Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan

Development and psychometric evaluation of the asthma Action plan questionnaire (AAPQ)

OBJECTIVE

To develop a practical and psychometrically sound tool to evaluate caregiver knowledge of their child's asthma action plan (AAP).

METHODS

A pilot study was conducted in a sample of 40 caregivers of children with asthma to assess the content validity, item difficulty, and item discrimination of the Asthma Action Plan Questionnaire (AAPQ). The inter-rater and intra-rater agreement of the AAPQ's scoring rubric were also examined. Subsequently, a large-scale study was conducted in a sample of 80 caregivers of children with asthma and 40 caregivers of children without current asthma and no prior exposure to patients with asthma to evaluate the internal consistency, test-retest reliability, and known-groups validity of the AAPQ.

RESULTS

The 7-item AAPQ demonstrated acceptable content validity (a scale-content validity index of 0.98) and internal consistency (Cronbach's alpha =.63 and mean inter-item correlation coefficient of.20) and very strong test-retest reliability over a two-to-four-week period (r = .88, p < .001). The AAPQ discriminated between caregivers of children with asthma and caregivers of children without asthma (M ± SD 8.3 ± 1.6 vs. 4.3 ± 1.7, p < .001, respectively).

CONCLUSION

The AAPQ is a valid and reliable questionnaire that provides an assessment of caregivers' knowledge of their child's AAP and can guide educational interventions by healthcare providers.

Testing the hypothesis of subtypes of nonadherence in schizophrenia and schizoaffective disorder: A prospective study

BACKGROUND

Nonadherence is a major problem in the treatment of psychotic disorders. It has been hypothesized that nonadherent patients with schizophrenia are not a homogeneous population and subtypes of nonadherence might exist, but this hypothesis has not been specifically tested.

AIM

To test the hypothesis of subtypes of nonadherence in schizophrenia and schizoaffective disorder.

METHODS

This prospective study included 110 consecutively admitted patients diagnosed with schizophrenia or schizoaffective disorder. Assessments were performed at baseline and at 6 mo follow-up after discharge. Sociodemographic, clinical, psychopathological and treatment-related variables were evaluated. Adherence was defined as the concurrence of adherence to antipsychotic treatment and outpatient follow-up during the six-month period. Adherence to antipsychotic treatment was defined as the concurrence of objective and subjective adherence. Sixty-four patients (58%) fulfilled nonadherence criteria at the end of the follow-up period and were categorized according to their subtype of nonadherence.

RESULTS

In nonadherent patients (n = 64), 32 (50%) fulfilled criteria of intentional nonadherence, and 32 (50%) of unintentional nonadherence (UNA). Unintentional nonadherent patients, as compared to intentional nonadherent patients, are characterized by older age, lower educational level, worse cognitive and negative symptoms, greater severity, worse knowledge of their treatment regimen, greater prevalence of supervision of the treatment, lower number of prior hospitalizations and greater use of nonpsychiatric treatment, anticholinergics and hypnotics. Low educational level (OR = 26.1; 95%CI: 2.819-241), worse treatment knowledge at six months (OR per unit = 0.904; 95%CI: 0.853-0.957) and nonpsychiatric treatment at six months (OR = 15.8; 95%CI: 1.790-139) were independently associated to UNA.

CONCLUSION

Differentiated subtypes of nonadherence according to intentionality seem to exist in patients with schizophrenia and schizoaffective disorder. Our findings suggest the need for differentiated approach, both in future research and in clinical practice.

Improvements in cognition following hospital discharge of community dwelling seniors

BACKGROUND

Seniors frequently struggle during the transition home following an acute hospitalization resulting in frequent rehospitalizations. Studies consistently show a lack of comprehension of discharge instructions.

OBJECTIVES

To determine the frequency of low cognition at hospital discharge among community dwelling seniors and the changes in cognition that occur one month following hospitalization.

DESIGN

Face-to-face surveys were performed at hospital discharge and one month later in the home of the subject. The Mini-Mental Status Examination (MMSE), Backward Digit Span, and 15 Word Immediate and Delayed Recall Tests were used to evaluate cognition. Low cognition was determined to be a score of less than 25 on the MMSE for subjects with high school education and less than 18 for subjects with less than high school education.

PARTICIPANTS

Two hundred community-dwelling seniors ≥ 70 years, admitted to acute medicine services >24 hours, consenting to their own procedures, not having previously documented cognitive loss, and not admitted for cognitive changes.

RESULTS

Upon hospital discharge, 31.5% of subjects had previously unrecognized low cognition. One month later, 58% of these patients no longer had low cognition (p < 0.001). Of those subjects with low cognition, the MMSE improved by an average of 4 points one month post-discharge. Within the MMSE, subjects experienced significant improvements in the areas of orientation, registration, repetition, comprehension, naming, reading, writing, and calculation.

CONCLUSION

Low cognition at discharge is common among elderly patients without dementia, and cognition often improves one month post-hospitalization. Seniors may not comprehend discharge instructions, and patient self-management may be better taught as an outpatient following discharge rather than at the time of hospital discharge. Discharge interventions should incorporate screening of seniors for low cognition prior to hospital discharge to provide optimal transitional care.

Patient's satisfaction and distress compared with expectations of the medical staff

OBJECTIVE

Patient satisfaction is increasingly used to measure and evaluate patient treatment in hospital. The aim of this study is to assess satisfaction regarding communication, support and the degree of anxiety and depression among the patients, and to compare reports from the patients with the expectations of the staff.

METHODS

In a prospective study, 176 (93%) of the patients and 52 (80%) of the nurses completed a similar questionnaire. Degree of satisfaction was measured on a five-point scale (0-4), and degree of anxiety and depression was measured with the hospital anxiety and depression scale (HAD).

RESULTS

Satisfaction regarding communication with nurses (3.4+/-0.07) and physicians (3.0+/-0.08) was higher than expected by the staff (2.9+/-0.09 and 2.4+/-0.09, respectively) (p<0.01). The staff expected a higher degree of anxiety (2.3+/-0.10 versus 1.5+/-0.12) (p<0.01). The patients scored significantly higher on HAD anxiety compared with the population in general. The HAD score correlated negatively with the level of satisfaction.

CONCLUSION

The patients generally showed a high degree of satisfaction with communication and support. The staff underestimated the patients' degree of satisfaction and overestimated their degree of anxiety.

PRACTICE IMPLICATIONS

Knowledge of patients' degree of satisfaction is important for satisfactory communication with the staff, compliance with treatment and in order to reduce staff's concern for their care.

Make No Assumptions: Communication Between Persons With Disabilities and Clinicians

Fundamentally improving health care quality requires providing care that respects patients' preferences, needs, and values. This goal holds special resonance for persons with disabilities, many of whom find others defining and circumscribing their lives and opportunities. Achieving patient centeredness demands open communication between patients and clinicians, unhampered by prior and often erroneous assumptions about patients' goals, aspirations, and abilities. Building on this communication, optimal care involves collaboration between patients and clinicians, each bringing his or her particular expertise to the table. Interviews with individuals with diverse disabilities revealed a common theme of faulty communication between patients and clinicians. Some shortfalls relate to basic failures to accommodate communication needs, whereas others result from clinicians' erroneous perceptions of medical aspects of persons' underlying conditions, the role of assistive technologies, and how disability affects people's daily lives. Crafting collaborative care partnerships between patients and clinicians requires transforming traditional patient-clinician relationships. Following two basic precepts immeasurably improves communication between clinicians and patients with disabilities: first, make no assumptions, and second, just ask patients about their needs and preferences.

PROSPECTIVE RANDOMISED CONTROLLED TRIAL ON THE ROLE OF PATIENT INFORMATION LEAFLETS IN OBTAINING INFORMED CONSENT

BACKGROUND

The aim of this study was to determine whether patient information leaflets help to improve patient recall during the process of informed consent.

METHODS

A prospective randomized controlled trial that compared a group of patients who were posted a patient information leaflet with those given verbal consent only was carried out. The study was conducted at the orthopaedic unit of a district general hospital. A total of 110 patients were selected, of whom 57 were randomly allocated to receive patient information leaflets by post and 53 were given verbal consent only. The outcome measure was the recall of information given to the patient. This was tested on admission by using a questionnaire. Each patient was allocated a score out of 10.

RESULTS

There was a significant difference between the patients in the group that received patient information leaflets and those in the group that did not (P < 0.0001; confidence interval, 2.0-3.1).

CONCLUSION

Patient information leaflets are a useful tool for the surgeon to improve the recall of the information given to the patient, in order to facilitate informed consent.

Customer satisfaction

PURPOSE

This paper seeks to present an analysis of the literature examining objective information concerning the subject of customer service, as it applies to the current medical practice. Hopefully, this information will be synthesized to generate a cogent approach to correlate customer service with quality.

DESIGN/METHODOLOGY/APPROACH

Articles were obtained by an English language search of MEDLINE from January 1976 to July 2005. This computerized search was supplemented with literature from the author's personal collection of peer-reviewed articles on customer service in a medical setting. This information was presented in a qualitative fashion.

FINDINGS

There is a significant lack of objective data correlating customer service objectives, patient satisfaction and quality of care. Patients present predominantly for the convenience of emergency department care. Specifics of satisfaction are directed to the timing, and amount of "caring". Demographic correlates including symptom presentation, practice style, location and physician issues directly impact on satisfaction. It is most helpful to develop a productive plan for the "difficult patient", emphasizing communication and empathy. Profiling of the customer satisfaction experience is best accomplished by examining the specifics of satisfaction, nature of the ED patient, demographic profile, symptom presentation and physician interventions emphasizing communication--especially with the difficult patient.

ORIGINALITY/VALUE

The current emergency medicine customer service dilemmas are a complex interaction of both patient and physician factors specifically targeting both efficiency and patient satisfaction. Awareness of these issues particular to the emergency patient can help to maximize efficiency, minimize subsequent medicolegal risk and improve patient care if a tailored management plan is formulated.

Using information technology for patient education: realizing surplus value?

Computer-based patient information systems are introduced to replace traditional forms of patient education like brochures, leaflets, videotapes and, to a certain extent, face-to-face communication. In this paper, we claim that though computer-based patient information systems potentially have many advantages compared to traditional means, the surplus value of these systems is much harder to realize than often expected. By reporting on two computer-based patient information systems, both found to be unsuccessful, we will show that building computer-based patient information systems for patient education requires a thorough analysis of the advantages and limitations of IT compared to traditional forms of patient education. When this condition is fulfilled, however, these systems have the potential to improve health status and to be a valuable supplement to (rather than a substitute for) traditional means of patient education.

Patient and physician factors predict patients' comprehension of health information

While patients frequently do not comprehend health information, little is known about patient and physician factors that influence lack of comprehension. To assess effectiveness of health information exchange, 19 physicians and 145 patients were given post-encounter questionnaires to evaluate the preceding visit. We analyzed differences in beliefs between patients who comprehended health information and patients who did not, and whether physicians' attitudes and self-assessment of their educational abilities influenced this comprehension. Patients with insufficient comprehension were more likely to have schooling below college and cited language as a barrier. Physicians who believed health information delivery to be important had fewer patients with comprehension difficulties, while physicians who assessed themselves as very effective educators had significantly more patients with lack of comprehension, compared with physicians who did not feel as effective. Patients' comprehension of health information was associated not only with patient factors but also with physicians' attitude and self-assessment.

Assessing the information needs of post-myocardial infarction patients: a systematic review

We systematically reviewed studies examining information needs of post-myocardial infarction patients and their families. Electronic databases and bibliographies of relevant papers were searched and experts in the field contacted to find relevant studies. A standardised data form was used to extract data on study populations, instruments and results. Of 14 published studies, 6 used the same instrument. Information about risk factors ranked as the most important category overall, followed by information on cardiac anatomy and physiology, medications, and physical activity. Information about miscellaneous items, diet, psychological factors, and the CCU, although ranked lower, were still rated important. Some variation between settings was evident. Patients preferred physicians over nurses as information givers. Differences were found between patient and nurse ratings of information categories. Differences were found in the self-perceived information needs of patients responding to different instruments, indicating a priming effect. Changes in ranking of information categories between CCU, PCCU and PD are congruent with decreasing levels of patient dependency. The information needs of women and other post-MI subgroups, including the elderly, minority ethnic groups, patients with severe coronary disease, and deprived patients, have not been assessed. Patients have not been involved in the design of information needs assessment instruments.

Effect of telephone follow-up on the physical well-being dimension of quality of life in patients with cancer

OBJECTIVE

To evaluate the effect of telephone follow-up on the physical well-being dimension of health-related quality of life in patients with cancer.

DESIGN

Randomized, controlled trial.

SETTING

Public teaching hospital.

PATIENTS

One hundred fifty patients with cancer who were discharged to home from the hospital.

INTERVENTION

Patients received a telephone follow-up call 48-72 hours after discharge. Information was solicited regarding drug-related (and other) problems. Problems were addressed, and advice and support were given.

MEASUREMENTS AND MAIN RESULTS

Analysis of variance revealed no differences in the physical well-being dimension of health-related quality of life between patients who received telephone follow-up and a control group who did not. Sixty-eight percent of the follow-up group and 40% of the control group (p = 0.007) reported having had at least one contact with a health professional.

CONCLUSION

One possible explanation for the lack of effect of the intervention is that high-risk patients in the control group received a similar intervention from other health care professionals. We suggest that telephone follow-up be coordinated among health professionals.

Going home from hospital: the carer/patient dyad

AIMS

This study aimed to provide an in-depth understanding of the process of hospital discharge experienced by the carers of patients 'at risk' of unsuccessful discharge from medical wards in three hospitals in the North of England.

BACKGROUND

The Community Care Act and the Carers Recognition and Services Act placed responsibility on service providers to ensure the smooth discharge of patients from hospital making sure that appropriate community services are in place to support the patient and their informal carer following discharge from hospital. The study, from which this paper is taken, identified patients at risk of unsuccessful discharge and tracked the experiences of the patient and their carer through the discharge process. For the purpose of the study unsuccessful discharge is defined as unplanned readmission within 6 weeks of discharge or extended length of stay.

DESIGN

The study combined qualitative and quantitative methods to identify factors leading to unsuccessful discharge. Logistic regression was used retrospectively with the records of 1500 patients to identify factors predicting unsuccessful discharge. A sample of medical patients predicted to be at risk of unsuccessful discharge, their formal and informal carers, were followed through the discharge process using qualitative techniques to look at decision-making and outcomes related to discharge.

FINDINGS

This paper presents findings relating to patient/carer experiences of the discharge process. It explores the obligate moral climate in which the role of carer is negotiated between professionals, patients, family members, friends and neighbours and the differing assumptions about duty associated with caring roles in hospital and in family and community settings.

CONCLUSION

The discussion adopts a critical theory perspective to examine the contradictions confronting practitioners, patients and carers arising from hospital policies which promote cost-effective and efficient use of expensive technical resources while simultaneously seeking to identify and meet the needs of patients and carers for care.

Patient education in the emergency department

The emergency department (ED) visit provides an opportunity for patient education. Many ED patients have poor access to regular health care, including patient education. Accreditation standards, legal considerations, and cost-efficiency concerns encourage the clinician to implement formal patient education in the ED. More importantly, published clinical studies evaluating patient education in both the ED and comparable settings support the hypothesis that ED-based patient education improves outcomes. The article discusses considerations for instructional material, highlights challenges to ED-based patient education, and suggests possibilities for future research.

Management decisions regarding community-acquired pneumonia

The successful management of community-acquired pneumonia requires many management decisions, including a decision as to the site of care, the type and duration of antibiotic therapy, and a discharge decision for patients who require hospitalization. A number of recent studies have defined and tested criteria for some of the management decisions indicated above.