RESULTS
We examined 35 encounters; we excluded 13 encounters based on our criteria. Collectively, 77 surveys were completed: 22 by providers (18 led by a neurointensivist care physician, four were led by resident or advance practice provider), 22 by the observer, 22 by families, and 11 by nurses. Mean values are reported in Table 1 and responses in each category in Figure 1 and Table 3.
Only 28 out of 231 responses to the first three questions (12%) were Neutral, Disagree, or Strongly Disagree. Traditional measures of inter-rater agreement (Krippendorf’s Alpha, Intra-Class Coefficients, and Cronbach’s Alpha) are not well defined with so little dispersion. For this reason, we defined concordance using the degree of difference defined above (Table 2). Analysis of Questions 1-3 yielded 99 cross-comparisons per question and total 297 responses. Two hundred and sixty-one responses demonstrated concordance and 36 showed discordance (88% concordance, 12% discordance). Most responses for Questions 1 and 3 were in the “Strongly Agree” or “Agree” category. Concordance between all groups was high, particularly for Questions 1 and 3 (96 and 94%, respectively), suggesting that all parties agreed on quality of the communication. Question 2 on whether communication impacted healthcare decisions had a lower rate of overall concordance (72%) than the other two questions (p<0.01). This discordance was greatest when comparing family/provider and family/nurse responses, although there were no statistically significant differences between pairs of responders. Analysis of exact concordance on the condensed three-point scare yielded similar results (Table 4).
The discordance among participants for Question 1 did not affect respondents’ general satisfaction with provider’s communication during the encounter (Table 3). For encounters with complete concordance, 73% of respondents strongly agreed that they were satisfied with the provider’s communication. Among encounters with at least one discordant crossmatch, that number was 70%. Even for encounters where three or more cross-matched responses were discordant, participants answered “Strongly Agree” for Question 1 regarding satisfaction with the encounter 68% of the time.
Question 4a assessed the provider’s comfort with discussing the patient’s prognosis with the family. All 22 providers reported that they strongly agreed or agreed (n=16 and 6, respectively) that they were comfortable discussing the prognosis with families. Question 4b assessed the family’s general satisfaction with the care the patient received. All respondents either strongly agreed or agreed (n=19 and 3, respectively) that they were satisfied with the quality of care.
Questions 5-9 yielded 148 responses; six responses were recorded as none or not sure. Some respondents provided multiple remarks (159 positive, 17 negative), yielding 176 keywords classified into six domains. Common remarks involved educational content (46%), empathy (21%), and engagement (19%) (Figure 2). The observer, families, and nurses primarily focused on educational content and empathy (86%, 84%, and 73%, respectively). Providers commented on either educational content or empathy in 49% of remarks. Providers and the observer noted the “physical setting of the meeting” in 14% of remarks. Empathy was the most frequently cited domain by families (31%) and the observer (30%).