"Do You Want to Talk to [the Patient]?" Impact of Visit Modality on Shared Decision Making in Pediatric Primary Care

Introduction. Telemedicine may improve access to care for children, but whether telemedicine alters decision-making processes is not known. We aimed to describe differences in shared decision making (SDM) in telemedicine and in-person pediatric primary care visits with children with chronic conditions. Methods. We conducted qualitative analyses of primary care visits video recorded across 6 pediatric primary care practices. Telemedicine visits were matched to in-person visits on age, diagnosis, timing of visit, and clinical site. Each recording was summarized by a trained reviewer. The summaries were then coded and analyzed using a framework approach. Codes were organized into a matrix to facilitate thematic analyses both within and across visits and visit types. Results. We analyzed 16 telemedicine and 18 in-person visits with 34 unique patients and 12 unique clinicians. The samples of telemedicine and in-person visits were similar in distribution across patient and parent characteristics. Most of the visits discussed attention-deficit/hyperactivity disorder. Thematic analysis identified 2 major themes. First, employment of SDM processes do not differ by visit modality. Across constructs of team talk, options talk, and decision talk, optimal SDM processes were lacking in both visit modalities. Second, visit modality affects the patient's decision engagement. Patients were physically present during all in-person visits but only briefly present during most telemedicine visits, limiting their opportunities to engage in decision making. Conclusion. Our study did not identify qualitative differences in SDM across the mode of pediatric primary care delivery: telemedicine versus in person. These data may alleviate concerns about potential negative effects of telemedicine on communication in pediatric primary care visits for chronic conditions. However, there is a need to improve shared decision making across visit types in pediatric primary care.

Our study demonstrates that the mode of pediatric primary care delivery does not affect the use of SDM in primary care visits for pediatric chronic conditions.There are opportunities to improve SDM across both care modalities.Future work should consider how approaches to increasing SDM and family decision engagement may differ by visit modality.