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

RESULTS

All Patient Encounters

A total of 35 attendings (18 medicine, 17 pediatrics) were observed, representing 51% of 69 eligible attendings. By design, study observations included a median of 3 rounds per attending (range 1-5), summing to 88 total rounds (46 medicine, 42 pediatrics) and 783 patient encounters (388 medicine, 395 pediatrics; Table 1).

The median duration of rounding sessions was 1.8 hours, median patient census was 9, and median patient encounter was 13 minutes. The duration of rounds and minutes per patient were longest at Med-2 and shortest at Peds-1. See Table 1 for other team characteristics.

Peer Evaluations of SDM Encounters

Characteristics of Patients

We observed SDM encounters in 254 unique patients (117 medicine, 137 pediatrics), representing 32% of all observed encounters. Patient mean age was 56 years for medicine and 7.4 years for pediatrics. Overall, 54% of patients were white, 11% were Asian, and 10% were African American; race was not reported for 21% of patients. Pediatrics services had more SDM encounters with Hispanic patients (31% vs. 9%) and Spanish-speaking patients (14% vs < 2%; Table 2). Patient complexity ranged from case mix index (CMI) 1.17 (Med-1) to 2. 11 (Peds-1).

Teams spent a median of 13 minutes per SDM encounter, which was not higher than the round median. SDM topics discussed included 47% treatment, 15% diagnostic, 30% both treatment and diagnostic, and 7% other.

Variation in SDM Quality Among Attending Physicians

Overall Peer-RPAD Scores were normally distributed. After adjusting for the nested study design, the overall mean (standard error) score was 4.16 (0.11). Score variability among attendings differed significantly by service (LRT P = .0067). For example, raw scores were lower and more variable among attending physicians at Med-2 than other among attendings in other services (see Appendix Figure in Supporting Information). However, when service was included in the model as a fixed effect, mean scores varied significantly, from 3.0 at Med-2 to 4.7 at Med-1 (P < .0001), but the random variation among attendings no longer differed significantly by service (P = .13). This finding supports the hypothesis that service-level influences are stronger than influences of individual attending physicians, that is, that variation between services exceeded variation among attendings within service.

Aspects of SDM That Are More Prevalent on Rounds

Based on Peer-RPAD item scores, the most frequently observed behaviors across all services included “Matched medical language to the patient’s level of understanding” (Item 6, 0.75) and “Explained the clinical issue or nature of the decision” (Item 1, 0.74; panel A of Figure). The least frequently observed behaviors included “Asked if patient had any questions” (Item 7, 0.34), “Examined barriers to follow-through with the treatment plan” (Item 4, 0.15), and “Checked understanding of the patient’s point of view” (Item 9, 0.06).

Rounds and Patient Characteristics Associated With Peer-RPAD Scores

In univariate models, Peer-RPAD scores decreased significantly with round-level average minutes per patient and were elevated during a patient’s second week of hospitalization. In the multivariable model including all covariates in Table 3, mean Peer-RPAD scores varied by service (lower at Med-2 than elsewhere), patient gender (slightly higher among women and girls), week of hospitalization (highest during the second week), and time spent with the patient and/or guardian (more time correlated with higher scores). In a reduced multivariable model restricted to the covariates that were statistically significant in either model (P ≤ .20), all 5 associations remained significant P ≤ .05. However, the difference in means by gender was only 0.3, and only 18% of patients were hospitalized for more than 1 week.

Patient-RPAD Results: Dissimilar Perspectives of Patients and/or Guardians and Physician Observers

Of 254 peer-evaluated SDM encounters, 149 (59%) patients and/or guardians were available and consented to same-day interviews, allowing comparison of paired peer and patient evaluations of SDM in this subset. The response rate was 66% among patients whose primary language was English versus 15% among others. Peer-RPAD scores by interview response status were similar overall (responders, 4.17; nonresponders, 4.13; P = .83) and by service (interaction P = .30).

Among responders, mean Patient-RPAD scores were 6.8 to 7.1 for medicine services and 7.6 to 7.8 for pediatric services (P = .01). The overall mean Patient-RPAD score, 7.46, was significantly greater than the paired Peer-RPAD score by 3.5 (P = .011); however, correlations were not statistically significantly different from 0 (by service, each P > .12).

To understand drivers of the differences between Peer-RPAD and Patient-RPAD scores, we analyzed findings by item. Each mean patient-item score exceeded its peer counterpart (P ≤ .01; panel B of Figure). Peer-item scores fell below 33% on 2 items (Items 9 and 4) and only exceeded 67% on 2 items (Items 1 and 6), whereas patient-item scores ranged from 60% (Item 8) to 97% (Item 7). Three paired differences exceeded 50% (Items 9, 4, and 7) and 3 were below 20% (Items 6, 8 and 1), underlying the lack of correlation between peer and patient scores.