Kathryn Goggins

Characteristics Associated With Postdischarge Medication Errors

OBJECTIVE To examine the association of patient- and medication-related factors with postdischarge medication errors. PATIENTS AND METHODS The Vanderbilt Inpatient Cohort Study includes adults hospitalized with acute coronary syndromes and/or acute decompensated heart failure. We measured health literacy, subjective numeracy, marital status, cognition, social support, educational attainment, income, depression, global health status, and medication adherence in patients enrolled from October 1, 2011, through August 31, 2012. We used binomial logistic regression to determine predictors of discordance between the discharge medication list and the patient-reported list during postdischarge medication review. RESULTS Among 471 patients (mean age, 59 years), the mean total number of medications reported was 12, and 79 patients (16.8%) had inadequate or marginal health literacy. A total of 242 patients (51.4%) were taking 1 or more discordant medication (ie, appeared on either the discharge list or patient-reported list but not both), 129 (27.4%) failed to report a medication on their discharge list, and 168 (35.7%) reported a medication not on their discharge list. In addition, 279 participants (59.2%) had a misunderstanding in indication, dose, or frequency in a cardiac medication. In multivariable analyses, higher subjective numeracy (odds ratio [OR], 0.81; 95% CI, 0.67-0.98) was associated with lower odds of having discordant medications. For cardiac medications, participants with higher health literacy (OR, 0.84; 95% CI, 0.74-0.95), with higher subjective numeracy (OR, 0.77; 95% CI, 0.63-0.95), and who were female (OR, 0.60; 95% CI, 0.46-0.78) had lower odds of misunderstandings in indication, dose, or frequency. CONCLUSION Medication errors are present in approximately half of patients after hospital discharge and are more common among patients with lower numeracy or health literacy.

Medication Nonadherence Before Hospitalization for Acute Cardiac Events

Medication nonadherence increases the risk of hospitalization and poor outcomes, particularly among patients with cardiovascular disease. The purpose of this study was to examine characteristics associated with medication nonadherence among adults hospitalized for cardiovascular disease. Patients in the Vanderbilt Inpatient Cohort Study who were admitted for acute coronary syndrome or heart failure completed validated assessments of self-reported medication adherence (the Adherence to Refills and Medications Scale), demographic characteristics, health literacy, numeracy, social support, depressive symptoms, and health competence. We modeled the independent predictors of nonadherence before hospitalization, standardizing estimated effects by each predictors interquartile range. Among 1,967 patients studied, 70.7% indicated at least some degree of medication nonadherence leading up to their hospitalization. Adherence was significantly lower among patients with lower health literacy (0.18-point change in adherence score per interquartile range change in health literacy), lower numeracy (0.28), lower health competence (0.30), and more depressive symptoms (0.52) and those of younger age, of non-White race, of male gender, or with less social support. Medication nonadherence in the period before hospitalization is more prevalent among patients with lower health literacy, numeracy, or other intervenable psychosocial factors. Addressing these factors in a coordinated care model may reduce hospitalization rates.

The Impact of Health Literacy on Surgical Outcomes Following Radical Cystectomy

Health literacy is the ability to obtain, comprehend, and act on medical information and is an independent predictor of health outcomes in patients with chronic health conditions. However, little has been reported regarding the potential association of health literacy and surgical outcomes. We hypothesized that patient complications after radical cystectomy would be associated with health literacy. In a sample of 368 patients, we found that higher health literacy scores (as determined by the Brief Health Literacy Screen) were associated with decreased odds of developing minor complications (odds ratio = 0.90, 95% confidence interval [0.83, 0.97]). Health literacy should be considered when caring for patients undergoing radical cystectomy and should serve as a potential indicator of the need for additional resources to improve postoperative outcomes.

Predictors of Health Care System and Physician Distrust in Hospitalized Cardiac Patients

Trusting relationships among patients, physicians, and the health care system is important in encouraging self-care behaviors in cardiovascular patients. This study aimed to assess the prevalence of health care system and physician distrust in this population, compare the 2 forms of distrust, and describe the demographic, socioeconomic, and psychosocial predictors of high distrust. A total of 1,232 hospitalized adults with acute coronary syndrome or heart failure were enrolled in a prospective, observational study assessing health care system distrust and physician distrust. High health care system distrust (35%) was observed across the population, with lower levels of interpersonal physician distrust (16%). In a multivariate analysis, poor social support and coping skills were strong predictors of both health care system (p = .026, p = .003) and physician distrust (p < .001, p = .006). Individuals with low or marginal health literacy had a higher likelihood of physician distrust (p < .001), but no relation was found between health literacy and health care system distrust. In conclusion, distrust is common among acutely ill cardiac patients. Those with low social support and low coping skills are more distrusting of physicians and the health care system.

Association of Health Literacy With Postoperative Outcomes in Patients Undergoing Major Abdominal Surgery

Importance Low health literacy is known to adversely affect health outcomes in patients with chronic medical conditions. To our knowledge, the association of health literacy with postoperative outcomes has not been studied in-depth in a surgical patient population. Objective To evaluate the association of health literacy with postoperative outcomes in patients undergoing major abdominal surgery. Design, Setting, and Participants From November 2010 to December 2013, 1239 patients who were undergoing elective gastric, colorectal, hepatic, and pancreatic resections for both benign and malignant disease at a single academic institution were retrospectively reviewed. Patient demographics, education, insurance status, procedure type, American Society of Anesthesiologists status, Charlson comorbidity index, and postoperative outcomes, including length of stay, emergency department visits, and hospital readmissions, were reviewed from electronic medical records. Health literacy levels were assessed using the Brief Health Literacy Screen, a validated tool that was administered by nursing staff members on hospital admission. Multivariate analysis was used to determine the association of health literacy levels on postoperative outcomes, controlling for patient demographics and clinical characteristics. Main Outcomes and Measures The association of health literacy with postoperative 30-day emergency department visits, 90-day hospital readmissions, and index hospitalization length of stay. Results Of the 1239 patients who participated in this study, 624 (50.4%) were women, 1083 (87.4%) where white, 96 (7.7%) were black, and 60 (4.8%) were of other race/ethnicity. The mean (SD) Brief Health Literacy Screen score was 12.9 (SD, 2.75; range, 3-15) and the median educational attainment was 13.0 years. Patients with lower health literacy levels had a longer length of stay in unadjusted (95% CI, 0.95-0.99; P = .004) and adjusted (95% CI, 0.03-0.26; P = .02) analyses. However, lower health literacy was not significantly associated with increased rates of 30-day emergency department visits or 90-day hospital readmissions. Conclusions and Relevance Lower health literacy levels are independently associated with longer index hospitalization lengths of stay for patients who are undergoing major abdominal surgery. The role of health literacy needs to be further evaluated within surgical practices to improve health care outcomes and use.

What Patient Characteristics Influence Nurses’ Assessment of Health Literacy?

Overestimation of patients’ health literacy skills is common among nurses and physicians. At Vanderbilt University Hospital, nurses routinely ask patients the 3 Brief Health Literacy Screen (BHLS) questions. Data from 2 studies that recruited patients at Vanderbilt University Hospital—the Health Literacy Screening (HEALS) study and the Vanderbilt Inpatient Cohort Study (VICS)—were analyzed to compare the BHLS score recorded by nurses during clinical care with the score recorded by trained research assistants during the same hospitalization. Logistic regression models determined which patient characteristics were associated with nurses documenting higher health literacy scores than research assistants. Overall, the majority (60%) of health literacy scores were accurate, though nurses recorded meaningfully higher health literacy scores in 28.4% of HEALS patients and 35.6% of VICS patients. In the HEALS cohort, patients who were male and had less education were more likely to have higher health literacy scores recorded by nurses (odds ratio [OR] = 1.93, 95% confidence interval [CI] [1.24, 3.00]; and OR = 0.80, 95% CI [0.74, 0.88], respectively). In the VICS cohort, patients who were older, were male, and had less education were more likely to have higher health literacy scores recorded by nurses (OR = 1.01, 95% CI [1.003, 1.02]; OR = 1.49, 95% CI [1.20, 1.84]; and OR = 0.87, 95% CI [0.83, 0.90], respectively). These findings suggest that health literacy scores recorded by nurses for male patients and patients with less education could be overestimated. Thus, health care professionals should be aware of this tendency and should verify the results of routine health literacy screening tests, especially in certain patient groups.

The Impact of Health Literacy and Clinicodemographic Factors on Use of Discharge Services after Radical Cystectomy

Purpose: There are few data on the relationship between health literacy and discharge disposition. We hypothesized that patient discharge needs after radical cystectomy are affected by health literacy. Materials and Methods: We identified 504 patients who underwent radical cystectomy and completed the validated BHLS (Brief Health Literacy Screen) after November 2010. Bivariate and logistic regression analyses were performed to determine whether health literacy is associated with the use of discharge resources after radical cystectomy. Results: Of patients treated with radical cystectomy 50.6% required discharge services and had lower health literacy (BHLS 11.9 vs 12.5, p = 0.016) than patients discharged home without services. On multivariable analysis older age (OR 1.1, 95% CI 1.0–1.1, p = 0.002), female gender (OR 2.3, 95% CI 1.2–4.4, p = 0.019), body mass index (OR 1.1, 95% CI 1.0–1.1, p = 0.034), Charlson comorbidity index score (OR 1.1, 95% CI 1.0–1.2, p = 0.037) and length of stay (OR 1.1, 95% CI 1.0–1.2, p = 0.019) were significantly associated with the use of discharge resources. Patients with continent vs incontinent urinary diversion were less likely to require discharge services (OR 0.4, 95% CI 0.2–0.8, p = 0.013). Conclusions: Older age, female gender, body mass index, comorbidities, length of stay and incontinent diversion are associated with increased use of discharge resources after radical cystectomy. Low health literacy may affect patient discharge disposition but it was not significant on multivariable analysis. Factors that influence the complex self‐care required of patients after cystectomy should be considered during discharge planning.

Know thy eHealth user: Development of biopsychosocial personas from a study of older adults with heart failure.

BACKGROUND Personas are a canonical user-centered design method increasingly used in health informatics research. Personas-empirically-derived user archetypes-can be used by eHealth designers to gain a robust understanding of their target end users such as patients. OBJECTIVE To develop biopsychosocial personas of older patients with heart failure using quantitative analysis of survey data. METHOD Data were collected using standardized surveys and medical record abstraction from 32 older adults with heart failure recently hospitalized for acute heart failure exacerbation. Hierarchical cluster analysis was performed on a final dataset of n=30. Nonparametric analyses were used to identify differences between clusters on 30 clustering variables and seven outcome variables. RESULTS Six clusters were produced, ranging in size from two to eight patients per cluster. Clusters differed significantly on these biopsychosocial domains and subdomains: demographics (age, sex); medical status (comorbid diabetes); functional status (exhaustion, household work ability, hygiene care ability, physical ability); psychological status (depression, health literacy, numeracy); technology (Internet availability); healthcare system (visit by home healthcare, trust in providers); social context (informal caregiver support, cohabitation, marital status); and economic context (employment status). Tabular and narrative persona descriptions provide an easy reference guide for informatics designers. DISCUSSION Personas development using approaches such as clustering of structured survey data is an important tool for health informatics professionals. We describe insights from our study of patients with heart failure, then recommend a generic ten-step personas development process. Methods strengths and limitations of the study and of personas development generally are discussed.

Refractory primary medication nonadherence: Prevalence and predictors after pharmacist counseling at hospital discharge

Successful secondary prevention of cardiovascular disease relies on medication therapy; thus, minimizing nonadherence is a focus for improving patient outcomes. Receipt of discharge medication counseling has been associated with improved drug knowledge and adherence. We evaluated the prevalence and predictors of postdischarge primary nonadherence (not filling new prescriptions) in patients who received discharge medication counseling by a pharmacist (ie, refractory to intervention) as part of a randomized controlled trial. Of 341 patients, 9.4% of patients did not fill all prescriptions after discharge. Patients who were living alone were more likely to not fill their medications compared to those who were married or cohabitating (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.01-4.8, P = 0.047). Patients who were discharged with greater than 10 medications were also more likely to demonstrate primary nonadherence (OR: 2.3, 95% CI: 1.05-4.98, P = 0.036). Patients with lower income were less likely to fill prescriptions in univariate analysis (P = 0.04) but not multivariable analysis. Our study demonstrates that among patients hospitalized for acute cardiovascular events, primary medication nonadherence persisted despite discharge medication counseling. Targeted or multimodal approaches that address patient-specific barriers, such as cost, social isolation, and polypharmacy, in addition to discharge counseling, may further facilitate adherence.

Development of a multivariable model to predict vulnerability in older American patients hospitalised with cardiovascular disease

Objectives To identify vulnerable cardiovascular patients in the hospital using a self-reported function-based screening tool. Participants Prospective observational cohort study of 445 individuals aged ≥65 years admitted to a university medical centre hospital within the USA with acute coronary syndrome and/or decompensated heart failure. Methods Participants completed an inperson interview during hospitalisation, which included vulnerable functional status using the Vulnerable Elders Survey (VES-13), sociodemographic, healthcare utilisation practices and clinical patient-specific measures. A multivariable proportional odds logistic regression model examined associations between VES-13 and prior healthcare utilisation, as well as other coincident medical and psychosocial risk factors for poor outcomes in cardiovascular disease. Results Vulnerability was highly prevalent (54%) and associated with a higher number of clinic visits, emergency room visits and hospitalisations (all p<0.001). A multivariable analysis demonstrating a 1-point increase in VES-13 (vulnerability) was independently associated with being female (OR 1.55, p=0.030), diagnosis of heart failure (OR 3.11, p<0.001), prior hospitalisations (OR 1.30, p<0.001), low social support (OR 1.42, p=0.007) and depression (p<0.001). A lower VES-13 score (lower vulnerability) was associated with increased health literacy (OR 0.70, p=0.002). Conclusions Vulnerability to functional decline is highly prevalent in hospitalised older cardiovascular patients and was associated with patient risk factors for adverse outcomes and an increased use of healthcare services.