Purpose: A “contextual error” is a medical error that occurs when a physician fails to take into account information that is expressed outside of a patient´s physical boundaries – i.e. their context – that is essential to planning appropriate care. Using incognito standardized patients, we measured the propensity of physicians to elicit contextual (vs. biomedical) information and to make contextual (vs. biomedical) errors in treatment plans, as well as the avoidable direct costs of these errors to patient care.
Method: Over 18 months, 98 internal medicine attending physicians at 8 Midwestern VA and non-VA practices were visited in vivo by incognito actors presenting variants of 4 previously-validated cases that jointly manipulated the presence or absence of contextual and biomedical factors that could lead to errors in treatment. For each visit, we obtained data on whether the physician elicited necessary information and incorporated it in the treatment plan recorded in the visit note. Mixed models were fitted to examine factors associated with failed elicitation or incorporation of information. Costs of missed services or unnecessary services in each visit were computed using Medicare cost-based reimbursement data.
Result: Biomedical and contextual information were elicited equally often when available (70% vs. 69%). In baseline variants, treatment plans were appropriate in 76% of visits; when errors were possible, 29% of plans were appropriate when only a biomedical error was possible, 15% of plans were appropriate when only a contextual error was possible, and 2% of plans were appropriate when both types of errors (all differences significant). Most errors involved failure to order necessary services, but contextual errors were more likely to result in simultaneous underuse of necessary services and provision of unnecessary services. Contextual errors alone resulted in an estimated additional cost of care of $74,697 (median $194/visit), which was significantly greater than the $14,967 associated with biomedical errors alone (median $23/visit; Wilcoxon p<.001).
Conclusion: Inattention to contextual information, such as patients´ transportation, economic situation, or caretaker responsibilities can have dramatic and measurable implications for quality and cost of care, in some cases beyond those resulting from inattention to laboratory values and medication dosages when delivering care. This study suggests a need for greater prioritization of contextual information in planning patients´ care to reduce medical errors and costs.
Candidate for the Lee B. Lusted Student Prize Competition