Contextualized Care Planning Results in Improved Veteran Outcomes and Significant Cost Savings
Contextualizing care is the process of adapting research evidence to patient context. For example, recognizing that a patient is not managing their diabetes because they cannot afford the medication and switching them to a less costly alternative is a contextualized care plan. The failure to appropriately adapt treatment in accordance with patient context is termed a contextual error. These can adversely impact healthcare outcomes and drive up healthcare costs – but they are difficult to detect. A reliable way to ascertain whether a care plan is contextualized is to audio record the encounter in addition to reviewing the medical record. An efficient method for collecting audio recordings is to invite patients to carry audio recorders into their visits. This study evaluated the effectiveness of a quality improvement program in which providers receive ongoing feedback on their attention to patient contextual factors based on audio recordings of their clinical encounters. From May 1, 2017 to May 22, 2019, 4,496 audio recordings were made by patients across six VA medical centers during visits with 666 providers in ambulatory care clinics. Four to six months following each recorded encounter, the patient medical record was examined for contextual red flags and whether they had improved. Investigators also assessed costs savings, factoring in covariates for site and patient demographics.
- Contextualized care planning was associated with a significantly greater likelihood of improved outcomes – and resulted in significant cost savings from avoided hospitalizations.
- At baseline, providers addressed 413 of out 618 contextual factors in their care plans (67%). Following either standard or enhanced feedback, they addressed 1,707 out of 2,367 contextual factors (72%), a significant improvement. In a budget impact analysis, estimated savings from avoided hospitalizations were $25.2 million at a cost of $337,000 for the intervention.
- Giving clinicians ongoing feedback on their attention to the life challenges that their patients face may be an effective strategy for heightening their awareness and attention to social determinants of health, which may significantly improve healthcare outcomes and reduce costs. QI programs may be well advised to consider routine incorporation of training in contextualizing care through audit and feedback.
- Estimated cost savings were based on the panel population and phase of participation in the program rather than on individual patient contextualized care results.
- Findings suggest that providers reduced hospitalization rates by improving care to their panel, but it is possible that other confounding influences were present.
This study was funded by HSR&D (IIR 15-452). Dr. Weiner is Deputy Director of HSR&D’s Center of Innovation for Complex Chronic Healthcare (CINCCH).
Weiner S, Schwartz A, Altman L, et.al. 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 Network Open. July 31, 2020.