Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication

Nonintensive care unit patients who were deemed medically stable by the team were eligible for peer observation and participation in a subsequent patient interview once during the study period. Pediatric patients were invited for an interview if they were between 13 and 21 years old and had the option of having a parent or guardian present; if the pediatric patients were less than 13 years old or they were not interested in being interviewed, then their parents or guardians were invited to be interviewed. Interpreters were on rounds, and thus, non-English participants were able to participate in the peer observations, but could not participate in patient interviews because interpreters were not available during afternoons for study purposes. Consent was obtained from all participating patients and/or guardians.

Data Collection

Round and Patient Characteristics

Peer observers recorded rounding, team, and patient characteristics using a standardized form. Rounding data included date, attending name, duration of rounds, and patient census. Patient level data included the decision(s) discussed, the seniority of the clinician leading the discussion, team composition, minutes spent discussing the patient (both with the patient and/or guardian and total time), hospitalization week, and patient’s primary language. Additional patient data obtained from electronic health records included age, gender, race, ethnicity, date of admission, and admitting diagnosis.

SDM Measures

Peer-observed SDM behaviors were quantified per patient encounter using the 9-item Rochester Participatory Decision-Making Scale (RPAD), with credit given for SDM behaviors exhibited by anyone on the rounding team (team-level metric).²⁷ Each item was scored on a 3-point scale (0 = absent, 0.5 = partial, and 1 = present) for a maximum of 9 points, with higher scores indicating higher-quality SDM (Peer-RPAD Score). We created semistructured patient interview guides by adapting each RPAD item into layperson language (Patient-RPAD Score) and adding open-ended questions to assess the patient experience.

Peer-Observer Training

Eight peer-observers (7 hospitalists and 1 palliative care physician) were trained to perform RPAD ratings using videos of patient encounters. Initially, raters viewed videos together and discussed ratings for each RPAD item. The observers incorporated behavioral anchors and clinical examples into the development of an RPAD rating guide, which they subsequently used to independently score 4 videos from an online medical communication library.²⁸ These scores were discussed to resolve any differences before 4 additional videos were independently viewed, scored, and compared. Interrater reliability was achieved when the standard deviation of summed SDM scores across raters was less than 1 for all 4 videos.

Patient Interviewers

Interviewers were English-speaking volunteers without formal medical training. They were educated in hospital etiquette by a physician and in administering patient interviews through peer-to-peer role playing and an observation and feedback interview with at least 1 patient.

Data Analysis

The analysis set included every unique patient with whom a medical decision was made by an eligible clinical team. To account for the nested study design (patient-level scores within rounds, rounds within attending, and attendings within service), we used mixed-effects models to estimate mean (summary or item) RPAD score by levels of fixed covariate(s). The models included random effects accounting for attending-level and round-level correlations among scores via variance components, and allowing the attending-level random effect to differ by service. Analyses were performed using SAS version 9.4 (SAS Institute Inc, Cary, NC). We used descriptive statistics to summarize round- and patient-level characteristics.

SDM Variation by Attending and Service

Box plots were used to summarize raw patient-level, Peer-RPAD scores by service and attending. By using the methods described above, we estimated the mean score overall and by service. In both models, we examined the statistical significance of service-specific variation in attending-level random effects by using likelihood-ratio test (LRT) to compare models.

SDM Variation by Round and Patient Characteristics

We used the models described above to identify covariates associated with Peer-RPAD scores. We fit univariate models separately for each covariate, then fit 2 multivariable models, including (1) all covariates and (2) all effects significant in either model at P ≤ .20 according to F tests. For uniformity of presentation, we express continuous covariates categorically; however, we report P values based on continuous versions. Means generated by the multivariable models were calculated at the mean values of all other covariates in model.

Patient-Level RPAD Data

A subsample of patients completed semistructured interviews with analogous RPAD questions. To identify possible selection bias in the full sample, we summarized response rates by service and patient language and modeled Peer-RPAD scores by interview response status. Among responders, we estimated the mean Peer-RPAD and Patient-RPAD scores and their paired differences and correlations, testing for non-zero correlations via the Spearman rank test.