'Art' of Interpersonal Medicine Improves Patient Outcomes

Lara C. Pullen, PhD

April 15, 2013

Patients experience improved healthcare outcomes when care is planned around the patient's needs and circumstances, according to a new study. Although this statement may seem intuitive, the study documents an association between contextualizing patient care, also known as patient-centered decision making (PCDM), and patient care outcomes.

Saul J. Weiner, MD, from the University of Illinois at Chicago, and colleagues published the results of their observational study in the April 16 issue of the Annals of Internal Medicine. The authors included 139 eligible resident primary care physicians in 2 participating veterans administration clinics. The study took place in 2012 and included more than 115,000 patient visits with 33,242 unique patients.

The authors did not select the patient population, and the context and clinical problems varied considerably from patient to patient. The authors evaluated physician performance using "4C": content coding for contextualization of care. This involves a multilayered series of experienced coders who look for "red flags" in the chart and audio recordings of the patient encounter.

The authors identified 774 patients who agreed to bring a concealed audio recorder into their visit with the physician and return it after the visit. Individual physicians were autorecorded until the authors had 3 unique visits in which contextual red flags could be identified.

A review of the' autorecorded encounters identified 548 contextual red flags such as multiple missed appointments or deteriorating self-management of a chronic condition. Approximately half (208) of the contextual factors were confirmed when the patients volunteered information or the physicians probed. Physicians probed contextual red flags and addressed them in care plans to differing extents based on the presenting contextual red flag.

The authors obtained outcome date for 157 contextual factors, and PCDM was found to address 96 of these factors. Healthcare outcomes improved in 71% (n = 68) of the contextual factors when PCDM was used. In contrast, healthcare outcomes only improved in 46% (n = 28) of the factors when PCDM was not used (P = .002). The authors also found that repeat visits to the same physician resulted in improved patient outcomes.

In an accompanying editorial, Hanan J. Aboumatar, MD, MPH, and Lisa A. Cooper, MD, MPH, both from Johns Hopkins University School of Medicine in Baltimore, Maryland, write, "To make substantial improvements in health outcomes and health care quality, health care professionals and organizations should move beyond traditional health care provision models; redefine their responsibilities to and partnerships with patients, families, and other community groups and institutions; and build systems that couple elicitation of patients' contexts with services and support structures that address their particular social determinants of health. We agree wholeheartedly with Weiner and colleagues that further contextualization of patient-centered health care is required to improve health outcomes. Patient-centered care can become more contextualized by addressing not only the 'who,' 'what,' and 'why' of health care but also the 'who else,' 'what matters most,' 'where,' 'when,' and 'how' of improving patient outcomes and, in so doing, can fulfill its promise."

The editorial was supported by the National Heart, Lung, and Blood Institute. The authors and editorialists have disclosed no relevant financial relationships.

Ann Intern Med. 2013;158:573-579, 628-629. Article abstract, Editorial extract

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