Content Coding for Contextualization of Care: Evaluating Physician Performance at Patient-Centered Decision Making
Content Coding for Contextualization of Care: Evaluating Physician Performance at Patient-Centered Decision Making
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DOI：
10.1177/0272989x13493146
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发表时间：
2014-01-01
影响因子：
3.6
通讯作者：
Weaver, Frances M.
中科院分区：
文献类型：
--
作者：
Weiner, Saul J.;Kelly, Brendan;Weaver, Frances M.
背景和目标。根据个体患者的护理调整最佳证据被称为情境化护理或以患者为中心的决策（PCDM）。 PCDM 将临床相关的患者特定情况和行为（即患者的背景）纳入制定适合具体情况的护理计划。目的是开发一种分析医患互动的方法，以确定决策是否以患者为中心。方法。患者在与医生会面时携带隐藏的录音机。审查了记录和医疗记录，以寻找线索，表明背景因素（例如无法支付药物费用或相互竞争的责任）可能会破坏原本适当的护理计划，使其无效。团队反复改进了编码过程，以在确定（a）临床医生是否探索了影响护理的潜在背景因素的线索背景危险信号，（b）是否确认了背景因素的存在，以及（c）它们是否在最终护理计划中得到解决时，实现了较高的参与者间一致性。结果。开发了一种医疗记录数据提取工具来识别背景危险信号，例如错过预约或对可治疗的慢性病失去控制，这表明背景因素可能会影响护理。用于编码临床医生是否探索背景危险信号、是否识别背景因素以及这些因素是否在护理计划中得到解决的评分者间一致性（Cohen's kappa）分别为 88%（0.76，P < 0.001）、94%（0.88，P < 0.001）和 85%（0.69，P < 0.001）。结论。可以使用检查护理计划中是否解决了必要的背景信息（如果存在）的方案，以较高的参与者间一致性来评估 PCDM。
Background 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 cluestermed contextual red flagsfor 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.