Contextual Errors and Failures in Individualizing Patient Care

Weiner, Saul J.; Schwartz, Alan; Weaver, Frances M.; Goldberg, Jack; Yudkowsky, Rachel; Sharma, Gunjan; Binns-Calvey, Amy; Preyss, Ben; Schapira, Marilyn M.; Persell, Stephen D.; Jacobs, Elizabeth A.; Abrams, Richard

doi:10.7326/0003-4819-153-2-201007200-00002

Cited by 163 publications

(148 citation statements)

References 14 publications

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“…Although contextual influences have a considerable impact on the success or failure of a diabetes self-management regimen, they are seldom adequately discussed and incorporated into the treatment plan during the medical visit. 35 For this reason, patients who receive medical care that meets guidelines for technical quality (i.e. receiving appropriate laboratory tests and examinations), and are put on clinically appropriate medication regimens during the medical visit, may not succeed in diabetes self-management in their daily life context.…”

Section: Discussionmentioning

confidence: 99%

Self-reported Neighborhood Safety and Nonadherence to Treatment Regimens Among Patients with Type 2 Diabetes

Billimek

Sorkin

2011

J GEN INTERN MED

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Section: Discussionmentioning

confidence: 99%

Self-reported Neighborhood Safety and Nonadherence to Treatment Regimens Among Patients with Type 2 Diabetes

Billimek

Sorkin

2011

J GEN INTERN MED

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“…Their plans were correct in 73 % of the uncomplicated baseline encounters, 38 % of the biomedically complicated encounters, 22 % of the contextually complicated encounters, and 9 % of the biomedically and contextually complicated encounters. 12 Tables 3 and 4 present the frequency of utterance types for physicians and USPs, respectively, across all encounters, and separately for those encounters in which the physician's plan was correct vs. incorrect. Encounters with correct plans appeared to have slightly higher median numbers of physician utterances classified as patient engagement and positive rapport-building, and higher median numbers of patient utterances classified as information giving and positive rapport-building.…”

Section: Resultsmentioning

confidence: 99%

“…Further details of case development and study design are described in a prior publication, in which we first reported the contextual error rates of the physicians in this study. 12 The assessment of performance in the management of the uncomplicated and biomedically complicated variants of cases is based on guidelines grounded in research evidence. However, assessment of performance in the management of the contextually complex variants-where appropriate care requires not following guidelines-required a novel method of case development and validation which is detailed elsewhere.…”

Section: Case Development and Validationmentioning

confidence: 99%

“…All encounters occurred between April 2007 and April 2009. 12 The institutional review boards of the University of Illinois at Chicago, the Jesse Brown VA Medical Center, and all affiliates approved the study. …”

Section: Unannounced Standardized Patientsmentioning

confidence: 99%

“…They were randomly assigned to one of 16 permuted blocks that combined four cases and variants in a partial factorial arrangement, so that each physician was assigned one of each of four cases with a different variant in each, for a total of four visits per physician. 12 After the physician had written their note, following each encounter, they were notified they had seen a fake patient and asked via email if they thought the patient had been authentic. Participants provided demographic information on their age, ethnicity, gender, medical education, and clinical experience.…”

Section: Physician Samplementioning

confidence: 99%

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Unannounced Standardized Patient Assessment of the Roter Interaction Analysis System: The Challenge of Measuring Patient-Centered Communication

et al. 2012

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BACKGROUND: Despite wide-spread endorsement of patient-centered communication (PCC) in health care, there has been little evidence that it leads to positive change in health outcomes. The lack of correlation may be due either to an overestimation of the value of PCC or to a measurement problem. If PCC measures do not capture elements of the interaction that determine whether the resulting care plan is patient-centered, they will confound efforts to link PCC to outcomes. OBJECTIVE: To evaluate whether one widely used measure of PCC, the Roter Interaction Analysis System (RIAS), captures patient-centered care planning. DESIGN: RIAS was employed in the coding of unannounced standardized patient (USP) encounters that were scripted so that the failure to address patient contextual factors would result in an ineffective plan of care. The design enabled an assessment of whether RIAS can differentiate between communication behavior that does and does not result in a care plan that takes into account a patient's circumstances and needs. PARTICIPANTS: Eight actors role playing four scripted cases (one African American and one Caucasian for each case) in 399 visits to 111 internal medicine attending physicians. MAIN MEASURES: RIAS measures included composites for physician utterance types and (in separate models) two different previously applied RIAS patientcenteredness summary composites. The gold standard comparison measure was whether the physician's treatment plan, as abstracted from the visit note, successfully addressed the patient's problem. Mixed effects regression models were used to evaluate the relationship between RIAS measures and USP measured performance, controlling for a variety of design features. KEY RESULTS: None of the RIAS measures of PCC differentiated encounters in which care planning was patient-centered from care planning in which it was not. CONCLUSIONS: RIAS, which codes each utterance during a visit into mutually exclusive and exhaustive categories, does not differentiate between conversations leading to and not leading to care plans that accommodate patients' circumstances and needs.

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Patient-Centered Care Means Better Health Care

Kirwan¹

2011

Arch Intern Med

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relation between PIMs and adverse events, length of stay, discharge to higher levels of care, or in-hospital mortality. Schamder et al 4 reduced PIM use among hospitalized patients, but this reduction did not result in fewer adverse reactions.Inappropriate use of medications is problematic, but most medication-related harms do not involve PIMs. All together, more than 40 generally recognized PIMs cause an estimated 3.6% of emergency department visits for adverse events among US older adults, while just 3 other drugs (warfarin, insulin, and digoxin) account for 10 times more visits. 5 In the hospital setting, approximately 40% of Medicare patients are treated with anticoagulation and warfarin, heparin, and low-molecular weight heparins are associated with adverse events in 8.2%, 13.6%, and 9.6% of these patients, respectively. 6 Fittingly, reducing harm from anticoagulation is a Joint Commission national patient safety goal. 7 As another example, hospitalacquired, hospital-onset Clostridium difficile infections cause an estimated 165 000 cases, 9000 deaths, and $1.3 billion in excess costs in the United States annually, and one of the most crucial modifiable factors in their prevention is antimicrobial overuse. 8 While C difficile infections and anticoagulant adverse events cannot be prevented with simple prescribing alerts alone, until studies demonstrate that reductions in PIM use substantially improve patient safety outcomes, future health information technology innovations should focus on such issues that are consistently linked to common, serious, and preventable harms rather than on narrow metrics of pharmacologic appropriateness lacking clinical context.

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Contextual Errors and Failures in Individualizing Patient Care

Abstract: U.S. Department of Veterans Affairs Health Services Research and Development Service

Cited by 163 publications

References 14 publications

Self-reported Neighborhood Safety and Nonadherence to Treatment Regimens Among Patients with Type 2 Diabetes

Self-reported Neighborhood Safety and Nonadherence to Treatment Regimens Among Patients with Type 2 Diabetes

Unannounced Standardized Patient Assessment of the Roter Interaction Analysis System: The Challenge of Measuring Patient-Centered Communication

Patient-Centered Care Means Better Health Care

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