Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication
BACKGROUND: Shared decision-making (SDM) improves patient engagement and may improve outpatient health outcomes. Little is known about inpatient SDM.
OBJECTIVE: To assess overall quality, provider behaviors, and contextual predictors of SDM during inpatient rounds on medicine and pediatrics hospitalist services.
DESIGN: A 12-week, cross-sectional, single-blinded observational study of team SDM behaviors during rounds, followed by semistructured patient interviews.
SETTING: Two large quaternary care academic medical centers.
PARTICIPANTS: Thirty-five inpatient teams (18 medicine, 17 pediatrics) and 254 unique patient encounters (117 medicine, 137 pediatrics).
INTERVENTION: Observational study.
MEASUREMENTS: We used a 9-item Rochester Participatory Decision-Making Scale (RPAD) measured team-level SDM behaviors. Same-day interviews using a modified RPAD assessed patient perceptions of SDM.
RESULTS: Characteristics associated with increased SDM in the multivariate analysis included the following: service, patient gender, timing of rounds during patient’s hospital stay, and amount of time rounding per patient (P < .05). The most frequently observed behaviors across all services included explaining the clinical issue and matching medical language to the patient’s level of understanding. The least frequently observed behaviors included checking understanding of the patient’s point of view, examining barriers to follow-through, and asking if the patient has any questions. Patients and guardians had substantially higher ratings for SDM quality compared to peer observers (7.2 vs 4.4 out of 9).
CONCLUSIONS: Important opportunities exist to improve inpatient SDM. Team size, number of learners, patient census, and type of decision being made did not affect SDM, suggesting that even large, busy services can perform SDM if properly trained.
© 2018 Society of Hospital Medicine
The ethos of medicine has shifted from paternalistic, physician-driven care to patient autonomy and engagement, in which the physician shares information and advises.1-3 Although there are ethical, legal, and practical reasons to respect patient preferences,1-4 patient engagement also fosters quality and safety5 and may improve clinical outcomes.5-8 Patients whose preferences are respected are more likely to trust their doctor, feel empowered, and adhere to treatments.9
Providers may partner with patients through shared decision-making (SDM).10,11 Several SDM models describe the process of providers and patients balancing evidence, preferences and context to arrive at a clinical decision.12-15 The National Academy of Medicine and the American Academy of Pediatrics has called for more SDM,16,17 including when clinical evidence is limited,2 equally beneficial options exist,18 clinical stakes are high,19 and even with deferential patients.20 Despite its value, SDM does not reliably occur21,22 and SDM training is often unavailable.4 Clinical decision tools, patient education aids, and various training interventions have shown promising, although inconsistent results.23, 24
Little is known about SDM in inpatient settings where unique patient, clinician, and environmental factors may influence SDM. This study describes the quality and possible predictors of inpatient SDM during attending rounds in 4 academic training settings. Although SDM may occur anytime during a hospitalization, attending rounds present a valuable opportunity for SDM observation given their centrality to inpatient care and teaching.25,26 Because attending physicians bear ultimate responsibility for patient management, we examined whether SDM performance varies among attendings within each service. In addition, we tested the hypothesis that service-level, team-level, and patient-level features explain variation in SDM quality more than individual attending physicians. Finally, we compared peer-observer perspectives of SDM behaviors with patient and/or guardian perspectives.
METHODS
Study Design and Setting
This cross-sectional, observational study examined the diversity of SDM practice within and between 4 inpatient services during attending rounds, including the internal medicine and pediatrics services at Stanford University and the University of California, San Francisco (UCSF). Both institutions provide quaternary care to diverse patient populations with approximately half enrolled in Medicare and/or Medicaid.
One institution had 42 internal medicine (Med-1) and 15 pediatric hospitalists (Peds-1) compared to 8 internal medicine (Med-2) and 12 pediatric hospitalists (Peds-2) at the second location. Both pediatric services used family-centered rounds that included discussions between the patients’ families and the whole team. One medicine service used a similar rounding model that did not necessarily involve the patients’ families. In contrast, the smaller medicine service typically began rounds by discussing all patients in a conference room and then visiting select patients afterwards.
From August 2014 to November 2014, peer observers gathered data on team SDM behaviors during attending rounds. After the rounding team departed, nonphysician interviewers surveyed consenting patients’ (or guardians’) views of the SDM experience, yielding paired evaluations for a subset of SDM encounters. Institutional review board approval was obtained from Stanford University and UCSF.
Participants and Inclusion Criteria
Attending physicians were hospitalists who supervised rounds at least 1 month per year, and did not include those conducting the study. All provided verbal assent to be observed on 3 days within a 7-day period. While team composition varied as needed (eg, to include the nurse, pharmacist, interpreter, etc), we restricted study observations to those teams with an attending and at least one learner (eg, resident, intern, medical student) to capture the influence of attending physicians in their training role. Because services vary in number of attendings on staff, rounds assigned per attending, and patients per round, it was not possible to enroll equal sample sizes per service in the study.
