| Background:Lumbar spinal stenosis(LSS)is a degenerative disease with low back pain and intermittent neurogenic claudication as its main clinical features.It is one of the major causes of low back pain with a variety of clinical presentations,which has a significant negative impact on the independence and quality of life of senior people and places a significant social and financial burden on society.Both Chinese and Western medicine have a variety of techniques to treating LSS,but most lack evidence and involve some hazards.In addition,the present guidelines only address one illness condition,and there is a dearth of practice-appropriate decision making.Shared decision making(SDM)is necessary due to the variety of LSS presentations,the complexity of geriatric comorbidities,and the risk-to-effectiveness ratio of various medications.Patients should be given standardized information about available treatments,their own values and goals should be elicited and articulated,and the program should be tailored to the patient’s symptoms and functional objectives.Patient decision aids(PtDAs)can facilitate SDM for patients and doctors.Objective:To construct a SDM-PtDAs for the treatment of lumbar spinal stenosis with conservative Chinese and Western medicine,and to explore strategies for implementing shared decision making and the set of barriers and facilitators to implement SDM for patients with lumbar spinal stenosis.Methods:①Databases were searched for the clinical practice guidelines,consensuses and specifications about DLSS,including CBM,CNKI,Wanfang Data,VIP,PubMed,Medlive,WHO,NICE,GIN,NGC and SIGN.The retrieval period was set from January 1,2010 to February 1,2023.The methodological quality and reporting quality of the included studies were evaluated by two independent valuators,and the recommendations in the articles was compared under the uniform grading criteria.②Based on a comparative analysis of the quality ratings and recommendations of LSS guidelines,the higher quality guidelines were selected as the best evidence for current LSS.Through multiple rounds of expert consensus questionnaires,expert consensus was reached on the types of interventions,patient symptom stratification criteria,stepped care criteria and intervention methods included in each step,outcome indicators and their measurement tools for patient efficacy evaluation,evaluation time,treatment combination recommendations,and treatment process to be included in the Lumbar Spinal Stenosis Patient Decision Aid,which was finally presented in the form of an open pathway algorithm for the treatment of lumbar spinal stenosis with conservative Chinese and Western medicine in a stepped care as the main content of the Lumbar Spinal Stenosis Patient Decision Aid.③A qualitative research method using semi-structured interviews was used to investigate and explore specific strategies for SDM in Lumbar Spinal Stenosis and how best to integrate them into practice and patient decision aids.Exploring the understanding,barriers and facilitators to implement shared decision making in patients with lumbar spinal stenosis The aim is to better implement,validate and promote the shared decision-making model for patients with lumbar spinal stenosis.Results:A total of 7 related articles were brought into study,including 5 guideline articles and 2 consensus articles.One of the guidelines was based on TCM,and four were evidence-based guidelines.The evaluation results of AGREE Ⅱ showed that the ratios of the actual total score to the full score of the 7 included articles was 78.2%,57.8%,53.6%,45.7%,45.3%,37.7%and 28.0%,from highest to the lowest.RIGHT evaluation showed that the ratios of the actual total score to the full score of the 5 guidelines was 72.9%,72.9%,67.1%,62.9%and 34.3%,highest to the lowest.A total of 63 therapeutic and 16 non-therapeutic recommendations were formed in the 7 articles.In Study 2,a total of 40 clinical experts were invited to conduct four rounds of questionnaires.The comparison of guideline quality ratings and recommendations in Study 1 was used as the basis,combined with the evidence on TCM for LSS compiled by the group in the early stages of the study as the best evidence for interventions.Public education,physical exercise therapy,oral herbal Medicine,external herbal medicine,acupuncture,tui na manipulation,oral NSAIDs,oral opioids,acupuncture,epidural steroid injection,nerve block therapy and acupuncture cupping were included as interventions in the clinical pathway and matched to different treatment steps.Patients were classified as asymptomatic,mild,moderate and severe according to the severity of their symptoms,and a consensus was reached on the criteria for determining.Consensus was also established through expert consensus on the set of outcome indicators for efficacy evaluation in the clinical pathway,the timing of efficacy evaluation,criteria for judging efficacy,criteria for ascending and descending the treatment step,basic operational procedures for some therapies,recommendations for combinations of interventions and instructions for the use of pain medication.Thirteen patients with lumbar spinal stenosis were interviewed in a semi-structured way,and 6 themes and 23 sub-themes were coded by Nvivo software.The analysis was based on the "three-talk" and "three-goal"composite models,combined with the characteristics of LSS,to establish a real-time strategy for shared decision making in lumbar stenosis,based on a patient-centred approach and full access to patient values and treatment intentions.Nine facilitators and six barriers were identified.Conclusion:After literature research and expert consensus,this study initially constructed a shared decision making patient decision aid with a pathway algorithm for the treatment of lumbar spinal stenosis in a stepped care using conservative Chinese and Western medicine as the mainstay.A qualitative study was conducted to determine the implementation strategy and set of barriers and facilitators to implement SDM for patients with lumbar spinal stenosis. |
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