Cox Elizabeth D, Smith Maureen A, Brown Roger L
Center for Women's Health Research, University of Wisconsin School of Medicine and Public Health, 610 Walnut St, Madison, WI 53726, USA.
Pediatrics. 2007 Jul;120(1):e68-77. doi: 10.1542/peds.2006-2602.
Patient participation during decision-making can improve health outcomes and satisfaction, even for routine pediatric concerns. The tasks that are involved in decision-making include both information exchange and deliberation about potential options, yet deliberation (ie, the process of expressing and evaluating potential options to reach a decision) is often assessed subjectively, if at all. We objectively assessed the amount of deliberation; the involvement of parents and children in deliberation; and how deliberation is associated with child, physician, parent, and visit characteristics.
From videotapes of 101 children's acute care visits to 1 of 15 physicians, we coded the speaker, recipient, and timing of proposed plans (ie, options) and agreements or disagreements with the plans. Reliability of measures was assessed with Cohen's kappa or intraclass correlation coefficients; validity was assessed with Spearman correlations. Outcome measures included number of plans proposed, deliberation length, and parent/child involvement in deliberation as either active (child or parent proposed a plan or disagreed with a plan) or passive (physician alone proposed plans). Multivariable models that accounted for clustering by physician were used to relate child, physician, parent, and visit factors to deliberation measures.
The mean number of plans proposed was 4.1, and deliberation time averaged 2.9 minutes per visit. Passive involvement of parents/children occurred in 65% of visits. After adjustment, more plans were proposed in visits by girls, and shorter deliberations occurred with college-graduate parents. Longer visits were associated with more plans proposed, longer deliberation, and reduced odds for passive parent/child involvement.
Using a reliable and valid technique, deliberation was demonstrated to occupy a substantial portion of the visit and include multiple proposed plans, yet passive involvement of parents and children predominated. Results support the need to develop interventions to improve parent and child participation in deliberation.
患者参与决策制定能够改善健康结局并提高满意度，即便对于常规儿科问题亦是如此。决策制定所涉及的任务包括信息交流以及对潜在选择的审议，然而审议（即表达和评估潜在选择以达成决策的过程）即便有所评估，也往往是主观的。我们客观地评估了审议的量；父母和儿童在审议中的参与情况；以及审议如何与儿童、医生、父母和就诊特征相关联。
从101例儿童急性病就诊的录像中选取15位医生中的1位的就诊录像，我们对提议计划（即选择）的发言者、接受者和时间以及对计划的同意或不同意情况进行编码。使用科恩kappa系数或组内相关系数评估测量的可靠性；使用斯皮尔曼相关性评估有效性。结局指标包括提议计划的数量、审议时长以及父母/儿童作为积极参与者（儿童或父母提议计划或不同意计划）或消极参与者（仅由医生提议计划）参与审议的情况。采用考虑医生聚类的多变量模型将儿童、医生、父母和就诊因素与审议指标相关联。
提议计划的平均数量为4.1个，每次就诊的审议时间平均为2.9分钟。65%的就诊中父母/儿童为消极参与。调整后，女孩就诊时提议的计划更多，大学毕业的父母参与的审议时间更短。就诊时间越长，提议的计划越多，审议时间越长，父母/儿童消极参与的几率越低。
通过一种可靠且有效的技术，证明审议在就诊过程中占了相当一部分时间，且包括多个提议计划，但父母和儿童的消极参与占主导。结果支持有必要制定干预措施以改善父母和儿童参与审议的情况。
