Retrospective Study of Symptoms in Post-Discharge Patients
Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.
As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.
The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.
Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.
Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.
Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.
The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.
To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.
Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.