Outcomes Improved When VA Physicians Took Veterans’ Individual Challenges Into Consideration

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By Brenda L. Mooney

Saul J. Weiner MD

CHICAGO — Health outcomes improved when VA physicians took patients’ individual situations into account and customized care, according to a new study.

The study conducted by researchers from the Jesse Brown and Edward Hines Jr. VAMCs in the Chicago area, the Durham, NC, VAMC and the University of Illinois at Chicago (UIC), was the largest ever to be conducted using real patients to collect data about their doctors’ behavior using concealed audio recorders. The VA-funded study appeared this spring in the Annals of Internal Medicine.1

“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 lead author Saul J. Weiner MD of the Jesse Brown VAMC and UIC. The study sought to determine if patient-centered decision-making impacted healthcare outcomes.

For the study, 774 actual patients secretly recorded their visits with 139 resident physicians at two Chicago VA internal medicine facilities. While the physicians all had agreed to participate in the study, they were not told which patients were recording them.

“Incognito audio recording provides accurate information about how doctors practice that you can’t obtain any other way,” explained co-author Alan Schwartz, PhD, of UIC.

A coding method was developed to score physicians based on whether they individualized a patient’s care plan by taking into account key contextual factors, including financial hardship, transportation problems, competing responsibilities, social support and other factors. Inattention to those issues was identified as “contextual errors” in patient care. Each participating physician was repeatedly audio-recorded until the researchers obtained three encounters with contextual red flags.

“If the patient has, for example, a chronic condition like diabetes or hypertension that’s going out of control, we would say that 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.

The PACT (Patient Aligned Care Team) is better helping to provide individualized care at VA. Each team consists of a physician, nurse, pharmacist, social worker and health technician who coordinate with the Veteran his immediate and life-long health and wellness needs. Photo courtesy of Butler, PA, VAMC

When a contextual factor was identified, either as a result of physician questioning or because a patient volunteered the information, physicians were scored on the basis of whether they adapted the care plan to it.

Researchers then reviewed each patient’s medical record and evaluated the recordings to determine if a care plan was patient-centered, taking three questions into consideration:

  • Are there contextual red flags?
  • If so, did the physician recognize the red flags and question the patient about contextual factors that could be addressed in a care plan, or did the patient volunteer such information?
  • If so, did the physician address the contextual factors in the recommended care plan?

In nine months of follow-up, researchers determined whether the original red flag had been partially or fully resolved.

The final data included 403 encounters with a total of 548 red flags — 208 contextual factors were confirmed either when physicians probed or patients volunteered information. The study noted that, when contextual factors were essential to the care plan, physicians made a customized care plan 59% of the time, failing to do so 41% of the time.

Of the cases where a contextualized care plan was created, 71% of the cases had good outcomes, compared with 46% in which physicians did not develop a contextualized care plan.

Weiner said some of the results might seem intuitive — obviously fewer missed appointments will occur if a patient without transportation is referred to a clinic-supported van service — but “this is the first study to document an association between contextualizing patient care and patient care outcomes.”

Study authors concluded, “Attention to patient needs and circumstances when planning care is associated with improved health care outcomes.”

  1. Weiner, SJ, Schwartz A, Sharma G, Binns-Calvey A, et. al. Patient-Centered Decision Making and Health Care Outcomes An Observational Study. Annals of Internal Medicine. 2013 Apr;158(8):573-579.

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