Is the problem list in the eye of the beholder? An exploration of consistency across physicians
Is the problem list in the eye of the beholder? An exploration of consistency across physicians
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DOI：
10.1093/jamia/ocv211
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发表时间：
2016-09-01
影响因子：
6.4
通讯作者：
Friedman, Charles P.
中科院分区：
文献类型：
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作者：
Krauss, John C.;Boonstra, Philip S.;Friedman, Charles P.
目的量化患者问题单在问题的数量、类型和排序方面在多个医生之间的差异，并评估医生组织和排序诊断的标准。材料与方法在实验环境中，32名初级保健医生为3个相同的复杂内科病例生成和排序问题单，以2-4页的详细摘要表示，随后表达了他们在列表中排序项目的标准。我们研究了问题列表长度的变异性。我们修改了先前验证的基于等级的相似性度量，范围从0到1，以量化列表对之间的一致性，并计算单个共识问题列表，从而最大化与每个医生的一致性。记录医生对问题单排序的推理。结果受试者的问题单具有高度的变异性。病例A的问题列表长度中位数为8(范围3-14)，病例B为10(范围4-20)，病例C为7(范围3-13)。考虑到列表的长度、内容和顺序，病例A、B和C在所有可能的医生配对中的一致指数的中位数分别为0.479、0.371和0.509。每个病例的医生名单和共识名单之间的中位数一致性分别为0.683、0.581和0.697(分别针对病例A、B和C)。在可能的1488对配对中，有2对是完全相同的。结论问题表是医生对患者健康状况的心理模型。这些心理模型被发现在不同的医生之间有很大的不同，这引发了这样的问题：由个别医生创建的问题清单是否能够达到他们改善护理协调的预期目的。
Objective Quantify the variability of patients' problem lists - in terms of the number, type, and ordering of problems - across multiple physicians and assess physicians' criteria for organizing and ranking diagnoses.Materials and Methods In an experimental setting, 32 primary care physicians generated and ordered problem lists for three identical complex internal medicine cases expressed as detailed 2- to 4-page abstracts and subsequently expressed their criteria for ordering items in the list. We studied variability in problem list length. We modified a previously validated rank-based similarity measure, with range of zero to one, to quantify agreement between pairs of lists and calculate a single consensus problem list that maximizes agreement with each physician. Physicians' reasoning for the ordering of the problem lists was recorded.Results Subjects' problem lists were highly variable. The median problem list length was 8 (range: 3-14) for Case A, 10 (range: 4-20) for Case B, and 7 (range: 3-13) for Case C. The median indices of agreement - taking into account the length, content, and order of lists - over all possible physician pairings was 0.479, 0.371, 0.509, for Cases A, B, and C, respectively. The median agreements between the physicians' lists and the consensus list for each case were 0.683, 0.581, and 0.697 (for Cases A, B, and C, respectively). Out of a possible 1488 pairings, 2 lists were identical. Physicians most frequently ranked problem list items based on their acuity and immediate threat to health.Conclusions The problem list is a physician's mental model of a patient's health status. These mental models were found to vary significantly between physicians, raising questions about whether problem lists created by individual physicians can serve their intended purpose to improve care coordination.