Published online July 2, 2007
PEDIATRICS Vol. 120 No. 1 July 2007, pp. e68-e77 (doi:10.1542/peds.2006-2602)
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ARTICLE

Evaluating Deliberation in Pediatric Primary Care

Elizabeth D. Cox, MD, PhDa,b, Maureen A. Smith, MD, PhD, MPHb and Roger L. Brown, PhDc

a Center for Women's Health Research
b Department of Population Health Sciences, School of Medicine and Public Health
c School of Nursing, University of Wisconsin, Madison, Wisconsin

OBJECTIVE. 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.

METHODS. 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.

RESULTS. 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.

CONCLUSIONS. 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.

Key Words: participatory decision making • deliberation • primary care • physician–patient/parent communication

Abbreviations: ICC—intraclass correlation coefficient • IRR—incidence rate ratio • CI—confidence interval • OR—odds ratio

Accepted Dec 12, 2006.