Patient-Centered Decision-Making and Health-Care Outcomes
Clinical question: Does recognition of contextual domains in the care plan lead to resolution of patients’ presenting problems?
Background: Patient-centered decision-making, or contextualization of care, adapts best evidence to the care of the individual patient. Examples of contextual domains include access to care, social support, and financial situation. Contextual errors (e.g. unrecognized domains) are, on average, more costly than errors in evidenced-based medicine.
Study design: Observational study.
Setting: VA ambulatory-care centers.
Synopsis: A total of 548 patient-derived audio recordings of physician encounters that included contextual red flags (e.g. missed appointments, HbA1c >8%) were reviewed at two VA hospital ambulatory-care centers using the content coding for contextualization of care (4C) method. Prospectively determined good and poor outcomes were derived from specific red flags (e.g. keeping next appointment, decrease in HbA1c). Of the 548 red flags, 208 were associated with contextual domains using the 4C method. Some 59% of physicians recognized contextual domains in care-plan development, leading to good outcomes in 71% of red flags. As many as 41% of physicians did not recognize contextual domains, leading to poor outcomes in 54% of red-flag instances.
Hospitalists should be aware of contextual domains and red flags (e.g. readmissions), and this study provides a method of evaluating patient-centered decision-making in the hospital setting. However, the inherently subjective 4C method may underestimate the number of contextual domains.
Bottom line: Recognition and incorporation of contextual domains in care-plan development in the ambulatory setting are associated with improved contextual red flag outcomes.
Citation: Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573-579.
Adverse Surgical Outcomes in Schizophrenia Patients
Clinical question: What is the full spectrum of postoperative complications and mortality in schizophrenic patients receiving in-hospital major surgery?
Background: Schizophrenia affects an estimated 4 to 7 per 1,000 persons worldwide, and patients with schizophrenia are at increased risk of diabetes, cardiovascular disease, and stroke with subsequent increased mortality risk. The correlation between severity of mental illness and postoperative in-hospital mortality has not been validated in previous studies.
Study design: Population-based, cross-sectional study.
Setting: Taiwan hospitals.
Synopsis: Using the Taiwan National Health Insurance Research Database, researchers examined claims from 2004 to 2007 and retrospectively identified 8,967 schizophrenic patients who underwent major inpatient surgery and were hospitalized for more than one day. Primary outcomes included acute myocardial infarction, acute renal failure, stroke, and in-hospital mortality within 30 days. Postoperative complications and mortality rates were compared between schizophrenic patients and patients without mental illness.
Schizophrenic patients had higher rates of many primary outcomes, including 30-day postoperative mortality, compared with patients without mental illness, after adjusting for sex, age, surgery type, and hospital setting. The risk for 30-day mortality rose with the number of preoperative schizophrenia-related services provided. Limitations include the nature of retrospective analysis and generalizability.
Bottom line: Compared to patients without mental illness, schizophrenic patients have an increased risk of acute renal failure, pneumonia, septicemia, and 30-day mortality in the postoperative setting, with higher mortality rates in schizophrenic patients with more severe disease.
Citation: Liao CC, Shen WW, Chang CC, Chang H, Chen T. Surgical adverse outcomes in patients with schizophrenia. Ann Surg. 2013;257:433-438.
