Contextual Errors Often Complicate Medical Care

Laurie Barclay, MD

July 21, 2010

July 21, 2010 — Physicians' lack of attention to patient's contextual information, such as transportation needs, finances, literacy, or caregiving, can lead to contextual errors complicating medical care, according to the results of an incomplete randomized block design study published in the July 19 issue of Annals of Internal Medicine.

"A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care," write Saul J. Weiner, MD, from Veterans Affairs Center for the Management of Complex Chronic Care, University of Illinois at Chicago, and colleagues. "In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care."

The study goal was to evaluate how often and under what circumstances physicians examine contextual and biomedical red flags and how well they use what they learn to avoid medical errors. Of 14 practices included in the study, 2 were academic clinics, 1 was a core safety net provider, and 3 were US Department of Veterans Affairs facilities, and the remaining sites came from 2 community-based primary care networks.

Between April 2007 and April 2009, unannounced, standardized patients (actors following scripts) visited 111 attending physicians in internal medicine and presented variants of 4 scenarios. Each variant of the case scenarios was either uncomplicated or included a contextual red flag, a biomedical red flag, or both providing hints to complicating factors. When physicians asked about these red flags, responses of the standardized patients varied in whether they revealed an underlying complicating biomedical and/or contextual factor that could cause management errors.

The main study endpoints were the proportion of visits in which physicians asked about contextual and biomedical factors in response to hints or red flags, and the proportion of visits in which physicians designed error-free treatment plans.

Ninety-six (86.5%) of the physicians completed the study. Some physicians moved or closed their practice following initiation of the study. The total number of patient encounters coded was 399. Coding was based predominately on audio recordings of the encounter, but also on actor checklists and physician notes.

Compared with biomedical red flags, physicians were less likely to ask about contextual red flags (63% vs 51%). For the treatment plan to be error-free, probing for contextual or biomedical information in response to red flags was generally necessary but was not sufficient. Error-free care was provided in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters. Of the 191 biomedically complicated encounters, physicians planned appropriate treatment 31% of the time when elicitation occurred but only 6% of the time when it did not. Of the 185 contextually complicated encounters, physicians planned appropriate treatment 20% of the time when elicitation occurred and only 3% of the time when it did not.

"Inattention to contextual information, such as a patient's transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance," the study authors write.

In addition, the authors describe earlier research in which evidence-based medicine has been defined as "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." Therefore, the authors explain, "a conscientious and judicious approach requires that physicians investigate indicators of clinically important patient contextual factors and adapt their care plan accordingly."

Limitations of this study include that it used only 4 case scenarios, that there were some missing data, and that there was an inability to measure actual rates of contextual errors occurring in primary care settings or during return visits. In addition, the hints provided by the actors regarding underlying contextual issues may have been too subtle.

"Although tracking physician adherence to guidelines as a quality indicator is straightforward, determining whether physicians are appropriately individualizing care is not," the study authors conclude. "Broadening the assessment of physician performance to include this metric unmasks serious performance problems. Strategies that address the challenge of individualizing clinical decisions through both provider education and new measures of performance are urgently needed."

In an accompanying editorial, Michael A. LaCombe, MD, from Maine General Medical Center in Augusta, notes that patient illiteracy is often a significant source of contextual error.

"[These] results are both interesting and unsurprising to the practicing physician," Dr. LaCombe writes. "We are rushed; buffeted by multiple, often conflicting demands; and faced with end-of-the-day forms, chart dictation, and callbacks, and too often rely on clinical reflex, with little time left to think — and thinking is vital to avoiding contextual error."

The US Department of Veterans Affairs Health Services Research and Development Service supported this study. Dr. Weiner and Dr. Schwartz are coowners of Institute for Practice and Provider Improvement, Inc. The other study authors have disclosed no relevant financial relationships. Dr. LaCombe has disclosed no relevant financial relationships.

Ann Intern Med. 2010;153:69-75.

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