Hospital Discharge Practice: Room for Improvement in Communication, Comprehension

Leora I. Horwitz, MD, MHS Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, ConnecticutMedicalResearch.com Interview with:

Leora I. Horwitz, MD, MHS
Section of General Internal Medicine, Department of Medicine,
Yale School of Medicine,
Center for Outcomes Research and Evaluation,
Yale–New Haven Hospital, New Haven, Connecticut

MedicalResearch.com: What are the main findings of the study?

Answer: We interviewed nearly 400 older patients who had been admitted with heart failure, pneumonia or heart attack within one week of going home from the hospital. We also reviewed the medical records of 377 of the patients. We found, for example, that:

  • 40% of patients could not understand or explain the reason they were in the hospital in the first place;
  • A fourth of discharge instructions were written in medical jargon that a patient was not likely to understand;
  • Only a third of patients were discharged with scheduled follow-up with a primary care physician or cardiology specialist;
  • Only 44% accurately recalled details of their appointments.

In other words, we didn’t do a very good job of preparing patients for discharge, and perhaps as a result, patients were pretty confused about important things they needed to know after they were home.

We just published a companion paper in the Journal of Hospital Medicine last week in which we looked at the discharge summaries for the same patients – that is, the summary of the hospitalization that is meant to help the outpatient doctor understand what happened in the hospital. Turns out we were just as bad at communicating with doctors as with patients – we focused on details of the hospitalization rather than what needed to happen next or what needed to be followed up, and in a third of cases, we didn’t even send the summary to the outpatient doctor. In fact out of 377 discharge summaries, we didn’t find a single one that was done on the day of discharge, sent to the outpatient doctor, and included all key content recommended by major specialty societies.

MedicalResearch.com: Were any of the findings unexpected?

Answer: Unfortunately, our results weren’t all that different from studies from other institutions. Lots of researchers have found that patients understand much less than we think about their hospital stays – probably because of a combination of things: we are not very good at explaining, we are not very focused on the post-discharge period, patients are sick and often confused and find it hard to remember a lot of new information.

What was surprising about this study though was the mismatch between patient perception and their actual knowledge. Even though their knowledge wasn’t very accurate and the instructions doctors gave them not very patient-friendly, nearly all the patients told us they understood what to do just fine, understood their diagnosis, found their materials very readable, and so forth. Yet we were writing things like “You had unstable angina” or “You should follow a 2g Na diet” in their instructions. This is concerning in that we typically assess the quality of our discharge care by asking patients how they felt about it. If their perceptions are too rosy-colored, we may be fooling ourselves into thinking we are doing a pretty good job when in fact our patients don’t understand key things at all.

MedicalResearch.com:  What should clinicians and patients take away from your report?

Answer: Clinicians should take a good hard look at their practices. Do they do discharge summaries on the day of discharge and send them to the outpatient doctor?

  • Does everyone go home with an appointment?
  • Are the patient instructions actually patient-friendly, or are they written in medical jargon?
  • And they should consider calling a few patients up and actually checking to see what they know.Teachers give their students tests to see what they know, and are held accountable to state exams. We never hold our clinicians accountable to be sure their patients understand what they are saying.

Patients should be aware that there are a few things they need to know going home – what their diagnosis was, what their medications should be, what their follow-up plans are, what they need to watch out for, and what still needs to be follow up by their outpatient doctor. They should not be shy about asking the same questions over and over until they are sure they understand and they should involve friends and family whenever possible. The National Patient Safety Foundation has an excellent program called Ask Me 3 which is worth adopting as a patient:

  • What is my main problem?
  • What do I need to do?
  • Why is it important for me to do this?

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Answer: Our study was not large enough to see whether the lack of discharge planning and/or lack of understanding on the part of patients actually led to adverse outcomes after discharge. Is this in part why readmission rates are so high? We are not sure. Future research might try to establish a causal link more directly. But it is important to remember that there is no single silver bullet. It is almost certainly not enough just to give everyone an appointment, or just to be sure that everyone understands their diagnosis, or just to send the outpatient doctor the discharge summary. It is likely that we will need to get all of those things – and others – right in order to see an effect on adverse outcomes.

Citation:

Horwitz LI, Moriarty JP, Chen C, et al. Quality of Discharge Practices and Patient Understanding at an Academic Medical Center. JAMA Intern Med. 2013;():-. doi:10.1001/jamainternmed.2013.9318.

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