Hospital discharge and transition, whether back into the community or to other levels of care, are burdened by a lack of standardization and can be executed poorly—making them treacherous periods for patients.
Indeed, 20% of discharges are complicated by adverse events within 30 days, often resulting in avoidable trips to the emergency department and rehospitalization. Nationwide, 25% of patients are readmitted within 90 days, often because the fragmented discharge process leaves them vulnerable to iatrogenic complications.
Yet few studies have examined the discharge process in depth. Until now, none have looked at it from the patient’s point of view, lead author Lee Strunin, PhD, and colleagues Meg Stone, MPH, and Brian Jack, MD, write in the September-October edition of the Journal of Hospital Medicine. They interviewed 21 low-income patients in an inner-city hospital in Boston to identify the factors most closely associated with the risk of readmission.
The patients had a mean age of 46, and all had been hospitalized at least once within the previous six months. Twenty of the 21 patients were in the hospital for the same primary problem they were admitted for on their previous stay. The interviews lasted 20 to 45 minutes with each patient and addressed the patient’s ability to obtain follow-up care, care after discharge, and social support.
In most cases, inability to understand discharge instructions was not a problem. All participants could describe those instructions as well as their medical condition, why they were admitted to the hospital, and the medications they were taking.
—Brian Jack, MD, associate professor of family medicine, Boston University Medical Center
“For the participants in this study, difficult life circumstances posed a greater barrier to recuperation than lack of medical knowledge,” the investigators write. Patients complained of little or no support in such areas as child care, transportation to medical appointments, or attempts to overcome alcoholism or drug abuse. Many patients could not follow instructions to rest because they had to work or care for young children.
Half the patients reported psychological conditions such as depression and stress, which interfered with their ability to follow their treatment plan. For example, an 18-year-old black woman with diabetes told of how she would do well for a while, following diet and medication recommendations and monitoring her blood sugar regularly, only to become depressed and lose motivation. She was not receiving treatment for her depression. Another woman with polycystic kidney disease described pain that was sometimes so intense she had to delegate the housekeeping chores to her 5-year-old son.
Even though the patients in this study appeared to understand their illnesses and what to do (under ideal circumstances) after they went home, poor health literacy could be one explanation for these findings, senior author Dr. Jack tells The Hospitalist.
“We have data now that patients with low health literacy are less ready for discharge,” says Dr. Jack, associate professor of family medicine, Boston University Medical Center, and the department’s founding vice chair for academic affairs. He and his colleagues are developing patient-centered interventions to mitigate the discrepancies between people who are more or less health-literate. “To the degree that the middle-class population has higher health literacy, [outcomes after discharge] might vary,” he says.
These findings demonstrate the critical effect life circumstances outside the hospital have on a patient’s recovery, the authors say in the paper, adding that the patients’ experiences “clearly demonstrate the ways in which stresses make it difficult or impossible to attain sufficient rest to heal, maintain behavior change necessary to improve health, and follow instructions given by clinicians at the time of discharge.”
They further point out that interventions aimed at low-income patients should include social support and assistance with daily responsibilities.
“A focus on each patient’s life circumstance is critical,” Dr. Jack explains. For example, it isn’t sufficient simply to tell the patient when to come back for a stress test. Hospitals or caseworkers should also determine if “it is a day the patient can go, do they have a ride, daycare, do they know where the test is, which doctor will follow up the results, will they be seeing that doctor, and so on. There are now recent data suggesting that most tests ordered after discharge are never done.”
From this and other studies on the subject, it seems intuitive that providing these supports for at-risk patients should reduce rehospitalization rates. Is there any evidence this is the case?
“Not yet,” Dr. Jack says. “But stay tuned.” TH
Norra MacReady is a medical writer based in California.