Med Decis Making - Content coding for contextualization of care: evaluating physician performance at patient-centered decision making.

Tópicos

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Resumo

CKGROUND AND OBJECTIVE: . Adapting best evidence to the care of the individual patient has been characterized as "contextualizing care" or "patient-centered decision making" (PCDM). PCDM incorporates clinically relevant, patient-specific circumstances and behaviors, that is, the patient's context, into formulating a contextually appropriate plan of care. The objective was to develop a method for analyzing physician-patient interactions to ascertain whether decision making is patient centered.METHODS: . Patients carried concealed audio recorders during encounters with their physicians. Recordings and medical records were reviewed for clues that contextual factors, such as an inability to pay for a medication or competing responsibilities, might undermine an otherwise appropriate care plan, rendering it ineffective. Iteratively, the team refined a coding process to achieve high interrater agreement in determining (a) whether the clinician explored the clues-termed "contextual red flags"-for possible underlying contextual factors affecting care, (b) whether the presence of contextual factors was confirmed and, if so, (c) whether they were addressed in the final care plan.RESULTS: . A medical record data extraction instrument was developed to identify contextual red flags such as missed appointments or loss of control of a treatable chronic condition which signal that contextual factors may be affecting care. Interrater agreement (Cohen's kappa) for coding whether the clinician explored contextual red flags, whether a contextual factor was identified, and whether the factors were addressed in the care plan was 88% (0.76, P < 0.001), 94% (0.88, P < 0.001), and 85% (0.69, P < 0.001) respectively.CONCLUSIONS: . PCDM can be assessed with high interrater agreement using a protocol that examines whether essential contextual information (when present) is addressed in the plan of care.

Resumo Limpo

ckground object adapt best evid care individu patient character contextu care patientcent decis make pcdm pcdm incorpor clinic relev patientspecif circumst behavior patient context formul contextu appropri plan care object develop method analyz physicianpati interact ascertain whether decis make patient centeredmethod patient carri conceal audio record encount physician record medic record review clue contextu factor inabl pay medic compet respons might undermin otherwis appropri care plan render ineffect iter team refin code process achiev high interrat agreement determin whether clinician explor cluesterm contextu red flagsfor possibl under contextu factor affect care b whether presenc contextu factor confirm c whether address final care planresult medic record data extract instrument develop identifi contextu red flag miss appoint loss control treatabl chronic condit signal contextu factor may affect care interrat agreement cohen kappa code whether clinician explor contextu red flag whether contextu factor identifi whether factor address care plan p p p respectivelyconclus pcdm can assess high interrat agreement use protocol examin whether essenti contextu inform present address plan care

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