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Patients’ Circumstances Count in Care Planning


 

Hospitals, insurers, and regulators today direct unparalleled time and resources toward battling medical errors. According to research from Saul Weiner, MD, a teacher and hospitalist at the University of Illinois, Chicago, one type of error is being ignored.

“I found that contextual errors are as least as common and probably even more serious in inpatient care,” Dr. Weiner says. Contextual errors occur when physicians neglect to recognize the crucial role a patient’s life plays in care planning, he says. “I would argue that there are contextual issues in virtually every admission,” he adds.

Dr. Weiner and his team are trying to prove the importance of systematizing how physicians learn to contextualize care. For their research, published in the September 2007 issue of Medical Decision Making, the doctors trained actors to present scenarios in which contextual information was essential to planning appropriate care. They then tested 54 internal medicine residents to see how many would provide contextually appropriate care. More than half made serious errors.1

Why Now?

From the time Dr. Weiner started precepting residents in 1997, he noticed many were quick to fit patients into categories where they could apply evidence-based approaches to care. “But I sometimes sensed that there was something not so straightforward about a particular patient’s situation, some unexplained issue for why the patient wasn’t taking his asthma meds properly, or was coming in today of all days,” he says. When he and the residents would re-question such patients, “key factors often arose that made everything change about the way we wanted to manage them.”

For him, the seminal case occurred in 2002 when a patient who came to the preoperative testing clinic for bariatric surgery. She qualified for surgery, although because of history of adhesions, the surgery was going to be open rather than laparoscopic. When she said she was looking forward to getting the surgery so she could better care for her son, a red flag went up for Dr. Weiner.

“Patients don’t typically offer such reflections,” he says. Further probing revealed that she had a son in his 20s with a fatal disease, she was the sole caregiver, and her husband was an alcoholic. “She really hadn’t processed the fact that she would not be able to do anything for 40 days,” Dr. Weiner says. “Suddenly, when she got that, she wound up canceling surgery.”

The importance of learning a patietn’s contextual factors depends on the setting and the availability of resources, such as case managers, social workers, and outpatient chronic disease teams. Even with those resources, the onus still is on the hospitalist to determine an effective plan of care using context, he says.

Cases of Context

Re-questioning of these inpatients and their families revealed contextual factors that significantly affected the plan of care.

Case 1: A 46-year-old Spanish-speaking woman with diabetes mellitus, end-stage renal disease on hemodialysis (HD) came to the emergency room with fluid overload secondary to missed HD and with hyperglycemia. She had several similar prior ER visits.

Red Flag: She missed HD several times, with frequent admissions for a preventable problem. No one asked why.

Contextual Narrative 1: Patient’s son is s/p renal transplant and receives nearly weekly care at the same hospital. The patient receives HD at a center in the opposite direction from her home. Frequently, she must choose between her son’s care and her own. He is her priority.

Solution: Transfer her HD to the same hospital where her son receives care.

Contextual Narrative 2: Questions about her worsening diabetes control reveals she cannot read her medications clearly due to worsening eyesight. An argument with an ophthalmologist she’d seen a year before led her to go without care.

Solution: Find a new ophthalmologist.

Contextual factors: Access to care (transportation) and attitudes toward the healthcare provider and healthcare system.

Case 2: A 57-year-old diabetic man is admitted with two pre-syncopal episodes, with palpitations. Both times he drinks some juice and feels better.

Red Flag: When the physician is taking history, the patient keeps mixing up his medications and dosages.

Contextual Narrative: He has poor health literacy, probably a combination of a limited education and an undiagnosed learning disability. He had help with his meds at his former home, but since moving to care for his aging mother, he is now on his own.

Solution: Recognize the literacy issues and work to find a solution (pre-filled syringes, diabetic education, etc.).

Contextual factors: Cognitive abilities.

Case 3: A middle-aged patient has newly worsening asthma.

Red Flag: He mentions during the intake exam that it’s been hard since he lost his job.

Contextual Narrative: Through his wife’s employer, he’s on an insurance plan that provides him only with major medical coverage, not medications. He’s been using an expensive brand name inhaler incorrectly (every couple of days instead of daily) when less costly generics are available.

Solution: Get him a prescription for an affordable generic medication.

Contextual factors: Economic situation.

Case 4: A 52-year-old woman with a CVA neurogenic bladder had recent multiple admission for UTIs. She had previously done well.

Red Flag: On the third admission the resident was puzzled as to how the patient catheterized herself given that she had little use of her arms.

Contextual Narrative: On questioning, the woman explained that her husband assists in catheterizing her, but his worsening alcoholism no longer made him reliable.

Solution: The primary care physician was notified, and met with the patient and her adult daughter to develop another caretaker plan.

Contextual factors: Caretaker responsibilities.

How Well Do Hospitalists Spot Red Flags?

Tuning up the radar to prevent these errors comes down to providers asking one question and listening to one answer: What is the best thing I can do for this patient at this time? Watch for red flags, statements patients make or actions they take that may signal something lying beneath the surface that could make a huge difference in outcomes, Dr. Weiner says.

Spotting red flags isn’t always easy for hospitalists, who don’t see the same patients on a regular basis, says William Stinnette, MD, hospitalist with Kaiser Permanente in San Rafael, Calif. “Unless patients are a part of that ‘revolving door,’ with frequent visits to the hospital, we have to work up most of our patients with limited background knowledge,” he says.

Contextual Categories with Examples of Questions to Ask Patients

  • Cognitive abilities: Is she capable of taking these medications correctly?
  • Emotional state: Is he too distressed to consider his options now?
  • Cultural beliefs: How does her home country view preventative medicine?
  • Spiritual beliefs: Could her minister help her reach a decision?
  • Access to care: Can we monitor her on warfarin adequately if she doesn’t have transportation?
  • Social support: Now that he is weaker, will his wife still be able to care for him at home?
  • Caretaker responsibilities: Who will take care of her disabled child while she recovers from surgery?
  • Attitude toward illness: Why is he reluctant to take pain medication when he is suffering?
  • Relationship with healthcare provider: Will she be comfortable calling me if her dyspnea gets worse?
  • Economic situation: Should I look for another medication that costs less?

Source: Weiner SJ. Contextualizing medical decisions to individualize care: Lessons from the qualitative sciences. J Gen Intern Med. 2004;19(3):281-5.

Dr. Stinnette, who has worked in hospital medicine groups in both small and large facilities, believes the ability to ferret out contextual factors depends on the setting and teh availability of resources, such as case managers, social workers, and outpatient chornic disease teams. Even with those resources, the onus is still on the hospitalist to determine an effective plan of care using context, he says.

Dr. Weiner agrees. “Clinical decision-making,” he writes in the Medical Decision Making article, “requires two distinct skills: the ability to classify patients’ conditions into diagnostic and management categories that permit the application of research evidence, and the ability to individualize (contextualize) care for patients whose circumstances and needs require variation from a standardized approach.”1

Though most hospitalists recognize the importance of doing this, according to Dr. Weiner, they lack a systematic and coherent way to do so.2

Standardized Training

Physicians are well trained in assessing biomedical information, but not in listening for contextual red flags. “When you need to know what’s unique about a particular patient that might be relevant to the case, you don’t really know what you’re searching for,” Dr. Weiner says. “You just need clarity, and that is theory-building or inductive reasoning, a very different skill.”

Since July, with support from the National Board of Medical Examiners, the University of Illinois, Chicago, team has been testing a contextual-care curriculum for fourth-year medical students to complete during their inpatient medical sub-internships. In the randomized controlled trial, half of the trainees receive the intervention, half do not. Those getting trained learn that when they intuitively feel there is more to a patient’s story, they should return to the patient to find out why.

They also learn to conduct a contextual history by asking simple, straightforward questions, keeping in mind potential areas of context, including the patient’s emotional state and cultural beliefs (see sidebar, “Cases of Context”). Through this process, the residents learn to identify ways to avoid contextual errors in their patients’ care.

At the end of the month-long curriculum, all trainees are tested in the patient laboratory. “The simulated patients are trained to present with complex histories,” Dr. Weiner says. If residents don’t probe properly, the patients don’t reveal the context. Both groups—those who’ve had the intervention and those who have not—interview the patients, and the study is tracking which physicians get the cases ‘correct.’ ”

The Cost of Errors

For a next phase of research, the university has enrolled about 100 physicians from multiple centers in the Chicago/Milwaukee area to participate in visits by undercover actors simulating real patients. The cases require uncovering contextual information to avoid making errors when planning their care.

After each visit, the team downloads and scores the physician’s note, identifying both unnecessary tests and missed opportunities. Using Medicare reimbursement data, the team assigns a dollar amount to these errors that would have occurred had the patients been real. Dr. Weiner predicts publicizing the financial costs will bring more attention to the problem.

Access to Care Issues

Actually, physicians should talk to their patients about the cost of their care, says David O. Meltzer, MD, PhD, associate professor and chief of the Section of Hospital Medicine at the University of Chicago Medical Center. In research published in the Journal of the American Medical Association in 2003, Dr. Meltzer and colleagues found patient costs may be associated with medication nonadherence and considerable economic burden.3

“You have to ask a patient the type of questions that will be most revealing, including the broader questions, such as ‘Are there any challenges in your life to getting the care that we’ve discussed after you leave the hospital?’ ” Dr. Stinnette, of Kaiser, says.

In their study, Dr. Meltzer and colleagues also showed that although physicians and patients agree it is important to talk about money issues, it doesn’t commonly happen.3

“In a public hospital where there are greater numbers of uninsured patients, I expect it is much more a frequent topic of conversation,” Dr. Meltzer says. “My suspicion is that the people at greatest risk are uninsured patients who are hospitalized in settings where most patients are insured, and physicians are not attuned to bringing up this issue.”

Although a great deal of literature now deals with physician-patient communication, the techniques seem too scripted to Dr. Weiner. “When you engage with the patient simply as one person who is concerned about another,” he says, “you much more naturally find out what you could do that might help them.”

References

  1. Weiner SJ, Schwartz A, Yudkowsky R, et al. Evaluating physician performance at individualizing care: A pilot study tracking contextual errors in medical decision-making. Med Decis Making 2007;27(6):726-34.
  2. Weiner SJ. Contextualizing medical decisions to individualize care: Lessons from the qualitative sciences. J Gen Intern Med 2004;19(3):281-5.
  3. Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA 2003;290(7):953-958.

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