Carolyn Dickens

Health Literacy and Nursing: An Update.

Health literacy refers to a patients knowledge and skill in making informed health care decisions. Low health literacy is associated with poor health outcomes that nurses have the potential to affect. Screening tools are available to assess a patients health literacy, but not all are easy to use. Recently health literacy experts have recommended that all patients be treated as if they have low health literacy. The authors review the recent definitions and dimensions of health literacy, the prevalence and characteristics of patients with low health literacy, and strategies nurses can use in clinical settings.

Low bleeding risk from cardiac catheterization in patients with advanced liver disease

Patients with hepatic failure often develop multifactorial coagulopathies [1]. While these coagulopathies pose an increased risk of hemorrhage, the magnitude of that risk and the ideal management strategy in the context of cardiac catheterization is uncertain. Cardiologists are naturally inclined to extrapolate from other conditions with similar phenotypes, namely, the elevated international normalized ratio (INR) that one achieves with warfarin anticoagulation [2]. However, the underlying causes of the elevated INR in patients with hepatic disease and in patients on warfarin are not identical [1,3], and it would be incorrect to assume that a similar degree of INR elevation represents a similar hemorrhagic diathesis. The INR in liver disease is not due entirely to depletion of vitamin K-dependent factors as it is with warfarin and the elevated INR is not entirely normalized by measures targeting factor deficiency, i.e., vitamin K administration or infusion of fresh frozen plasma [1,3]. The coagulopathy in liver disease is more complex than mere depletion of coagulation factors and includes the presence of dysfibrinogenemia leading to impaired ability to form dimers and low-grade accelerated intravascular coagulation. These characteristics of liver disease coagulopathy have been cited as contributing to abnormalities of tests of coagulation without necessarily increasing hemorrhagic risk [3]. There is very limited data on the risks of cardiac catheterization in patients with coagulopathy due to hepatic failure [4]. Our aim was to examine the risk of hemorrhage in liver failure patients undergoing catheterization.

A primary care, electronic health record-based strategy to promote safe drug use: study protocol for a randomized controlled trial

BackgroundThe Northwestern University Center for Education and Research on Therapeutics (CERT), funded by the Agency for Healthcare Research and Quality, is one of seven such centers in the USA. The thematic focus of the Northwestern CERT is ‘Tools for Optimizing Medication Safety.’ Ensuring drug safety is essential, as many adults struggle to take medications, with estimates indicating that only half of adults take drugs as prescribed. This report describes the methods and rationale for one innovative project within the CERT: the ‘Primary Care, Electronic Health Record-Based Strategy to Promote Safe and Appropriate Drug Use’.Methods/DesignThe overall objective of this 5-year study is to evaluate a health literacy-informed, electronic health record-based strategy for promoting safe and effective prescription medication use in a primary care setting. A total of 600 English and Spanish-speaking patients with diabetes will be consecutively recruited to participate in the study. Patients will be randomized to receive either usual care or the intervention; those in the intervention arm will receive a set of print materials designed to support medication use and prompt provider counseling and medication reconciliation. Participants will be interviewed in person after their index clinic visit and again one month later. Process outcomes related to intervention delivery will be recorded. A medical chart review will be performed at 6 months. Patient outcome measures include medication understanding, adherence and clinical measures (hemoglobin A1c, blood pressure, and cholesterol; exploratory outcomes only).DiscussionThrough this study, we will be able to examine the impact of a health literacy-informed, electronic health record-based strategy on medication understanding and adherence among diabetic primary care patients. The measurement of process outcomes will help inform how the strategy might ultimately be refined and disseminated to other sites. Strategies such as these are needed to address the multifaceted challenges related to medication self-management among patients with chronic conditions.Trial registrationClinicaltrials.gov NCT01669473.

Improving the Heart Failure Readmission Rate at an Urban Medical Center

Background: Heart failure (HF) is a chronic health condition that affects over 5 million people annually. It is the most common cause of 30-day readmissions with nearly 90% of these readmissions being unplanned. CMS requires hospitals to publicly report 30 day readmission rates for HF with the goal of improving accountability. In 2006, this hospitals 30-day readmission rate was 27% as compared to the national average of 24%. Purpose: To analyze the impact of several quality improvement interventions on 30-day readmission rates for HF at this urban medical center. Intervention: The following interdisciplinary interventions were implemented in the third quarter of 2009: (1) improved nursing discharge education regarding heart failure (ie. sodium restricted diet, medication adherence, daily weight); (2) a detailed medication list was given to patients; (3) patients received an appointment within 2 weeks with an advanced practice nurse (APN) specializing in heart failure; (4) HF patients received their medications prior to discharge; (5) all patients received a follow-up phone call by an APN within 7-10 days of discharge; (6) the hospital billing personnel analyzed patients charts to ensure that HF admissions were being coded appropriately. Methods: Patients were included if their initial admission was coded DRG 428 as their primary diagnosis and were readmitted within 30 days with any diagnosis. Data was summarized into 7, 14, and 30 day readmission rates. Rates were compared prior to the intervention and after. Pearson chi square was used to compare the two groups. Conclusion: At one year, the 30-day readmission rate decreased from 27.1% to 18.2% (p = 0.000) the 14 day readmission rate decreased from 15.1% to 9.1% (p=.003) and the 7 day readmission rate decreased from 8.8% to 5.5% (p=.038). Overall, patients were 1.6 times less likely to be readmitted for HF after the intervention. Recommendations: Hospitals can implement tailored interdisciplinary interventions to decrease their readmission rates. Sustainability of these process improvements will be critical to maintaining a high level of care for HF patients.

Letter by DiDomenico et al Regarding Article, “Recent National Trends in Readmission Rates After Heart Failure Hospitalization”

To the Editor: In 2009, the Centers for Medicare and Medicaid Services began reporting publicly 30-day readmission rates for acute decompensated heart failure in an effort to highlight preventable readmissions, improve care, and control costs. This decision was based, in part, on recent observations of elderly Medicare fee-for-service beneficiaries that found a median readmission rate of 24.4% (range, 15.9% to 34.4%).1 A follow-up study by Ross et al2 published in Circulation: Heart Failure evaluated trends in readmission after acute decompensated heart failure hospitalization and found similar readmission rates (23.7% to 23.9%) over the 3-year period from 2004 to 2006. Both of these …

Mr. G And The Revolving Door: Breaking The Readmission Cycle At A Safety-Net Hospital

A patient with complex needs returns to the hospital again and again, despite his care teams efforts to reduce readmissions.

Patient-Centered Tablet Application for Improving Medication Adherence after a Drug-Eluting Stent

Background/aims This study’s objective was to evaluate a patient-centered educational electronic tablet application, “My Interventional Drug-Eluting Stent Educational App” (MyIDEA) to see if there was an increase in patient knowledge about dual antiplatelet therapy (DAPT) and medication possession ratio (MPR) compared to treatment as usual. Methods In a pilot project, 24 elderly (≥50 years old) research participants were recruited after a drug-eluting stent. Eleven were randomized to the control arm and 13 to the interventional arm. All the participants completed psychological and knowledge questionnaires. Adherence was assessed through MPR, which was calculated at 3 months for all participants who were scheduled for second and third follow-up visits. Results Relative to control, the interventional group had a 10% average increase in MPR. As compared to the interventional group, more patients in the control group had poor adherence (<80% MPR). The psychological data revealed a single imbalance in anxiety between the control and interventional groups. On average, interventional participants spent 21 min using MyIDEA. Discussion Consumer health informatics has enabled us to engage patients with their health data using novel methods. Consumer health technology needs to focus more on patient knowledge and engagement to improve long-term health. MyIDEA takes a unique approach in targeting DAPT from the onset. Conclusion MyIDEA leverages patient-centered information with clinical care and the electronic health record highlighting the patients’ role as a team member in their own health care. The patients think critically about adverse events and how to solve issues before leaving the hospital.