title: Content coding for contextualization of care: evaluating physician performance at patient-centered decision making.
abstract: . Adapting best evidence to the care of the individual patient has been characterized as "contextualizing care" or "patient-centered decision making" (PCDM). PCDM incorporates clinically relevant, patient-specific circumstances and behaviors, that is, the patient's context, into formulating a contextually appropriate plan of care. The objective was to develop a method for analyzing physician-patient interactions to ascertain whether decision making is patient centered.
  
  
  
  . Patients carried concealed audio recorders during encounters with their physicians. Recordings and medical records were reviewed for clues that contextual factors, such as an inability to pay for a medication or competing responsibilities, might undermine an otherwise appropriate care plan, rendering it ineffective. Iteratively, the team refined a coding process to achieve high interrater agreement in determining (a) whether the clinician explored the clues-termed "contextual red flags"-for possible underlying contextual factors affecting care, (b) whether the presence of contextual factors was confirmed and, if so, (c) whether they were addressed in the final care plan.
  
  
  
  . A medical record data extraction instrument was developed to identify contextual red flags such as missed appointments or loss of control of a treatable chronic condition which signal that contextual factors may be affecting care. Interrater agreement (Cohen's kappa) for coding whether the clinician explored contextual red flags, whether a contextual factor was identified, and whether the factors were addressed in the care plan was 88% (0.76, P < 0.001), 94% (0.88, P < 0.001), and 85% (0.69, P < 0.001) respectively.
  
  
  
  . PCDM can be assessed with high interrater agreement using a protocol that examines whether essential contextual information (when present) is addressed in the plan of care.
authors.affiliation: Jesse Brown VA Medical Center, Chicago, IL (SJW, NA, AB, GS).|VA Center for Management of Complex Chronic Care, Chicago, IL (SJW, BK, NA, AB, GS, FMW)|University of Illinois at Chicago, Chicago, IL (SJW, BK, NA, AB, GS, AS)
authors.forename: Saul J
authors.initials: SJ
authors.lastname: Weiner
authors.affiliation: VA Center for Management of Complex Chronic Care, Chicago, IL (SJW, BK, NA, AB, GS, FMW)|University of Illinois at Chicago, Chicago, IL (SJW, BK, NA, AB, GS, AS)|Edward Hines VA Medical Center, Hines, IL (BK, FMW)
authors.forename: Brendan
authors.initials: B
authors.lastname: Kelly
authors.affiliation: Jesse Brown VA Medical Center, Chicago, IL (SJW, NA, AB, GS).|VA Center for Management of Complex Chronic Care, Chicago, IL (SJW, BK, NA, AB, GS, FMW)|University of Illinois at Chicago, Chicago, IL (SJW, BK, NA, AB, GS, AS)
authors.forename: Naomi
authors.initials: N
authors.lastname: Ashley
authors.affiliation: Jesse Brown VA Medical Center, Chicago, IL (SJW, NA, AB, GS).|VA Center for Management of Complex Chronic Care, Chicago, IL (SJW, BK, NA, AB, GS, FMW)|University of Illinois at Chicago, Chicago, IL (SJW, BK, NA, AB, GS, AS)
authors.forename: Amy
authors.initials: A
authors.lastname: Binns-Calvey
authors.affiliation: Jesse Brown VA Medical Center, Chicago, IL (SJW, NA, AB, GS).|VA Center for Management of Complex Chronic Care, Chicago, IL (SJW, BK, NA, AB, GS, FMW)|University of Illinois at Chicago, Chicago, IL (SJW, BK, NA, AB, GS, AS)
authors.forename: Gunjan
authors.initials: G
authors.lastname: Sharma
authors.affiliation: University of Illinois at Chicago, Chicago, IL (SJW, BK, NA, AB, GS, AS)
authors.forename: Alan
authors.initials: A
authors.lastname: Schwartz
authors.affiliation: Edward Hines VA Medical Center, Hines, IL (BK, FMW)|Stritch School of Medicine, Loyola University (FMW)
authors.forename: Frances M
authors.initials: FM
authors.lastname: Weaver
mesh_terms: D003657:Decision Making; D006801:Humans; D015588:Observer Variation; D010358:Patient Participation; D018802:Patient-Centered Care; D010818:Practice Patterns, Physicians'
keywords: clinical decision making; patient-centered care; performance assessment