title: The unexpected in primary care: a multicenter study on the emergence of unvoiced patient agenda.
abstract: OBJECTIVE
  Within the time constraints of a typical physician-patient encounter, the full patient agenda will rarely be voiced. Unexpectedly revealed issues that were neither on the patient's list of items for discussion nor anticipated by the physician constitute an emerging agenda. We aimed to quantify the occurrence rate of emerging agendas in primary care practices and to explain the variation between patients and practices.
  
  
  METHODS
  This observational cross-sectional study involved 182 primary care practices in 9 European cultural regions. Consecutive primary care consultations were videotaped and rated. Patients completed preconsultation and postconsultation questionnaires assessing their expectations and perceived care. Emerging agenda, determined by using 11-item preconsultation and postconsultation questionnaires, was defined as care perceived by the patient to be in addition to expected care, after adjustment for cultural variations of patient expectations.
  
  
  RESULTS
  For consultations involving 2,243 patients (mean age, 44.8 years, 58.4% women), every sixth (15.8%) consultation revealed emerging psychosocial agenda. Biomedical agenda emerged in 14.5% of the consultations. Rates for unmet expectations were 13.6% and 10.3%, respectively, for psychosocial and biomedical problems. Practices showed considerable heterogeneity of occurrence of emerging agenda (biomedical, median 13%, range 0%-67%; psychosocial, median 14%, range 0%-53%). After controlling for region and patient baseline characteristics, variables significantly related to emerging agenda were patient expectations and biomedical or psychosocial discourse content, but not consultation time or sex of the patient. A large proportion of the variance attributable to physicians remained concealed in a practice dummy variable (explaining up to 8% of the variance).
  
  
  CONCLUSIONS
  Unexpected agenda emerges in every sixth to seventh consultation in outpatient primary care visits.
authors.affiliation: Horten-Zentrum für praxisorientierte, Forschung und Wissenstransfer, Zurich, Switzerland. Michael.Peltenburg@hin.ch
authors.forename: Michael
authors.initials: M
authors.lastname: Peltenburg
authors.forename: Joachim E
authors.initials: JE
authors.lastname: Fischer
authors.forename: Ottomar
authors.initials: O
authors.lastname: Bahrs
authors.forename: Sandra
authors.initials: S
authors.lastname: van Dulmen
authors.forename: Atie
authors.initials: A
authors.lastname: van den Brink-Muinen
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000592:standards; D004632:Emergency Medical Services / Q000592:standards*; D005060:Europe; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data*; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires