Multidisciplinary group performance in the context of integrated care: measurement of integration intensity

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• 作者：Dr Matthew J Harris ; DPhil^a ; ^{m.harris@imperial.ac.uk} ; Felix Greaves ; BMBCh^a ; Laura Gunn ; PhD^a ; Geva Greenfield ; PhD^a ; Sue Patterson ; PhD^b ; Josip Car ; PhD^a ; Prof Azeem Majeed ; MD^a ; Yannis Pappas ; PhD^c
• 刊名：The Lancet
• 出版年：2012
• 出版时间：23 November, 2012
• 年：2012
• 卷：380
• 期：supp_S3
• 页码：S13
• 全文大小：1K

文摘

Background

In the context of integrated care, multidisciplinary group (MDG) meetings involve participants who are not only from different professional groups but also from different organisational backgrounds within a complex local health economy. Such meetings therefore provide opportunities for participants to discuss complex care of individual patients, as well as ways to improve working within that local health economy¡ªie, working in a more integrative manner. We used an innovative coding scheme and method to explore the communication patterns within MDGs of a large-scale integrated care pilot (the North-West London Integrated Care Pilot). We investigated the extent to which case discussions foster an integrative way of working between MDG participants.

Methods

Case discussions in four MDG meetings were audio recorded and transcribed. Scripts were divided into utterances, or units of meaning, of about equal length representing a complete phrase or sentence. A second researcher then checked these utterances, and disagreements were resolved through consensus. Two coders independently coded utterances according to their integrative potential, which was defined against three independent domains: the level (ie, individual, collective, and systems); the valence (problem, information, and solution); and the focus (concrete and abstract). Utterances were coded first with respect to level, then valence, and then focus, to avoid any bias to code preferentially towards one permutation of the three codes. Inter-rater and intra-rater reliability was tested with kappa scores on one randomly selected case discussion. Intra-rater scores were taken 2 weeks apart to avoid possible code recall. We developed an ordinal scale based on mathematical weights for the 18 permutations of level, valence, and focus. Standardised mean integration scores were calculated for case discussions across utterance deciles, corresponding roughly to time deciles, indicating how integrative intensity changed during the conversation.

Findings

We transcribed and coded 23 case discussions in four different MDG groups. Inter-rater and intra-rater reliability was good, as shown by the prevalence and bias-adjusted kappa scores for one randomly selected case discussion. We coded 4209 utterances. The proportion of utterances differed according to participant type (consultant 14¡¤6 % ; presenting general practitioner 38¡¤8 % ; chair 7¡¤8 % ; non-presenting general practitioner 2¡¤3 % ; allied health professional 4¡¤8 % ). Utterances were predominantly coded at low levels of integrative intensity. Allied health professionals accounted for a fairly low proportion of utterances; however, they tended to speak at higher integrative levels. We noted evidence for a gradual increase (R² 0¡¤66) in integrative intensity during the case discussions, but on the basis of analysis of the minutes and action points arising from these discussions, this evidence did not translate into future actions.

Interpretation

We characterise the MDGs as having consultative characteristics with some trend towards collaboration, but best resemble community-based ward rounds. The increase in integration scores did not tend to translate into actions for the groups to take forward. The role of the chair and the improved participation of non-presenting general practitioners and allied health professionals seem important, especially because allied health professionals contribute greatly to higher integrative scores. Traditional communication patterns of medical dominance are being perpetuated in the MDGs, suggesting that more could be done to sensitise participants to the value of full participation from all members of the group. Case discussions in integrated care MDGs are opportunities for health professionals to learn from each other's cases and explore how services could work together better to improve care generally. Our characterisation of these MDGs shows that more could be done in this regard. Reviews of decision making and communication in primary and community care show a dearth of empirical research examining real-time dynamics. Our method enables researchers to detect evolutionary changes in the integrative intensity of the group over time and make comparisons between MDGs.

Funding

Imperial College Healthcare Charity.