Priority-setting and shared-decision making in primary care: a secondary analysis of the GP consultations archive

Problem

Primary care physicians make decisions about allocating resources, while also acting as the patient’s advocate. However, there is a concern that these decisions may inhibit patient-centred care. Previous interview studies with GPs reported that these decisions tend to occur implicitly. It remains unclear how doctors convey allocation decisions to the patient and how it influences on the patient’s perception about shared decision-making process.

Approach

This is a secondary analysis with multiple methods using One in a million: primary care consultations archive. We undertook a cross-sectional study with the survey data to examine the impact on patient perceptions of decision-making when their expected outcome was not achieved (such as referral). The primary outcome was set as the binary outcome about post-consultation perceived shared decision-making, that is, looking at whether patients perceived the decision was made in line with shared decision-making process or not. These were measured using the Patient control Preference Scale (Degner et al.,1997), the Physician perception of decision-making (Janz et al., 2004) and the Patient perception of decision-making (Janz et al., 2004). We also conducted a qualitative analysis of the transcripts from the consultations to investigate how those priority setting issues arise and how doctors manage patients’ demands. Cases were selected based on the patients’ pre-consultation surveys indicating that they expected to receive onward care. We thematically analysed the transcripts and constantly compared the themes and codes emerging from the data to develop a thematical understanding.

Findings

In the post-consultation survey, 104 patients indicated they had been given a referral, 81 GPs said they had made a referral and 57 GPs and patients were in agreement. Thus, the transcript data was also used for determining the exposure group (i.e. those who did or did not receive referrals) in the quantitative analysis. For the qualitative analysis, 60 consultations were selected to date. Among them, 39 patients were female, and 21 patients were male. The patients’ age ranged from 20 to 87 (mean: 51 years). From the consultation data, there was evidence of GPs acting at different points as agents both for the healthcare system and for the patient. There was also some indication that they sometimes tried to combine elements of these roles. For example, GPs (i) acted as a ‘gatekeeper’ and thus as an agent for society but also regarded their role as conducting the ‘groundwork’ on behalf of the patient, before that patient sees a specialist (ii) declined the patient’s request for referral but sought their preferences for other treatment or diagnostic processes.

Consequences

Priority-setting during consultations is not necessarily conducted implicitly. Facing rationing decisions, GPs often demonstrated their ability to move between these agent roles and balance how they played out within the consultation.