Content coding for contextualization of care: Evaluating physician performance at patient-centered decision making

摘要

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 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.