Miriam E. Tucker

May 08, 2016

WASHINGTON, DC — The contextual aspects of a patient's life — such as the ability to pay for medication, the ability to understand instructions, and the availability of social support — are a major determinant of outcomes and can affect healthcare costs.

Not addressing such factors, or making a contextual error, can result in unnecessary tests, procedures, and medications, said Saul Weiner, MD, from the Institute for Health Research and Policy at the University of Illinois at Chicago. He led a workshop on the contextualization of care here at American College of Physicians Internal Medicine 2016.

"To get the care plan right, it's not necessarily enough just to have the science right and know what the guidelines are. A lot of times, getting the care plan right means addressing specific life challenges the patient has to following the care plan," he told Medscape Medical News.

The concept is particularly salient today because physicians are being measured on numerous aspects of care contained in the medical record, where contextual factors are not accounted for.

"When you look at a chart and audit performance, you'll never see the contextual error. It looks like the physician identified the clinical situation, drew on the research evidence, and maybe even elicited patient preference to come up with a care plan, and that's documented," said Dr Weiner.

The care plan, however, "may be an absolute failure for that person because of some life issue that was never elicited. A contextual error occurs when the care plan is wrong for that patient," he explained.

"We're getting overmeasured on some of the wrong things, and we're not getting measured on some of the things that count to patients," said Mark Mayer, MD, director of internal medicine education at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

Aside from patient satisfaction scores, "other things that matter more to patients" should be measured, he said.

"Another issue is the frustration a lot of physicians have with the burdens of the electronic health record and of coding so many things," Dr Mayer told Medscape Medical News. "This is making some of them pay less attention to contextual issues."

Data Suggest Contextual Errors Cost

In a previous study, Dr Weiner and his colleagues assessed 774 patient encounters that took place in internal medicine clinics at two Veterans Affairs facilities (Ann Intern Med. 2013;158:573-579). From audio recordings of the encounters, the team identified 548 "contextual red flags," or clues, that something is affecting the patient's care, such as something a patient says or a sudden deterioration in the self-management of a chronic condition.

Outcome data were available for 157 contextual factors, and care plans devised by the physicians addressed 96 of these. Health outcomes were more likely to improve when contextual factors were addressed than when they were not (71% vs 46%; P = .002).

This finding shouldn't really be surprising, Dr Weiner said. "If you find out why someone isn't taking their insulin and address it, they're more likely to control their diabetes than if you don't and just add more medicine. We've shown that attention to context is a huge predictor of outcomes," he explained.

In another study Dr Weiner was involved in, actors visited 111 internal medicine attending physicians with identical complaints that included contextual components (BMJ Qual Saf. 2012;21:918-924).

The researchers estimated that for 399 visits, the cost of missed or unnecessary services related to contextual errors would be approximately $174,000. Of this, only $8745 was discernible from a review of the medical records alone.

No one is actually measuring whether I'm providing patients with the right care.

"If you ignore context, you tend to order a lot more unnecessary tests, and you end up with overuse and misuse of medical services. If you don't know that the real reason a patient loses control of a chronic condition is a life issue, you tend to work them up for all kinds of things," Dr Weiner pointed out. In that study, "we actually quantified the cost of contextual error."

The duration of visits was the same whether the physician homed in on contextual issues or not. "This was very much a surprise. We thought it would take longer. However, it's not so much a time issue, but how wide angle a lens the physician has," he explained. "There are wide variations in performance in this very important domain."

During the workshop, Dr Weiner played an audio recording of an actor playing a patient with diabetes who was experiencing symptoms that could have been syncope, but could also have been hypoglycemia. The physician did some probing and discovered that the patient had a learning disability and recently lost the support of a neighbor who had been helping him draw up the correct insulin dose.

Two live actors played out other typical scenarios during the workshop: a woman seeking nonurgent hip surgery who was taking care of a son with muscular dystrophy, making the surgery inadvisable; and a man with asthma exacerbations who, workshop attendees determined after some probing, had lost his job and couldn't afford inhalers.

Dr Weiner advised that the best way to elicit relevant information is to ask direct questions. Physicians should not worry about seeming intrusive or rude. In reality, patients might be embarrassed to raise issues themselves, particularly money issues, but usually they welcome such questions.

However, "no one is actually measuring whether I'm providing patients with the right care," said Dr Weiner. The only way to capture data on this aspect of care is to audiotape the encounters and, currently, there is no place for that in the electronic medical record.

Dr Weiner reports being on the medical advisory board for Accolade, a company that trains health assistants, and receiving funding primarily from the Department of Veterans Affairs and the National Board of Medical Examiners. Dr Mayer has disclosed no relevant financial relationships.

American College of Physicians (ACP) Internal Medicine 2016. Presented May 6, 2016.


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