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Functional Health Literacy and Understanding of Medications at Discharge
BRIEF REPORT
PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
Functional Health Literacy and Understanding of Medications at Discharge MICHAEL J. MANIACI, MD; MICHAEL G. HECKMAN, MS; AND NANCY L. DAWSON, MD The objective of this study was to evaluate patient knowledge of newly prescribed medication after hospital discharge. We reviewed the charts of 172 patients who were discharged from February 1, 2006, through April 25, 2006, from the internal medicine residency service at a community-based teaching hospital with prescriptions for 1 or more new medications. Between 4 and 18 days after discharge, patients were contacted by telephone and asked about the name, number, dosages, schedule, purpose, and adverse effects of the new medication(s) and whether they could name their medical contact person. We recorded the number of correct answers, patient age, and years of education. Of the survey respondents, 86% were aware that they had been prescribed new medications, but fewer could identify the name (64%) or number (74%) of new medications or their dosages (56%), schedule (68%), or purpose (64%). Only 11% could recall being told of any adverse effects, and only 22% could name at least 1 adverse effect. Older patients tended to answer fewer questions correctly (P=.02). We observed no association between the number of correctly answered questions and years of education (P=.57), time between discharge and survey (P=.17), or number of new medications (P=.65). Overall, we found that patients had limited knowledge about their medications after discharge from an internal medicine residency service, with age but not years of education significantly associated with level of knowledge.
Mayo Clin Proc. 2008;83(5):554-558
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he US Department of Health and Human Services defines health literacy as “the capacity to obtain, interpret, and understand basic health information and services needed to make appropriate health care decisions.”1 With advances in medical technology, the practice of medicine has become more complicated and assessing patients’ ability to understand complex medical information more challenging. The percentage of American adults with inadequate health literacy skills increased from 40% in 19922 to nearly 50% (90 million people) in 2004.3 Patients with poor health literacy have increased risk of hospital admission.4 Poor health literacy is also associated with poorer outcomes for common chronic diseases such as asthma and depression.5,6 Lindau et al7 reported that women with poor health literacy are less likely to pursue follow-up care after abnormal Papanicolaou test results. Adequate communication is essential to improve patients’ comprehension of medical information, particularly during hospitalization. Patients must interact effectively with physicians and other health care professionals and have a firm grasp of their medical situation, diagnosis, and medications to actively participate in the healing process. Because outpatient success may depend on this understanding, one of the most important physician-patient inter554
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actions is the hospital discharge process. Health information received by patients at discharge is critical to the success of their outpatient care plan because it guides them when they are no longer under a physician’s supervision and so more likely to make an error. If recently voiced concerns about patient safety8 are to be addressed, the problem of patients with poor health literacy must be confronted. As the medical community becomes more For editorial aware of this problem and its implica- comment, tions for patient safety, more effective see page 520 methods can be developed to combat poor medical comprehension.9,10 Patients’ understanding of medications at discharge is poor,11 but few studies have quantified the level of understanding after discharge or the factors that influence it. As patient age increases, health literacy decreases substantially,12 and a negative relationship exists between patient age and knowledge of the purpose of medications at discharge.13 In addition, as the number of medications increases, the understanding of instructions about these medications decreases.13,14 Our study investigated the degree of knowledge that patients had about their new medications after verbal review and discharge from an internal medicine residency service. We also examined the relationship between this degree of knowledge and factors such as patient age and education level. PATIENTS AND METHODS The study was approved by the Mayo Clinic Institutional Review Board. Patients were treated in a 330-bed, community teaching hospital, 1 of 7 hospitals in a city with a population of approximately 800,000. Although any patient from the surrounding community could have been admitted through the emergency department, most inpatients were established with the outpatient clinic before admission; therefore, medications usually were already in
From the Division of Hospital Internal Medicine (M.J.M., N.L.D.) and Biostatistics Unit (M.G.H.), Mayo Clinic, Jacksonville, FL. Address reprint requests and correspondence to Nancy L. Dawson, MD, Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 ([email protected]). © 2008 Mayo Foundation for Medical Education and Research
May 2008;83(5):554-558
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PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
172 Patients discharged with new medications
34 Excluded because of prior visit with primary physician 21 Could not be contacted (eg, not at home, inaccurate telephone number) 11 Excluded because unable to answer mental status screening questions accurately 3 Died after discharge 2 Readmitted to the hospital 1 Transferred to skilled nursing facility 100 Completed the survey
FIGURE. Flow of patients through the study.
the electronic medical record before hospital admission. During admission, nursing staff confirmed all medications with the patient’s electronic medical record. If discrepancies were identified (eg, no medications entered previously), the outpatient medication list was corrected or the new information was entered during the initial nursing assessment on the day of admission. At discharge, nursing staff reviewed all medications with the patient or caregiver, and all new medication names, dosages, and schedules were discussed. Nurses, who led the discharge encounter process, were instructed to review all portions of the discharge instruction form with the patient, including medications; however, the encounter was not standardized. The time spent with each patient during this process varied. If present, family members or caregivers were included in the discussion, but they were not required to attend. All medications, including those that were new, were listed on the discharge form given to the patient. Patients were given the opportunity to ask questions about any of their medications. After the review was completed, the physician, nurse, and patient signed the form indicating agreement with the prescribed medications. From February 1, 2006, through April 25, 2006, charts of all patients discharged from the internal medicine residency service were reviewed within 3 days of discharge. Handwritten discharge instruction forms and dictated discharge summaries, both with a complete list of all medications prescribed at discharge, were compared with the previously reconciled outpatient medication list for each patient. Patients with at least 1 new medication prescribed at discharge were eligible for the study. A new medication was defined as any medication not taken by the patient at the time of admission. Dosage changes of existing medications were not considered new medications for the purMayo Clin Proc.
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poses of this study. We excluded patients who were discharged to a skilled nursing facility or rehabilitation center and those who saw a physician or were readmitted to the hospital before we attempted initial contact. A physician study investigator (N.L.D. or M.J.M.) contacted all eligible patients by telephone, with the first available contact of all study patients occurring between 4 and 18 days after discharge. The last survey was completed on May 4, 2006. Verbal consent was obtained from each patient before initiation of the survey at the time of the telephone call. To determine the patient’s ability to complete the interview, mental status initially was assessed by asking each patient a series of questions, including the current date and the patient’s date of discharge and current address. Patients unable to correctly answer all screening questions were excluded. The study was continued until 100 surveys (approximately 0.5% of annual discharges from this hospital) were completed (Figure). The patients, discharging physicians, and nurses who gave the discharge instructions were unaware of the study at discharge. DATA COLLECTION Baseline information was collected from the patient charts and included age, number of new medications, and time from discharge to telephone interview. During the interview, patients were asked to identify the following information about their new medications: (1) whether any had been prescribed, (2) name, (3) number, (4) dosage (in milligrams), (5) dosing schedule, (6) purpose, (7) whether adverse effects had been discussed at discharge, (8) adverse effects, and (9) contact person if questions arose. These interview questions were designed to give an overall view of patients’ understanding of instructions at discharge and personal medical knowledge. The number of years of education was also recorded. Patients were allowed to refer to the
May 2008;83(5):554-558
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555
PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
TABLE 1. Characteristics of Surveyed Patients Variable
Mean ± SD
Range
Age (y) Education (y) New medications (No.) Time between discharge and telephone interview (d)
63.1±16.5 13.6±2.5 2.0±1.2
20-96 8-20 1-6
8.2±3.2
3-18
medication list they were given at discharge and to read from prescription bottles that were available during the interview. We recorded whether patients gave the correct answer for each of the first 7 questions. If more than 1 new medication had been prescribed, the patient had to report all new medications (and the dosages and dosing schedule) for the answer to be counted as correct. In addition, only true potential adverse effects were considered correct answers for question 8, although only 1 needed to be named by the patient for the answer to be counted as correct. STATISTICAL ANALYSES Numerical measurements were summarized using mean ± SD and range. Linear regression models were used to investigate associations with the total number of correctly answered questions. Age, years of education, time between discharge and telephone interview, and the number of new medications were considered as possible covariates in these models using forward selection and a P<.05 criterion for model entry. S-Plus software version 8.0.1 (Insightful Corporation, Seattle, WA) was used for the statistical analysis.
TABLE 2. New Medications Prescribed at Discharge for 100 Patients Type of medication
No. of prescriptions (N=200)
Anticoagulant Antidepressant Antihistamine Antimicrobial Cardiac Angiotensin-converting enzyme inhibitor β-Blocker Diuretic Lipid-lowering agent Other Endocrine Gastrointestinal Antiemetic Antiulcer Laxative Other Narcotic Pulmonary Urologic Total
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4 12 5 2 6 9 1 200
TABLE 3. Summary of Survey to Assess Knowledge of Discharge Medications No. of patients (N=100)
a
Of the 172 patients discharged with new medications during the study period, 100 completed the interview (Figure). The characteristics of patients completing the study are summarized in Table 1, and a breakdown by type of the 200 new medications prescribed is provided in Table 2. Table 3 shows the number of patients who answered the medication-related questions correctly. Of the study patients, 86% were aware that they had been prescribed a new medication at discharge, but fewer (74%) knew the number of new medications and even fewer (64%) could name them. Of the interviewed patients, just over half (56%) knew dosages and 68% knew dosing schedules; 64% could identify the purpose of the medication. Although 22% of patients could name an adverse effect of a new medication, only 11% said they had been instructed on adverse effects at the time of discharge. Table 4 summarizes associations between the number of correctly answered questions and patient age, years of education, time between discharge and interview, and 556
4 11 5 6 9 22
number of new medications. Older patients answered fewer questions correctly (P=.02), but we observed no association between the number of correctly answered questions and years of education (P=.57), time between discharge and interview (P=.17), or number of new medications (P=.65).
Item
RESULTS
18 4 1 81
•
Survey questions 1. Were you prescribed any new medications? 2. What are the names of the new medications? 3. How many new medications were you prescribed? 4. What is the recommended dose of each of the new medications? 5. How often should you take each of the new medications? 6. What is the purpose of each of the new medications? 7. Did anyone tell you the adverse effects of the new medications? 8. What are the adverse effects of the new medications? 9. Who would you contact if you had a question about your new medication? Primary care physician Hospital Pharmacist Don’t know Other Number of correctly answered survey questionsb 0-2 3-5 6-7 a b
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86 64 74 56 68 64 11 22 45 11 5 32 7 25 27 48
Data represent the number of patients who provided the correct answer. The highest possible score was 7. Questions 7 (answer of yes or no) and 9 (answer of name) did not have correct or incorrect answers.
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PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
TABLE 4. Patient Characteristics and Correctly Answered Survey Questions No. of correctly answered questionsb
Variablea Age (y) ≤65 (n=51) >65 (n=49) Education (y) ≤13 (n=52) >13 (≥1 y of college) (n=48) Time between discharge and telephone interview (d) ≤7 (n=55) >7 (n=45) No. of new medications ≤2 (n=74) >2 (n=26)
P valuec .02
4.8±2.4 3.9±2.4 .57 4.4±2.3 4.3±2.6 .17 4.4±2.5 4.3±2.3 .65 4.3±2.5 4.5±2.3
a
Patients were categorized into 2 groups by establishing the sample median as the threshold value. b Data are reported as mean ± SD. c P values were calculated by linear regression models adjusted for age. Each variable was considered to be continuous in these models.
DISCUSSION Functional health literacy regarding medications prescribed at discharge was poor in our study population. Almost 15% of patients were unaware that they had been prescribed a new medication. Only about half the patients knew specific information about their medications, such as dosage (56%), dosing schedules (68%), and purpose (64%). This lack of understanding indicates functional deficits in health care understanding and places patients at risk for considerable morbidity, including disease recurrence or other negative outcomes. Toren et al15 showed that almost 20% of discharged patients who did not fully understand their medication requirements revisited the emergency department within 30 days of discharge, and up to 35% visited the emergency department 2 or more times. Phillips et al16 showed that patients with chronic heart failure and low health literacy had a higher hospital readmission rate, incurred higher costs, and used more resources. Howard et al17 confirmed that patients with low health literacy used health care services inefficiently and incurred higher costs. Low comprehension may also lead to poor adherence to drug regimens, which may result in adverse medicationrelated events.18-20 Health care professionals need to take basic steps to improve the understanding and health literacy of patients at discharge. It remains unclear whether the poor functional comprehension reported here resulted from patient factors alone or also from the inability of health care professionals to communicate medical information adequately. Our finding that higher education did not correlate with better understanding suggests that the health care professional– patient interaction is currently inadequate. The communiMayo Clin Proc.
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cation skills of health care professionals must be assessed, and clinicians must be educated to recognize the limited health literacy of patients and be equipped with tools to overcome these limitations. Physicians could become more proficient at patient instruction if residency and continuing medical education curricula included training in communication. 21 Programs such as the American Medical Association’s Health Literacy Train-the-Trainer program,22 which teaches health care professionals how to conduct health literacy programs, are an important step toward such improved education and communication. Redesigning discharge paperwork to clearly show all new medications and standardizing the discharge process could also improve patients’understanding. Also needed are processes to help focus patients’ attention and give followup health care professionals a clear posthospitalization plan. Physician awareness of patient health illiteracy is vital. Although patients at our institution receive medication instructions from the prescribing physician and a nurse before discharge, we showed that this instruction was inadequate for complete understanding. Even though patients could ask the physician and nurse questions before discharge, their knowledge of discharge medications was poor. Thus, it cannot be assumed that patients understand verbal instructions after 1 or 2 sessions. Among other techniques, asking patients to repeat instructions could improve their understanding of health information.23 Furthermore, health care professionals can help clarify medication instructions by eliminating abbreviations and complex medical terms and by giving patients more specific instructions regarding medication administration. One of the more unsettling findings of our study was that only 11% of patients could recall being told about the adverse effects of their new medications, a percentage even lower than that reported in a previous study. Calkins et al24 reported that physicians thought that almost all their patients (89%) understood the possible adverse effects of their prescribed medications, but only slightly more than half of surveyed patients (57%) reported that they did so at discharge. Toren et al15 showed that many patients who were prescribed new medications received no counseling or information regarding adverse effects. Because patients with low health literacy have a particularly difficult time reading prescription medication warning labels,25 the absence of oral instruction may lead to greater risk of serious adverse effects. Education of health care professionals and patients is crucial to ensure the delivery of safe and effective health care. Our results supported the findings of previous studies that showed an association between increased patient age and decreased understanding of medication instructions at discharge.12,13 However, in contrast to previous studies,13,14 our study showed that the number of new medications was
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PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
not associated with a poorer understanding of medication instructions. One reason for this difference could be that the average number of new medications in our study (average, 2.0; range, 1.0-6.0) was lower than in previous studies (average, 3.5; range, 1.0-14.0). Also inconsistent with a previous study14 was our finding that understanding of instructions about medication was not associated with educational status. Davis et al25 reported that a lower literacy level and a greater number of medications were independently associated with misunderstanding instructions on labels. Although that study and our current one had a similar number of patients and used interviews as the data collection method, Davis et al classified patients by literacy level (adequate, marginal, or inadequate), whereas our study focused on level of education completed, perhaps accounting for some of the differing results. Also, the percentage of patients with postsecondary education (13 or more years) was higher in our study than in the study by Davis et al (48% vs 29%). Our results suggest that functional health literacy may not correlate directly with education level and that more advanced reading levels do not ensure adequate understanding of health issues and medication instructions. One limitation of our study may be the relatively high level of education of our patients (average, 13.6 years of education). This level of education is typical of the population that is regularly seen at our institution (educated and nonindigent) but may have caused us to overestimate the percentage of patients who understand their medications. We suspect that the percentage of patients who understand their medications in a more diverse population could be lower. However, as stated previously, we did not find a correlation between years of education and knowledge of medications at discharge; thus, the level of education may have had little effect. In addition, although the discharge medication instruction process was similar for each patient, it was not completely standardized, and we did not directly observe the instructions being given to patients. Although physicians and nursing staff both are charged with the task of discussing medications with patients at discharge, as instructed by the discharge sheet, adherence to this instruction process may not have been consistent. Our findings reemphasize the need for continuing education in patientcaregiver communication. CONCLUSION In showing that patients’understanding of new medications prescribed at discharge is inadequate, our study underlines the importance of addressing health illiteracy. Research is needed to find tools that effectively reduce the risk to patients and lower the costs of health care delivery. Innovative train-the-trainer programs and redesigned processes 558
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and patient literature are important initiatives, but more work clearly is needed. REFERENCES 1. Healthy People 2010: Health communication. 2000:11-20. Office of Disease Prevention and Health Promotion Web site. http://www.healthypeople.gov /document/HTML/Volume1/11HealthCom.htm. Accessed March 11, 2008. 2. Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. Adult literacy in America: a first look at the findings of the National Adult Literacy Survey. 3rd ed. National Center for Education Statistics Web site. http://nces.ed.gov/pubsearch/pubsinfo .asp?pubid=93275. Accessed March 11, 2008. 3. Kindig D, Affonso D, Chudler E, et al, eds. Health Literacy: a Prescription to End Confusion. Washington, DC: National Academies Press; 2004. http://books .nap.edu/html/health_literacy/reportbrief.pdf. Accessed March 12, 2008. 4. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13(12):791-798. 5. Mancuso CA, Rincon M. Impact of health literacy on longitudinal asthma outcomes. J Gen Intern Med. 2006;21(8):813-817. 6. Lincoln A, Paasche-Orlow MK, Cheng DM, et al. Impact of health literacy on depressive symptoms and mental health-related quality of life among adults with addiction. J Gen Intern Med. 2006;21(8):818-822. 7. Lindau ST, Basu A, Leitsch SA. Health literacy as a predictor of follow-up after an abnormal Pap smear: a prospective study. J Gen Intern Med. 2006; 21(8): 829-834. 8. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347(24):1933-1940. 9. Kripalani S, Paasche-Orlow MK, Parker RM, Saha S. Advancing the field of health literacy [editorial]. J Gen Intern Med. 2006;21:804-805. doi: 10.1111/ j.1525-1497.2006.00568.x. 10. Carmona RH. Health literacy: a national priority [editorial]. J Gen Intern Med. 2006;21:803. doi: 10.1111/j.1525-1497.2006.00569.x. 11. Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8):991-994. 12. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281(6):545-551. 13. King JL, Schommer JC, Wirsching RG. Patients’ knowledge of medication care plans after hospital discharge. Am J Health Syst Pharm. 1998;55(13):13891393. 14. Davis TC, Wolf MS, Bass PF III, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006 Dec 19;145(12):887-894. Epub 2006 Nov 29. 15. Toren O, Kerzman H, Koren N, Baron-Epel O. Patients’ knowledge regarding medication therapy and the association with health services utilization. Eur J Cardiovasc Nurs. 2006 Dec;5(4):311-316. Epub 2006 Jan 19. 16. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis [published correction appears in JAMA. 2004;292(9):1022]. JAMA. 2004;291(11):1358-1367. 17. Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees [published correction appears in Am J Med. 2005;118(8):933]. Am J Med. 2005;118(4):371-377. 18. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-1564. 19. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107-1116. 20. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167. 21. Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of communications training on medical student performance. JAMA. 2003;290(9):1157-1165. 22. American Medical Association Foundation. Health Literacy Train-theTrainer Program. Chicago, IL: American Medical Association Foundation; c19952006 [updated 2005 Jun 02]. http://www.ama-assn.org/ama/pub/category /15141.html. Accessed April 14, 2008. 23. Sudore RL, Landefeld CS, Williams BA, Barnes DE, Lindquist K, Schillinger D. Use of a modified informed consent process among vulnerable patients: a descriptive study [published correction appears in J Gen Intern Med. 2006;21(9):1009]. J Gen Intern Med. 2006;21(8):867-873. 24. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients’ understanding of the postdischarge treatment plan. Arch Intern Med. 1997;157(9):1026-1030. 25. Davis TC, Wolf MS, Bass PF III, et al. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med. 2006;21(8):847-851.
May 2008;83(5):554-558
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PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
Functional Health Literacy and Understanding of Medications at Discharge MICHAEL J. MANIACI, MD; MICHAEL G. HECKMAN, MS; AND NANCY L. DAWSON, MD The objective of this study was to evaluate patient knowledge of newly prescribed medication after hospital discharge. We reviewed the charts of 172 patients who were discharged from February 1, 2006, through April 25, 2006, from the internal medicine residency service at a community-based teaching hospital with prescriptions for 1 or more new medications. Between 4 and 18 days after discharge, patients were contacted by telephone and asked about the name, number, dosages, schedule, purpose, and adverse effects of the new medication(s) and whether they could name their medical contact person. We recorded the number of correct answers, patient age, and years of education. Of the survey respondents, 86% were aware that they had been prescribed new medications, but fewer could identify the name (64%) or number (74%) of new medications or their dosages (56%), schedule (68%), or purpose (64%). Only 11% could recall being told of any adverse effects, and only 22% could name at least 1 adverse effect. Older patients tended to answer fewer questions correctly (P=.02). We observed no association between the number of correctly answered questions and years of education (P=.57), time between discharge and survey (P=.17), or number of new medications (P=.65). Overall, we found that patients had limited knowledge about their medications after discharge from an internal medicine residency service, with age but not years of education significantly associated with level of knowledge.
Mayo Clin Proc. 2008;83(5):554-558
T
he US Department of Health and Human Services defines health literacy as “the capacity to obtain, interpret, and understand basic health information and services needed to make appropriate health care decisions.”1 With advances in medical technology, the practice of medicine has become more complicated and assessing patients’ ability to understand complex medical information more challenging. The percentage of American adults with inadequate health literacy skills increased from 40% in 19922 to nearly 50% (90 million people) in 2004.3 Patients with poor health literacy have increased risk of hospital admission.4 Poor health literacy is also associated with poorer outcomes for common chronic diseases such as asthma and depression.5,6 Lindau et al7 reported that women with poor health literacy are less likely to pursue follow-up care after abnormal Papanicolaou test results. Adequate communication is essential to improve patients’ comprehension of medical information, particularly during hospitalization. Patients must interact effectively with physicians and other health care professionals and have a firm grasp of their medical situation, diagnosis, and medications to actively participate in the healing process. Because outpatient success may depend on this understanding, one of the most important physician-patient inter554
Mayo Clin Proc.
•
actions is the hospital discharge process. Health information received by patients at discharge is critical to the success of their outpatient care plan because it guides them when they are no longer under a physician’s supervision and so more likely to make an error. If recently voiced concerns about patient safety8 are to be addressed, the problem of patients with poor health literacy must be confronted. As the medical community becomes more For editorial aware of this problem and its implica- comment, tions for patient safety, more effective see page 520 methods can be developed to combat poor medical comprehension.9,10 Patients’ understanding of medications at discharge is poor,11 but few studies have quantified the level of understanding after discharge or the factors that influence it. As patient age increases, health literacy decreases substantially,12 and a negative relationship exists between patient age and knowledge of the purpose of medications at discharge.13 In addition, as the number of medications increases, the understanding of instructions about these medications decreases.13,14 Our study investigated the degree of knowledge that patients had about their new medications after verbal review and discharge from an internal medicine residency service. We also examined the relationship between this degree of knowledge and factors such as patient age and education level. PATIENTS AND METHODS The study was approved by the Mayo Clinic Institutional Review Board. Patients were treated in a 330-bed, community teaching hospital, 1 of 7 hospitals in a city with a population of approximately 800,000. Although any patient from the surrounding community could have been admitted through the emergency department, most inpatients were established with the outpatient clinic before admission; therefore, medications usually were already in
From the Division of Hospital Internal Medicine (M.J.M., N.L.D.) and Biostatistics Unit (M.G.H.), Mayo Clinic, Jacksonville, FL. Address reprint requests and correspondence to Nancy L. Dawson, MD, Division of Hospital Internal Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 ([email protected]). © 2008 Mayo Foundation for Medical Education and Research
May 2008;83(5):554-558
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PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
172 Patients discharged with new medications
34 Excluded because of prior visit with primary physician 21 Could not be contacted (eg, not at home, inaccurate telephone number) 11 Excluded because unable to answer mental status screening questions accurately 3 Died after discharge 2 Readmitted to the hospital 1 Transferred to skilled nursing facility 100 Completed the survey
FIGURE. Flow of patients through the study.
the electronic medical record before hospital admission. During admission, nursing staff confirmed all medications with the patient’s electronic medical record. If discrepancies were identified (eg, no medications entered previously), the outpatient medication list was corrected or the new information was entered during the initial nursing assessment on the day of admission. At discharge, nursing staff reviewed all medications with the patient or caregiver, and all new medication names, dosages, and schedules were discussed. Nurses, who led the discharge encounter process, were instructed to review all portions of the discharge instruction form with the patient, including medications; however, the encounter was not standardized. The time spent with each patient during this process varied. If present, family members or caregivers were included in the discussion, but they were not required to attend. All medications, including those that were new, were listed on the discharge form given to the patient. Patients were given the opportunity to ask questions about any of their medications. After the review was completed, the physician, nurse, and patient signed the form indicating agreement with the prescribed medications. From February 1, 2006, through April 25, 2006, charts of all patients discharged from the internal medicine residency service were reviewed within 3 days of discharge. Handwritten discharge instruction forms and dictated discharge summaries, both with a complete list of all medications prescribed at discharge, were compared with the previously reconciled outpatient medication list for each patient. Patients with at least 1 new medication prescribed at discharge were eligible for the study. A new medication was defined as any medication not taken by the patient at the time of admission. Dosage changes of existing medications were not considered new medications for the purMayo Clin Proc.
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poses of this study. We excluded patients who were discharged to a skilled nursing facility or rehabilitation center and those who saw a physician or were readmitted to the hospital before we attempted initial contact. A physician study investigator (N.L.D. or M.J.M.) contacted all eligible patients by telephone, with the first available contact of all study patients occurring between 4 and 18 days after discharge. The last survey was completed on May 4, 2006. Verbal consent was obtained from each patient before initiation of the survey at the time of the telephone call. To determine the patient’s ability to complete the interview, mental status initially was assessed by asking each patient a series of questions, including the current date and the patient’s date of discharge and current address. Patients unable to correctly answer all screening questions were excluded. The study was continued until 100 surveys (approximately 0.5% of annual discharges from this hospital) were completed (Figure). The patients, discharging physicians, and nurses who gave the discharge instructions were unaware of the study at discharge. DATA COLLECTION Baseline information was collected from the patient charts and included age, number of new medications, and time from discharge to telephone interview. During the interview, patients were asked to identify the following information about their new medications: (1) whether any had been prescribed, (2) name, (3) number, (4) dosage (in milligrams), (5) dosing schedule, (6) purpose, (7) whether adverse effects had been discussed at discharge, (8) adverse effects, and (9) contact person if questions arose. These interview questions were designed to give an overall view of patients’ understanding of instructions at discharge and personal medical knowledge. The number of years of education was also recorded. Patients were allowed to refer to the
May 2008;83(5):554-558
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
555
PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
TABLE 1. Characteristics of Surveyed Patients Variable
Mean ± SD
Range
Age (y) Education (y) New medications (No.) Time between discharge and telephone interview (d)
63.1±16.5 13.6±2.5 2.0±1.2
20-96 8-20 1-6
8.2±3.2
3-18
medication list they were given at discharge and to read from prescription bottles that were available during the interview. We recorded whether patients gave the correct answer for each of the first 7 questions. If more than 1 new medication had been prescribed, the patient had to report all new medications (and the dosages and dosing schedule) for the answer to be counted as correct. In addition, only true potential adverse effects were considered correct answers for question 8, although only 1 needed to be named by the patient for the answer to be counted as correct. STATISTICAL ANALYSES Numerical measurements were summarized using mean ± SD and range. Linear regression models were used to investigate associations with the total number of correctly answered questions. Age, years of education, time between discharge and telephone interview, and the number of new medications were considered as possible covariates in these models using forward selection and a P<.05 criterion for model entry. S-Plus software version 8.0.1 (Insightful Corporation, Seattle, WA) was used for the statistical analysis.
TABLE 2. New Medications Prescribed at Discharge for 100 Patients Type of medication
No. of prescriptions (N=200)
Anticoagulant Antidepressant Antihistamine Antimicrobial Cardiac Angiotensin-converting enzyme inhibitor β-Blocker Diuretic Lipid-lowering agent Other Endocrine Gastrointestinal Antiemetic Antiulcer Laxative Other Narcotic Pulmonary Urologic Total
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4 12 5 2 6 9 1 200
TABLE 3. Summary of Survey to Assess Knowledge of Discharge Medications No. of patients (N=100)
a
Of the 172 patients discharged with new medications during the study period, 100 completed the interview (Figure). The characteristics of patients completing the study are summarized in Table 1, and a breakdown by type of the 200 new medications prescribed is provided in Table 2. Table 3 shows the number of patients who answered the medication-related questions correctly. Of the study patients, 86% were aware that they had been prescribed a new medication at discharge, but fewer (74%) knew the number of new medications and even fewer (64%) could name them. Of the interviewed patients, just over half (56%) knew dosages and 68% knew dosing schedules; 64% could identify the purpose of the medication. Although 22% of patients could name an adverse effect of a new medication, only 11% said they had been instructed on adverse effects at the time of discharge. Table 4 summarizes associations between the number of correctly answered questions and patient age, years of education, time between discharge and interview, and 556
4 11 5 6 9 22
number of new medications. Older patients answered fewer questions correctly (P=.02), but we observed no association between the number of correctly answered questions and years of education (P=.57), time between discharge and interview (P=.17), or number of new medications (P=.65).
Item
RESULTS
18 4 1 81
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Survey questions 1. Were you prescribed any new medications? 2. What are the names of the new medications? 3. How many new medications were you prescribed? 4. What is the recommended dose of each of the new medications? 5. How often should you take each of the new medications? 6. What is the purpose of each of the new medications? 7. Did anyone tell you the adverse effects of the new medications? 8. What are the adverse effects of the new medications? 9. Who would you contact if you had a question about your new medication? Primary care physician Hospital Pharmacist Don’t know Other Number of correctly answered survey questionsb 0-2 3-5 6-7 a b
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86 64 74 56 68 64 11 22 45 11 5 32 7 25 27 48
Data represent the number of patients who provided the correct answer. The highest possible score was 7. Questions 7 (answer of yes or no) and 9 (answer of name) did not have correct or incorrect answers.
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PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
TABLE 4. Patient Characteristics and Correctly Answered Survey Questions No. of correctly answered questionsb
Variablea Age (y) ≤65 (n=51) >65 (n=49) Education (y) ≤13 (n=52) >13 (≥1 y of college) (n=48) Time between discharge and telephone interview (d) ≤7 (n=55) >7 (n=45) No. of new medications ≤2 (n=74) >2 (n=26)
P valuec .02
4.8±2.4 3.9±2.4 .57 4.4±2.3 4.3±2.6 .17 4.4±2.5 4.3±2.3 .65 4.3±2.5 4.5±2.3
a
Patients were categorized into 2 groups by establishing the sample median as the threshold value. b Data are reported as mean ± SD. c P values were calculated by linear regression models adjusted for age. Each variable was considered to be continuous in these models.
DISCUSSION Functional health literacy regarding medications prescribed at discharge was poor in our study population. Almost 15% of patients were unaware that they had been prescribed a new medication. Only about half the patients knew specific information about their medications, such as dosage (56%), dosing schedules (68%), and purpose (64%). This lack of understanding indicates functional deficits in health care understanding and places patients at risk for considerable morbidity, including disease recurrence or other negative outcomes. Toren et al15 showed that almost 20% of discharged patients who did not fully understand their medication requirements revisited the emergency department within 30 days of discharge, and up to 35% visited the emergency department 2 or more times. Phillips et al16 showed that patients with chronic heart failure and low health literacy had a higher hospital readmission rate, incurred higher costs, and used more resources. Howard et al17 confirmed that patients with low health literacy used health care services inefficiently and incurred higher costs. Low comprehension may also lead to poor adherence to drug regimens, which may result in adverse medicationrelated events.18-20 Health care professionals need to take basic steps to improve the understanding and health literacy of patients at discharge. It remains unclear whether the poor functional comprehension reported here resulted from patient factors alone or also from the inability of health care professionals to communicate medical information adequately. Our finding that higher education did not correlate with better understanding suggests that the health care professional– patient interaction is currently inadequate. The communiMayo Clin Proc.
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cation skills of health care professionals must be assessed, and clinicians must be educated to recognize the limited health literacy of patients and be equipped with tools to overcome these limitations. Physicians could become more proficient at patient instruction if residency and continuing medical education curricula included training in communication. 21 Programs such as the American Medical Association’s Health Literacy Train-the-Trainer program,22 which teaches health care professionals how to conduct health literacy programs, are an important step toward such improved education and communication. Redesigning discharge paperwork to clearly show all new medications and standardizing the discharge process could also improve patients’understanding. Also needed are processes to help focus patients’ attention and give followup health care professionals a clear posthospitalization plan. Physician awareness of patient health illiteracy is vital. Although patients at our institution receive medication instructions from the prescribing physician and a nurse before discharge, we showed that this instruction was inadequate for complete understanding. Even though patients could ask the physician and nurse questions before discharge, their knowledge of discharge medications was poor. Thus, it cannot be assumed that patients understand verbal instructions after 1 or 2 sessions. Among other techniques, asking patients to repeat instructions could improve their understanding of health information.23 Furthermore, health care professionals can help clarify medication instructions by eliminating abbreviations and complex medical terms and by giving patients more specific instructions regarding medication administration. One of the more unsettling findings of our study was that only 11% of patients could recall being told about the adverse effects of their new medications, a percentage even lower than that reported in a previous study. Calkins et al24 reported that physicians thought that almost all their patients (89%) understood the possible adverse effects of their prescribed medications, but only slightly more than half of surveyed patients (57%) reported that they did so at discharge. Toren et al15 showed that many patients who were prescribed new medications received no counseling or information regarding adverse effects. Because patients with low health literacy have a particularly difficult time reading prescription medication warning labels,25 the absence of oral instruction may lead to greater risk of serious adverse effects. Education of health care professionals and patients is crucial to ensure the delivery of safe and effective health care. Our results supported the findings of previous studies that showed an association between increased patient age and decreased understanding of medication instructions at discharge.12,13 However, in contrast to previous studies,13,14 our study showed that the number of new medications was
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PATIENTS’ UNDERSTANDING OF MEDICATIONS AT DISCHARGE
not associated with a poorer understanding of medication instructions. One reason for this difference could be that the average number of new medications in our study (average, 2.0; range, 1.0-6.0) was lower than in previous studies (average, 3.5; range, 1.0-14.0). Also inconsistent with a previous study14 was our finding that understanding of instructions about medication was not associated with educational status. Davis et al25 reported that a lower literacy level and a greater number of medications were independently associated with misunderstanding instructions on labels. Although that study and our current one had a similar number of patients and used interviews as the data collection method, Davis et al classified patients by literacy level (adequate, marginal, or inadequate), whereas our study focused on level of education completed, perhaps accounting for some of the differing results. Also, the percentage of patients with postsecondary education (13 or more years) was higher in our study than in the study by Davis et al (48% vs 29%). Our results suggest that functional health literacy may not correlate directly with education level and that more advanced reading levels do not ensure adequate understanding of health issues and medication instructions. One limitation of our study may be the relatively high level of education of our patients (average, 13.6 years of education). This level of education is typical of the population that is regularly seen at our institution (educated and nonindigent) but may have caused us to overestimate the percentage of patients who understand their medications. We suspect that the percentage of patients who understand their medications in a more diverse population could be lower. However, as stated previously, we did not find a correlation between years of education and knowledge of medications at discharge; thus, the level of education may have had little effect. In addition, although the discharge medication instruction process was similar for each patient, it was not completely standardized, and we did not directly observe the instructions being given to patients. Although physicians and nursing staff both are charged with the task of discussing medications with patients at discharge, as instructed by the discharge sheet, adherence to this instruction process may not have been consistent. Our findings reemphasize the need for continuing education in patientcaregiver communication. CONCLUSION In showing that patients’understanding of new medications prescribed at discharge is inadequate, our study underlines the importance of addressing health illiteracy. Research is needed to find tools that effectively reduce the risk to patients and lower the costs of health care delivery. Innovative train-the-trainer programs and redesigned processes 558
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and patient literature are important initiatives, but more work clearly is needed. REFERENCES 1. Healthy People 2010: Health communication. 2000:11-20. Office of Disease Prevention and Health Promotion Web site. http://www.healthypeople.gov /document/HTML/Volume1/11HealthCom.htm. Accessed March 11, 2008. 2. Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. Adult literacy in America: a first look at the findings of the National Adult Literacy Survey. 3rd ed. National Center for Education Statistics Web site. http://nces.ed.gov/pubsearch/pubsinfo .asp?pubid=93275. Accessed March 11, 2008. 3. Kindig D, Affonso D, Chudler E, et al, eds. Health Literacy: a Prescription to End Confusion. Washington, DC: National Academies Press; 2004. http://books .nap.edu/html/health_literacy/reportbrief.pdf. Accessed March 12, 2008. 4. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13(12):791-798. 5. Mancuso CA, Rincon M. Impact of health literacy on longitudinal asthma outcomes. J Gen Intern Med. 2006;21(8):813-817. 6. Lincoln A, Paasche-Orlow MK, Cheng DM, et al. Impact of health literacy on depressive symptoms and mental health-related quality of life among adults with addiction. J Gen Intern Med. 2006;21(8):818-822. 7. Lindau ST, Basu A, Leitsch SA. Health literacy as a predictor of follow-up after an abnormal Pap smear: a prospective study. J Gen Intern Med. 2006; 21(8): 829-834. 8. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347(24):1933-1940. 9. Kripalani S, Paasche-Orlow MK, Parker RM, Saha S. Advancing the field of health literacy [editorial]. J Gen Intern Med. 2006;21:804-805. doi: 10.1111/ j.1525-1497.2006.00568.x. 10. Carmona RH. Health literacy: a national priority [editorial]. J Gen Intern Med. 2006;21:803. doi: 10.1111/j.1525-1497.2006.00569.x. 11. Makaryus AN, Friedman EA. Patients’ understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8):991-994. 12. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281(6):545-551. 13. King JL, Schommer JC, Wirsching RG. Patients’ knowledge of medication care plans after hospital discharge. Am J Health Syst Pharm. 1998;55(13):13891393. 14. Davis TC, Wolf MS, Bass PF III, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006 Dec 19;145(12):887-894. Epub 2006 Nov 29. 15. Toren O, Kerzman H, Koren N, Baron-Epel O. Patients’ knowledge regarding medication therapy and the association with health services utilization. Eur J Cardiovasc Nurs. 2006 Dec;5(4):311-316. Epub 2006 Jan 19. 16. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis [published correction appears in JAMA. 2004;292(9):1022]. JAMA. 2004;291(11):1358-1367. 17. Howard DH, Gazmararian J, Parker RM. The impact of low health literacy on the medical costs of Medicare managed care enrollees [published correction appears in Am J Med. 2005;118(8):933]. Am J Med. 2005;118(4):371-377. 18. Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348(16):1556-1564. 19. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107-1116. 20. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167. 21. Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of communications training on medical student performance. JAMA. 2003;290(9):1157-1165. 22. American Medical Association Foundation. Health Literacy Train-theTrainer Program. Chicago, IL: American Medical Association Foundation; c19952006 [updated 2005 Jun 02]. http://www.ama-assn.org/ama/pub/category /15141.html. Accessed April 14, 2008. 23. Sudore RL, Landefeld CS, Williams BA, Barnes DE, Lindquist K, Schillinger D. Use of a modified informed consent process among vulnerable patients: a descriptive study [published correction appears in J Gen Intern Med. 2006;21(9):1009]. J Gen Intern Med. 2006;21(8):867-873. 24. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients’ understanding of the postdischarge treatment plan. Arch Intern Med. 1997;157(9):1026-1030. 25. Davis TC, Wolf MS, Bass PF III, et al. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med. 2006;21(8):847-851.
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