Abstract
Evidence-based care plans can fail when they do not consider relevant patient life circumstances, termed contextual factors, such as a loss of social support or financial hardship. Preventing these contextual errors can reduce obstacles to effective care. To evaluate the effectiveness of a quality improvement program in which clinicians receive ongoing feedback on their attention to patient contextual factors. In this quality improvement study, patients at 6 Department of Veterans Affairs outpatient facilities audio recorded their primary care visits from May 2017 to May 2019. Encounters were analyzed using the Content Coding for Contextualization of Care (4C) method. A feedback intervention based on the 4C coded analysis was introduced using a stepped wedge design. In the 4C coding schema, clues that patients are struggling with contextual factors are termed contextual red flags (eg, sudden loss of control of a chronic condition), and a positive outcome is prospectively defined for each encounter as a quantifiable improvement of the contextual red flag. Data analysis was performed from May to October 2019. Clinicians received feedback at 2 intensity levels on their attention to patient contextual factors and on predefined patient outcomes at 4 to 6 months. Contextual error rates, patient outcomes, and hospitalization rates and costs were measured. The patients (mean age, 62.0 years; 92% male) recorded 4496 encounters with 666 clinicians. At baseline, clinicians addressed 413 of 618 contextual factors in their care plans (67%). After either standard or enhanced feedback, they addressed 1707 of 2367 contextual factors (72%), a significant difference (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .01). In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes (adjusted odds ratio, 2.5; 95% CI, 1.5-4.1; P < .001). In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million (95% CI, $23.9-$26.6 million), at a cost of $337 242 for the intervention. These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations. In addition, the intervention is associated with substantial cost savings.
Highlights
Contextualizing care is the process of adapting research evidence to patient context.[1,2] For example, recognizing that a patient has lost control of their diabetes because they cannot afford insulin glargine and switching them to a less costly alternative is a contextualized care plan
In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes
In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million, at a cost of $337 242 for the intervention. These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations
Summary
Contextualizing care is the process of adapting research evidence to patient context.[1,2] For example, recognizing that a patient has lost control of their diabetes because they cannot afford insulin glargine and switching them to a less costly alternative is a contextualized care plan. The physician is likely to document in their note that they responded to the patient’s poor diabetes control by increasing their insulin glargine dosage, which would seem reasonable. They are not likely to document that the patient cannot afford the medication, because they never elicited that information
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