Effective care requires diagnosing and treating clinical conditions using evidence-based practices and adapting care plans to individuals’ unique circumstances, or context. For instance, increasing the dosage of a medication to treat worsening disease may be appropriate, according to guidelines, but ineffective if the underlying problem is that the patient cannot afford the medication or is unable to take it as scheduled because of competing responsibilities.
Failing to recognize and account for contextual factors that are essential to planning effective care has been termed “contextual error.” Conversely, the habitual practice of attending to patients’ life circumstances when planning care to avoid such errors has been termed “patient-centered decision making” or “contextualized care.”
Contextualizing care is a three-step process: First, clinicians must recognize clues (eg, recent loss of disease control) that patients may have underlying unaddressed contextual issues. When these “contextual red flags” are recognized, they must ask patients about it, a process called “contextual probing.” If patients reveal an underlying “contextual factor,” physicians should attempt to address it in care plans.
Does Contextualized Care Improve Outcomes?
To investigate the effect of contextualizing care, my colleagues and I conducted a study—published in Annals of Internal Medicine—that aimed to determine if contextualized care improved healthcare outcomes. We evaluated patients who agreed to surreptitiously record their interactions with clinicians. Medical records and audio recordings of these encounters were then screened for contextual red flags and, when present, for contextual factors. Physicians were scored on the basis of whether they adapted care plans to the factor. The study involved 774 patients with common chronic conditions and 139 resident physicians.
Among 548 red flags that were identified, 208 were confirmed as reflecting an underlying contextual factor. Outcome data were available for 157 contextual factors, of which care plans addressed 96. Healthcare outcomes improved in 71% of cases that were contextualized, compared with a rate of just 46% for those that disregarded patient factors. After controlling for potentially confounding variables, patients with contextualized care plans had almost four times greater odds of showing improvements in healthcare outcomes.
Evaluating Physicians on Overall Decision Making
Our findings suggest that there is a substantial benefit to patients when clinicians successfully address life context in their care plans. It’s clear that healthcare organizations should move beyond evaluating physician performance based exclusively on adherence to biomedical algorithms in order to fully evaluate the quality of decision making in healthcare. In addition, physicians and healthcare teams need to further attend to partnerships with patients, families, and other institutions to assure that healthcare is not only evidence-based but that decision making is patient-centered.
Readings & Resources (click to view)
Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573-579. Available at: http://annals.org/article.aspx?articleid=1676452.
Schwartz A, Weiner SJ, Weaver F, Goldberg J, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, Jordan N. Uncharted Territory: Measuring Costs of Diagnostic Errors Outside the Medical Record. BMJ Quality & Safety. 2012;21:918-924.
Schwartz A, Weiner SJ, Harris IB, Binns-Calvey A. An educational intervention for contextualizing patient care and medical students’ abilities to probe for contextual issues in simulated patients. JAMA. 2010; 304:1191-1197.
Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, Schapira M, Persell SD, Jacobs E, Abrams R. Contextual errors and failures in individualizing patient care: A multicenter study. Ann Intern Med. 2010;153(2):69-75.
Aboumatar H, Cooper L. Contextualizing patient-centered care to fulfill its promise of better health outcomes: beyond who, what, and why.” Ann Intern Med. 2013;158:628-629.