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Contextual Errors and Failures in Individualizing Patient Care: A Multicenter Study

Saul J. Weiner, MD; Alan Schwartz, PhD; Frances Weaver, PhD; Julie Goldberg, PhD; Rachel Yudkowsky, MD, MHPE; Gunjan Sharma, PhD; Amy Binns-Calvey; Ben Preyss, BA; Marilyn M. Schapira, MD, MPH; Stephen D. Persell, MD, MPH; Elizabeth Jacobs, MD, MPP; and Richard I. Abrams, MD
[+] Article and Author Information

From Veterans Affairs Center for the Management of Complex Chronic Care, University of Illinois at Chicago, Jesse Brown Veterans Affairs Medical Center, Feinberg School of Medicine, Northwestern University, John H. Stroger, Jr. Hospital, and Rush University Medical Center, Chicago, Illinois; Edward Hines Veterans Affairs Medical Center, Hines, Illinois; and Clement J. Zablocki Veterans Affairs Medical Center and Medical College of Wisconsin, Milwaukee, Wisconsin.


Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs or the U.S. government.

Acknowledgment: The authors thank Simon Auster, MD, JD, Uniformed Services University of the Health Sciences, and Michael Berbaum, PhD, University of Illinois at Chicago, for their constructive input, particularly during the planning and analysis stages of the study.

Grant Support: By the Department of Veterans Affairs Health Services Research and Development Service (grant IIR 04-107).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0665.

Reproducible Research Statement:Study protocol and statistical code: Available at www.cmc3.research.va.gov. Data set: Not available.

Requests for Single Reprints: Saul J. Weiner, MD, University of Illinois at Chicago, Academic and Educational Affairs, College of Medicine, 1853 West Polk Street, CMW 105, Chicago, IL 60612-7324; e-mail, sweiner@uic.edu.

Current Author Addresses: Dr. Weiner: Jesse Brown Veterans Affairs Medical Center, Medical Service, Department of Veterans Affairs, and University of Illinois at Chicago, Academic and Educational Affairs, College of Medicine, 1853 West Polk Street, CMW 105, Chicago, IL 60612-7324.

Drs. Schwartz, Goldberg, and Yudkowsky 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: Center for Management of Complex Chronic Care, 151H, Building 1, Room B260, 5000 South 5th Avenue, Hines Veterans Affairs Hospital, Hines, IL 60141.

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

Mr. Preyss: 1502 West Ohio Street, 2F, Chicago, IL 60642.

Dr. Schapira: Center for Patient Care and Outcomes Research, 8701 Watertown Plank Road, Milwaukee, WI 53226.

Dr. Persell: Division of General Internal Medicine, Feinberg School of Medicine, Institute for Healthcare Studies, Northwestern University, 750 North Lake Shore Drive, 10th Floor, Chicago, IL 60611.

Dr. Jacobs: Collaborative Research Unit, John H. Stroger, Jr. Hospital of Cook County and Rush University Medical Center, 1900 West Polk Street, Chicago, IL 60612.

Dr. Abrams: Rush University Medical Center, Department of Medicine, Room 301 Jones, 1653 West Congress Parkway, Chicago, IL 60612.

Author Contributions: Conception and design: S.J. Weiner, A. Schwartz, F. Weaver, J. Goldberg.

Analysis and interpretation of the data: S.J. Weiner, A. Schwartz, M.M. Schapira.

Drafting of the article: S.J. Weiner, A. Schwartz, M.M. Schapira.

Critical revision of the article for important intellectual content: S.J. Weiner, A. Schwartz, J. Goldberg, R. Yudkowsky, M.M. Schapira, S.D. Persell, E. Jacobs.

Final approval of the article: S.J. Weiner, A. Schwartz, F. Weaver, J. Goldberg, R. Yudkowsky, M.M. Schapira, S.D. Persell, E. Jacobs, R. Abrams.

Provision of study materials or patients: S.J. Weiner, M.M. Schapira, S.D. Persell, E. Jacobs, R. Abrams.

Statistical expertise: A. Schwartz.

Obtaining of funding: S.J. Weiner, F. Weaver, J. Goldberg.

Administrative, technical, or logistic support: S.J. Weiner, F. Weaver, J. Goldberg, G. Sharma, A. Binns-Calvey, M.M. Schapira, E. Jacobs, R. Abrams.

Collection and assembly of data: S.J. Weiner, J. Goldberg, R. Yudkowsky, G. Sharma, A. Binns-Calvey, M.M. Schapira, S.D. Persell, E. Jacobs.


Ann Intern Med. 2010;153(2):69-75. doi:10.7326/0003-4819-153-2-201007200-00002
Text Size: A A A

This article has been corrected. For original version, click “Original Version (PDF)” in column 2.

Background: A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.

Objective: To explore the frequency and circumstances under which physicians probe contextual and biomedical red flags and avoid treatment error by incorporating what they learn from these probes.

Design: An incomplete randomized block design in which unannounced, standardized patients visited 111 internal medicine attending physicians between April 2007 and April 2009 and presented variants of 4 scenarios. In all scenarios, patients presented both a contextual and a biomedical red flag. Responses to probing about flags varied in whether they revealed an underlying complicating biomedical or contextual factor (or both) that would lead to errors in management if overlooked.

Setting: 14 practices, including 2 academic clinics, 2 community-based primary care networks with multiple sites, a core safety net provider, and 3 U.S. Department of Veterans Affairs facilities.

Measurements: Primary outcomes were the proportion of visits in which physicians probed for contextual and biomedical factors in response to hints or red flags and the proportion of visits that resulted in error-free treatment plans.

Results: Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters.

Limitations: Only 4 case scenarios were used. The study assessed physicians' propensity to make errors when every encounter provided an opportunity to do so and did not measure actual error rates that occur in primary care settings because of inattention to context.

Conclusion: Inattention to contextual information, such as a patient's transportation needs, economic situation, or caretaker responsibilities, can lead to contextual error, which is not currently measured in assessments of physician performance.

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

Figures

Grahic Jump Location
Figure 2.
Unadjusted rates of probing, by case and variant.

Error bars show the upper boundary of the 95% CI.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Unadjusted rates of appropriate treatment plan, by case or variant.

Error bars show the upper boundary of the 95% CI.

Grahic Jump Location

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The need for biomedically and contextually sound care plans in complex patients: thoughts on creating a better practice environment.
Posted on July 31, 2010
Roger G. Kathol
Cartesian Solutions, Inc.
Conflict of Interest: None Declared

To the Editor: Weiner and colleagues(1) provide evidence that error- free treatment plans are rarely created for patients with biomedical and contextual complexity (9%) and are uncommonly created for those with contextual or biomedical complexity alone, 22% and 38% respectively. This is not surprising given that primary care physicians are already expected to devote one and a half times their available patient contact hours to providing preventive, chronic care, and acute medical services.(2) Nonetheless, implementing improved skills in error-free or, at least, error-reduced care plans for the complex one to five percent of patients who use a quarter to a third of health resources(3) will be essential for patient-centered medical homes and accountable care organizations to succeed in augmenting quality care and lowering health-related costs.(4) Removing barriers to improvement in these most needy and expensive patients can only be accomplished through consistent identification and outcome-changing intervention, including contextual life situation support.

Weiner and colleagues(1) thus raise a practical system-based question in this time of health reform, i.e., can already overtaxed clinicians be expected to personally uncover and create individualized care plans in those with biomedical and contextual complexity? Logically, to do so would require decreasing the number of patients per physician panel, thereby increasing available patient contact time; expanding the number of treatment level clinicians (physicians, physician assistants, nurse practitioners, etc.); and/or adding specialized support personnel to clinician teams, such as case managers,(5) that can assist treating practitioners individualize complex patient biopsychosocial and health system support.

As physicians intimately involved in augmenting the care of patients with health complexity, we see Weiner and colleagues(1) findings as a clinical challenge for physicians wishing to practice quality medicine. Perhaps a greater challenge, however, is for those involved in system- level care delivery enhancement, e.g., designing patient-centered medical homes or accountable care organizations, to create financially sustainable practice environments that allow practitioners time to consistently address biomedical and contextual needs in patients with complicated life and health situations.

References

1. Weiner SJ, Schwartz A, Weaver F, et al. Contextual errors and failures in individualizing patient care: a multicenter study. Ann Intern Med. 2010;153(2):69-75.

2. Bindman AB, Forrest CB, Britt H, Crampton P, Majeed A. Diagnostic scope of and exposure to primary care physicians in Australia, New Zealand, and the United States: cross sectional analysis of results from three national surveys. BMJ. 2007;334(7606):1261.

3. Zuvekas SH, Cohen JW. Prescription drugs and the changing concentration of health care expenditures. Health Aff (Millwood). 2007;26(1):249-57.

4. McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Aff (Millwood);29(5):982-90.

5. Kathol RG, Perez R, Cohen JS. The Integrated Case Management Manual: Assisting Complex Patients Regain Physical and Mental Health. 1st ed New York City: Springer Publishing; 2010.

Conflict of Interest:

Owners of a health complexity and physical and mental health integration medical management company.

Author's Reply Re:The need for biomedically and contextually sound care plans in complex patients: thoughts on creating a better practice environment.
Posted on September 15, 2010
Saul J. Weiner
Jesse Brown VA Medical Center and University of Illinois at Chicago
Conflict of Interest: None Declared

IN RESPONSE: One of the findings of our study (1) that surprised us was that while physicians who spent more time with patients were more likely to probe for biomedical or contextual red flags, they were not more likely to provide contextually appropriate care. In the case of a patient whose health literacy problems accounted for an inability to dose his diabetes medications correctly, for instance, physicians more often identified the literacy issue during longer visits, but were not more likely to appropriately intervene. Those who intervened, however, did not on average have longer visits. Physicians who avoid contextual errors seem to think differently, considering context not as an afterthought, but as a part of the clinical reasoning process. We have recently studied an educational intervention that suggests such reasoning processes can be effectively taught (2).

Drs. Kathol and Kathol propose that if physicians had more time and specialized support personnel, such as case managers and mid-level providers they would be more likely to provide contextually appropriate care. While we did not find that additional time alone helped, it may well be that the combination of additional time and a medical home environment, would substantially improve care. Physicians who, during longer visits, unmasked health literacy problems as the root cause of a patient's poor diabetes control may simply have concluded that there was nothing they could do about it, not having for instance, a diabetes educator who could assist. We share the Kathols' concern that the major challenge for those in system-level care delivery enhancement, is designing financially sustainable practice environments that support physicians who have developed the cognitive skills to individualize care, with the resources and tools needed to do so.

References

1. Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, Binns-Calvey A, Preyss B, Schapira M, Persell SD, Jacobs E, Abrams R. Contextual errors and failures in individualizing patient care: A multicenter study. Ann Intern Med. 2010;153(2):69-75.

2. Schwartz A. Weiner SJ, Harris I, Binns-Calvey A. An educational intervention for contextualizing patient care and medical students' abilities to probe for contextual issues in simulated patients. JAMA. 304(11):1191-1197

Conflict of Interest:

None declared

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