Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System. JAMA Netw Open 2020 Jul 01;3(7):e209644
Date
08/01/2020Pubmed ID
32735338Pubmed Central ID
PMC7395234DOI
10.1001/jamanetworkopen.2020.9644Scopus ID
2-s2.0-85089125883 (requires institutional sign-in at Scopus site) 22 CitationsAbstract
IMPORTANCE: Evidence-based care plans can fail when they do not consider relevant patient life circumstances, termed contextual factors, such as a loss of social support or financial hardship. Preventing these contextual errors can reduce obstacles to effective care.
OBJECTIVE: To evaluate the effectiveness of a quality improvement program in which clinicians receive ongoing feedback on their attention to patient contextual factors.
DESIGN, SETTING, AND PARTICIPANTS: In this quality improvement study, patients at 6 Department of Veterans Affairs outpatient facilities audio recorded their primary care visits from May 2017 to May 2019. Encounters were analyzed using the Content Coding for Contextualization of Care (4C) method. A feedback intervention based on the 4C coded analysis was introduced using a stepped wedge design. In the 4C coding schema, clues that patients are struggling with contextual factors are termed contextual red flags (eg, sudden loss of control of a chronic condition), and a positive outcome is prospectively defined for each encounter as a quantifiable improvement of the contextual red flag. Data analysis was performed from May to October 2019.
INTERVENTIONS: Clinicians received feedback at 2 intensity levels on their attention to patient contextual factors and on predefined patient outcomes at 4 to 6 months.
MAIN OUTCOMES AND MEASURES: Contextual error rates, patient outcomes, and hospitalization rates and costs were measured.
RESULTS: The patients (mean age, 62.0 years; 92% male) recorded 4496 encounters with 666 clinicians. At baseline, clinicians addressed 413 of 618 contextual factors in their care plans (67%). After either standard or enhanced feedback, they addressed 1707 of 2367 contextual factors (72%), a significant difference (odds ratio, 1.3; 95% CI, 1.1-1.6; P = .01). In a mixed-effects logistic regression model, contextualized care planning was associated with a greater likelihood of improved outcomes (adjusted odds ratio, 2.5; 95% CI, 1.5-4.1; P < .001). In a budget analysis, estimated savings from avoided hospitalizations were $25.2 million (95% CI, $23.9-$26.6 million), at a cost of $337 242 for the intervention.
CONCLUSIONS AND RELEVANCE: These findings suggest that patient-collected audio recordings of the medical encounter with feedback may enhance clinician attention to contextual factors, improve outcomes, and reduce hospitalizations. In addition, the intervention is associated with substantial cost savings.
Author List
Weiner S, Schwartz A, Altman L, Ball S, Bartle B, Binns-Calvey A, Chan C, Falck-Ytter C, Frenchman M, Gee B, Jackson JL, Jordan N, Kass B, Kelly B, Safdar N, Scholcoff C, Sharma G, Weaver F, Wopat MAuthors
Jeffrey L. Jackson MD Professor in the Medicine department at Medical College of WisconsinCecilia Scholcoff MD Associate Professor in the Medicine department at Medical College of Wisconsin
MESH terms used to index this publication - Major topics in bold
Cost ControlFeedback
Female
Health Care Costs
Humans
Male
Middle Aged
Patient-Centered Care
Quality Improvement
Tape Recording
United States
United States Department of Veterans Affairs
