Intern Emerg Med DOI 10.1007/s11739-015-1311-8
EM - ORIGINAL
Examining patient comprehension of emergency department discharge instructions: Who says they understand when they do not? Margaret Jane Lin1 • Adva Gutman Tirosh2 • Alden Landry1
Received: 3 June 2015 / Accepted: 22 August 2015 Ó SIMI 2015
Abstract Patient comprehension of emergency department (ED) discharge instructions is important for ensuring that patients understand their diagnosis, recommendations for treatment, appropriate follow-up, and reasons to return. However, many patients may not fully understand their instructions. Furthermore, some patients may state they understand their instructions even when they do not. We surveyed 75 patients on their perception of their understanding of their ED discharge instructions, and asked them specific questions about the instructions. We also performed a chart review, and examined patients’ answers for correlation with the written instructions and medical chart. We then performed a statistical analysis evaluating which patients claimed understanding but who were found to have poor understanding on chart review. Overall, there was no significant correlation between patient self-reported understanding and physician evaluation of their understanding (q = 0.221, p = 0.08). However, among female patients and patients with less than 4 years of college, there was significant positive correlation between self-report and physician evaluation of comprehension (q = 0.326, p = 0.04 and q = 0.344, p = 0.04, respectively), whereas
& Margaret Jane Lin [email protected] Adva Gutman Tirosh [email protected] Alden Landry [email protected] 1
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, WCC-2, Boston, MA 02215, USA
2
Soroka Clinical Research Center, Soroka University Medical Center, Beersheba, Israel
there was no correlation for male patients and those with more than 16 years of education (q = 0.008, p = 0.9, q = -0.041, p = 0.84, respectively). Patients’ perception of their understanding may not be accurate, especially among men, and those with greater than college education. Identifying which patients say they understand their discharge instructions, but may actually have poor comprehension could help focus future interventions on improving comprehension. Keywords Emergency department Discharge instructions Patient comprehension Communication
Introduction Effective communication between healthcare providers and patients is an important aspect of high-quality patient care [1–3]. In the fast-paced, high acuity setting of the emergency department (ED), clear communication is especially important since patients receive new diagnoses and instructions on treatment and follow-up plans [4]. However, these very characteristics of the ED can make effective communication difficult [5–7]. There has been increasing emphasis and research on ED discharge instructions and interventions to improve patient comprehension [8–13]. These studies show that discharge instructions are often written at literacy levels that exceed patients’ levels, and that patients have difficulty comprehending their discharge instructions. Further, patients often do not recognize their lack of understanding [14]. It is unclear what kinds of interventions would be beneficial to improve understanding, and which patients should be targeted. Understanding which patients are especially affected by lack of understanding and which aspects of the
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healthcare provider–patient interaction lead to the greatest knowledge deficits is important for designing interventions to improve communication and patient comprehension [14, 15]. In this study, we examined patient’s comprehension of their ED diagnosis, workup, treatment and follow-up instructions. We also surveyed their opinion of healthcare communication, and their understanding of discharge instructions. In particular, we focused on patients who may not report their lack of understanding, as this may not be recognized by medical staff, and these patients might benefit from additional interventions.
Materials and methods We performed a prospective, observational study of patients presenting to a tertiary, urban, academic medical center with approximately 55,000 visits per year. Patients were included in the study if they met the following criteria: Adult patient C18 years old who received discharge instructions for ‘‘abdominal pain’’ (Reading Grade Level 8.3, Flesch-Kincaid Grade level), ‘‘chest pain’’ (Reading Grade Level 6.5) and ‘‘nausea and vomiting’’ (Reading Grade Level 4.7). These are preexisting, prewritten discharge instructions, and these diagnoses were chosen because they are amongst the most commonly given discharge instructions at our institution. Providers can also free text additional information for patients. Patients were excluded for: high acuity/distress per the Attending ED physician, altered mental status, aphasia, developmental delay, dementia, or insurmountable communication barrier, non-English speaking patients, possible sexual assault, and acute psychiatric illness. Patients were given a survey at the end of their health care encounter (‘‘Appendix’’). This was performed after the patient was discharged, but prior to their leaving the ED. We grouped patient understanding into categories: (1) clinical diagnosis, (2) ED care, (3) post-discharge instructions, including discharge medications, and (4) reasons to return to the ED. The first half of the survey included openended questions on these four categories. The second half of the survey asked the patients to rate their comprehension of the discharge instructions, focusing on diagnosis, postdischarge instructions and reasons to seek care, and also the overall communication by health care providers in the ED. This survey was adapted from a previous study on patient understanding of discharge instructions [10]. Demographic data on patients including age, gender, race/ethnicity, highest level of education achieved, income, insurance, reason for ED visit, and medical diagnosis were
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also obtained. Patients were also screened with a Single Item Literacy Screener (SILS) questions, which has been shown to be effective screening tools for health literacy [16]. After patient discharge, two independent emergency physicians (MJL, AML) performed a chart review of all enrolled patients, and scored patient’s answers on a 5-point scale, with 5 being complete concordance or agreement with physician chart review (‘‘Appendix’’). For patients with a \5 score, the lack of agreement was further characterized as discordant (i.e., disagreeing with physician documentation) or omitted (i.e., did not include key aspects) information [10]. Any disagreements between the reviewing physicians were discussed until agreement was achieved. Categorization of patients In our study, we focused on patient understanding of discharge instructions and their perception of their own understanding. The aim was to recognize whether medical staff can rely on the patient self-testimony. In order to characterize when we can rely on the patient, we defined the patients who do not report when they do not understand, meaning they report understanding, while actual understanding is lower than optimal. Unreliable subjects were defined as those who stated their understanding above the median, but had actual understanding lower than median. Data analysis We created two variables: (1) patient self-scoring: sum of the five questions the subjects were asked about their understanding, (2) physician scoring: sum of the four questions the physician evaluators used to assess patient understanding. We then compared these two variables and analyzed them for correlation. Continuous variables with a normal distribution are presented as mean and standard deviation. Ordinary variables or continuous variables with a non-normal distribution are presented as medians with inter-quartile ranges (IQR). Categorical variables are presented as counts and percentages. We used a student’s t test to compare continuous parametric variables. The Mann– Whitney and Wilcoxon test methods were used for nonparametric variables. Categorical variables were tested using Pearson’s v2 test for contingency tables or Fisher exact test, as appropriate. Correlations between variables were tested using Spearman test. All statistical tests and/or confidence intervals, as appropriate, were performed at a = 0.05 (two-sided). The data were analyzed using IBM SPSS Statistics software.
Intern Emerg Med
fewer native English speakers than the included subjects (p = 0.039). There were no other statistically significant differences between the two groups.
Results Patient demographics Our study was a study of 75 adult patients (see Table 1). This was a pilot study with a convenience sampling of patients. In our cohort, there were 11 patients who had missing data regarding understanding of instructions, and these were excluded from analysis. Included patients were 35.9 % male with a mean age of 44.7 years. Between the included and excluded patients, the missing subjects had
Table 1 Baseline characteristics of the subjects Characteristic
N = 75
Age, mean ± SD (years)
45.5 ± 18.9
Gender, male (%)
26 (34.7)
Ethnicity, N (%) White
40 (53.3)
Black
20 (26.7)
Asian
1 (1.3)
Hispanic
7 (9.3)
Other
7 (9.3)
Native language, English (%)
68 (91.9)
Insurance status, N (%) MassHealth
8 (11)
Medicare or Medicaid
15 (20.5)
Private
50 (68.5)
Years of education, median (inter-quartile range)
15 (12–16)
College, N (%)
56 (74.7)
Post college degree, N (%)
18 (24.7)
Employment status, N (%) Currently employed
46 (61.3)
Unemployed Retired
15 (20) 14 (18.7)
Housing status, N (%) Property owner
27 (36)
Renting
41 (54.7)
Other (living with friends or relatives)
7 (9.3)
Patient comprehension In our cohort overall, there was no significant correlation between patient self-reported understanding and physician evaluation of their understanding (q = 0.221, p = 0.08, Fig. 1). Overall, physician evaluation of patients showed lower levels of understanding compared to patient self-perceived understanding. Out of a score of 5, the mean physician evaluation was 3.66 whereas the patient mean reported score was 4.6. Among female patients, there was a significant positive correlation between patient reported understanding and physician evaluation of understanding (q = 0.326, p = 0.04), while among male patients there was no correlation (q = 0.008, p = 0.9, Fig. 2). Among patients with less than 16 years of education (did not finish college), there was also a significant positive correlation between patient reported understanding and physician evaluation of understanding (q = 0.344, p = 0.04), whereas for those that finished college, there was no correlation (q = -0.041, p = 0.84, Fig. 3). The majority of disagreement between emergency physician post visit evaluation and patient responses to discharge instructions were due to omitted information (did not mention key aspects) rather than discordant information (had incorrect information) (Table 2). In 80 % of patients, key aspects of the ED work up were omitted, and in nearly 70 % of patients, key aspects of reasons to return were omitted. Interestingly, among the categories of ED diagnosis, post-discharge care, and reasons to return, patients reported the highest level of understanding in the category of
Smoking status, N (%) Never Former or current
52 (70.3) 22 (19.8)
Lifelong consumption of [100 or more cigarettes, N (%)
21 (28)
Daily consumption of alcohol, N (%)
13 (17.3)
Have one personal doctor, N (%) How many medications that need a doctor’s prescription are you currently taking, median (interquartile range)
66 (88) 2 (0–5)
How many visits have you made to an emergency department in the last year, median (inter-quartile range)
1 (1–2) Fig. 1 Patient self-reported understanding vs. physician evaluation of understanding
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Discussion
Fig. 2 Patient self-scoring vs. physician scoring, divided by gender
Fig. 3 Patient self scoring vs. physician scoring, divided by median years of education
Table 2 Characterization of differences between patient responses and post visit physician evaluation Category
Type
Yes (%)
Diagnosis
Discordant
15 (20.3)
Omitted
37 (50)
Discordant Omitted
8 (10.7) 60 (80)
ED care Post-ED care Return instructions
Discordant
10 (13.3)
Omitted
43 (57.3)
Discordant
10 (13.3)
Omitted
52 (69.3)
reasons to return (mean of 4.89), while this was the category with the lowest score for physician evaluation (3.46). Patients reported lowest understanding of their diagnosis (4.39) among these categories (Fig. 4a–c). Patients with higher health literacy on SILS also had no correlation between self-reported understanding and physician evaluation (Table 3).
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In our study, we find that patients’ perception of their understanding of discharge instructions does not necessarily correlate with actual understanding of discharge instructions. In general, patients rate a higher understanding of instructions compared with physician evaluation of their understanding. This lack of correlation is pronounced in patients with higher education levels and of the male gender. Patient’s answers on the Single Item Literacy Screener (SILS) [16], which are questions used as a marker for health literacy, had no correlation with their physician evaluated level of understanding. While the SILS is not a perfect measure of health literacy, these findings indicate that even health literacy may not predict patients’ understanding of their discharge instructions. Of the categories of questions asked, patients noted least understanding of their ED diagnosis. Given that our population included discharged patients receiving a diagnosis of ‘‘chest pain,’’ ‘‘abdominal pain’’ and ‘‘vomiting and diarrhea,’’ it is not surprising that patients may not know a firm diagnosis of the cause of their symptoms. Often these patients are ruled out for dangerous etiologies that require admission or intervention in order to be discharged, but may not received a definitive diagnosis in the ED. Often in emergency medicine discharge instructions, much emphasis is placed on reasons to return to the ED. Interestingly, patients tended to rate their understanding of these reasons as high, while physician evaluation tended to be low for this, indicating a possible lack of understanding despite patient perception.
Limitations Our study has several limitations. First, ours is a small sample size, which limits the strength of the conclusions. Further, we did have 11 patients with missing data, and among these patients, there were fewer native English speaking patients, which could affect discharge instruction comprehension. However, there were no other significant demographic differences among these patients. Our ED population was also relatively well-educated with the median years of education being 15 years, or 3 years of college, which limits the generalizability of our findings to other institutions. Our study used post-visit physician evaluation to assess for patient understanding of the discharge instructions. These were attending ED physicians who performed a chart review of the patients’ visit and the written discharge
Intern Emerg Med Fig. 4 Comparisons of patient responses and physician evaluation for specific questions. Questions rated from poor (1) to excellent (5)
a
Mean 4.39
Rate how well you feel your doctor explained your problem Diagnosis Physician grade
3.73
median P value 5 rho= 0.059 P= 0.63 4
b
Rate how well you understand why you need to do these steps Post ED Care Physician Grade C1
Mean 4.52 3.8
median P value 5 rho= 0.196 P= 0.09 4
c
How easy to understand are the symptoms to watch out for and reasons to seek medical care? Return Instructions Physician Grade
Mean 4.89 3.46
median P value 5 rho= 0.196 P= 0.49 4
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Intern Emerg Med Table 3 Literacy questions—statistical comparison between the unreliable and the rest of the subjects
Conclusion
Characteristic
Other (N = 49, 76.6 %)
Unreliable (N = 15, 23.4 %)
p value
Question 16, never (%)
42 (85)
14 (93.3)
0.67
Question 17, extremely (%)
36 (76.6)
14 (93.3)
0.67
Patient understanding of discharge instructions is an important aspect of ED provider–patient communication and adequate care. Our investigation reveals possible areas of communication as well as specific patient populations to target to ensure proper and safe understanding.
Question 18, excellent or very good (%)
40 (81.6)
14 (93.3)
0.43
Median of three question sum
47 (100)
15 (100)
Acknowledgments The authors would like to thank Nathan Shapiro, M.D. for help in reviewing the manuscript. Compliance with ethical standards The authors declare that they have no conflict
* p values from Chi square
Conflict of interest of interest.
instructions, and compared them to patient’s responses on post-encounter surveys. As these were not the treating physicians, and they did not have access to any verbal discharge instructions given to the patient, it is possible that the post-visit physician evaluation may not fully be able to evaluate true understanding of discharge instructions. However, we attempted to decrease bias by having two physicians review the discharge instructions.
Statement of human and animal rights All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1976, as revised in 2008.
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Informed consent Informed consent was obtained from all patients included in this study.
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Appendix
Appendix Patient Survey 1.) Rate how well you feel your doctor explained your problem:* 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 2a.) Rate how well you feel your nurse explained your problem:* 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent
2b.) What did your doctor or nurse tell you is wrong with you, i.e. what is your diagnosis?* ______________________________________________________________ 2c.) What tests did you have done in the emergency department? ________________________________________________________________ 2d.) To research assistant: If patient states “imaging studies”, ask: “What kind of imaging study?” If patient answers type of imaging study without prompting, write it here. ______________________________________________________________ 2e.)To research assistant: If patient states “labwork”, “blood tests” or “urine tests”, ask, “what were these testing for?” If patient answers the purpose of the testing, for example “blood tests for heart attack,” without prompting, write it here. _____________________________________________________________ 3a.) Rate how well you understand what you need to do as the next step(s) in treating your main problem:* 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 3b.) Did your doctor tell you to take any medications? * ______________________________________________________________
3c.) How did he or she tell you to use/take each of them?* ______________________________________________________________
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3d.) What does the medication do?* ____________________________________________________________
3e.) What else did your doctor tell you, you should do? * _____________________________________________________________ 3f.) What are the signs and symptoms that you should return to the emergency department?* _______________________________________________________________ 4.) Rate how well you understand why you need to do these steps:* 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 5.) Rate your overall communication experience with your doctor: 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 6.) Rate your overall communication experience with your nurse: 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 7.) How easy to understand are the written discharge instructions overall? 1 Difficult to understand 2 Somewhat difficult to understand 3 Understandable 4 Somewhat easy to understand 5 Easy to understand 8.) How easy to understand are the symptoms to watch out for and reasons to seek medical care?* 1 Difficult to understand 2 Somewhat difficult to understand 3 Understandable 4 Somewhat easy to understand 5 Easy to understand
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9.) How much did you learn from spoken communication from doctors and nurses versus written discharge instructions? 1 All my understanding is from spoken communication 2 Most of my understanding is from spoken communication 3 My understanding is equally from spoken communication and written discharge instructions 4 Most of my understanding is from written discharge instructions 5 All my understanding is from written discharge instructions MRN ID________________ Grading scale: 1. No evidence of understanding/no concordance 2. Vague understanding/minimal concordance 3. Partial understanding/partial concordance 4. Good understanding/near concordance 5. Excellent understanding/complete concordance N/A Not able to assess A) Diagnosis and Cause (question: 2b) 1) Concordance score ______________ If answer above is not 5: 2) Discordant information (circle 1) YES 3) Omitted information (circle 1) YES
NO NO
B) ED care (tests and treatments) (questions: 2c, 2d, 2e) 1) Concordance score ______________ If answer above is not 5: 2) Discordant information (circle 1) YES 3) Omitted information (circle 1) YES
NO NO
C) Post-discharge care (Prescriptions, Ancillary measures, follow up) (questions: 3b, 3c 3d, 3e) 1) Concordance score ______________ If answer above is not 5: 2) Discordant information (circle 1) YES 3) Omitted information (circle 1) YES
NO NO
D) Return to ED instructions (question: 3f) 1) Concordance score ______________ If answer above is not 5: 2) Discordant information (circle 1) YES 3) Omitted information (circle 1) YES
NO NO
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References 1. Commission J (2013) Facts about patient-centered communications. http://www.jointcommission.org/assets/1/18/Patient_Cen tered_Communications_7_3_12.pdf. Accessed 1 May 2014 2. Makoul G, Schofield T (1999) Communication teaching and assessment in medical education: an international consensus statement. Netherlands Institute of Primary Health Care. Patient Educ Couns 37(2):191–195 3. Stewart MA (1995) Effective physician-patient communication and health outcomes: a review. CMAJ 152(9):1423–1433 4. Eisenberg EM, Murphy AG, Sutcliff K et al (2005) Communication in emergency medicine: implications for patient safety. Commun Monogr 72:390–413 5. Engel K, Buckley B, McCarthy D, Forth V, Adams J (2010) Communication amidst chaos: challenges to patient communication in the emergency department. J Clin Outcomes Manag 17(10):449–452 6. Aminzadeh F, Dalziel WB (2002) Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med 39(3):238–247 7. Govindarajan P, Larkin GL, Rhodes KV, Piazza G, Byczkowski TL, Edwards M et al (2010) Patient-centered integrated networks of emergency care: consensus-based recommendations and future research priorities. Acad Emerg Med 17(12):1322–1329 8. Williams DM, Counselman FL, Caggiano CD (1996) Emergency department discharge instructions and patient literacy: a problem of disparity. Am J Emerg Med 14(1):19–22
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9. Waisman Y, Siegal N, Chemo M, Siegal G, Amir L, Blachar Y et al (2003) Do parents understand emergency department discharge instructions? A survey analysis. Isr Med Assoc J 5(8):567–570 10. Spandorfer JM, Karras DJ, Hughes LA, Caputo C (1995) Comprehension of discharge instructions by patients in an urban emergency department. Ann Emerg Med 25(1):71–74 11. Jolly BT, Scott JL, Sanford SM (1995) Simplification of emergency department discharge instructions improves patient comprehension. Ann Emerg Med 26(4):443–446 12. Crane JA (1997) Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med 15(1):1–7 13. McCarthy DM, Engel KG, Buckley BA, Forth VE, Schmidt MJ, Adams JG et al (2012) Emergency department discharge instructions: lessons learned through developing new patient education materials. Emerg Med Int 2012:306859 14. Engel KG, Buckley BA, Forth VE, McCarthy DM, Ellison EP, Schmidt MJ et al (2012) Patient understanding of emergency department discharge instructions: where are knowledge deficits greatest? Acad Emerg Med 19(9):E1035–E1044 15. Hastings SN, Heflin MT (2005) A systematic review of interventions to improve outcomes for elders discharged from the emergency department. Acad Emerg Med 12(10):978–986 16. Chew LD, Bradley KA, Boyko EJ (2004) Brief questions to identify patients with inadequate health literacy. Fam Med 36(8):588–594
EM - ORIGINAL
Examining patient comprehension of emergency department discharge instructions: Who says they understand when they do not? Margaret Jane Lin1 • Adva Gutman Tirosh2 • Alden Landry1
Received: 3 June 2015 / Accepted: 22 August 2015 Ó SIMI 2015
Abstract Patient comprehension of emergency department (ED) discharge instructions is important for ensuring that patients understand their diagnosis, recommendations for treatment, appropriate follow-up, and reasons to return. However, many patients may not fully understand their instructions. Furthermore, some patients may state they understand their instructions even when they do not. We surveyed 75 patients on their perception of their understanding of their ED discharge instructions, and asked them specific questions about the instructions. We also performed a chart review, and examined patients’ answers for correlation with the written instructions and medical chart. We then performed a statistical analysis evaluating which patients claimed understanding but who were found to have poor understanding on chart review. Overall, there was no significant correlation between patient self-reported understanding and physician evaluation of their understanding (q = 0.221, p = 0.08). However, among female patients and patients with less than 4 years of college, there was significant positive correlation between self-report and physician evaluation of comprehension (q = 0.326, p = 0.04 and q = 0.344, p = 0.04, respectively), whereas
& Margaret Jane Lin [email protected] Adva Gutman Tirosh [email protected] Alden Landry [email protected] 1
Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, WCC-2, Boston, MA 02215, USA
2
Soroka Clinical Research Center, Soroka University Medical Center, Beersheba, Israel
there was no correlation for male patients and those with more than 16 years of education (q = 0.008, p = 0.9, q = -0.041, p = 0.84, respectively). Patients’ perception of their understanding may not be accurate, especially among men, and those with greater than college education. Identifying which patients say they understand their discharge instructions, but may actually have poor comprehension could help focus future interventions on improving comprehension. Keywords Emergency department Discharge instructions Patient comprehension Communication
Introduction Effective communication between healthcare providers and patients is an important aspect of high-quality patient care [1–3]. In the fast-paced, high acuity setting of the emergency department (ED), clear communication is especially important since patients receive new diagnoses and instructions on treatment and follow-up plans [4]. However, these very characteristics of the ED can make effective communication difficult [5–7]. There has been increasing emphasis and research on ED discharge instructions and interventions to improve patient comprehension [8–13]. These studies show that discharge instructions are often written at literacy levels that exceed patients’ levels, and that patients have difficulty comprehending their discharge instructions. Further, patients often do not recognize their lack of understanding [14]. It is unclear what kinds of interventions would be beneficial to improve understanding, and which patients should be targeted. Understanding which patients are especially affected by lack of understanding and which aspects of the
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healthcare provider–patient interaction lead to the greatest knowledge deficits is important for designing interventions to improve communication and patient comprehension [14, 15]. In this study, we examined patient’s comprehension of their ED diagnosis, workup, treatment and follow-up instructions. We also surveyed their opinion of healthcare communication, and their understanding of discharge instructions. In particular, we focused on patients who may not report their lack of understanding, as this may not be recognized by medical staff, and these patients might benefit from additional interventions.
Materials and methods We performed a prospective, observational study of patients presenting to a tertiary, urban, academic medical center with approximately 55,000 visits per year. Patients were included in the study if they met the following criteria: Adult patient C18 years old who received discharge instructions for ‘‘abdominal pain’’ (Reading Grade Level 8.3, Flesch-Kincaid Grade level), ‘‘chest pain’’ (Reading Grade Level 6.5) and ‘‘nausea and vomiting’’ (Reading Grade Level 4.7). These are preexisting, prewritten discharge instructions, and these diagnoses were chosen because they are amongst the most commonly given discharge instructions at our institution. Providers can also free text additional information for patients. Patients were excluded for: high acuity/distress per the Attending ED physician, altered mental status, aphasia, developmental delay, dementia, or insurmountable communication barrier, non-English speaking patients, possible sexual assault, and acute psychiatric illness. Patients were given a survey at the end of their health care encounter (‘‘Appendix’’). This was performed after the patient was discharged, but prior to their leaving the ED. We grouped patient understanding into categories: (1) clinical diagnosis, (2) ED care, (3) post-discharge instructions, including discharge medications, and (4) reasons to return to the ED. The first half of the survey included openended questions on these four categories. The second half of the survey asked the patients to rate their comprehension of the discharge instructions, focusing on diagnosis, postdischarge instructions and reasons to seek care, and also the overall communication by health care providers in the ED. This survey was adapted from a previous study on patient understanding of discharge instructions [10]. Demographic data on patients including age, gender, race/ethnicity, highest level of education achieved, income, insurance, reason for ED visit, and medical diagnosis were
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also obtained. Patients were also screened with a Single Item Literacy Screener (SILS) questions, which has been shown to be effective screening tools for health literacy [16]. After patient discharge, two independent emergency physicians (MJL, AML) performed a chart review of all enrolled patients, and scored patient’s answers on a 5-point scale, with 5 being complete concordance or agreement with physician chart review (‘‘Appendix’’). For patients with a \5 score, the lack of agreement was further characterized as discordant (i.e., disagreeing with physician documentation) or omitted (i.e., did not include key aspects) information [10]. Any disagreements between the reviewing physicians were discussed until agreement was achieved. Categorization of patients In our study, we focused on patient understanding of discharge instructions and their perception of their own understanding. The aim was to recognize whether medical staff can rely on the patient self-testimony. In order to characterize when we can rely on the patient, we defined the patients who do not report when they do not understand, meaning they report understanding, while actual understanding is lower than optimal. Unreliable subjects were defined as those who stated their understanding above the median, but had actual understanding lower than median. Data analysis We created two variables: (1) patient self-scoring: sum of the five questions the subjects were asked about their understanding, (2) physician scoring: sum of the four questions the physician evaluators used to assess patient understanding. We then compared these two variables and analyzed them for correlation. Continuous variables with a normal distribution are presented as mean and standard deviation. Ordinary variables or continuous variables with a non-normal distribution are presented as medians with inter-quartile ranges (IQR). Categorical variables are presented as counts and percentages. We used a student’s t test to compare continuous parametric variables. The Mann– Whitney and Wilcoxon test methods were used for nonparametric variables. Categorical variables were tested using Pearson’s v2 test for contingency tables or Fisher exact test, as appropriate. Correlations between variables were tested using Spearman test. All statistical tests and/or confidence intervals, as appropriate, were performed at a = 0.05 (two-sided). The data were analyzed using IBM SPSS Statistics software.
Intern Emerg Med
fewer native English speakers than the included subjects (p = 0.039). There were no other statistically significant differences between the two groups.
Results Patient demographics Our study was a study of 75 adult patients (see Table 1). This was a pilot study with a convenience sampling of patients. In our cohort, there were 11 patients who had missing data regarding understanding of instructions, and these were excluded from analysis. Included patients were 35.9 % male with a mean age of 44.7 years. Between the included and excluded patients, the missing subjects had
Table 1 Baseline characteristics of the subjects Characteristic
N = 75
Age, mean ± SD (years)
45.5 ± 18.9
Gender, male (%)
26 (34.7)
Ethnicity, N (%) White
40 (53.3)
Black
20 (26.7)
Asian
1 (1.3)
Hispanic
7 (9.3)
Other
7 (9.3)
Native language, English (%)
68 (91.9)
Insurance status, N (%) MassHealth
8 (11)
Medicare or Medicaid
15 (20.5)
Private
50 (68.5)
Years of education, median (inter-quartile range)
15 (12–16)
College, N (%)
56 (74.7)
Post college degree, N (%)
18 (24.7)
Employment status, N (%) Currently employed
46 (61.3)
Unemployed Retired
15 (20) 14 (18.7)
Housing status, N (%) Property owner
27 (36)
Renting
41 (54.7)
Other (living with friends or relatives)
7 (9.3)
Patient comprehension In our cohort overall, there was no significant correlation between patient self-reported understanding and physician evaluation of their understanding (q = 0.221, p = 0.08, Fig. 1). Overall, physician evaluation of patients showed lower levels of understanding compared to patient self-perceived understanding. Out of a score of 5, the mean physician evaluation was 3.66 whereas the patient mean reported score was 4.6. Among female patients, there was a significant positive correlation between patient reported understanding and physician evaluation of understanding (q = 0.326, p = 0.04), while among male patients there was no correlation (q = 0.008, p = 0.9, Fig. 2). Among patients with less than 16 years of education (did not finish college), there was also a significant positive correlation between patient reported understanding and physician evaluation of understanding (q = 0.344, p = 0.04), whereas for those that finished college, there was no correlation (q = -0.041, p = 0.84, Fig. 3). The majority of disagreement between emergency physician post visit evaluation and patient responses to discharge instructions were due to omitted information (did not mention key aspects) rather than discordant information (had incorrect information) (Table 2). In 80 % of patients, key aspects of the ED work up were omitted, and in nearly 70 % of patients, key aspects of reasons to return were omitted. Interestingly, among the categories of ED diagnosis, post-discharge care, and reasons to return, patients reported the highest level of understanding in the category of
Smoking status, N (%) Never Former or current
52 (70.3) 22 (19.8)
Lifelong consumption of [100 or more cigarettes, N (%)
21 (28)
Daily consumption of alcohol, N (%)
13 (17.3)
Have one personal doctor, N (%) How many medications that need a doctor’s prescription are you currently taking, median (interquartile range)
66 (88) 2 (0–5)
How many visits have you made to an emergency department in the last year, median (inter-quartile range)
1 (1–2) Fig. 1 Patient self-reported understanding vs. physician evaluation of understanding
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Discussion
Fig. 2 Patient self-scoring vs. physician scoring, divided by gender
Fig. 3 Patient self scoring vs. physician scoring, divided by median years of education
Table 2 Characterization of differences between patient responses and post visit physician evaluation Category
Type
Yes (%)
Diagnosis
Discordant
15 (20.3)
Omitted
37 (50)
Discordant Omitted
8 (10.7) 60 (80)
ED care Post-ED care Return instructions
Discordant
10 (13.3)
Omitted
43 (57.3)
Discordant
10 (13.3)
Omitted
52 (69.3)
reasons to return (mean of 4.89), while this was the category with the lowest score for physician evaluation (3.46). Patients reported lowest understanding of their diagnosis (4.39) among these categories (Fig. 4a–c). Patients with higher health literacy on SILS also had no correlation between self-reported understanding and physician evaluation (Table 3).
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In our study, we find that patients’ perception of their understanding of discharge instructions does not necessarily correlate with actual understanding of discharge instructions. In general, patients rate a higher understanding of instructions compared with physician evaluation of their understanding. This lack of correlation is pronounced in patients with higher education levels and of the male gender. Patient’s answers on the Single Item Literacy Screener (SILS) [16], which are questions used as a marker for health literacy, had no correlation with their physician evaluated level of understanding. While the SILS is not a perfect measure of health literacy, these findings indicate that even health literacy may not predict patients’ understanding of their discharge instructions. Of the categories of questions asked, patients noted least understanding of their ED diagnosis. Given that our population included discharged patients receiving a diagnosis of ‘‘chest pain,’’ ‘‘abdominal pain’’ and ‘‘vomiting and diarrhea,’’ it is not surprising that patients may not know a firm diagnosis of the cause of their symptoms. Often these patients are ruled out for dangerous etiologies that require admission or intervention in order to be discharged, but may not received a definitive diagnosis in the ED. Often in emergency medicine discharge instructions, much emphasis is placed on reasons to return to the ED. Interestingly, patients tended to rate their understanding of these reasons as high, while physician evaluation tended to be low for this, indicating a possible lack of understanding despite patient perception.
Limitations Our study has several limitations. First, ours is a small sample size, which limits the strength of the conclusions. Further, we did have 11 patients with missing data, and among these patients, there were fewer native English speaking patients, which could affect discharge instruction comprehension. However, there were no other significant demographic differences among these patients. Our ED population was also relatively well-educated with the median years of education being 15 years, or 3 years of college, which limits the generalizability of our findings to other institutions. Our study used post-visit physician evaluation to assess for patient understanding of the discharge instructions. These were attending ED physicians who performed a chart review of the patients’ visit and the written discharge
Intern Emerg Med Fig. 4 Comparisons of patient responses and physician evaluation for specific questions. Questions rated from poor (1) to excellent (5)
a
Mean 4.39
Rate how well you feel your doctor explained your problem Diagnosis Physician grade
3.73
median P value 5 rho= 0.059 P= 0.63 4
b
Rate how well you understand why you need to do these steps Post ED Care Physician Grade C1
Mean 4.52 3.8
median P value 5 rho= 0.196 P= 0.09 4
c
How easy to understand are the symptoms to watch out for and reasons to seek medical care? Return Instructions Physician Grade
Mean 4.89 3.46
median P value 5 rho= 0.196 P= 0.49 4
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Intern Emerg Med Table 3 Literacy questions—statistical comparison between the unreliable and the rest of the subjects
Conclusion
Characteristic
Other (N = 49, 76.6 %)
Unreliable (N = 15, 23.4 %)
p value
Question 16, never (%)
42 (85)
14 (93.3)
0.67
Question 17, extremely (%)
36 (76.6)
14 (93.3)
0.67
Patient understanding of discharge instructions is an important aspect of ED provider–patient communication and adequate care. Our investigation reveals possible areas of communication as well as specific patient populations to target to ensure proper and safe understanding.
Question 18, excellent or very good (%)
40 (81.6)
14 (93.3)
0.43
Median of three question sum
47 (100)
15 (100)
Acknowledgments The authors would like to thank Nathan Shapiro, M.D. for help in reviewing the manuscript. Compliance with ethical standards The authors declare that they have no conflict
* p values from Chi square
Conflict of interest of interest.
instructions, and compared them to patient’s responses on post-encounter surveys. As these were not the treating physicians, and they did not have access to any verbal discharge instructions given to the patient, it is possible that the post-visit physician evaluation may not fully be able to evaluate true understanding of discharge instructions. However, we attempted to decrease bias by having two physicians review the discharge instructions.
Statement of human and animal rights All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1976, as revised in 2008.
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Informed consent Informed consent was obtained from all patients included in this study.
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Appendix
Appendix Patient Survey 1.) Rate how well you feel your doctor explained your problem:* 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 2a.) Rate how well you feel your nurse explained your problem:* 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent
2b.) What did your doctor or nurse tell you is wrong with you, i.e. what is your diagnosis?* ______________________________________________________________ 2c.) What tests did you have done in the emergency department? ________________________________________________________________ 2d.) To research assistant: If patient states “imaging studies”, ask: “What kind of imaging study?” If patient answers type of imaging study without prompting, write it here. ______________________________________________________________ 2e.)To research assistant: If patient states “labwork”, “blood tests” or “urine tests”, ask, “what were these testing for?” If patient answers the purpose of the testing, for example “blood tests for heart attack,” without prompting, write it here. _____________________________________________________________ 3a.) Rate how well you understand what you need to do as the next step(s) in treating your main problem:* 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 3b.) Did your doctor tell you to take any medications? * ______________________________________________________________
3c.) How did he or she tell you to use/take each of them?* ______________________________________________________________
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3d.) What does the medication do?* ____________________________________________________________
3e.) What else did your doctor tell you, you should do? * _____________________________________________________________ 3f.) What are the signs and symptoms that you should return to the emergency department?* _______________________________________________________________ 4.) Rate how well you understand why you need to do these steps:* 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 5.) Rate your overall communication experience with your doctor: 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 6.) Rate your overall communication experience with your nurse: 1 Poor 2 Fair 3 Good 4 Very Good 5 Excellent 7.) How easy to understand are the written discharge instructions overall? 1 Difficult to understand 2 Somewhat difficult to understand 3 Understandable 4 Somewhat easy to understand 5 Easy to understand 8.) How easy to understand are the symptoms to watch out for and reasons to seek medical care?* 1 Difficult to understand 2 Somewhat difficult to understand 3 Understandable 4 Somewhat easy to understand 5 Easy to understand
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9.) How much did you learn from spoken communication from doctors and nurses versus written discharge instructions? 1 All my understanding is from spoken communication 2 Most of my understanding is from spoken communication 3 My understanding is equally from spoken communication and written discharge instructions 4 Most of my understanding is from written discharge instructions 5 All my understanding is from written discharge instructions MRN ID________________ Grading scale: 1. No evidence of understanding/no concordance 2. Vague understanding/minimal concordance 3. Partial understanding/partial concordance 4. Good understanding/near concordance 5. Excellent understanding/complete concordance N/A Not able to assess A) Diagnosis and Cause (question: 2b) 1) Concordance score ______________ If answer above is not 5: 2) Discordant information (circle 1) YES 3) Omitted information (circle 1) YES
NO NO
B) ED care (tests and treatments) (questions: 2c, 2d, 2e) 1) Concordance score ______________ If answer above is not 5: 2) Discordant information (circle 1) YES 3) Omitted information (circle 1) YES
NO NO
C) Post-discharge care (Prescriptions, Ancillary measures, follow up) (questions: 3b, 3c 3d, 3e) 1) Concordance score ______________ If answer above is not 5: 2) Discordant information (circle 1) YES 3) Omitted information (circle 1) YES
NO NO
D) Return to ED instructions (question: 3f) 1) Concordance score ______________ If answer above is not 5: 2) Discordant information (circle 1) YES 3) Omitted information (circle 1) YES
NO NO
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