Saul J. Weiner

Contextualizing medical decisions to individualize care: lessons from the qualitative sciences.

Clinical decision making can be described as answering one question: “What is the best next thing for this patient at this time?” In addition to incorporating clinical information, research evidence, and patient preferences, the process requires considering contextual factors that are unique to each patient and relevant to their care. The failure to do so, thereby compromising that care, can be called a “contextual error.” Although proponents of evidence-based clinical decision making and many scholars of the medical interview emphasize the importance of individualizing care, no operational definition is provided for the concept, nor is any methodology proposed for the interpretation of clinically relevant patient-specific variables. By conceptualizing the physician-patient encounter as a participant-observer case study with an N of 1, this essay describes how existing approaches to studying social systems can provide clinicians with a systematic approach to individualizing their clinical decision making.

Patients' Perceptions of Screening for Health Literacy: Reactions to the Newest Vital Sign

Difficulties in caring for patients with limited health literacy have prompted interest in health literacy screening. Several prior studies, however, have suggested that health literacy testing can lead to feelings of shame and stigmatization. In this study, we examine patient reaction to the Newest Vital Sign (NVS), a screening instrument developed specifically for use in primary care. Data were collected in 2008 in the Morehouse School of Medicine, Department of Family Medicine Primary Care Clinics, where health literacy screening was implemented as part of routine intake procedures. Following the visit, patients completed a series of questions assessing their screening experiences. A total of 179 patients completed both the NVS and the reaction survey. Nearly all (> 99%) patients reported that the screening did not cause them to feel shameful. There were also no differences in the reported prevalence of shame (p ≤ .33) by literacy level. Finally, when asked if they would recommend clinical screening, 97% of patients answered in the affirmative. These results suggest that screening for limited health literacy in primary care may not automatically elicit feelings of shame. Even patients with the lowest levels of literacy were both comfortable with and strongly supportive of clinical screening.

I can't afford that!: dilemmas in the care of the uninsured and underinsured.

When patients lack sufficient health care insurance, financial matters become integrally intertwined with biomedical considerations in the process of clinical decision making. With a growing medically indigent population, clinicians may be compelled to bend billing or reimbursement rules, lower standards, or turn patients away when they cannot afford the costs of care. This article focuses on 3 types of dilemmas that clinicians face when patients cannot pay for needed medical services: (1) whether to refer the individual to a safety net provider, such as a public clinic; (2) whether to forgo indicated tests and therapies because of cost; and (3) whether to reduce fees by fee waivers or other adjustments in billing. Clinicians’ responses to these dilemmas impact on quality of care, continuity, safety net providers, and the liability risk of committing billing violations or offering nonstandard care. Caring for the underinsured in the current health care climate requires an understanding of billing regulations, a commitment to informed consent, and a beneficent approach to finding individualized solutions to each patient care/financial dilemma. To effect change, however, physicians must address issues of social justice outside of the office through political and social activism.

From research evidence to context: the challenge of individualizing care.

When strong research evidence supports a low risk intervention that is easy to implement, the practice of medicine may seem straightforward. The decision, for instance, to prescribe a β blocker for a patient who has had a myocardial infarction is generally clear cut. However, as the possibility of harm increases, the evidence for efficacy diminishes, or the steps to implementation become more complex, challenges abound. Deciding whether to recommend adjusted dose warfarin in a 75 year old man with newly diagnosed atrial fibrillation and a previous history of stroke can become nearly overwhelming as we delve into the particulars of his life: that he recently relocated to a second floor flat after his wife died and has slipped on the stairs twice; that his daughter will be moving in with him to help out, but not for 6 months; that he can only arrange transport to the clinic to get his international normalised ratio checked bimonthly; and that he is also taking amiodarone, which will make dosing more difficult. We may opt to talk with his daughter to see if she can come sooner, to his cardiologist to determine if he can substitute another antiarrhythmic, and to the visiting nurses association to see if they can monitor him in his home. Our plan of care will evolve as we factor in these options. Unless we ask the right questions, we are likely to miss the contextual issues that are so often essential to care. Even in apparently straightforward cases such as the initiation of β blocker therapy described above, recognising that a …

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.

Unannounced Standardized Patient Assessment of the Roter Interaction Analysis System: The Challenge of Measuring Patient-Centered Communication

ABSTRACTBACKGROUNDDespite wide-spread endorsement of patient-centered communication (PCC) in health care, there has been little evidence that it leads to positive change in health outcomes. The lack of correlation may be due either to an overestimation of the value of PCC or to a measurement problem. If PCC measures do not capture elements of the interaction that determine whether the resulting care plan is patient-centered, they will confound efforts to link PCC to outcomes.OBJECTIVETo evaluate whether one widely used measure of PCC, the Roter Interaction Analysis System (RIAS), captures patient-centered care planning.DESIGNRIAS was employed in the coding of unannounced standardized patient (USP) encounters that were scripted so that the failure to address patient contextual factors would result in an ineffective plan of care. The design enabled an assessment of whether RIAS can differentiate between communication behavior that does and does not result in a care plan that takes into account a patient’s circumstances and needs.PARTICIPANTSEight actors role playing four scripted cases (one African American and one Caucasian for each case) in 399 visits to 111 internal medicine attending physicians.MAIN MEASURESRIAS measures included composites for physician utterance types and (in separate models) two different previously applied RIAS patient-centeredness summary composites. The gold standard comparison measure was whether the physician’s treatment plan, as abstracted from the visit note, successfully addressed the patient’s problem. Mixed effects regression models were used to evaluate the relationship between RIAS measures and USP measured performance, controlling for a variety of design features.KEY RESULTSNone of the RIAS measures of PCC differentiated encounters in which care planning was patient-centered from care planning in which it was not.CONCLUSIONSRIAS, which codes each utterance during a visit into mutually exclusive and exhaustive categories, does not differentiate between conversations leading to and not leading to care plans that accommodate patients’ circumstances and needs.

An Urban School Based Comparative Study of Experiences and Perceptions Differentiating Public Health Insurance Eligible Immigrant Families with and without Coverage for their Children

Introduction We explore why some low income immigrant families enroll in government financed health insurance plans for their children, while others also eligible do not enroll. Methods Our team conducted and analyzed audiotaped semi-structured interviews with families of 8 insured and 10 uninsured children focused on knowledge of and experience with seeking health insurance coverage. Results Common among families not enrolled in government sponsored plans were misperceptions about the insurance system, including a suspicion of the government monitoring them and/or lack of familiarity with the concept of insurance itself. Among families that did enroll, the predominant theme was the essential role of their sponsor, other kin or community in educating and assisting them with the application process. Conclusions Prior research has identified external obstacles to enrollment. Our findings indicate the additional importance of facilitating social support, particularly from sponsors in mentoring new arrivals through the process of seeking insurance coverage.

Providers contextualise care more often when they discover patient context by asking: meta-analysis of three primary data sets

Objectives One important component of patient-centred care is provider incorporation of patient contextual factors—life circumstances relevant to their care—in managing the patients health. The current study uses data sets collected from direct observation of care to examine if how a provider learns contextual information influences whether the provider incorporates the information into a care plan. Methods Three data sets were reanalysed: a research study with physicians, a quality improvement project with physicians and a performance measurement project with telephone health assistants. In each data set, investigators compute rates of incorporation of patient contextual factors into the care plan for encounters in which factors were elicited in response to a probe by the provider versus revealed spontaneously by the patient. We report the rates, CIs and associated ORs for each study and overall using a random effects meta-analysis. Results Providers elicited 57%, 49% and 30% of patient contextual factors identified in encounters in each data set. Patient contextual factors identified in response to probes were incorporated into the plan of care more frequently than those revealed spontaneously by patients (68% vs 46%, 71% vs 54% and 93% vs 77%, respectively). The summary OR for incorporation of patient contextual factors into the care plan when the factor was probed versus revealed spontaneously was 4.16 (95% CI 2.0 to 8.6). While this estimate was associated with significant heterogeneity (I2=76%), the ORs for the individual data sets were 2.53 (1.4 to 4.5), 6.25 (4.9 to 8.0) and 4.2 (0.9 to 19.3). Conclusions In encounters where addressing patient contextual factors may play an important role in care decisions, factors that are elicited actively by the provider are more likely to be incorporated in the care plan than factors revealed spontaneously by the patient. These differences in the care process associated with provider performance can only be demonstrated through direct observation.

Managing the Unmanaged : A Case Study of Intra-institutional Determinants of Uncompensated Care at Healthcare Institutions With Differing Ownership Models

Study Objective:This study presents a case analysis of how 3 urban medical centers with differing ownership models, within 1 metropolitan area, ration access to uncompensated care to uninsured patients. Methods:Data was triangulated from 3 sources: hospital financial reports by service line for a fiscal year, a survey of 292 self-pay patients, and the self-pay policies and practices of clerical personnel described in a previous publication. Results:Although the public, for-profit and not-for-profit institutions used different strategies for managing self-pays, there were also commonalities in the experiences indigent patients reported. The public institution provided the broadest access to the largest percentage of self-pay patients but offset the burden with the most successful prepayment and collection practices. The for-profit site obeyed federal regulations mandating emergency care but severely curtailed other services, and the not-for-profit limited assess (but not to the extent of the for-profit) and pursued collection (but not to the extent of the public). At all sites, actual practices by clerical staff often diverged from institutions’ written self-pay policies. The probability of being turned away because of inability to pay ranged from 0% to 40% with front line personnel exercising considerable discretion on a case-by-case basis. Conclusions:Large institutional providers balance their particular social and legal obligations with strategies to limit access and optimize prepayment and collection. Stated policies generally do not reflect the practices of personnel. Uninsured patients are forced to navigate a capricious system that manages them as a liability rather than as a legitimate client.

Directly observed care: can unannounced standardized patients address a gap in performance measurement?

There are three potential sources of information for evaluating a clinician’s performance: documentation, patient report, and directly observed care. Current measures draw on just two of these: data recorded in the medical record and surveys of patients. Neither captures an array of performance characteristics, including clinician attention to symptoms and signs while taking a history or conducting a physical exam, accurate recording in the medical record of information obtained during the encounter, evidence based communication strategies for preventive care counseling, and effective communication behavior. Unannounced Standardized Patients (USPs) have been widely deployed as a research strategy for systematically uncovering significant performance deficits in each of these areas, but have not been adopted for quality improvement. Likely obstacles include concerns about the ethics of sending health professionals sham patients, the technical challenges of the subterfuge, and concerns about the relatively small sample sizes and substantial costs involved. However, the high frequency of significant and remediable performance deficits unmasked by USPs, and the potential to adapt registration and record keeping systems to accommodate their visits, suggest that their selective and purposeful deployment could be a cost effective and powerful strategy for addressing a gap in performance measurement.