Table 1. Prospectively Determined Outcomes Based on the Presenting Contextual Red Flag.
| Red flag (source) | Criteria | Outcome | ||
|---|---|---|---|---|
| Good (red flag documented to improve or resolve) | Bad (red flag documented to worsen or persist) | No change (red flag documented at same level or not documented as changed) | ||
| Uncontrolled chronic condition for which the patient is being treated (EHR, audio recording) | HbA1c level has increased since prior measurement by >1 percentage point; SBP and/or DBP has increased since prior measurement by >10 mm Hg | Any decrease in HbA1c level; any decrease in SBP or DBP | Any increase in HbA1c level; any increase in SBP or DBP | No change in HbA1c level; no change in SBP or DBP |
| Appointment nonadherence: clinics, laboratory tests, imaging, procedures (EHR, patient questionnaire, audio recording) | Missed ≥2 clinical encounters in past 4 mo; missed ≥1 laboratory tests and/or scheduled study in past 4 mo | Patient misses fewer appointments during the next 4 mo; patient completes scheduled laboratory tests and/or scheduled studies | Patient misses more appointments in the next 4 mo; patient completes fewer scheduled laboratory tests and/or scheduled studies | Patient misses same number of appointments in next 4 mo; patient misses same proportion of scheduled tests or studies |
| ED visits (EHR, patient questionnaire, audio recording) | ≥2 ED visits in past 4 mo | Patient has fewer ED visits | Patient has more ED visits | Patient has same number of ED visits |
| Medication nonadherence (patient questionnaire, audio recording) | Answers “yes” to “Are you having any difficulty taking medications the way you have been told to take them?” and/or mentions it during visit | Patient takes medications as prescribed | Patient does not take medications as prescribed | Medical adherence not documented |
| Missed preventive care (patient questionnaire, audio recording) | Answers “yes” to “In the past 6 mo, have you declined any treatments, tests, or procedures that your provider recommended, like vaccines, blood tests, a colonoscopy?” and/or mentions it during visit | Patient receives recommended treatments, tests, or procedures | Patient does not receive recommended treatments, tests, or procedures | Patient receipt of treatments, tests, or procedures not documented |
| Weight gain or loss (audio recording) | ≥4.5 kg (10 lb) gained or lost since last appointment | If overweight, weight is lower; if underweight, weight is higher | If overweight, weight is higher; if underweight, weight is lower | Patient weight stays the same |
| Unaware of diagnosis and/or results (audio recording) | Patient mentions that they are unaware of diagnosis or test results that should have been communicated to patient | Patient is aware of diagnosis or results | Patient is still unaware of diagnosis or results | Patient awareness or unawareness not documented |
| Difficulty with equipment (patient questionnaire, audio recording) | Unable to use or decline to use medical equipment, or using someone else’s equipment | Using own equipment | Not using (own) equipment | Patient use of equipment not documented |
| General statements by patients that are concerning such as “I’m not eating” (patient questionnaire, audio recording) | Individualized | Individualized and prospectively determined | Individualized and prospectively determined | Individualized, prospectively determined outcome not documented |
Abbreviations: DBP, diastolic blood pressure; ED, emergency department; EHR, electronic health record; HbA1c, hemoglobin A1c; SBP, systolic blood pressure.