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Clinical decisions presented to patients in hospital encounters: a cross-sectional study using a novel taxonomy
  1. Eirik Hugaas Ofstad1,
  2. Jan C Frich2,
  3. Edvin Schei3,
  4. Richard M Frankel4,
  5. Jūratė Šaltytė Benth5,
  6. Pål Gulbrandsen1,5
  1. 1 The Research Centre, Akershus University Hospital, Lorenskog, Norway
  2. 2 Institute of Health and Society, University of Oslo, Oslo, Norway
  3. 3 Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
  4. 4 Indiana University School of Medicine, VA HSR and Development Center for Health Information and Communication, Indianapolis, Indiana, USA
  5. 5 Institute of Clinical Medicine, University of Oslo, Lorenskog, Norway
  1. Correspondence to Dr Eirik Hugaas Ofstad; eirikofstad{at}gmail.com

Abstract

Objective To identify and classify all clinical decisions that emerged in a sample of patient–physician encounters and compare different categories of decisions across clinical settings and personal characteristics.

Design Cross-sectional descriptive evaluation of hospital encounters videotaped in 2007–2008 using a novel taxonomy to identify and classify clinically relevant decisions (both actions and judgements).

Participants and setting 372 patients and 58 physicians from 17 clinical specialties in ward round (WR), emergency room (ER) and outpatient (OP) encounters in a Norwegian university hospital.

Results The 372 encounters contained 4976 clinically relevant decisions. The average number of decisions per encounter was 13.4 (min–max 2–40, SD 6.8). The overall distribution of the 10 topical categories in all encounters was: defining problem: 30%, evaluating test result: 17%, drug related: 13%, gathering additional information: 10%, contact related: 10%, advice and precaution: 8%, therapeutic procedure related: 5%, deferment: 4%, legal and insurance related: 2% and treatment goal: 1%. Across three temporal categories, the distribution of decisions was 71% here-and-now, 16% preformed and 13% conditional. On average, there were 15.7 decisions per encounter in internal medicine specialties, 7.1 in ear–nose–throat encounters and 11.0–13.6 in the remaining specialties. WR encounters contained significantly more drug-related decisions than OP encounters (P=0.031) and preformed decisions than ER and OP encounters (P<0.001). ER encounters contained significantly more gathering additional information decisions than OP and WR encounters (P<0.001) and fewer problem defining decisions than WR encounters (P=0.028). There was no significant difference in the average number of decisions related to the physician’s and patient’s age or gender.

Conclusions Patient–physician encounters contain a larger number of clinically relevant decisions than described in previous studies. Comprehensive descriptions of how decisions, both as judgements and actions, are communicated in medical encounters may serve as a first step in assessing clinical practice with respect to efficiency and quality on a provider or system level.

  • communication
  • hospital medicine
  • medical decision-making
  • patient-physician communication
  • physician behaviour
  • shared decision-making

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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Footnotes

  • EHO and PG contributed equally.

  • Contributors EHO and PG contributed equally to this study. PG conceived the study and put together the study group. EHO analysed the first 30 videos and selected statements to be discussed in the study group. EHO, JCF, ES and PG took part in all seven group meetings, and all four authors independently analysed the 20 videos for inter-rater reliability measurements. Because of language barrier, RMF did not part take in analysis of the videos, but transcribed and translated statements were presented to RMF during the analytic phase. EHO analysed 372 videos. PG analysed every 20th of these videos to check for inter-rater drift. EHO and PG analysed the data with simple descriptive statistics. JSB performed multilevel statistical analyses. EHO, JCF, ES, RMF, JSB and PG analysed the data and reviewed the manuscript for its intellectual content. All authors had full access to all the data and take responsibility for the integrity of the data and accuracy of the analysis. EHO is guarantor.

  • Funding This project is funded by South Eastern Norway Regional Health Authority (grant number 2010003).

  • Disclaimer The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

  • Competing interests None declared.

  • Ethics approval The study was approved by the Regional Ethics Committee for Medical Research of South-East Norway (1.2009/1415).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data available.