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Original Research |

IMPROVING PATIENT CARE

Patient-Centered Decision Making and Health Care Outcomes: An Observational Study

Saul J. Weiner, MD; Alan Schwartz, PhD; Gunjan Sharma, PhD; Amy Binns-Calvey, BA; Naomi Ashley, BA; Brendan Kelly, BA; Amit Dayal, MD; Sonal Patel, MD; Frances M. Weaver, PhD; and Ilene Harris, PhD
[+] Article and Author Information

From Jesse Brown Veterans Affairs Medical Center and University of Illinois at Chicago, Chicago, Illinois; Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois; and Durham Veterans Affairs Medical Center, Durham, North Carolina.

Disclaimer: Dr. Weiner had full access to all of the data in the study and takes responsibility for their integrity and the accuracy of the analysis.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2719.

Reproducible Research Statement: Study protocol and statistical code: Available on request. Data set: Not available.

Requests for Single Reprints: Saul J. Weiner, MD, University of Illinois at Chicago, 2730 UH MC 103, 601 South Morgan, Chicago, IL 60607-7128; e-mail, sweiner@uic.edu.

Current Author Addresses: Dr. Weiner: Jesse Brown VA Medical Center, Building 11A, R&D (MC 151), 820 South Damen Avenue, Chicago, IL 60612; University of Illinois at Chicago, 2730 UH MC 103, 601 South Morgan, Chicago, IL 60607-7128.

Drs. Schwartz and Harris and Ms. Binns-Calvey: Department of Medical Education, MC 591, University of Illinois at Chicago College of Medicine, 808 South Wood Street, Chicago, IL 60612.

Dr. Weaver and Mr. Kelly: Center for Management of Complex Chronic Care, Hines Veterans Affairs Hospital, 151H, Building 1, Room B260, 5000 South 5th Avenue, Hines, IL 60141.

Dr. Sharma and Ms. Ashley: Jesse Brown Veterans Affairs Medical Center, Building 11A, MC 151, 820 South Damen Avenue, Chicago, IL 60612.

Dr. Dayal: Edward J. Hines, Jr. VA Hospital, South Primary Care Building 228, 3rd Floor, 5th and Roosevelt, Hines, IL 60141.

Dr. Patel: Durham VA Medical Center, Ambulatory Care Service, 508 Fulton Street, Durham, NC 27705.

Author Contributions: Conception and design: S.J. Weiner, A. Schwartz, A. Binns-Calvey, I. Harris.

Analysis and interpretation of the data: S.J. Weiner, A. Schwartz, G. Sharma, A. Binns-Calvey, N. Ashley, B. Kelly, A. Dayal, F.M. Weaver.

Drafting of the article: S.J. Weiner.

Critical revision of the article for important intellectual content: S.J. Weiner, A. Schwartz, A. Binns-Calvey, S. Patel, F.M. Weaver, I. Harris.

Final approval of the article: S.J. Weiner, A. Schwartz, G. Sharma, A. Binns-Calvey, A. Dayal, F.M. Weaver, I. Harris.

Provision of study materials or patients: G. Sharma, A. Binns-Calvey, I. Harris.

Statistical expertise: A. Schwartz.

Obtaining of funding: S.J. Weiner.

Administrative, technical, or logistic support: S.J. Weiner, G. Sharma, A. Binns-Calvey, A. Dayal, F.M. Weaver, I. Harris.

Collection and assembly of data: S.J. Weiner, G. Sharma, A. Binns-Calvey, N. Ashley, B. Kelly, A. Dayal, S. Patel.


Ann Intern Med. 2013;158(8):573-579. doi:10.7326/0003-4819-158-8-201304160-00001
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Chinese translation

Background: Patient-centered decision making (PCDM) is the process of identifying clinically relevant, patient-specific circumstances and behaviors to formulate a contextually appropriate care plan.

Objective: To ascertain whether encounters in which PCDM occurs are followed by improved health care outcomes compared with encounters where there is inattention to patient context.

Design: Patients surreptitiously audio-recorded encounters with their physicians. Medical records of these encounters were then screened for “contextual red flags,” such as deteriorating self-management of a chronic condition, that could reflect such underlying contextual factors as competing responsibilities or loss of social support. When a contextual factor was identified, either as a result of physician questioning or because a patient volunteered information, physicians were scored on the basis of whether they adapted the care plan to it.

Setting: Internal medicine clinics at 2 Veterans Affairs facilities.

Participants: 774 patients audio-recorded encounters with 139 resident physicians.

Measurements: Individualized outcome measures were based on the contextual red flag, such as improved blood pressure control in a patient presenting with hypertension and loss of medication coverage. Outcome coders were blinded to physician performance.

Results: Among 548 contextual red flags, 208 contextual factors were confirmed, either when physicians probed or patients volunteered information. Physician attention to contextual factors (both probing for them and addressing them in care plans) varied according to the presenting contextual red flags. Outcome data were available for 157 contextual factors, of which PCDM was found to address 96. Of these, health care outcomes improved in 68 (71%), compared with 28 (46%) of the 61 that were not addressed by PCDM (P = 0.002).

Limitation: The extent to which the findings can be generalized to other clinical settings is unknown.

Conclusion: Attention to patient needs and circumstances when planning care is associated with improved health care outcomes.

Primary Funding Source: U.S. Department of Veterans Affairs, Health Services Research & Development Service.

Figures

Grahic Jump Location
Figure 1.

Study flow diagram.

RA = research assistant.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Outcomes according to physician performance at contextualizing care.

Grahic Jump Location

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Comments

Submit a Comment
Medicine and Poetry
Posted on April 17, 2013
Joshua Blum
Denver Health and Hospital Authority
Conflict of Interest: None Declared
The article by Drs. Aboumatar and Cooperon patient-centered care demonstrates how to wring every last bit of romance and nuance from that final frontier of medical magic: the doctor-patient interaction. Reducing this relationship to a ratio of 'psychosocial, rapport-building, and facilitative utterances to those that further only the biomedical agenda' might be helpful to understand from a research standpoint, but is utterly nauseating to read about. While I welcome their conclusion that 'further contextualization of patient-centered health care is required to improve health outcomes,' describing communication in such technocratic and ultimately soulless language serves as a perfect example of why every other aspect of medicine, outside of the moments spent in the direct care of patients, has become so unfulfilling, and why reading poetry will always be better than reading about poetry.
The Romance is Indeed Dead
Posted on September 15, 2013
Marcille Labban
St. Joseph's Regional Medical Center
Conflict of Interest: None Declared
While I understand the dollars and cents aspect and benefit of this study, I couldn't agree with Dr. Blum more.
This is a stomach turning read. The fact that a study needs to be conducted to determine the effect of your doctor simply asking "how are things?" and "What's been going on with you" is truly saddening.
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