Danielle M. McCarthy

What Did the Doctor Say? Health Literacy and Recall of Medical Instructions

Background:Limited literacy has repeatedly been linked to problems comprehending health information, although the majority of studies to date have focused on reading various print health materials. We sought to investigate patients’ ability to recall spoken medical instructions in the context of a hypothetical clinical encounter, and whether limited health literacy would adversely affect performance on the task. Methods:A total of 755 patients aged 55 to 74 were recruited from 1 academic internal medicine clinic and 3 federally qualified health centers. Participants’ health literacy skills and recall of spoken medical instructions for 2 standard hypothetical video scenarios [wound care, gastroesophageal reflux disease (GERD) diagnosis] were assessed. Results:The majority (71.6%) of participants had adequate health literacy skills, and these individuals performed significantly better in correctly recalling spoken information than those with marginal and low literacy in both scenarios: [wound care—mean (SD): low 2.5 (1.3) vs. marginal 3.5 (1.3) vs. adequate 4.6 (1.1); P<0.001), GERD: low 4.2(1.7) vs. marginal 5.2 (1.7) vs. adequate 6.5 (1.7); P<0.001]. Regardless of literacy level, overall recall of information was poor. Few recognized pain (28.5%) or fever (28.2%) as signs of infection. Only 40.5% of participants correctly recalled when to take their GERD pills. Conclusions:Many older adults may have difficulty remembering verbal instructions conveyed during clinical encounters. We found those with lower health literacy to have poorer ability to recall information. Greater provider awareness of the impact of low health literacy on the recall of spoken instructions may guide providers to communicate more effectively and employ strategies to confirm patient understanding.

Patient Understanding of Emergency Department Discharge Instructions: Where Are Knowledge Deficits Greatest?

OBJECTIVES Many patients are discharged from the emergency department (ED) with an incomplete understanding of the information needed to safely care for themselves at home. Patients have demonstrated particular difficulty in understanding post-ED care instructions (including medications, home care, and follow-up). The objective of this study was to further characterize these deficits and identify gaps in knowledge that may place the patient at risk for complications or poor outcomes. METHODS This was a prospective cohort, phone interview-based study of 159 adult English-speaking patients within 24 to 36 hours of ED discharge. Patient knowledge was assessed for five diagnoses (ankle sprain, back pain, head injury, kidney stone, and laceration) across the following five domains: diagnosis, medications, home care, follow-up, and return instructions. Knowledge was determined based on the concordance between direct patient recall and diagnosis-specific discharge instructions combined with chart review. Two authors scored each case independently and discussed discrepancies before providing a final score for each domain (no, minimal, partial, or complete comprehension). Descriptive statistics were used for the analyses. RESULTS The study population was 50% female with a median age of 41 years (interquartile range [IQR] = 29 to 53 years). Knowledge deficits were demonstrated by the majority of patients in the domain of home care instructions (80%) and return instructions (79%). Less frequent deficits were found for the domains of follow-up (39%), medications (22%), and diagnosis (14%). Minimal or no understanding in at least one domain was demonstrated by greater than two-thirds of patients and was found in 40% of cases for home care and 51% for return instructions. These deficits occurred less frequently for domains of follow-up (18%), diagnosis (3%), and medications (3%). CONCLUSIONS Patients demonstrate the most frequent knowledge deficits for home care and return instructions, raising significant concerns for adherence and outcomes.

Literacy and race as risk factors for low rates of advance directives in older adults.

To examine the effect of the relationship between literacy and other individual‐level factors on having an advance directive (AD).

Examining Emergency Department Communication Through a Staff-Based Participatory Research Method: Identifying Barriers and Solutions to Meaningful Change

STUDY OBJECTIVE We test an initiative with the staff-based participatory research (SBPR) method to elicit communication barriers and engage staff in identifying strategies to improve communication within our emergency department (ED). METHODS ED staff at an urban hospital with 85,000 ED visits per year participated in a 3.5-hour multidisciplinary workshop. The workshop was offered 6 times and involved: (1) large group discussion to review the importance of communication within the ED and discuss findings from a recent survey of patient perceptions of ED-team communication; (2) small group discussions eliciting staff perceptions of communication barriers and best practices/strategies to address these challenges; and (3) large group discussions sharing and refining emergent themes and suggested strategies. Three coders analyzed summaries from group discussions by using latent content and constant comparative analysis to identify focal themes. RESULTS A total of 127 staff members, including attending physicians, residents, nurses, ED assistants, and secretaries, participated in the workshop (overall participation rate 59.6%; range 46.7% to 73.3% by staff type). Coders identified a framework of 4 themes describing barriers and proposed interventions: (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. The majority of participants (81.4%) reported that their participation would cause them to make changes in their clinical practice. CONCLUSION Involving staff in discussing barriers and facilitators to communication within the ED can result in a meaningful process of empowerment, as well as the identification of feasible strategies and solutions at both the individual and system levels.

Emergency Department Discharge Instructions: Lessons Learned through Developing New Patient Education Materials

Our multidisciplinary team developed a new set of discharge instructions for five common emergency department diagnoses using recommended tools for creating literacy-appropriate and patient-centered education materials. We found that the recommended tools for document creation were essential in constructing the new instructions. However, while the tools were necessary, they were not sufficient. This paper describes the insights gained and lessons learned in this document creation process.

Patient Input into the Development and Enhancement of ED Discharge Instructions: A Focus Group Study

OBJECTIVES Previous research indicates that patients have difficulty understanding ED discharge instructions; these findings have important implications for adherence and outcomes. The objective of this study was to obtain direct patient input to inform specific revisions to discharge documents created through a literacy-guided approach and to identify common themes within patient feedback that can serve as a framework for the creation of discharge documents in the future. METHODS Based on extensive literature review and input from ED providers, subspecialists, and health literacy and communication experts, discharge instructions were created for 5 common ED diagnoses. Participants were recruited from a federally qualified health center to participate in a series of 5 focus group sessions. Demographic information was obtained and a Rapid Estimate of Adult Literacy in Medicine (REALM) assessment was performed. During each of the 1-hour focus group sessions, participants reviewed discharge instructions for 1 of 5 diagnoses. Participants were asked to provide input into the content, organization, and presentation of the documents. Using qualitative techniques, latent and manifest content analysis was performed to code for emergent themes across all 5 diagnoses. RESULTS Fifty-seven percent of participants were female and the average age was 32 years. The average REALM score was 57.3. Through qualitative analysis, 8 emergent themes were identified from the focus groups. CONCLUSIONS Patient input provides meaningful guidance in the development of diagnosis-specific discharge instructions. Several themes and patterns were identified, with broad significance for the design of ED discharge instructions.

Hospitalization for caffeine abuse is associated with abuse of other pharmaceutical products.

STUDY OBJECTIVE The aim of this study was to examine the characteristics and outcomes of patients seeking treatment for abuse of supplemental caffeine. METHODS This was a 3-year analysis conducted of all consecutive cases involving caffeine abuse in patients 10 years and older reported to a regional poison center. Excluded were suicide attempts, therapeutic errors, and cases involving only a coffee or tea product. RESULTS Two hundred fifty-four cases met inclusion criteria. Mean age was 20.5 years, 50% were women. Caffeine was in the form of a nondietary medication in 201 cases, a dietary supplement in 35 cases, and a caffeine-enhanced beverage in 35 cases. Caffeine was abused alone in 174 (68%), with alcohol in 7, illegal drugs in 6 cases, and with other pharmaceutical products in 81 (29%) cases. Thirty-four patients (13% of total) were hospitalized for medical complications from caffeine. Only concomitant abuse of other pharmaceutical products was associated with hospitalization (odds ratio, 3.8; 95% CI, 1.8-8.8; P = .0004). CONCLUSION In this cohort, supplemental caffeine was abused primarily by young adults. Concomitant recreational abuse of other pharmaceuticals was associated with hospitalization and warrants further investigation.

Self-Reported Use of Communication Techniques in the Emergency Department

BACKGROUND Communication is considered a core competency for physicians. However, the Emergency Department setting poses significant and unique communication challenges. OBJECTIVE The objective of this study was to explore self-reported use and perceptions of effectiveness and feasibility of communication techniques used by Emergency Physicians for communication with patients. METHODS This cross-sectional study utilized a previously published survey on eight communication techniques. Respondents were asked to quantify their personal use and perceptions of effectiveness and feasibility of each technique. Responses were analyzed for differences based on practice setting (community, academic) and provider role (attending, resident). The survey was administered to a convenience sample recruited at the national meeting of the American College of Emergency Physicians. RESULTS One hundred and sixty-nine participants were enrolled (70.5% male; 55.8% attending physicians, 44.2% residents; 66.2% practiced in academic settings). Using simple language and speaking slowly to patients were the only techniques identified as being used routinely by a majority of the sample (92.2% and 61.3%, respectively). A majority of the sample ranked seven of the techniques as effective; all techniques were considered feasible in the Emergency Department. No differences were noted across provider role or practice setting. CONCLUSION The majority of respondents are not utilizing communication techniques, despite their own beliefs that the techniques are effective and easy to implement in the Emergency Department. Additional research is needed to determine the effectiveness of these techniques and relevant barriers to their use.

Enhancing community disaster resilience through mass sporting events.

Disaster response requires rapid, complex action by multiple agencies that may rarely interact during nondisaster periods. Failures in communication and coordination between agencies have been pitfalls in the advancement of disaster preparedness. Recommendations of the Federal Emergency Management Agency address these needs and demonstrate commitment to successful disaster management, but they are challenging for communities to ensure. In this article we describe the application of Federal Emergency Management Agency guidelines to the 2008 and 2009 Chicago Marathon and discuss the details of our implementation strategy with a focus on optimizing communication. We believe that it is possible to enhance community disaster preparedness through practical application during mass sporting events.

Benzodiazepine-opioid co-prescribing in a national probability sample of ED encounters

Background: Benzodiazepine‐opioid combination therapy is potentially harmful due to the risk of synergistic respiratory depression, and the rate of death due to benzodiazepine‐opioid overdose is increasing. Little is known about the prevalence and characteristics of benzodiazepine‐opioid co‐prescribing from the ED setting. Methods: Secondary analysis of data from the National Hospital Ambulatory Medical Care Survey, using sample weights to generate population estimates. The primary objective was to describe the annual prevalence of benzodiazepine‐opioid co‐prescribing from 2006 to 2012, using 95% confidence intervals (95% CI) to compare adjacent years. The secondary objective was to compare characteristics of ED encounters receiving a benzodiazepine‐opioid co‐prescription versus those receiving an opioid prescription alone, using a multivariable logistic regression. Results: The prevalence of benzodiazepine‐opioid co‐prescribing did not significantly change from 2006 to 2012. During this period, 2.7% (95% CI: 2.5–2.8%) of ED encounters prescribed an opioid were also prescribed a benzodiazepine. Relative to encounters receiving an opioid prescription alone, encounters receiving a co‐prescription were more likely to represent a follow‐up rather than initial visit (Odds Ratio [OR] 1.52), receive more medications (OR 1.41) and fewer procedures (OR 0.48) while in the ED, and more likely to have a diagnosis related to mental disorder (OR 20.60) or musculoskeletal problem (OR 3.71). Conclusions: From 2006 to 2012, almost 3% of all ED encounters receiving an opioid prescription also received a benzodiazepine co‐prescription. The odds of benzodiazepine‐opioid co‐prescribing were significantly higher in ED encounters representing a follow‐up visit and in diagnoses relating to a mental disorder or musculoskeletal problem.