BACKGROUND: Health-care quality in primary care depends largely on the appropriateness of General Practitioners' (GPs; Primary Care or Family Physicians) decisions, which may be influenced by how difficult they perceive decisions to be. Patient scenarios (clinical or case vignettes) are widely used to investigate GPs' decision making. This review aimed to identify the extent to which perceived decision difficulty, decision appropriateness, and their relationship have been assessed in scenario studies of GPs' decision making; identify possible determinants of difficulty and appropriateness; and investigate the relationship between difficulty and appropriateness.
METHODS: MEDLINE, EMBASE, PsycINFO, the Cochrane Library and Web of Science were searched for scenario studies of GPs' decision making. One author completed article screening. Ten percent of titles and abstracts were checked by an independent volunteer, resulting in 91% agreement. Data on decision difficulty and appropriateness were extracted by one author and descriptively synthesised. Chi-squared tests were used to explore associations between decision appropriateness, decision type and decision appropriateness assessment method.
RESULTS: Of 152 included studies, 66 assessed decision appropriateness and five assessed perceived difficulty. While no studies assessed the relationship between perceived difficulty and appropriateness, one study objectively varied the difficulty of the scenarios and assessed the relationship between a measure of objective difficulty and appropriateness. Across 38 studies where calculations were possible, 62% of the decisions were appropriate as defined by the appropriateness standard used. Chi-squared tests identified statistically significant associations between decision appropriateness, decision type and decision appropriateness assessment method. Findings suggested a negative relationship between decision difficulty and appropriateness, while interventions may have the potential to reduce perceived difficulty.
CONCLUSIONS: Scenario-based research into GPs' decisions rarely considers the relationship between perceived decision difficulty and decision appropriateness. The links between these decisional components require further investigation.
We thank Fiona Stewart for assistance with search strategy development, and with identifying relevant electronic databases and clarifying hand-searching options. We also thank Brian Power for assistance with screening titles and abstracts. We thank Phil Hannaford for reviewing the manuscript and providing useful comments. This work was supported by a Medical Research Council Doctoral Training Grant awarded to the first author. The funding source had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
- systematic review
- clinical decision making
- decision difficulty
- decision appropriateness
- general practitioner
- primary care physician
- patient scenario