Responding to contextual factors revealed by old patients with heart failure in hospital interactions: An interaction-based study

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How hospital doctors recognize and respond to such contextual factors (CF) may influence health outcomes. This study aims to identify adherence related CF disclosed by old patients with heart failure during hospital interactions and to examine how doctors respond to them. Methods Audio-recordings from two key hospital interactions were collected from 42 old patients with heart failure. Occurrences of CF were identified based on a previously developed coding scheme and followed during the hospital interactions. We then analysed doctor’s responses to patient’s CF and categorized them as: (1) Solution-oriented, (2) Exploring (3) No follow-up. Results We identified 58 CF across 113 occurrences in 27 (64%) patients. Medication-related CF (47%) were the most frequently disclosed, followed by patient-specific (34%), condition-related (12%), and healthcare system-related factors (7%). Doctors’ responses varied: 26% (n = 15) of CF received no follow-up, 21% (n = 12) were only explored, 24% (n = 14) were explored and met with a solution-oriented action, and 29% (n = 17) were met with solution-oriented actions without any exploration from the doctor. Conclusions Older patients with heart failure often disclose important CF relevant to adherence during hospital interactions. Roughly half of these factors are not met with a solution-oriented response, with a substantial portion not being followed up by the doctors at all. Future research should explore how to better improve doctors’ ability to recognize and appropriately respond to CF disclosed by patients. Clinical Communication Heart Failure Contextual Factors Treatment adherence Patient-centered care Figures Figure 1 Background Patients affected by heart failure (HF) constitute a large and growing patient group with complex care needs. [ 1 – 3 ] Indeed, HF has a chronic and progressive nature; it usually affects old persons, who are also associated with polypharmacy, frailty, co-morbidities, and low treatment adherence [ 4 – 8 ]. Thus, old persons with HF are a particularly vulnerable patient population, with an overall poor prognosis, frequent hospitalization and high mortality [ 9 ]. How well patients adhere to their treatment plan plays a pivotal role in their outcomes, and addressing poor treatment adherence for this patient group is one of the primary avenues for improving outcomes as well as reducing overall healthcare costs [ 10 – 12 ]. Previous studies have revealed why old patients with HF likely struggle to adhere to their treatment plan, and what the consequences of suboptimal treatment adherence are, along with developing and implementing adherence supporting interventions [ 6 , 13 ]. Despite increasing availability of evidence-based technological and systematic interventions, non-adherence remains an unresolved complex problem [ 14 ]. Research into the root causes for non-adherence on both a systemic and individual level has revealed multiple factors contributing to non-adherence for this and other patient groups [ 15 , 16 ]. A leading factor for why patients with HF do not adhere to their plan is the high degree of polypharmacy inherent to the standard treatment for HF (typically between 4 to 5 medications), often further increased by the additional comorbidities that this patient group has (often resulting in regimens of over 10 medications) [ 4 , 17 ]. Patients’ ability and inclination to adhere to treatment plans are further influenced by each patient’s individual context, that is, non-biomedical factors in the patient’s life influencing therapeutic outcomes [ 18 , 19 ]. These factors, often referred to as contextual factors, are not limited to inherent patient-related factors such as the patients’ understanding of their diagnosis and treatment, but also include systemic factors such as their access to healthcare services, social support, and medication regimen, among others [ 16 , 20 , 21 ]. A doctor’s ability to recognize, explore, and address contextual factors is a central part of patient-centered care and a measure of clinical competency [ 19 ]. Improving doctors’ ability to recognize the contextual factors that patients reveal and tailor the patients’ treatment plan accordingly is considered a reliable pathway for reducing unwanted variability in patient outcomes [ 22 – 24 ]. This process of contextualizing clinical decisions, coined “contextualization of care” by Weiner et al [ 19 ], is mostly studied directly by examining clinical interactions between doctors and patients, as it is during these interactions contextual factors are most commonly made available to the doctors [ 19 , 21 – 23 ]. While there is an increasing wealth of knowledge and interest into if and how doctors contextualize decisions during clinical interactions, it is yet unexplored in the context of old in-patients with HF in a hospital setting. This study aimed to explore if and how hospital doctors address contextual factors disclosed by patients 65 years or older admitted to hospital with a HF diagnosis. In particular, we aimed to: Identify all contextual factors that patients describe as having a negative impact on their life or on their adherence, revealed during clinical interactions in hospital. Explore, characterize and quantify how doctors approached these contextual factors. Methods Study design This study has an exploratory interaction-based observational cohort design. Patients were admitted to hospital with a HF diagnosis. Primary data are audio-recordings of each patient’s first hospital ward visit and discharge visits. Data collection and participant recruitment Members of the research team recruited in-patients admitted to the heart ward at Akershus University Hospital with a HF diagnosis prior to their first encounter with a hospital doctor. We recruited patients Monday to Friday from February 2022 to February 2023. Patients were identified via patient admission lists and were approached and recruited along with their attending hospital doctor prior to their first ward visit. To be eligible for participation, patients had to be admitted to hospital with a HF diagnosis, be older than 65 years, be competent to give consent for participation, live within the uptake area of the hospital, and be responsible for administering their own medication. Two researchers independently observed and collected audio recordings of the first ward visit and the discharge visit. Audio recordings were transcribed, and relevant observational notes added to final transcriptions. For additional details regarding patient recruitment and data collection see Frigaard et al [25]. Analysis Identifying contextual factors We defined “contextual factor” (CF) as any patient behaviour, perceptions, experiences, or life circumstances that may constitute a barrier to the patient’s ability or inclination to follow a treatment plan. We identified CF that patients revealed during the hospital visits using a novel literature-based deductive approach described in Bjørnstad et al, 2025 [26]. In short, patient utterances containing references to well-known barriers to adherence among cardiovascular patients were extracted and categorized as having either no potential impact, as having a potential impact on the patient’s ability or inclination to follow a treatment plan (adherence impact) or as having a potential impact on the patient’s life (life impact), based on how the patients described them. Patient utterances referencing adherence barriers described as having a life or adherence impact by the patients were considered as CF. We then flagged all subsequent utterances containing references to the same factor (not necessarily with the same impact) across both the first ward visit and the discharge visit and recording each utterance as a re-occurrence of the overarching CF. After the initial impactful occurrence and all eventual reoccurrences of the CF had been identified, they were grouped into four categories based on their content: patient-specific factors, healthcare system-related factors, medication-related factors, and condition-related factors. Analysing doctors’ responses to CF For each occurrence of a CF, we analysed the doctors’ response in the sequence following each CF until a topic change. First, for each occurrence of the CF we described the specific action taken by the doctor, examples including “Gives information”, “Makes active change”, or “Changes topic”. We then evaluated whether these actions were: Solution-oriented: These were action-oriented responses aimed at resolving, mitigating, or otherwise addressing the factor, without additional investigation/discussion/gathering of information. These actions included medical decisions such as active changes to the patient’s treatment plan, providing the patient relevant information related to the CF, or other actions reflecting direct engagement with the CF in a way to address or resolve it, such as providing encouragement or simplifying relevant information. E.g., a patient mentions frequently forgetting to take their morning dose of HF medication. Without further inquiry the doctor suggests setting a daily reminder on the patient’s telephone or the use of a pill organizer. Exploring: doctors’ responses were considered exploring according to Frigaard et al (2025) definition (i.e., seeking more information about the patient’s perception or adherence behaviour) [25]. In these cases, the doctor gathered further new information regarding the CF, but did not implement any additional action to resolve, mitigate, or otherwise address the factor. This included the doctor giving the patient space to elaborate, or asking direct questions regarding the patient’s experience, perception, or circumstance. Note that requests for clarifications or checks for understanding were not enough to be considered “exploring”. E.g., a patient mentions how side effects from the HF medication interferes with daily tasks, doctor asks about the nature of side effects and the patient’s experience but does not take any further action. Exploring and Solution-oriented: in these cases, the doctor both explored the CF and made an action aimed at resolving, mitigating, or otherwise addressing the factor. E.g., a patient mentions they often skip doses of HF medication due to side effects, the doctor asks follow-up questions regarding the patient experience with side effects and how they interfere with the patient’s life. The doctor then takes a concrete action such as altering the prescribed dosage or gives information regarding alternative time points the patient may administer the medication which may interfere less with the patient’s daily life. No follow-up: in these cases, the doctor response in the sequence initiated by the CF did not follow up on the CF and was not linked in content to the CF. Therefore, the doctor neither explored the CF nor made any solution-oriented action in response to the CF. These were frequently cases when the doctor changed the topic, thereby closing the sequence. E.g., a patient states she often experiences anxiety related to her illness. The doctor responds by asking about the patient’s previously prescribed medications. While some actions did not fall under the above-mentioned categories (i.e., “checking understanding”, “request for clarification”, “acknowledging”) we found that these actions did not happen in isolation and were always part of sequences in which the doctor’s actions fit into one of the above categories. Thus, we decided not to code them as distinct, separate actions. Then, doctors’ responses to the CF and its eventual reoccurrences along the same or different interactions were reviewed holistically. If the doctors took a solution-oriented action in response to any (re)occurrence of the CF, the doctors’ responses to the CF were overall labelled as “Solution-oriented”. If the doctors took a solution-oriented action and explored any (re)occurrence of the CF, the response to the CF was overall labelled as “Exploring & Solution-oriented”. If the doctors did not deal in any way or in any moment with the CF occurrences, the response was overall labelled as “No follow-up”. The doctors’ responses and the specific actions taken for each occurrence of a CF were described, extracted and summarized for each of the categories. Figure 1 provides an overview of the coding approach. All CF with their eventual reoccurrences and doctors’ responses were analysed independently by two researchers (HB, JM) using an excel document along with de-identified patient and doctor characteristics. Disagreements were discussed until resolution. Descriptive and inferential statistics were performed via R [27]. Wilcoxon rank-sum test with continuity correction was performed to analyse the relationship between the number of occurrences for addressed vs un-addressed factors. Fisher's Exact Test for Count Data was performed to examine effect of impact and domains on the doctors’ responses to CF. Lastly a correlational analysis was performed to examine number of re-occurrences for a factor, and the number of actions taken by doctors. Insert figure 1 here: Ethical considerations This project is part of the MAPINFOTRANS project funded by the Norwegian Research Council and was considered exempt from review by the Regional Committee for Medical and Health Research Ethics in Southeast Norway (ref: 273688). This study complies the principles outlined int the Declaration of Helsinki. All participants provided written informed consent, including consent for anonymized responses/quotes to be published, all data collection and handling were approved by the Data Protection Officer at the hospital (ref: 2021_146). All sensitive data was stored in the University of Oslo’s Services for sensitive data (TSD). Availability of data and materials The datasets used and/or analysed during the current study, including anonymized excerpts of clinical interactions, are available from the corresponding author on reasonable request. Results Study design This study has an exploratory interaction-based observational cohort design. Patients were admitted to hospital with a HF diagnosis. Primary data are audio-recordings of each patient’s first hospital ward visit and discharge visits. Data collection and participant recruitment Members of the research team recruited in-patients admitted to the heart ward at Akershus University Hospital with a HF diagnosis prior to their first encounter with a hospital doctor. We recruited patients Monday to Friday from February 2022 to February 2023. Patients were identified via patient admission lists and were approached and recruited along with their attending hospital doctor prior to their first ward visit. To be eligible for participation, patients had to be admitted to hospital with a HF diagnosis, be older than 65 years, be competent to give consent for participation, live within the uptake area of the hospital, and be responsible for administering their own medication. Two researchers independently observed and collected audio recordings of the first ward visit and the discharge visit. Audio recordings were transcribed, and relevant observational notes added to final transcriptions. For additional details regarding patient recruitment and data collection see Frigaard et al [25]. Analysis Identifying contextual factors We defined “contextual factor” (CF) as any patient behaviour, perceptions, experiences, or life circumstances that may constitute a barrier to the patient’s ability or inclination to follow a treatment plan. We identified CF that patients revealed during the hospital visits using a novel literature-based deductive approach described in Bjørnstad et al, 2025 [26]. In short, patient utterances containing references to well-known barriers to adherence among cardiovascular patients were extracted and categorized as having either no potential impact, as having a potential impact on the patient’s ability or inclination to follow a treatment plan (adherence impact) or as having a potential impact on the patient’s life (life impact), based on how the patients described them. Patient utterances referencing adherence barriers described as having a life or adherence impact by the patients were considered as CF. We then flagged all subsequent utterances containing references to the same factor (not necessarily with the same impact) across both the first ward visit and the discharge visit and recording each utterance as a re-occurrence of the overarching CF. After the initial impactful occurrence and all eventual reoccurrences of the CF had been identified, they were grouped into four categories based on their content: patient-specific factors, healthcare system-related factors, medication-related factors, and condition-related factors. Analysing doctors’ responses to CF For each occurrence of a CF, we analysed the doctors’ response in the sequence following each CF until a topic change. First, for each occurrence of the CF we described the specific action taken by the doctor, examples including “Gives information”, “Makes active change”, or “Changes topic”. We then evaluated whether these actions were: Solution-oriented: These were action-oriented responses aimed at resolving, mitigating, or otherwise addressing the factor, without additional investigation/discussion/gathering of information. These actions included medical decisions such as active changes to the patient’s treatment plan, providing the patient relevant information related to the CF, or other actions reflecting direct engagement with the CF in a way to address or resolve it, such as providing encouragement or simplifying relevant information. E.g., a patient mentions frequently forgetting to take their morning dose of HF medication. Without further inquiry the doctor suggests setting a daily reminder on the patient’s telephone or the use of a pill organizer. Exploring: doctors’ responses were considered exploring according to Frigaard et al (2025) definition (i.e., seeking more information about the patient’s perception or adherence behaviour) [25]. In these cases, the doctor gathered further new information regarding the CF, but did not implement any additional action to resolve, mitigate, or otherwise address the factor. This included the doctor giving the patient space to elaborate, or asking direct questions regarding the patient’s experience, perception, or circumstance. Note that requests for clarifications or checks for understanding were not enough to be considered “exploring”. E.g., a patient mentions how side effects from the HF medication interferes with daily tasks, doctor asks about the nature of side effects and the patient’s experience but does not take any further action. Exploring and Solution-oriented: in these cases, the doctor both explored the CF and made an action aimed at resolving, mitigating, or otherwise addressing the factor. E.g., a patient mentions they often skip doses of HF medication due to side effects, the doctor asks follow-up questions regarding the patient experience with side effects and how they interfere with the patient’s life. The doctor then takes a concrete action such as altering the prescribed dosage or gives information regarding alternative time points the patient may administer the medication which may interfere less with the patient’s daily life. No follow-up: in these cases, the doctor response in the sequence initiated by the CF did not follow up on the CF and was not linked in content to the CF. Therefore, the doctor neither explored the CF nor made any solution-oriented action in response to the CF. These were frequently cases when the doctor changed the topic, thereby closing the sequence. E.g., a patient states she often experiences anxiety related to her illness. The doctor responds by asking about the patient’s previously prescribed medications. While some actions did not fall under the above-mentioned categories (i.e., “checking understanding”, “request for clarification”, “acknowledging”) we found that these actions did not happen in isolation and were always part of sequences in which the doctor’s actions fit into one of the above categories. Thus, we decided not to code them as distinct, separate actions. Then, doctors’ responses to the CF and its eventual reoccurrences along the same or different interactions were reviewed holistically. If the doctors took a solution-oriented action in response to any (re)occurrence of the CF, the doctors’ responses to the CF were overall labelled as “Solution-oriented”. If the doctors took a solution-oriented action and explored any (re)occurrence of the CF, the response to the CF was overall labelled as “Exploring & Solution-oriented”. If the doctors did not deal in any way or in any moment with the CF occurrences, the response was overall labelled as “No follow-up”. The doctors’ responses and the specific actions taken for each occurrence of a CF were described, extracted and summarized for each of the categories. Figure 1 provides an overview of the coding approach. All CF with their eventual reoccurrences and doctors’ responses were analysed independently by two researchers (HB, JM) using an excel document along with de-identified patient and doctor characteristics. Disagreements were discussed until resolution. Descriptive and inferential statistics were performed via R [27]. Wilcoxon rank-sum test with continuity correction was performed to analyse the relationship between the number of occurrences for addressed vs un-addressed factors. Fisher's Exact Test for Count Data was performed to examine effect of impact and domains on the doctors’ responses to CF. Lastly a correlational analysis was performed to examine number of re-occurrences for a factor, and the number of actions taken by doctors. Insert figure 1 here: Ethical considerations This project is part of the MAPINFOTRANS project funded by the Norwegian Research Council and was considered exempt from review by the Regional Committee for Medical and Health Research Ethics in Southeast Norway (ref: 273688). This study complies the principles outlined int the Declaration of Helsinki. All participants provided written informed consent, including consent for anonymized responses/quotes to be published, all data collection and handling were approved by the Data Protection Officer at the hospital (ref: 2021_146). All sensitive data was stored in the University of Oslo’s Services for sensitive data (TSD). Availability of data and materials The datasets used and/or analysed during the current study, including anonymized excerpts of clinical interactions, are available from the corresponding author on reasonable request. Discussion This study is the first to examine how doctors respond to the contextual factors (CF) revealed in hospital interactions by old patients with HF. While many factors common to this patient population have been studied and associated with patient treatment adherence [5,15,28], this study offers a unique view on what CF associated with poor treatment adherence old HF patients actually disclose to hospital doctors. How doctors respond to these factors could potentially absolve or mitigate the negative impact they have on the patient’s life and adherence to their treatment plan, and should therefore be considered as clinically important, and a part of patient-centered care [29,30]. We found that hospital cardiologists responded to these factors with solution-oriented actions about half the time, while not following up approximately a quarter of the time. Doctors’ responses were partially contingent on both the number of re-occurrences and the visit when the factors occurred. CF were less likely to be met with a solution-oriented response if they only occurred in the first visit, compared to those which occurred in both visits or just in the discharge visit. This finding may suggest that re-occurring CF may be inherently more salient to hospital doctors, giving doctors more opportunities to address them. It could also suggest that the discharge visits are better suited for solution-oriented responses. In Norwegian hospitals, the discharge visit is often oriented towards sharing an already defined treatment plan and the most relevant information regarding the patients transition to home [31]. CFs that occurred through several interactions at the hospital may therefore be more likely to be responded to with a solution at this stage. We found that 65% of our patients disclosed at least one contextual factor to their doctor during their stay at the hospital. Our findings align with previous studies examining patient context in primary care visits [23,29,32]. In a 2020 study by Weiner et al, 61% of 4496 primary care visits contained a “contextual red flag” (an indication of a contextual factor), resulting in 2985 identified contextual factors [33]. Our results indicate that patients disclose CF also when interacting with hospital doctors, similar to what has been reported in previous studies in primary care [23,32,33]. As for the type of CF disclosed, we found that nearly half pertained to the patient’s experience or perception regarding their medications, with medication side effects being by far the most frequent factor brought up by the patients. When looking at what type of solution-oriented actions doctors implemented in response to medication-related factors, we found that the action “Offers information” was the most common. Out of the 27 medication-related CF disclosed by patients, a substantial portion were not met with a solution-oriented response, 5 being explored with no accompanying solution-oriented action, while 6 were met with no action at all, indicating a need for doctors to be more proactive in addressing medication-related concerns that patient disclose during hospital interactions. The remaining 31 factors disclosed by patients largely consisted of patient-specific factors (n=20), all well established in literature as factors commonly associated with poor treatment adherence, including “conflicting priorities”, “depression and anxiety”, and “lack of social support” [20,34,35]. Less than half (n=9) of these CF were met with a solution-oriented response by the doctor, while seven were not followed up at all by the doctors. This finding may indicate a challenge or a knowledge gap for hospital doctors in terms of how to respond to patient-related CF. Previous studies has demonstrated that periods of hospitalizations strongly affect patients’ psychological and emotional state [36], and factors such as social isolation, lack of support, depression and anxiety are known recurrent themes affecting old patients’ post-discharge outcomes [37–39]. Studies focusing on hospital clinicians’ promptness in discussing factors like social support needs or spiritual and emotional concerns have showed trends similar to our findings [40,41], with e.g. hospital clinicians discussing spiritual concerns while patients are hospitalized only half of the times compared to what patients would want [41], and emotional concerns one fourth of the times [40]. Hospital clinicians’ ability or inclination to assess and address patients’ social needs may depend on varying conditions, with lack of time, workload and supporting cultures being a potential obstacle [42–44]. A relatively small proportion of the CF identified in this study related to the patient’s perception or experience with their condition. The low proportion of condition-related factors is somewhat surprising considering both the serious and debilitating physiological symptoms that heart failure patients commonly experience [1,45] and the high number of comorbidities [7]. Indeed, the patients in this study were discharged from hospital with an average of three diagnoses (SD=1.5). However, the literature on how condition-related factors affect patient adherence is mixed, as disease severity has been associated with improved medication adherence in some studies [35], while co-morbidities in heart failure patients have shown a significant negative impact on adherence [46]. Regardless, our results indicate that patients’ experience and perceptions regarding their condition play a smaller role as a barrier to adherence compared to other CF. Notably, we found that doctors responded to the occurrence of condition-related CF with solution-oriented actions in 5 out of 7 cases, the remaining 2 being further explored by the doctor, perhaps indicating that doctors are more prepared or inclined to address factors relating to the patient’s condition. Similarly, we found few healthcare system related factors, with only four occurring throughout the hospital visits. The low proportion of healthcare system related factors could be interpreted as an indication of the quality of care these patients receive. Norway is indeed among the countries in the world with highest staff resources and quality of care [47]. Also, doctors’ responses (only one in four was solution-oriented and another one exploring) may indicate the difficulty in addressing this type of CF, as they often represent past events or more structural aspects of healthcare. Overall, we found that roughly half of CF were met with a solution-oriented response from the doctors. In previous studies examining how doctors contextualize their care plans in response to CF, Weiner et al (2020) found that doctors addressed 67% of contextual factors identified in primary care visits [33]. If we consider “addressed” the CF met with a solution-oriented response, our findings suggest a poorer response by hospital doctors to the occurrences of CF. This discrepancy may be influenced by the difference in setting, both regarding the clinical environment, location, and patient population. Furthermore, as one fifth of the factors were explored by the doctors but not met with a solution-oriented response, there is a possibility that doctors either determined these factors as unimportant in the context of the hospital visits or that they made an alteration to the treatment plan at some other time point. Also, our study explored doctors’ responses to CF in a small, homogeneous, specific patient group, so results may be hard to compare to larger studies in other settings. Further studies may also be needed to ascertain the quality of these solution-oriented responses to CF, meaning if and how patients perceived these solutions as helpful and able to address barriers to care. Finally, hospital doctors referred patients to their GP several times in response to CF. When additionally scrutinizing each hospital visit, we found that all patients were referred to their GP at some point. This may reflect a general reliance on the GP follow up to address CF and provide a more contextualized treatment plan. Deferring the responsibility of addressing CF to GP’s, who may have a better perspective on their patient’s context, may be a reasonable option for hospital doctors, as a valid part of an integrated care model. However, there is currently no research or policies in place to ensure that this is implemented correctly, creating a possibility for diffusion of responsibility, miscommunication, and misunderstanding between the patients, hospital doctor and general practitioners. Sharing responsibility may require high coordination and good collaboration between hospital and primary care, as well as clear understanding of tasks, roles and responsibilities, something that is still a work in progress in the reflections of hospital doctors [48–50] . Limitations The primary limitation of this study is its limited generalizability resulting from (1) the small sample size, (2) the inclusion and exclusion criteria for participation, and (3) the extensive participation required for such a longitudinal study, perhaps resulting in a sample less frail and more resourceful than the average old HF patient. The second limitation is the potential for doctors’ and patients’ actions being influenced when knowingly being observed by a researcher. However, previous research into the effect of direct observation in clinical interactions has shown that an observer has little effect on most doctor-patient visits [51]. Furthermore, the presence of a recording device in clinical visits showed no association with how doctors probed for CF or contextualized their medical decisions in previous research [33]. While this study does show how doctors respond to CF in hospital visits, it does not determine whether the CF disclosed by patients were truly resolved or addressed by the doctors, as we did not assess the quality of the solution-oriented actions taken by doctors. While factors that were met with no follow up from the doctor could be considered un-resolved or unaddressed, similar to a “contextual error” in the 4C system [32], we cannot exclude the possibility that the factors were addressed by the doctors outside of the first visit and discharge. However, if CF were indeed addressed by doctors at alternative time points, this was not communicated with the patient immediately prior to leaving the hospital, indicating a gap in patient-provider communication and shared decision making. Conclusion This study examined how doctors responded to disclosures of contextual factors from old heart failure patients in a hospital setting. It provided a novel approach for exploring the actions doctors take in response to contextual factors, potentially a new avenue for research into the role of patient context in a hospital setting. Our findings show that patients often disclose important contextual factors relevant for their treatment adherence during interactions with their hospital doctors, many of which relate to their perceptions or experience with their medications. While doctors often respond to CF with solution-oriented actions or by exploring the factor, a significant number were not followed up on, potentially representing missed opportunities for the doctor to address factors leading to suboptimal treatment adherence and patient outcome. Declarations Disclosure No support from any organization for the submitted work; HS has received lecture fees from Amgen, Boehringer Ingelheim, Novartis, Novo-Nordisk and Sanofi-Aventis; PG has received lecture fees from Norwegian Brain Tumor Society, Pfizer and Takeda; JM is a member of Advisory Committee and Board of Trustees for the International Association for Communication in Healthcare EACH (unpaid), and received lecture fees from Oslo Metropolitan University and EACH; no other relationships or activities that could appear to have influenced the submitted work. Author Contribution H.B: Primary author, wrote main manuscript, data collections, data handling & analysis, made substantial contributions to the conception OR design of the workC.F: Data collection, data handling, made substantial contributions to the conception, substantial revisionsP.G: Project supervisor, Designed research protocol & made substantial contributions to the conception, substantial revisionsJ.G: , Designed research protocol & made substantial contributions to the conception, substantial revisionsH.S: made substantial contributions to the conception, substantial revisionsJ.M: Primary authors supervisor, Designed research protocol & made substantial contributions to the conception, substantial revisionsAll authors have approved the submitted version;AND to have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Acknowledgement Hospital staff at the Akershus university hospital heart ward for assistance with project development and data collection. Tone Breines Simonsen was instrumental in identifying potentially eligible participants for the study, and directly responsible for administrating and supporting the process related to patient recruitment. Ivar Bakke for transcriptions and MAPINFOTRANS Advisory Board members for support and advice. References Velagaleti RS, Vasan RS. Chapter 22 - Epidemiology of Heart Failure. In: Mann DL, editor. Heart Failure: A Companion to Braunwald’s Heart Disease (Second Edition). Philadelphia: W.B. Saunders; 2011. pp. 346–54. https://doi.org/10.1016/B978-1-4160-5895-3.10022-1 . Cobretti MR, Page RL, Linnebur SA, Deininger KM, Ambardekar AV, Lindenfeld J, et al. Medication regimen complexity in ambulatory older adults with heart failure. Clin Interv Aging. 2017;12:679–86. https://doi.org/10.2147/CIA.S130832 . Groenewegen A, Rutten FH, Mosterd A, Hoes AW. Epidemiology of heart failure. Eur J Heart Fail. 2020;22:1342–56. https://doi.org/10.1002/ejhf.1858 . Unlu O, Levitan EB, Reshetnyak E, Kneifati-Hayek J, Diaz I, Archambault A, et al. Polypharmacy in Older Adults Hospitalized for Heart Failure. Circulation: Heart Fail. 2020;13:e006977. https://doi.org/10.1161/CIRCHEARTFAILURE.120.006977 . Jankowska-Polańska B, Świątoniowska-Lonc N, Sławuta A, Krówczyńska D, Dudek K, Mazur G. Patient-Reported Compliance in older age patients with chronic heart failure. PLoS ONE. 2020;15:e0231076. https://doi.org/10.1371/journal.pone.0231076 . Ødegaard KM, Lirhus SS, Melberg HO, Hallén J, Halvorsen S. Adherence and persistence to pharmacotherapy in patients with heart failure: a nationwide cohort study, 2014–2020. ESC Heart Fail. 2022;10:405–15. https://doi.org/10.1002/ehf2.14206 . Murad K, Kitzman DW. Frailty and Multiple Comorbidities in the Elderly Patient with Heart Failure: Implications for Management. 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Medication Adherence and Compliance: Recipe for Improving Patient Outcomes. Pharm (Basel). 2022;10:106. https://doi.org/10.3390/pharmacy10050106 . Cheng C, Donovan G, Al-Jawad N, Jalal Z. The use of technology to improve medication adherence in heart failure patients: a systematic review of randomised controlled trials. J Pharm Policy Pract. 2023;16:81. https://doi.org/10.1186/s40545-023-00582-9 . Kardas P. From non-adherence to adherence: Can innovative solutions resolve a longstanding problem? Eur J Intern Med. 2024;119:6–12. https://doi.org/10.1016/j.ejim.2023.10.012 . Aggarwal B, Pender A, Mosca L, Mochari-Greenberger H. Factors associated with medication adherence among heart failure patients and their caregivers. J Nurs Educ Pract. 2015;5:22–7. https://doi.org/10.5430/jnep.v5n3p22 . Kvarnström K, Westerholm A, Airaksinen M, Liira H. Factors Contributing to Medication Adherence in Patients with a Chronic Condition: A Scoping Review of Qualitative Research. Pharmaceutics. 2021;13:1100. https://doi.org/10.3390/pharmaceutics13071100 . McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2023;44:3627–39. https://doi.org/10.1093/eurheartj/ehad195 . Cook CE, Bailliard A, Bent JA, Bialosky JE, Carlino E, Colloca L, et al. An international consensus definition for contextual factors: findings from a nominal group technique. Front Psychol. 2023;14:1178560. https://doi.org/10.3389/fpsyg.2023.1178560 . Weiner SJ. Contextualizing care: An essential and measurable clinical competency. Patient Educ Couns. 2022;105:594–8. https://doi.org/10.1016/j.pec.2021.06.016 . Peh KQE, Kwan YH, Goh H, Ramchandani H, Phang JK, Lim ZY, et al. An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks. J GEN INTERN MED. 2021;36:2784–95. https://doi.org/10.1007/s11606-021-06648-1 . Weiner SJ, Kelly B, Ashley N, Binns-Calvey A, Sharma G, Schwartz A, et al. Content Coding for Contextualization of Care: Evaluating Physician Performance at Patient-Centered Decision Making. Med Decis Mak. 2014;34:97–106. https://doi.org/10.1177/0272989X13493146 . Ball SL, Weiner SJ, Schwartz A, Altman L, Binns-Calvey A, Chan C, et al. Implementation of a patient-collected audio recording audit & feedback quality improvement program to prevent contextual error: stakeholder perspective. BMC Health Serv Res. 2021;21:891. https://doi.org/10.1186/s12913-021-06921-3 . Schwartz A, Weiner SJ, Binns-Calvey A, Weaver FM. Providers contextualise care more often when they discover patient context by asking: meta-analysis of three primary data sets. BMJ Qual Saf. 2016;25:159–63. https://doi.org/10.1136/bmjqs-2015-004283 . Noordman J, Heijmans M, Poortvliet R, Groene O, Ballester M, Ninov L et al. Identifying most important contextual factors for the implementation of self-management interventions: a Delphi study. Patient Educ Couns 2023:107843. https://doi.org/10.1016/j.pec.2023.107843 Frigaard C, Menichetti J, Schirmer H, Bjørnstad H, Breines Simonsen T, Wisløff T, et al. What do patients with heart failure disclose about medication adherence at home to their hospital and primary care doctors? Exploratory interaction-based observational cohort study. BMJ Open. 2024;14:e086440. https://doi.org/10.1136/bmjopen-2024-086440 . Bjørnstad H, Frigaard C, Gulbrandsen P, Gerwing J, Schirmer H, Menichetti J. Contextual Factors Affecting Adherence Revealed by Old Patients with Heart Failure in Hospital and Primary Care Interactions: A Descriptive Study. PPA 2025;19:1075–87.https://doi.org/10.2147/PPA.S505297. R: The R Project for Statistical Computing n.d. https://www.r-project.org/ (accessed January 28, 2025). Rashidi A, Kaistha P, Whitehead L, Robinson S. Factors that influence adherence to treatment plans amongst people living with cardiovascular disease: A review of published qualitative research studies. Int J Nurs Stud. 2020;110:103727. https://doi.org/10.1016/j.ijnurstu.2020.103727 . Weiner SJ, Schwartz A, Sharma G, Binns-Calvey A, Ashley N, Kelly B, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573–9. https://doi.org/10.7326/0003-4819-158-8-201304160-00001 . Aboumatar HJ, Cooper LA. Contextualizing Patient-Centered Care to Fulfill Its Promise of Better Health Outcomes: Beyond Who, What, and Why. Ann Intern Med. 2013;158:628–9. https://doi.org/10.7326/0003-4819-158-8-201304160-00008 . Rognan SE, Kälvemark Sporrong S, Bengtsson K, Lie HB, Andersson Y, Mowé M, et al. Discharge processes and medicines communication from the patient perspective: A qualitative study at an internal medicines ward in Norway. Health Expect. 2021;24:892–904. https://doi.org/10.1111/hex.13232 . Weiner SJ, Schwartz A, Weaver F, Goldberg J, Yudkowsky R, Sharma G, et al. Contextual Errors and Failures in Individualizing Patient Care. Ann Intern Med. 2010;153:69–75. https://doi.org/10.7326/0003-4819-153-2-201007200-00002 . Weiner S, Schwartz A, Altman L, Ball S, Bartle B, Binns-Calvey A, et al. Evaluation of a Patient-Collected Audio Audit and Feedback Quality Improvement Program on Clinician Attention to Patient Life Context and Health Care Costs in the Veterans Affairs Health Care System. JAMA Netw Open. 2020;3:e209644. https://doi.org/10.1001/jamanetworkopen.2020.9644 . Leslie KH, McCowan C, Pell JP. Adherence to cardiovascular medication: a review of systematic reviews. J Public Health (Oxf). 2019;41:e84–94. https://doi.org/10.1093/pubmed/fdy088 . Kardas P, Lewek P, Matyjaszczyk M. Determinants of patient adherence: a review of systematic reviews. Front Pharmacol. 2013;4:91. https://doi.org/10.3389/fphar.2013.00091 . Alzahrani N. The effect of hospitalization on patients’ emotional and psychological well-being among adult patients: An integrative review. Appl Nurs Res. 2021;61:151488. https://doi.org/10.1016/j.apnr.2021.151488 . Hussein Y, Edwards S, Patel HP. Psychological Impact of Hospital Discharge on the Older Person: A Systematic Review. Geriatrics. 2024;9:167. https://doi.org/10.3390/geriatrics9060167 . Poletti V, Pagnini F, Banfi P, Volpato E. The Role of Depression on Treatment Adherence in Patients with Heart Failure–a Systematic Review of the Literature. Curr Cardiol Rep. 2022;24:1995–2008. https://doi.org/10.1007/s11886-022-01815-0 . Kessing D, Denollet J, Widdershoven J, Kupper N. Psychological Determinants of Heart Failure Self-Care: Systematic Review and Meta-Analysis. Psychosom Med. 2016;78:412–31. https://doi.org/10.1097/PSY.0000000000000270 . Adams K, Cimino JEW, Arnold RM, Anderson WG. Why should I talk about emotion? Communication patterns associated with physician discussion of patient expressions of negative emotion in hospital admission encounters. Patient Educ Couns. 2012;89:44–50. https://doi.org/10.1016/j.pec.2012.04.005 . Williams JA, Meltzer D, Arora V, Chung G, Curlin FA. Attention to inpatients’ religious and spiritual concerns: predictors and association with patient satisfaction. J Gen Intern Med. 2011;26:1265–71. https://doi.org/10.1007/s11606-011-1781-y . Caverly TJ, Hayward RA. Dealing with the Lack of Time for Detailed Shared Decision-making in Primary Care: Everyday Shared Decision-making. J Gen Intern Med. 2020;35:3045–9. https://doi.org/10.1007/s11606-020-06043-2 . Gravel K, Légaré F, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals’ perceptions. Implement Sci. 2006;1:16. https://doi.org/10.1186/1748-5908-1-16 . Ramadurai D, Patel H, Peace S, Clapp JT, Hart JL. Integrating Social Determinants of Health in Critical Care. CHEST Crit Care. 2024;2:100057. https://doi.org/10.1016/j.chstcc.2024.100057 . Niklasson A, Maher J, Patil R, Sillén H, Chen J, Gwaltney C, et al. Living with heart failure: patient experiences and implications for physical activity and daily living. ESC Heart Fail. 2022;9:1206–15. https://doi.org/10.1002/ehf2.13795 . Mathes T, Jaschinski T, Pieper D. Adherence influencing factors – a systematic review of systematic reviews. Arch Public Health. 2014;72:37. https://doi.org/10.1186/2049-3258-72-37 . Aiken LH, Sermeus W, Van den Heede K, Sloane DM, Busse R, McKee M, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344:e1717. https://doi.org/10.1136/bmj.e1717 . Leonardsen A-CL, Werner A, Lurås H, Johannessen A-K. Hospital physicians’ experiences and reflections on their work and role in relation to older patients’ pathways - a qualitative study in two Norwegian hospitals. BMC Health Serv Res. 2022;22:443. https://doi.org/10.1186/s12913-022-07846-1 . Knutsen Glette M, Kringeland T, Røise O, Wiig S. Hospital physicians’ views on discharge and readmission processes: a qualitative study from Norway. BMJ Open. 2019;9:e031297. https://doi.org/10.1136/bmjopen-2019-031297 . Cam H, Wennlöf B, Gillespie U, Franzon K, Nielsen EI, Ling M, et al. The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals’ views. BMC Health Serv Res. 2023;23:1211. https://doi.org/10.1186/s12913-023-10192-5 . Goodwin MA, Stange KC, Zyzanski SJ, Crabtree BF, Borawski EA, Flocke SA. The Hawthorne Effect in Direct Observation Research with Physicians and Patients. J Eval Clin Pract. 2017;23:1322–8. https://doi.org/10.1111/jep.12781 . Tables Table 1 Patient and doctor characteristics Patient Characteristics (n = 42) n(%); mean ± SD Age (Y) 79.4 ± 6.4 Women 11 (26%) Marital status: Cohabiting / Married / Registered partner 25 (59%) Education level: Primary school 7 (17%) High school / Vocational school / Gymnasium 15 (36%) Bachelor's degree or equivalent (3 years) 10 (24%) Master's degree or equivalent (5 years) or higher 5 (12%) Montreal Cognitive Assessment (MoCA) Score (range 0–30; <26 signals a cognitive impairment) 23.5 ± 3.8 Patients with no history of heart failure 11 (26%) Ejection fraction (EF%) at discharge 36.7 ± 12.8 Number of diagnoses at discharge 3.2 ± 1.5 Number of medications at discharge 9.4 ± 3.2 Average change in medication from admission to discharge 2.4 ± 3.2 No previous work experience in healthcare 36 (86%) Not currently employed 37 (88%) Doctor characteristics (n = 39) Women, No. (%) 28 (72%) Age, Mean ± SD 37.2 ± 17 Years of Practice, Mean ± SD 4.9 ± 6.6 Doctors receiving communication training after medical school, No. (%) 9 (23%) Table 2 Doctors’ responses for the different domains of Contextual Factors Domain factors No Follow-up Exploring Solution-oriented Exploring & Solution-oriented Total Medication related 6 (22%) 5 (19%) 7 (26%) 9 (33%) 27 Patient-specific 7 (35%) 4 (20%) 7 (35%) 2 (10%) 20 Condition Related 0 2 (29%) 2 (29%) 3 (42%) 7 Healthcare-system related factors 2 (50%) 1 (25%) 1 (25%) 0 4 Table 3 Doctors’ actions within the category “Solution-oriented” Type of solution-oriented action Count Unique Patients Example Offer information 13 12 Doctor provides patient information regarding how medication works, and why they have been prescribed Make active change in treatment plan 11 10 Doctor expedites patient discharge Offer advice 8 7 Doctor advises patient to engage in exercise Refer to GP 7 7 Doctor states GP will be better position to address patient concern Offer system resources 4 4 Doctor offers patient extended home care from healthcare professionals Evaluate treatment change 2 2 Doctor states he will evaluate change in medication dosage Highlight importance 2 2 Doctor reiterates importance of prescribed medication in relation to upcoming operation Postpone decision 2 2 Doctor postpones change in medication after scheduling further tests /doctor postpones discharge pending additional discussion with patient Empower 6 5 Doctor encourages patients’ efforts to increase fluid intake Make recommendations 1 1 Doctor recommends significant other of patient to contact healthcare services for additional home care Simplify information 1 1 Doctor rephrases terminology to simpler terms when explaining function of medication Offer treatment alternative 1 1 Doctor offers alternative medication from the originally prescribed Sustain past decision 1 1 Doctor states that patient will continue with a reduced dose as decided by another doctors Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6656715","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473296471,"identity":"afaf5a59-6c74-47ac-93a5-07141b5366af","order_by":0,"name":"Herman Bjørnstad","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAr0lEQVRIiWNgGAWjYBACAwh1gJmfgbGBRC2SDaRqYTA4QKzDzNl7n274ueMOu/GN5MYHjDtsCGux7DludrP3zDNmsxuJzQaMZ9KIcNiNNLYbvG2HQVraJBjbDhOh5f4ztpt/gVqMZxCt5QYb222QLQYSRGs5k8Z2W7btGbPEmYfNBoltxPjl+DG2m2/b7iTzt6c/fPCxjYgQg4FkMJlAvAYGBjtSFI+CUTAKRsEIAwAoUD21M7IpvgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Oslo","correspondingAuthor":true,"prefix":"","firstName":"Herman","middleName":"","lastName":"Bjørnstad","suffix":""},{"id":473296473,"identity":"917fb04d-60d1-4bf7-aa8e-4cc644f82280","order_by":1,"name":"Christine Frigaard","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Christine","middleName":"","lastName":"Frigaard","suffix":""},{"id":473296475,"identity":"c7f9cf0f-d7c1-4748-9149-066db485bf98","order_by":2,"name":"Pål Gulbrandsen","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Pål","middleName":"","lastName":"Gulbrandsen","suffix":""},{"id":473296476,"identity":"0a2e21f8-959a-4972-9cee-4a9f6276712b","order_by":3,"name":"Jennifer Gerwing","email":"","orcid":"","institution":"Akershus University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Gerwing","suffix":""},{"id":473296477,"identity":"4a5ea5b7-c9b0-4e84-a69f-6070ab622e25","order_by":4,"name":"Henrik Schirmer","email":"","orcid":"","institution":"Dept of Cardiology, Akershus university hospital","correspondingAuthor":false,"prefix":"","firstName":"Henrik","middleName":"","lastName":"Schirmer","suffix":""},{"id":473296478,"identity":"f348b269-78a3-4843-8747-fb5d2c8d6076","order_by":5,"name":"Julia Menichetti","email":"","orcid":"","institution":"Akershus University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Julia","middleName":"","lastName":"Menichetti","suffix":""}],"badges":[],"createdAt":"2025-05-13 14:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6656715/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6656715/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13505-y","type":"published","date":"2025-10-01T15:57:26+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85171304,"identity":"0ba894f8-2546-459a-8914-fda1f4330c83","added_by":"auto","created_at":"2025-06-23 05:42:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43695,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of coding approach for contextual factor and doctor response.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6656715/v1/7f0f83c89fc7cd3ad1b4dc92.jpg"},{"id":92883734,"identity":"4e30e8a2-e532-4c6f-8437-e426edabcec0","added_by":"auto","created_at":"2025-10-06 16:08:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":863913,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6656715/v1/4d282ea8-6f3c-4fa9-b938-f63663f83731.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Responding to contextual factors revealed by old patients with heart failure in hospital interactions: An interaction-based study","fulltext":[{"header":"Background","content":"\u003cp\u003ePatients affected by heart failure (HF) constitute a large and growing patient group with complex care needs. [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Indeed, HF has a chronic and progressive nature; it usually affects old persons, who are also associated with polypharmacy, frailty, co-morbidities, and low treatment adherence [\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Thus, old persons with HF are a particularly vulnerable patient population, with an overall poor prognosis, frequent hospitalization and high mortality [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. How well patients adhere to their treatment plan plays a pivotal role in their outcomes, and addressing poor treatment adherence for this patient group is one of the primary avenues for improving outcomes as well as reducing overall healthcare costs [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious studies have revealed why old patients with HF likely struggle to adhere to their treatment plan, and what the consequences of suboptimal treatment adherence are, along with developing and implementing adherence supporting interventions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Despite increasing availability of evidence-based technological and systematic interventions, non-adherence remains an unresolved complex problem [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Research into the root causes for non-adherence on both a systemic and individual level has revealed multiple factors contributing to non-adherence for this and other patient groups [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA leading factor for why patients with HF do not adhere to their plan is the high degree of polypharmacy inherent to the standard treatment for HF (typically between 4 to 5 medications), often further increased by the additional comorbidities that this patient group has (often resulting in regimens of over 10 medications) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Patients\u0026rsquo; ability and inclination to adhere to treatment plans are further influenced by each patient\u0026rsquo;s individual context, that is, non-biomedical factors in the patient\u0026rsquo;s life influencing therapeutic outcomes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These factors, often referred to as contextual factors, are not limited to inherent patient-related factors such as the patients\u0026rsquo; understanding of their diagnosis and treatment, but also include systemic factors such as their access to healthcare services, social support, and medication regimen, among others [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA doctor\u0026rsquo;s ability to recognize, explore, and address contextual factors is a central part of patient-centered care and a measure of clinical competency [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Improving doctors\u0026rsquo; ability to recognize the contextual factors that patients reveal and tailor the patients\u0026rsquo; treatment plan accordingly is considered a reliable pathway for reducing unwanted variability in patient outcomes [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This process of contextualizing clinical decisions, coined \u0026ldquo;contextualization of care\u0026rdquo; by Weiner et al [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], is mostly studied directly by examining clinical interactions between doctors and patients, as it is during these interactions contextual factors are most commonly made available to the doctors [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. While there is an increasing wealth of knowledge and interest into if and how doctors contextualize decisions during clinical interactions, it is yet unexplored in the context of old in-patients with HF in a hospital setting.\u003c/p\u003e \u003cp\u003eThis study aimed to explore if and how hospital doctors address contextual factors disclosed by patients 65 years or older admitted to hospital with a HF diagnosis. In particular, we aimed to:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIdentify all contextual factors that patients describe as having a negative impact on their life or on their adherence, revealed during clinical interactions in hospital.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExplore, characterize and quantify how doctors approached these contextual factors.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eThis study has an exploratory interaction-based observational cohort design. Patients were admitted to hospital with a HF diagnosis. Primary data are audio-recordings of each patient\u0026rsquo;s first hospital ward visit and discharge visits.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData collection and participant recruitment\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eMembers of the research team recruited in-patients admitted to the heart ward at Akershus University Hospital with a HF diagnosis prior to their first encounter with a hospital doctor. We recruited patients Monday to Friday from February 2022 to February 2023. Patients were identified via patient admission lists and were approached and recruited along with their attending hospital doctor prior to their first ward visit. To be eligible for participation, patients had to be admitted to hospital with a HF diagnosis, be older than 65 years, be competent to give consent for participation, live within the uptake area of the hospital, and be responsible for administering their own medication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo researchers independently observed and collected audio recordings of the first ward visit and the discharge visit. Audio recordings were transcribed, and relevant observational notes added to final transcriptions. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor additional details regarding patient recruitment and data collection see Frigaard et al [25].\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAnalysis\u0026nbsp;\u003c/h2\u003e\n\u003ch3\u003eIdentifying contextual factors\u003c/h3\u003e\n\u003cp\u003eWe defined \u0026ldquo;contextual factor\u0026rdquo; (CF) as any patient behaviour, perceptions, experiences, or life circumstances that may constitute a barrier to the patient\u0026rsquo;s ability or inclination to follow a treatment plan. We identified CF that patients revealed during the hospital visits using a novel literature-based deductive approach described in Bj\u0026oslash;rnstad et al, 2025 [26]. In short, patient utterances containing references to well-known barriers to adherence among cardiovascular patients were extracted and categorized as having either no potential impact, as having a potential impact on the patient\u0026rsquo;s ability or inclination to follow a treatment plan (adherence impact) or as having a potential impact on the patient\u0026rsquo;s life (life impact), based on how the patients described them. Patient utterances referencing adherence barriers described as having a life or adherence impact by the patients were considered as CF. We then flagged all subsequent utterances containing references to the same factor (not necessarily with the same impact) across both the first ward visit and the discharge visit and recording each utterance as a re-occurrence of the overarching CF. After the initial impactful occurrence and all eventual reoccurrences of the CF had been identified, they were grouped into four categories based on their content: patient-specific factors, healthcare system-related factors, medication-related factors, and condition-related factors.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAnalysing doctors\u0026rsquo; responses to CF\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eFor each occurrence of a CF, we analysed the doctors\u0026rsquo; response in the sequence following each CF until a topic change.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFirst, for each occurrence of the CF we described the specific action taken by the doctor, examples including \u0026ldquo;Gives information\u0026rdquo;, \u0026ldquo;Makes active change\u0026rdquo;, or \u0026ldquo;Changes topic\u0026rdquo;. We then evaluated whether these actions were:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eSolution-oriented:\u0026nbsp;These were action-oriented responses aimed at resolving, mitigating, or otherwise addressing the factor, without additional investigation/discussion/gathering of information. These actions included medical decisions such as active changes to the patient\u0026rsquo;s treatment plan, providing the patient relevant information related to the CF, or other actions reflecting direct engagement with the CF in a way to address or resolve it, such as providing encouragement or simplifying relevant information.\u003cul\u003e\n \u003cli\u003eE.g., a patient mentions frequently forgetting to take their morning dose of HF medication. Without further inquiry the doctor suggests setting a daily reminder on the patient\u0026rsquo;s telephone or the use of a pill organizer.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eExploring: doctors\u0026rsquo; responses were considered exploring according to Frigaard et al (2025) definition (i.e., seeking more information about the patient\u0026rsquo;s perception or adherence behaviour) [25]. In these cases, the doctor gathered further new information regarding the CF, but did not implement any additional action to resolve, mitigate, or otherwise address the factor. This included the doctor giving the patient space to elaborate, or asking direct questions regarding the patient\u0026rsquo;s experience, perception, or circumstance. Note that requests for clarifications or checks for understanding were not enough to be considered \u0026ldquo;exploring\u0026rdquo;.\u0026nbsp;\u003cul\u003e\n \u003cli\u003eE.g., a patient mentions how side effects from the HF medication interferes with daily tasks, doctor asks about the nature of side effects and the patient\u0026rsquo;s experience but does not take any further action.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eExploring and Solution-oriented: in these cases, the doctor both explored the CF and made an action aimed at resolving, mitigating, or otherwise addressing the factor.\u003cul\u003e\n \u003cli\u003eE.g., a patient mentions they often skip doses of HF medication due to side effects, the doctor asks follow-up questions regarding the patient experience with side effects and how they interfere with the patient\u0026rsquo;s life. The doctor then takes a concrete action such as altering the prescribed dosage or gives information regarding alternative time points the patient may administer the medication which may interfere less with the patient\u0026rsquo;s daily life.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eNo follow-up: in these cases, the doctor response in the sequence initiated by the CF did not follow up on the CF and was not linked in content to the CF. Therefore, the doctor neither explored the CF nor made any solution-oriented action in response to the CF. These were frequently cases when the doctor changed the topic, thereby closing the sequence.\u0026nbsp;\u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003eE.g., a patient states she often experiences anxiety related to her illness. The doctor responds by asking about the patient\u0026rsquo;s previously prescribed medications.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWhile some actions did not fall under the above-mentioned categories (i.e., \u0026ldquo;checking understanding\u0026rdquo;, \u0026ldquo;request for clarification\u0026rdquo;, \u0026ldquo;acknowledging\u0026rdquo;) we found that these actions did not happen in isolation and were always part of sequences in which the doctor\u0026rsquo;s actions fit into one of the above categories. Thus, we decided not to code them as distinct, separate actions.\u003c/p\u003e\n\u003cp\u003eThen, doctors\u0026rsquo; responses to the CF and its eventual reoccurrences along the same or different interactions were reviewed holistically. If the doctors took a solution-oriented action in response to any (re)occurrence of the CF, the doctors\u0026rsquo; responses to the CF were overall labelled as \u0026ldquo;Solution-oriented\u0026rdquo;. If the doctors took a solution-oriented action and explored any (re)occurrence of the CF, the response to the CF was overall labelled as \u0026ldquo;Exploring \u0026amp; Solution-oriented\u0026rdquo;. If the doctors did not deal in any way or in any moment with the CF occurrences, the response was overall labelled as \u0026ldquo;No follow-up\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe doctors\u0026rsquo; responses and the specific actions taken for each occurrence of a CF were described, extracted and summarized for each of the categories. Figure 1 provides an overview of the coding approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll CF with their eventual reoccurrences and doctors\u0026rsquo; responses were analysed independently by two researchers (HB, JM) using an excel document along with de-identified patient and doctor characteristics. Disagreements were discussed until resolution.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDescriptive and inferential statistics were performed via R [27]. Wilcoxon rank-sum test with continuity correction was performed to analyse the relationship between the number of occurrences for addressed vs un-addressed factors. Fisher\u0026apos;s Exact Test for Count Data was performed to examine effect of impact and domains on the doctors\u0026rsquo; responses to CF. Lastly a correlational analysis was performed to examine number of re-occurrences for a factor, and the number of actions taken by doctors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInsert figure 1 here:\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEthical considerations \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis project is part of the MAPINFOTRANS project funded by the Norwegian Research Council and was considered exempt from review by the Regional Committee for Medical and Health Research Ethics in Southeast Norway (ref: 273688). This study complies the principles outlined int the Declaration of Helsinki. All participants provided written informed consent, including consent for anonymized responses/quotes to be published, all data collection and handling were approved by the Data Protection Officer at the hospital (ref: \u0026nbsp; 2021_146). All sensitive data was stored in the University of Oslo\u0026rsquo;s Services for sensitive data (TSD).\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study, including anonymized excerpts of clinical interactions, are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eThis study has an exploratory interaction-based observational cohort design. Patients were admitted to hospital with a HF diagnosis. Primary data are audio-recordings of each patient\u0026rsquo;s first hospital ward visit and discharge visits.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData collection and participant recruitment\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eMembers of the research team recruited in-patients admitted to the heart ward at Akershus University Hospital with a HF diagnosis prior to their first encounter with a hospital doctor. We recruited patients Monday to Friday from February 2022 to February 2023. Patients were identified via patient admission lists and were approached and recruited along with their attending hospital doctor prior to their first ward visit. To be eligible for participation, patients had to be admitted to hospital with a HF diagnosis, be older than 65 years, be competent to give consent for participation, live within the uptake area of the hospital, and be responsible for administering their own medication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo researchers independently observed and collected audio recordings of the first ward visit and the discharge visit. Audio recordings were transcribed, and relevant observational notes added to final transcriptions. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor additional details regarding patient recruitment and data collection see Frigaard et al [25].\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAnalysis\u0026nbsp;\u003c/h2\u003e\n\u003ch3\u003eIdentifying contextual factors\u003c/h3\u003e\n\u003cp\u003eWe defined \u0026ldquo;contextual factor\u0026rdquo; (CF) as any patient behaviour, perceptions, experiences, or life circumstances that may constitute a barrier to the patient\u0026rsquo;s ability or inclination to follow a treatment plan. We identified CF that patients revealed during the hospital visits using a novel literature-based deductive approach described in Bj\u0026oslash;rnstad et al, 2025 [26]. In short, patient utterances containing references to well-known barriers to adherence among cardiovascular patients were extracted and categorized as having either no potential impact, as having a potential impact on the patient\u0026rsquo;s ability or inclination to follow a treatment plan (adherence impact) or as having a potential impact on the patient\u0026rsquo;s life (life impact), based on how the patients described them. Patient utterances referencing adherence barriers described as having a life or adherence impact by the patients were considered as CF. We then flagged all subsequent utterances containing references to the same factor (not necessarily with the same impact) across both the first ward visit and the discharge visit and recording each utterance as a re-occurrence of the overarching CF. After the initial impactful occurrence and all eventual reoccurrences of the CF had been identified, they were grouped into four categories based on their content: patient-specific factors, healthcare system-related factors, medication-related factors, and condition-related factors.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eAnalysing doctors\u0026rsquo; responses to CF\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eFor each occurrence of a CF, we analysed the doctors\u0026rsquo; response in the sequence following each CF until a topic change.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFirst, for each occurrence of the CF we described the specific action taken by the doctor, examples including \u0026ldquo;Gives information\u0026rdquo;, \u0026ldquo;Makes active change\u0026rdquo;, or \u0026ldquo;Changes topic\u0026rdquo;. We then evaluated whether these actions were:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eSolution-oriented:\u0026nbsp;These were action-oriented responses aimed at resolving, mitigating, or otherwise addressing the factor, without additional investigation/discussion/gathering of information. These actions included medical decisions such as active changes to the patient\u0026rsquo;s treatment plan, providing the patient relevant information related to the CF, or other actions reflecting direct engagement with the CF in a way to address or resolve it, such as providing encouragement or simplifying relevant information.\u003cul\u003e\n \u003cli\u003eE.g., a patient mentions frequently forgetting to take their morning dose of HF medication. Without further inquiry the doctor suggests setting a daily reminder on the patient\u0026rsquo;s telephone or the use of a pill organizer.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eExploring: doctors\u0026rsquo; responses were considered exploring according to Frigaard et al (2025) definition (i.e., seeking more information about the patient\u0026rsquo;s perception or adherence behaviour) [25]. In these cases, the doctor gathered further new information regarding the CF, but did not implement any additional action to resolve, mitigate, or otherwise address the factor. This included the doctor giving the patient space to elaborate, or asking direct questions regarding the patient\u0026rsquo;s experience, perception, or circumstance. Note that requests for clarifications or checks for understanding were not enough to be considered \u0026ldquo;exploring\u0026rdquo;.\u0026nbsp;\u003cul\u003e\n \u003cli\u003eE.g., a patient mentions how side effects from the HF medication interferes with daily tasks, doctor asks about the nature of side effects and the patient\u0026rsquo;s experience but does not take any further action.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eExploring and Solution-oriented: in these cases, the doctor both explored the CF and made an action aimed at resolving, mitigating, or otherwise addressing the factor.\u003cul\u003e\n \u003cli\u003eE.g., a patient mentions they often skip doses of HF medication due to side effects, the doctor asks follow-up questions regarding the patient experience with side effects and how they interfere with the patient\u0026rsquo;s life. The doctor then takes a concrete action such as altering the prescribed dosage or gives information regarding alternative time points the patient may administer the medication which may interfere less with the patient\u0026rsquo;s daily life.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eNo follow-up: in these cases, the doctor response in the sequence initiated by the CF did not follow up on the CF and was not linked in content to the CF. Therefore, the doctor neither explored the CF nor made any solution-oriented action in response to the CF. These were frequently cases when the doctor changed the topic, thereby closing the sequence.\u0026nbsp;\u003cul style=\"list-style-type: circle;\"\u003e\n \u003cli\u003eE.g., a patient states she often experiences anxiety related to her illness. The doctor responds by asking about the patient\u0026rsquo;s previously prescribed medications.\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWhile some actions did not fall under the above-mentioned categories (i.e., \u0026ldquo;checking understanding\u0026rdquo;, \u0026ldquo;request for clarification\u0026rdquo;, \u0026ldquo;acknowledging\u0026rdquo;) we found that these actions did not happen in isolation and were always part of sequences in which the doctor\u0026rsquo;s actions fit into one of the above categories. Thus, we decided not to code them as distinct, separate actions.\u003c/p\u003e\n\u003cp\u003eThen, doctors\u0026rsquo; responses to the CF and its eventual reoccurrences along the same or different interactions were reviewed holistically. If the doctors took a solution-oriented action in response to any (re)occurrence of the CF, the doctors\u0026rsquo; responses to the CF were overall labelled as \u0026ldquo;Solution-oriented\u0026rdquo;. If the doctors took a solution-oriented action and explored any (re)occurrence of the CF, the response to the CF was overall labelled as \u0026ldquo;Exploring \u0026amp; Solution-oriented\u0026rdquo;. If the doctors did not deal in any way or in any moment with the CF occurrences, the response was overall labelled as \u0026ldquo;No follow-up\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe doctors\u0026rsquo; responses and the specific actions taken for each occurrence of a CF were described, extracted and summarized for each of the categories. Figure 1 provides an overview of the coding approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll CF with their eventual reoccurrences and doctors\u0026rsquo; responses were analysed independently by two researchers (HB, JM) using an excel document along with de-identified patient and doctor characteristics. Disagreements were discussed until resolution.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDescriptive and inferential statistics were performed via R [27]. Wilcoxon rank-sum test with continuity correction was performed to analyse the relationship between the number of occurrences for addressed vs un-addressed factors. Fisher\u0026apos;s Exact Test for Count Data was performed to examine effect of impact and domains on the doctors\u0026rsquo; responses to CF. Lastly a correlational analysis was performed to examine number of re-occurrences for a factor, and the number of actions taken by doctors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInsert figure 1 here:\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEthical considerations \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis project is part of the MAPINFOTRANS project funded by the Norwegian Research Council and was considered exempt from review by the Regional Committee for Medical and Health Research Ethics in Southeast Norway (ref: 273688). This study complies the principles outlined int the Declaration of Helsinki. All participants provided written informed consent, including consent for anonymized responses/quotes to be published, all data collection and handling were approved by the Data Protection Officer at the hospital (ref: \u0026nbsp; 2021_146). All sensitive data was stored in the University of Oslo\u0026rsquo;s Services for sensitive data (TSD).\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study, including anonymized excerpts of clinical interactions, are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to examine how doctors respond to the contextual factors (CF) revealed in hospital interactions by old patients with HF. While many \u0026nbsp;factors common to this patient population have been studied and associated with patient treatment adherence\u0026nbsp;[5,15,28], this study offers a unique view on what CF associated with poor treatment adherence old HF patients actually disclose to hospital doctors. How doctors respond to these factors could potentially absolve or mitigate the negative impact they have on the patient\u0026rsquo;s life and adherence to their treatment plan, and should therefore be considered as clinically important, and a part of patient-centered care\u0026nbsp;[29,30].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe found that hospital cardiologists responded to these factors with solution-oriented actions about half the time, while not following up approximately a quarter of the time. \u0026nbsp;Doctors\u0026rsquo; responses were partially contingent on both the number of re-occurrences and the visit when the factors occurred. CF were less likely to be met with a solution-oriented response if they only occurred in the first visit, compared to those which occurred in both visits or just in the discharge visit. This finding may suggest that re-occurring CF may be inherently more salient to hospital doctors, giving doctors more opportunities to address them. It could also suggest that the discharge visits are better suited for solution-oriented responses. In Norwegian hospitals, the discharge visit is often oriented towards sharing an already defined treatment plan and the most relevant information regarding the patients transition to home\u0026nbsp;[31]. CFs that occurred through several interactions at the hospital may therefore be more likely to be responded to with a solution at this stage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe found that 65% of our patients disclosed at least one contextual factor to their doctor during their stay at the hospital. Our findings align with previous studies examining patient context in primary care visits\u0026nbsp;[23,29,32]. In a 2020 study by Weiner et al, 61% of 4496 primary care visits contained a \u0026ldquo;contextual red flag\u0026rdquo; (an indication of a contextual factor), resulting in 2985 identified contextual factors\u0026nbsp;[33]. Our results indicate that patients disclose CF also when interacting with hospital doctors, similar to what has been reported in previous studies in primary care\u0026nbsp;[23,32,33].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs for the type of CF disclosed, we found that nearly half pertained to the patient\u0026rsquo;s experience or perception regarding their medications, with medication side effects being by far the most frequent factor brought up by the patients. When looking at what type of solution-oriented actions doctors implemented in response to medication-related factors, we found that the action \u0026ldquo;Offers information\u0026rdquo; was the most common. Out of the 27 medication-related CF disclosed by patients, a substantial portion were not met with a solution-oriented response, 5 being explored with no accompanying solution-oriented action, while 6 were met with no action at all, indicating a need for doctors to be more proactive in addressing medication-related concerns that patient disclose during hospital interactions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe remaining 31 factors disclosed by patients largely consisted of patient-specific factors (n=20), all well established in literature as factors commonly associated with poor treatment adherence, including \u0026ldquo;conflicting priorities\u0026rdquo;, \u0026ldquo;depression and anxiety\u0026rdquo;, and \u0026ldquo;lack of social support\u0026rdquo;\u0026nbsp;[20,34,35]. Less than half (n=9) of these CF were met with a solution-oriented response by the doctor, while seven were not followed up at all by the doctors. This finding may indicate a challenge or a knowledge gap for hospital doctors in terms of how to respond to patient-related CF. Previous studies has demonstrated that periods of hospitalizations strongly affect patients\u0026rsquo; psychological and emotional state\u0026nbsp;[36], and factors such as social isolation, lack of support, depression and anxiety are known recurrent themes affecting old patients\u0026rsquo; post-discharge outcomes\u0026nbsp;[37\u0026ndash;39]. Studies focusing on hospital clinicians\u0026rsquo; promptness in discussing factors like social support needs or spiritual and emotional concerns have showed trends similar to our findings\u0026nbsp;[40,41], with e.g. hospital clinicians discussing spiritual concerns while patients are hospitalized only half of the times compared to what patients would want\u0026nbsp;[41], and emotional concerns one fourth of the times\u0026nbsp;[40]. Hospital clinicians\u0026rsquo; ability or inclination to assess and address patients\u0026rsquo; social needs may depend on varying conditions, with lack of time, workload and supporting cultures being a potential obstacle\u0026nbsp;[42\u0026ndash;44].\u003c/p\u003e\n\u003cp\u003eA relatively small proportion of the CF identified in this study related to the patient\u0026rsquo;s perception or experience with their condition. The low proportion of condition-related factors is somewhat surprising considering both the serious and debilitating physiological symptoms that heart failure patients commonly experience\u0026nbsp;[1,45]\u0026nbsp;and the high number of comorbidities\u0026nbsp;[7]. Indeed, the patients in this study were discharged from hospital with an average of three diagnoses (SD=1.5). However, the literature on how condition-related factors affect patient adherence is mixed, as disease severity has been associated with improved medication adherence in some studies\u0026nbsp;[35], while co-morbidities in heart failure patients have shown a significant negative impact on adherence\u0026nbsp;[46]. Regardless, our results indicate that patients\u0026rsquo; experience and perceptions regarding their condition play a smaller role as a barrier to adherence compared to other CF. Notably, we found that doctors responded to the occurrence of condition-related CF with solution-oriented actions in 5 out of 7 cases, the remaining 2 being further explored by the doctor, perhaps indicating that doctors are more prepared or inclined to address factors relating to the patient\u0026rsquo;s condition.\u003c/p\u003e\n\u003cp\u003eSimilarly, we found few healthcare system related factors, with only four occurring throughout the hospital visits. The low proportion of healthcare system related factors could be interpreted as an indication of the quality of care these patients receive. Norway is indeed among the countries in the world with highest staff resources and quality of care\u0026nbsp;[47]. \u0026nbsp;Also, doctors\u0026rsquo; responses (only one in four was solution-oriented and another one exploring) may indicate the difficulty in addressing this type of CF, as they often represent past events or more structural aspects of healthcare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, we found that roughly half of CF were met with a solution-oriented response from the doctors. In previous studies examining how doctors contextualize their care plans in response to CF, Weiner et al (2020) found that doctors addressed 67% of contextual factors identified in primary care visits\u0026nbsp;[33]. If we consider \u0026ldquo;addressed\u0026rdquo; the CF met with a solution-oriented response, our findings suggest a poorer response by hospital doctors to the occurrences of CF. \u0026nbsp;This discrepancy may be influenced by the difference in setting, both regarding the clinical environment, location, and patient population. Furthermore, as one fifth of the factors were explored by the doctors but not met with a solution-oriented response, there is a possibility that doctors either determined these factors as unimportant in the context of the hospital visits or that they made an alteration to the treatment plan at some other time point. Also, our study explored doctors\u0026rsquo; responses to CF in a small, homogeneous, specific patient group, so results may be hard to compare to larger studies in other settings.\u003c/p\u003e\n\u003cp\u003eFurther studies may also be needed to ascertain the quality of these solution-oriented responses to CF, meaning if and how patients perceived these solutions as helpful and able to address barriers to care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, hospital doctors referred patients to their GP several times in response to CF. When additionally scrutinizing each hospital visit, we found that all patients were referred to their GP at some point. This may reflect a general reliance on the GP follow up to address CF and provide a more contextualized treatment plan. Deferring the responsibility of addressing CF to GP\u0026rsquo;s, who may have a better perspective on their patient\u0026rsquo;s context, may be a reasonable option for hospital doctors, as a valid part of an integrated care model. However, there is currently no research or policies in place to ensure that this is implemented correctly, creating a possibility for diffusion of responsibility, miscommunication, and misunderstanding between the patients, hospital doctor and general practitioners. Sharing responsibility may require high coordination and good collaboration between hospital and primary care, as well as clear understanding of tasks, roles and responsibilities, something that is still a work in progress in the reflections of hospital doctors\u0026nbsp;[48\u0026ndash;50]\u0026nbsp;.\u003c/p\u003e\n\u003ch2\u003eLimitations\u003c/h2\u003e\n\u003cp\u003eThe primary limitation of this study is its limited generalizability resulting from (1) the small sample size, (2) the inclusion and exclusion criteria for participation, and (3) the extensive participation required for such a longitudinal study, perhaps resulting in a sample less frail and more resourceful than the average old HF patient. \u0026nbsp;The second limitation is the potential for doctors\u0026rsquo; and patients\u0026rsquo; actions being influenced when knowingly being observed by a researcher. However, previous research into the effect of direct observation in clinical interactions has shown that an observer has little effect on most doctor-patient visits \u0026nbsp;[51]. Furthermore, the presence of a recording device in clinical visits showed no association with how doctors probed for CF or contextualized their medical decisions in previous research [33]. While this study does show how doctors respond to CF in hospital visits, it does not determine whether the CF disclosed by patients were truly resolved or addressed by the doctors, as we did not assess the quality of the solution-oriented actions taken by doctors. While factors that were met with no follow up from the doctor could be considered un-resolved or unaddressed, similar to a \u0026ldquo;contextual error\u0026rdquo; in the 4C system [32], we cannot exclude the possibility that the factors were addressed by the doctors outside of the first visit and discharge. However, if CF were indeed addressed by doctors at alternative time points, this was not communicated with the patient immediately prior to leaving the hospital, indicating a gap in patient-provider communication and shared decision making.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study examined how doctors responded to disclosures of contextual factors from old heart failure patients in a hospital setting. It provided a novel approach for exploring the actions doctors take in response to contextual factors, potentially a new avenue for research into the role of patient context in a hospital setting. Our findings show that patients often disclose important contextual factors relevant for their treatment adherence during interactions with their hospital doctors, many of which relate to their perceptions or experience with their medications. While doctors often respond to CF with solution-oriented actions or by exploring the factor, a significant number were not followed up on, potentially representing missed opportunities for the doctor to address factors leading to suboptimal treatment adherence and patient outcome.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDisclosure\u003c/h2\u003e \u003cp\u003e No support from any organization for the submitted work; HS has received lecture fees from Amgen, Boehringer Ingelheim, Novartis, Novo-Nordisk and Sanofi-Aventis; PG has received lecture fees from Norwegian Brain Tumor Society, Pfizer and Takeda; JM is a member of Advisory Committee and Board of Trustees for the International Association for Communication in Healthcare EACH (unpaid), and received lecture fees from Oslo Metropolitan University and EACH; no other relationships or activities that could appear to have influenced the submitted work.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eH.B: Primary author, wrote main manuscript, data collections, data handling \u0026amp; analysis, made substantial contributions to the conception OR design of the workC.F: Data collection, data handling, made substantial contributions to the conception, substantial revisionsP.G: Project supervisor, Designed research protocol \u0026amp; made substantial contributions to the conception, substantial revisionsJ.G: , Designed research protocol \u0026amp; made substantial contributions to the conception, substantial revisionsH.S: made substantial contributions to the conception, substantial revisionsJ.M: Primary authors supervisor, Designed research protocol \u0026amp; made substantial contributions to the conception, substantial revisionsAll authors have approved the submitted version;AND to have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eHospital staff at the Akershus university hospital heart ward for assistance with project development and data collection. Tone Breines Simonsen was instrumental in identifying potentially eligible participants for the study, and directly responsible for administrating and supporting the process related to patient recruitment. Ivar Bakke for transcriptions and MAPINFOTRANS Advisory Board members for support and advice.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVelagaleti RS, Vasan RS. Chapter 22 - Epidemiology of Heart Failure. In: Mann DL, editor. Heart Failure: A Companion to Braunwald\u0026rsquo;s Heart Disease (Second Edition). Philadelphia: W.B. 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Appl Nurs Res. 2021;61:151488. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.apnr.2021.151488\u003c/span\u003e\u003cspan address=\"10.1016/j.apnr.2021.151488\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussein Y, Edwards S, Patel HP. Psychological Impact of Hospital Discharge on the Older Person: A Systematic Review. Geriatrics. 2024;9:167. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/geriatrics9060167\u003c/span\u003e\u003cspan address=\"10.3390/geriatrics9060167\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePoletti V, Pagnini F, Banfi P, Volpato E. The Role of Depression on Treatment Adherence in Patients with Heart Failure\u0026ndash;a Systematic Review of the Literature. 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CHEST Crit Care. 2024;2:100057. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.chstcc.2024.100057\u003c/span\u003e\u003cspan address=\"10.1016/j.chstcc.2024.100057\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNiklasson A, Maher J, Patil R, Sill\u0026eacute;n H, Chen J, Gwaltney C, et al. Living with heart failure: patient experiences and implications for physical activity and daily living. ESC Heart Fail. 2022;9:1206\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ehf2.13795\u003c/span\u003e\u003cspan address=\"10.1002/ehf2.13795\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathes T, Jaschinski T, Pieper D. Adherence influencing factors \u0026ndash; a systematic review of systematic reviews. Arch Public Health. 2014;72:37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/2049-3258-72-37\u003c/span\u003e\u003cspan address=\"10.1186/2049-3258-72-37\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAiken LH, Sermeus W, Van den Heede K, Sloane DM, Busse R, McKee M, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344:e1717. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.e1717\u003c/span\u003e\u003cspan address=\"10.1136/bmj.e1717\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeonardsen A-CL, Werner A, Lur\u0026aring;s H, Johannessen A-K. Hospital physicians\u0026rsquo; experiences and reflections on their work and role in relation to older patients\u0026rsquo; pathways - a qualitative study in two Norwegian hospitals. BMC Health Serv Res. 2022;22:443. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-022-07846-1\u003c/span\u003e\u003cspan address=\"10.1186/s12913-022-07846-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnutsen Glette M, Kringeland T, R\u0026oslash;ise O, Wiig S. Hospital physicians\u0026rsquo; views on discharge and readmission processes: a qualitative study from Norway. BMJ Open. 2019;9:e031297. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjopen-2019-031297\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2019-031297\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCam H, Wennl\u0026ouml;f B, Gillespie U, Franzon K, Nielsen EI, Ling M, et al. The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals\u0026rsquo; views. BMC Health Serv Res. 2023;23:1211. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-023-10192-5\u003c/span\u003e\u003cspan address=\"10.1186/s12913-023-10192-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodwin MA, Stange KC, Zyzanski SJ, Crabtree BF, Borawski EA, Flocke SA. The Hawthorne Effect in Direct Observation Research with Physicians and Patients. J Eval Clin Pract. 2017;23:1322\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jep.12781\u003c/span\u003e\u003cspan address=\"10.1111/jep.12781\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":" \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient and doctor characteristics\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient Characteristics (n\u0026thinsp;=\u0026thinsp;42)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en(%); mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge (Y)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e79.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWomen\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (26%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMarital status: Cohabiting / Married / Registered partner\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e25 (59%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEducation level:\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003ePrimary school\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (17%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eHigh school / Vocational school / Gymnasium\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e15 (36%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eBachelor's degree or equivalent (3 years)\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e10 (24%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eMaster's degree or equivalent (5 years) or higher\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (12%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMontreal Cognitive Assessment (MoCA) Score \u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(range 0\u0026ndash;30; \u0026lt;26 signals a cognitive impairment)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatients with no history of heart failure\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (26%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEjection fraction (EF%) at discharge\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e36.7\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNumber of diagnoses at discharge\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNumber of medications at discharge\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAverage change in medication from admission to discharge\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo previous work experience in healthcare\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e36 (86%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNot currently employed\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e37 (88%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor characteristics (n\u0026thinsp;=\u0026thinsp;39)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWomen, No. (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e28 (72%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e37.2\u0026thinsp;\u0026plusmn;\u0026thinsp;17\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eYears of Practice, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctors receiving communication training after medical school, No. (%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9 (23%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctors\u0026rsquo; responses for the different domains of Contextual Factors\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDomain factors\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo Follow-up\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eExploring\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eSolution-oriented\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eExploring \u0026amp; Solution-oriented\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003eTotal\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMedication related\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (22%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (19%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (26%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e9 (33%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e27\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient-specific\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (35%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4 (20%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (35%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (10%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e20\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCondition Related\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (29%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (29%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (42%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHealthcare-system related factors\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (50%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (25%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (25%)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctors\u0026rsquo; actions within the category \u0026ldquo;Solution-oriented\u0026rdquo;\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eType of solution-oriented action\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eCount\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eUnique Patients\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eExample\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOffer information\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e13\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e12\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor provides patient information regarding how medication works, and why they have been prescribed\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMake active change in treatment plan\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e10\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor expedites patient discharge\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOffer advice\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor advises patient to engage in exercise\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRefer to GP\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor states GP will be better position to address patient concern\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOffer system resources\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor offers patient extended home care from healthcare professionals\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEvaluate treatment change\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor states he will evaluate change in medication dosage\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHighlight importance\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor reiterates importance of prescribed medication in relation to upcoming operation\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePostpone decision\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor postpones change in medication after scheduling further tests /doctor postpones discharge pending additional discussion with patient\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEmpower\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor encourages patients\u0026rsquo; efforts to increase fluid intake\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMake recommendations\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor recommends significant other of patient to contact healthcare services for additional home care\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSimplify information\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor rephrases terminology to simpler terms when explaining function of medication\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOffer treatment alternative\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor offers alternative medication from the originally prescribed\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSustain past decision\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eDoctor states that patient will continue with a reduced dose as decided by another doctors\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical Communication, Heart Failure, Contextual Factors, Treatment adherence, Patient-centered care","lastPublishedDoi":"10.21203/rs.3.rs-6656715/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6656715/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePatients with heart failure often face individual context-dependent challenges that affect their ability to follow a treatment plan. How hospital doctors recognize and respond to such contextual factors (CF) may influence health outcomes. This study aims to identify adherence related CF disclosed by old patients with heart failure during hospital interactions and to examine how doctors respond to them.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAudio-recordings from two key hospital interactions were collected from 42 old patients with heart failure. Occurrences of CF were identified based on a previously developed coding scheme and followed during the hospital interactions. We then analysed doctor\u0026rsquo;s responses to patient\u0026rsquo;s CF and categorized them as: (1) Solution-oriented, (2) Exploring (3) No follow-up.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe identified 58 CF across 113 occurrences in 27 (64%) patients. Medication-related CF (47%) were the most frequently disclosed, followed by patient-specific (34%), condition-related (12%), and healthcare system-related factors (7%). Doctors\u0026rsquo; responses varied: 26% (n\u0026thinsp;=\u0026thinsp;15) of CF received no follow-up, 21% (n\u0026thinsp;=\u0026thinsp;12) were only explored, 24% (n\u0026thinsp;=\u0026thinsp;14) were explored and met with a solution-oriented action, and 29% (n\u0026thinsp;=\u0026thinsp;17) were met with solution-oriented actions without any exploration from the doctor.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOlder patients with heart failure often disclose important CF relevant to adherence during hospital interactions. Roughly half of these factors are not met with a solution-oriented response, with a substantial portion not being followed up by the doctors at all. Future research should explore how to better improve doctors\u0026rsquo; ability to recognize and appropriately respond to CF disclosed by patients.\u003c/p\u003e","manuscriptTitle":"Responding to contextual factors revealed by old patients with heart failure in hospital interactions: An interaction-based study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 05:42:00","doi":"10.21203/rs.3.rs-6656715/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-18T11:14:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T09:00:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-10T00:39:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250344093786807946786314052993491022427","date":"2025-08-03T15:14:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291816280269847528093803973085626885819","date":"2025-08-01T13:37:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-14T07:48:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94483399191413842019960202760424699362","date":"2025-07-14T06:05:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"114420225790896630577727164764299185185","date":"2025-06-18T09:07:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-17T12:25:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-10T05:32:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-16T20:23:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-16T09:04:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-16T09:03:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d8eb4e1e-3445-4727-8e17-1bef54ae7026","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:01:31+00:00","versionOfRecord":{"articleIdentity":"rs-6656715","link":"https://doi.org/10.1186/s12913-025-13505-y","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-10-01 15:57:26","publishedOnDateReadable":"October 1st, 2025"},"versionCreatedAt":"2025-06-23 05:42:00","video":"","vorDoi":"10.1186/s12913-025-13505-y","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13505-y","workflowStages":[]},"version":"v1","identity":"rs-6656715","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6656715","identity":"rs-6656715","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}