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Intervening to Prevent Contextual Errors in Medical Decision Making

This study has been completed.
Information provided by (Responsible Party):
VA Office of Research and Development Identifier:
First received: March 3, 2009
Last updated: April 6, 2015
Last verified: October 2014
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

Condition Intervention
Psychosocial Circumstances Behavioral: Seminar and Practicum

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary Purpose: Health Services Research
Official Title: Intervening to Prevent Contextual Errors in Medical Decision Making

Further study details as provided by VA Office of Research and Development:

Primary Outcome Measures:
  • Health Outcome Improvement Rate [ Time Frame: 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 Outcome Measures:
  • Rate of Contextual Probing [ Time Frame: 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 [ Time Frame: During initial patient recordings ]
    Proportion of patient encounters in which the physician's plan of care addressed contextual factors identified in the audio recordings

Enrollment: 138
Study Start Date: October 2009
Study Completion Date: December 2012
Primary Completion Date: November 2012 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: 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.
Behavioral: Seminar 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.
No Intervention: No intervention
No educational intervention.

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.

Ages Eligible for Study:   Child, Adult, Senior
Sexes Eligible for Study:   All
Accepts 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
  Contacts and Locations
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Please refer to this study by its identifier: NCT00856557

United States, Illinois
Jesse Brown VA Medical Center, Chicago, IL
Chicago, Illinois, United States, 60612
Sponsors and Collaborators
VA Office of Research and Development
Principal Investigator: Saul J. Weiner, MD Jesse Brown VA Medical Center, Chicago, IL