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.