopl advanc cancer can complex focus like net benefit patient explor factor influenc doctor decis make situat sought gain understand barrier facilit applic best practicemethod think aloud exercis use standardis case scenario individu depth interview conduct transcrib think aloud exercis analys use protocol analysi interview use framework analysisparticip particip took part think aloud exercis particip interview depth group includ oncologist palliat physician general practition includ senior doctor trainingset two strateg health author region one north england one walesresult follow key issu aros data synthesi import patient prognosi concept appropri benefit burden diagnosi treatment lmwh warfarin treatment sourc inform chang practic although interlink describ distinct aspect factor influenc doctor decis areaconclus factor issu doctor take account decid whether send patient hospit investig anticoagul patient confirm suspect vte mani factor interweav influenc depend taken account doctor arriv point refer patient investig factor includ logist organis issu appear influenc whether patient investig treat lmwh confirm vte import servic optimis ensur hinder appropri investig manag individu patient

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