Hospitalized Patients’ Knowledge of Care: a Systematic Review

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Abstract

<div class="section"> <a class="named-anchor" id="d199349e226">  </a> <h5 class="section-title" id="d199349e227">Background</h5> <p id="Par1">Patients’ comprehension of their medical conditions is fundamental to patient-centered care. Hospitalizations present opportunities to educate patients but also challenges to patient comprehension given the complexity and rapid pace of clinical care. We conducted a systematic review of the literature to characterize the current state of inpatients’ knowledge of their hospitalization, assess the methods used to determine patient comprehension, and appraise the effects of interventions on improving knowledge. </p> </div><div class="section"> <a class="named-anchor" id="d199349e231">  </a> <h5 class="section-title" id="d199349e232">Methods</h5> <p id="Par2">We searched MEDLINE, EMBASE, and the Cochrane Library for articles published from January 1, 1995 through December 11, 2017. Eligible studies included patients under inpatient or observation status on internal medicine, family medicine, or neurology services. We extracted study characteristics (author, year, country, study design, sample size, patient characteristics, methods, intervention, primary endpoints, results) in a standardized fashion. The quality of observational studies was assessed using the NIH Quality Assessment Tool for Observation Cohort and Cross-Sectional Studies and the quality of interventional studies was assessed using adapted EPOC criteria from the Cochrane Collaboration. </p> </div><div class="section"> <a class="named-anchor" id="d199349e236">  </a> <h5 class="section-title" id="d199349e237">Results</h5> <p id="Par3">Twenty-eight studies met the criteria for inclusion, including 17 observational studies and 11 interventional studies. Patient knowledge of all aspects of their hospitalization was poor and patients often overestimated their knowledge. Older patients and those with lower education levels were more likely to have poorer knowledge. Intervention methods varied, but generally showed improvements in patient knowledge. Few interventional studies assessed the effect on health behaviors or outcomes and those that did were often underpowered. </p> </div><div class="section"> <a class="named-anchor" id="d199349e241">  </a> <h5 class="section-title" id="d199349e242">Discussion</h5> <p id="Par4">Clinicians should be aware that comprehension is often poor among hospitalized patients, especially in those with lower education and advanced age. Our results are limited by overall poor quality of interventional studies. Future research should use objective, standardized measures of patient comprehension and interventions should be multifaceted in approach, focusing on knowledge improvement while also addressing other factors influencing outcomes. </p> </div><div class="section"> <a class="named-anchor" id="d199349e246">  </a> <h5 class="section-title" id="d199349e247">Electronic supplementary material</h5> <p id="d199349e249">The online version of this article (10.1007/s11606-018-4658-5) contains supplementary material, which is available to authorized users. </p> </div>

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Most cited references 28

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Quality of discharge practices and patient understanding at an academic medical center.

Sandhya V. Kanade, Robert Fogerty, Christine Chen … (2013)

With growing national focus on reducing readmissions, there is a need to comprehensively assess the quality of transitional care, including discharge practices, patient perspectives, and patient understanding. To conduct a multifaceted evaluation of transitional care from a patient-centered perspective. Prospective observational cohort study, May 2009 through April 2010. Urban, academic medical center. Patients 65 years and older discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. Discharge practices, including presence of follow-up appointment and patient-friendly discharge instructions; patient understanding of diagnosis and follow-up appointment; and patient perceptions of and satisfaction with discharge care. The 395 enrolled patients (66.7% of those eligible) had a mean age of 77.2 years. Although 349 patients (95.6%) reported understanding the reason they had been in the hospital, only 218 patients (59.6%) were able to accurately describe their diagnosis in postdischarge interviews. Discharge instructions routinely included symptoms to watch out for (98.4%), activity instructions (97.3%), and diet advice (89.7%) in lay language; however, 99 written reasons for hospitalization (26.3%) did not use language likely to be intelligible to patients. Of the 123 patients (32.6%) discharged with a scheduled primary care or cardiology appointment, 54 (43.9%) accurately recalled details of either appointment. During postdischarge interviews, 118 patients (30.0%) reported receiving less than 1 day’s advance notice of discharge, and 246 (66.1%) reported that staff asked whether they would have the support they needed at home before discharge. Patient perceptions of discharge care quality and self-rated understanding were high, and written discharge instructions were generally comprehensive although not consistently clear. However, follow-up appointments and advance discharge planning were deficient, and patient understanding of key aspects of postdischarge care was poor. Patient perceptions and written documentation do not adequately reflect patient understanding of discharge care.

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Is "teach-back" associated with knowledge retention and hospital readmission in hospitalized heart failure patients?

Matthew White, Roxanne Garbez, Maureen Carroll … (2016)

Heart failure (HF) is a chronic and costly condition that affects approximately 5.8 million people in the United States, with an additional 670,000 diagnosed yearly. With high 30-day hospital readmission rates, the importance of determining effective means of preventing readmissions is imperative. Despite published guidelines emphasizing the importance of education in preventing readmissions, the most effective means of educating hospitalized patients with HF about their self-care remains unknown. The aim of this study was to determine if hospitalized HF patients educated with the teach-back method retain self-care educational information and whether it is associated with fewer hospital readmissions. A prospective cohort study design included 276 patients older than 65 years hospitalized with HF over a 13-month period. Patients were educated and evaluated using the teach-back method as part of usual care. Data on ability to recall educational information while hospitalized and during follow-up approximately 7 days after hospital discharge were collected. Readmissions were confirmed through follow-up telephone calls and review of medical records. Patients correctly answered 3 of 4, or 75%, of self-care teach-back questions 84.4% of the time while hospitalized and 77.1% of the time during follow-up telephone call. Greater time spent teaching was significantly associated with correctly answered questions (P < .001). Patients who answered teach-back questions correctly while hospitalized and during follow-up had nonsignificant (P = .775 and .609) reductions in all-cause 30-day hospital readmission rates, but a trend toward significance (P = .15) was found in patients who had readmissions for HF. The teach-back method is an effective method used to educate and assess learning. Patients educated longer retained significantly more information than did patients with briefer teaching. Correctly answered HF-specific teach-back questions were not associated with reductions in 30-day hospital readmission rates. Future studies that include patients randomized to receive usual care or teach-back education to compare readmissions and knowledge acquisition would provide further comparison of teach-back effectiveness.

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Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications.

Elisha Friesema, Daniel W. Baker, John Lindquist … (2012)

Inadequate health literacy is prevalent among seniors and is associated with poor health outcomes. At hospital discharge, medications are frequently changed and patients are informed of these changes via their discharge instructions. Explore the association between health literacy and medication discrepancies 48 hours after hospital discharge and determine the causes of discharge medication discrepancies. Face-to-face surveys assessing health literacy at hospital discharge using the short form of the Test of Functional Health Literacy in Adults (sTOFHLA). We obtained the medication lists from the written discharge instructions. At 48 hrs post-discharge, we phoned subjects to assess their current medication regimen, any medication discrepancies, and the causes of the discrepancies. Two hundred and fifty-four community-dwelling seniors ≥ 70 years, admitted to acute medicine services for >24 hours at an urban hospital. Of 254 seniors [mean age 79.3 yrs, 53.1% female], 142 (56%) had a medication discrepancy between their discharge instructions and their actual home medication use 48 hrs after discharge. Subjects with inadequate and marginal health literacy were significantly more likely to have unintentional non-adherence--meaning the subject did not understand how to take the medication [inadequate health literacy 47.7% vs. marginal 31.8% vs. adequate 20.5% p = 0.002]. Conversely, those with adequate health literacy were significantly more likely to have intentional non-adherence--meaning the subject understood the instructions but chose not to follow them as a reason for the medications discrepancy compared with marginal and inadequate health literacy [adequate 73.3% vs. marginal 11.1% vs. inadequate 15.6%, p < 0.001]. Another common cause of discrepancies was inaccurate discharge instructions (39.3%). Seniors with adequate health literacy are more inclined to purposefully not adhere to their discharge instructions. Seniors with inadequate health literacy are more likely to err due to misunderstanding their discharge instructions. Together, these results may explain why previous studies have shown a lack of association between health literacy and overall medication discrepancies.