Psychosocial Circumstances
Conditions
Keywords
Patients with complex psychosocial needs
Brief summary
This study assessed whether a medical education intervention improves the quality of medical decision making in the care of patients with complex psychosocial -- or contextual -- needs that are essential to address when planning their care. A group of internal medicine residents were randomly assigned to participate in the seminar and practicum and then they, along with a control group that had not participated, were assessed for the quality of their clinical decision making and its impact on patient care. The study also assessed whether contextualization of care is associated with better patient health care outcomes
Detailed description
We enrolled 139 internal medicine residents at 2 VA hospitals, Jesse Brown and Hines, in a randomized controlled design. Half participated in a 4 hour seminar series integrated into their ambulatory curriculum. Each month a total of 8 residents participated. Following the intervention there were 3 levels of assessment: (1) All participants, intervention and control, participated in a brief exercise interviewing 4 standardized patients (SPs). Note that we separately enlisted the assistance of 8 attending physicians to assist with case development for these SPs. (2) The research team subsequently enrolled 3 real patients from each physician's practice with red flags such as poor adherence, or missed visits, suggestive of contextual issues that need to be addressed. Physicians were scored on their performance at identifying the underlying contextual factors that account for these red flags and on formulating an appropriate plan of care. (3) The coders prospectively defined successful vs. unsuccessful outcomes for each case. At the follow up visit data was collected on whether the desired outcome was achieved. The analysis compared the skills, performance and outcomes of the intervention compared with the control group to determine the efficacy of training residents to individualize care.
Interventions
BEHAVIORALSeminar and Practicum
A 4 hour seminar and practicum for internal medicine residents designed to provide a systematic approach to identifying contextual factors essential to planning patient care.
Sponsors
US Department of Veterans Affairs
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Healthy volunteers
No
Inclusion criteria
* Internal Medicine Residency with continuity of care clinics at either Jesse Brown or Hines VA Medical Centers
Exclusion criteria
* All resident physicians who do not meet inclusion criteria
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Health Outcome Improvement Rate | After 9 months of the recorded visit | A target health outcome improvement for each patient is prospectively defined at the first visit in which a contextual red flag is noted. The study outcome is what proportion of a physician's patients achieve their target health outcome improvement as documented in the medical record at 9 months post first visit. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Rate of Contextual Probing | During initial patient recordings | Proportion of encounters in which physician probed contextual red flags expressed by patients and identified via audio recordings. |
| Rate of Contextual Planning | During initial patient recordings | Proportion of patient encounters in which the physician's plan of care addressed contextual factors identified in the audio recordings |
Countries
United States
Participant flow
Recruitment details
Resident physicians were consented and recruited from two clinical training facilities on a rolling basis over 30 months.
Participants by arm
| Arm | Count |
|---|---|
| Seminar and Practicum Seminar and practicum that occurs over 4 week period for internal medicine residents, designed to provide a systematic approach to identifying and addressing contextual factors essential to planning patient care.
Seminar and Practicum on Contextualizing Care: A 4 hour seminar and practicum for internal medicine residents designed to provide a systematic approach to identifying contextual factors essential to planning patient care. | 62 |
| No Intervention No educational intervention | 76 |
| Total | 138 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | No patients with contextual flags | 12 | 16 |
Baseline characteristics
| Characteristic | No Intervention | Total | Seminar and Practicum |
|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical Between 18 and 65 years | 76 Participants | 138 Participants | 62 Participants |
| Region of Enrollment United States | 76 participants | 138 participants | 62 participants |
| Sex: Female, Male Female | 43 Participants | 74 Participants | 31 Participants |
| Sex: Female, Male Male | 33 Participants | 64 Participants | 31 Participants |
| Year in residency PGY2 | 45 participants | 76 participants | 31 participants |
| Year in residency PGY3 | 19 participants | 43 participants | 24 participants |
| Year in residency Post Grad Yr (PGY) 1 | 12 participants | 19 participants | 7 participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 0 / 62 | 0 / 76 |
| serious Total, serious adverse events | 0 / 62 | 0 / 76 |
Outcome results
Primary
Health Outcome Improvement Rate
A target health outcome improvement for each patient is prospectively defined at the first visit in which a contextual red flag is noted. The study outcome is what proportion of a physician's patients achieve their target health outcome improvement as documented in the medical record at 9 months post first visit.
Time frame: After 9 months of the recorded visit
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Seminar and Practicum | Health Outcome Improvement Rate | 0.68 proportion of physician's patients | Standard Deviation 0.37 |
| No Intervention | Health Outcome Improvement Rate | 0.59 proportion of physician's patients | Standard Deviation 0.43 |
Comparison: Null hypothesis is equal distribution of proportion of successful encounters among groupsp-value: 0.33Wilcoxon (Mann-Whitney)
Comparison: Considering all encounters (n=179) of all physicians for who outcomes were measured (n=111) together, are encounters in which physicians contextualized the plan of care more likely to be associated with target health outcome achievement than encounters in which physicians did not, controlling for clustering of encounters within physicians. (Generalized logistic mixed model, with random intercept for physician)p-value: 0.036Mixed Models Analysis
Secondary
Rate of Contextual Planning
Proportion of patient encounters in which the physician's plan of care addressed contextual factors identified in the audio recordings
Time frame: During initial patient recordings
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Seminar and Practicum | Rate of Contextual Planning | .18 proportion of physician's patients | Standard Deviation 0.23 |
| No Intervention | Rate of Contextual Planning | .21 proportion of physician's patients | Standard Deviation 0.24 |
p-value: 0.39Wilcoxon (Mann-Whitney)
Secondary
Rate of Contextual Probing
Proportion of encounters in which physician probed contextual red flags expressed by patients and identified via audio recordings.
Time frame: During initial patient recordings
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Seminar and Practicum | Rate of Contextual Probing | .26 proportion of physician's patients | Standard Deviation 0.25 |
| No Intervention | Rate of Contextual Probing | .27 proportion of physician's patients | Standard Deviation 0.29 |
p-value: 0.99Wilcoxon (Mann-Whitney)