Listening to the Patient: A Typology of Contextual Red Flags in Disease Management Encounters.

PURPOSE: Patients send clues, often unwittingly, when they are grappling with a life challenge that complicates their care. For instance, a patient may lose control of a previously well-managed chronic condition or start missing appointments. When explored, these clues help clinicians uncover the life circumstance impacting the individual's ability to manage their health and health care. Such clues are termed "contextual red flags." Effective care requires recognizing them, asking about them, and customizing the care plan where feasible. We sought to develop a typology of contextual red flags by analyzing audio recordings along with the medical records of encounters between patients and providers in outpatient clinics. METHODS: During the course of 3 studies on physician attention to patient context conducted over a 5-year span (2012-2016), 4 full-time coders listened to the audios and reviewed the medical records of 2963 clinician-patient encounters. A list of contextual red flags was accrued and categorized until saturation was achieved. RESULTS: A total of 70 contextual red flags were sorted into 9 categories, comprising a typology of contextual red flags: uncontrolled chronic conditions; appointment adherence; resource utilization; medication adherence; adherence to plan of care; significant weight loss/gain; patient knowledge of health or health care status; medical equipment/supplies adherence; other. CONCLUSIONS: A relatively small number of clues that patients are struggling to self-manage their care warrant clinicians' exploring opportunities to adapt care plans to individual life circumstances. These contextual red flags group into an even smaller set of logical categories, providing a framework to guide clinicians about when to elicit additional information from patients about life challenges they are facing.

Alerting Doctors About Patient Life Challenges: A Randomized Control Trial of a Previsit Inventory of Contextual Factors.

Objective. Effective care attends to relevant patient life context. We tested whether a patient-completed inventory helps providers contextualize care and increases patients' perception of patient-centered care (PCC). Method. The inventory listed six red flags (e.g., emergency room visits) and if the patient checked any, prompted for related contextual factors (e.g., transportation difficulties). Patients were randomized to complete the inventory or watch health videos prior to their visit. Patients presented their inventory results to providers during audio-recorded encounters. Audios were coded for physician probing and incorporating context in care plans. Patients completed the Consultation and Relational Empathy (CARE) instrument after the encounter. Results. A total of 272 Veterans were randomized. Adjusting for covariates and clustering within providers, inventory patients rated visits as more patient-centered (44.5; standard error = 1.1) than controls (42.7, standard error = 1.1, P = 0.04, CARE range = 10-50). Providers were more likely to probe red flags (odds ratio = 1.54; confidence interval = 1.07-2.22; P = 0.02) when receiving the inventory, but not incorporating context into care planning. Conclusion. A previsit inventory of life context increased perceptions of PCC and providers' likelihood of exploring context but not contextualizing care. Information about patients' life challenges is not sufficient to assure that context informs provider decision making even when provided at the point of care by patients themselves.

Content coding for contextualization of care: evaluating physician performance at patient-centered decision making.

BACKGROUND AND OBJECTIVE: . Adapting best evidence to the care of the individual patient has been characterized as "contextualizing care" or "patient-centered decision making" (PCDM). PCDM incorporates clinically relevant, patient-specific circumstances and behaviors, that is, the patient's context, into formulating a contextually appropriate plan of care. The objective was to develop a method for analyzing physician-patient interactions to ascertain whether decision making is patient centered. METHODS: . Patients carried concealed audio recorders during encounters with their physicians. Recordings and medical records were reviewed for clues that contextual factors, such as an inability to pay for a medication or competing responsibilities, might undermine an otherwise appropriate care plan, rendering it ineffective. Iteratively, the team refined a coding process to achieve high interrater agreement in determining (a) whether the clinician explored the clues-termed "contextual red flags"-for possible underlying contextual factors affecting care, (b) whether the presence of contextual factors was confirmed and, if so, (c) whether they were addressed in the final care plan. RESULTS: . A medical record data extraction instrument was developed to identify contextual red flags such as missed appointments or loss of control of a treatable chronic condition which signal that contextual factors may be affecting care. Interrater agreement (Cohen's kappa) for coding whether the clinician explored contextual red flags, whether a contextual factor was identified, and whether the factors were addressed in the care plan was 88% (0.76, P < 0.001), 94% (0.88, P < 0.001), and 85% (0.69, P < 0.001) respectively. CONCLUSIONS: . PCDM can be assessed with high interrater agreement using a protocol that examines whether essential contextual information (when present) is addressed in the plan of care.

Patient-centered decision making and health care outcomes: an observational study.

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.