Illinois Medicine

Know Thy Patients Study finds individualized care that takes life circumstances into account more effective in improving health conditions W hen doctors individualize care in a way that takes patients' life circumstances into account, their health outcomes improve, according to a joint study by the College of Medicine and the U.S. Department of Veterans Affairs that used real patients to collect data about doctors' behavior using hidden audio recorders. "What our study really tells us is that the information that patients divulge during appointments about their life situation is critical to address and take into account if we're looking for optimal health care outcomes," said Saul Weiner, MD, the study's lead author. Weiner is vice provost for planning and programs, professor of 6 | Fa l l 2 0 13 medicine, pediatrics and medical education at the college and staff physician at the Jesse Brown VA Medical Center. The study recruited 774 patients who surreptitiously audio recorded their visits with 139 resident physicians, all of whom had agreed to participate but did not know which patients were recording them. One of the study's central goals was to determine if patient-centered decision making, defined as identifying clinically relevant information about a patient's circumstances or behaviors, impacted health care outcomes. "Incognito audio recording provides accurate information about how doctors practice that you can't obtain any other way," said Alan Schwartz, PhD, associate professor and associate head of medical education at the college, and a co-author of the paper. The researchers scored physicians' steps toward individualizing a patient's care plan by accounting for key contextual factors like financial hardship, transportation problems, competing responsibilities, social support and other factors. Inattention to issues like these leads to what are called "contextual errors" in patient care; for example, if a patient missed a lot of appointments, that's an issue the physician should ask about. "If the patient has, for example, a chronic condition like diabetes or hypertension that's going out of control, we would say that's also a contextual issue and probably a sign that something is going on in that patient's life that needs to be addressed," Weiner said. To determine if a care plan was patient-centered, the researchers reviewed the patient's medical record and evaluated the recordings, then answered three questions: • • Are there contextual red flags? If so, did the physician recognize them and question the patient about factors that could be addressed in a care plan? Or, did the patient volunteer such information? • And if such a discussion was held, did the physician address the answers gleaned in the recommended care plan? Researchers followed up with patients for nine months to examine their health care outcomes and determine if the original red flag had been partially or fully resolved. Each participating physician was repeatedly recorded until researchers obtained three encounters with contextual red flags. The final data included 403 encounters with a total of 548 red flags, which ended up boiling down to a total of 208 contextual factors. When those contextual factors were essential to the care plan, physicians included them in the care plan 59 percent of the time. In the cases where the physician made a contextualized care plan, there was a good outcome in 71 percent of the cases; where they did not, a good outcome occurred in 46 percent of cases. Weiner noted it may seem intuitive that there will be fewer missed appointments if a physician discovers a patient has a transportation-related issue and refers the patient to a clinic-supported van service. "But this is the first study to document an association between contextualizing patient care and patient care outcomes," he said. The study, which appeared in the April 16 issue of Annals of Internal Medicine, is funded by the U.S. Department of Veterans Affairs. Other co-authors include Ilene Harris, PhD, and Amy Binns-Calvey, research associate, College of Medicine; Amit Dayal, Frances Weaver and Brendan Kelly, Hines Veterans Affairs Hospital; Gunjan Sharma and Naomi Ashley, Jesse Brown Veterans Affairs Medical Center; and Sonal Patel, Durham VA Medical Center.

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