1. Quality of Physician-Patient Communication during Hospitalization
Sunil Kripalani, MD, MSc1; Terry A. Jacobson, MD2; C. Ileko Mugalla, PhD, MPH1; R. Courtney Cawthon, MPH1; Kurt J. Niesner, BS1; Viola Vaccarino, MD, PhD2
1Vanderbilt University, Nashville, TN; 2Emory University, Atlanta, GA
INTRODUCTION
Patients often do not understand or recall information presented during hospitalization.
Poor physician-patient communication is related to adverse events and readmissions.
Health literacy is strongly associated with patients’ understanding of health information.
Little research has examined the effect of patients’ health literacy on the quality and clarity of hospital-based communication.
OBJECTIVES
To assess patients’ ratings of the quality and clarity of in-hospital communication.
To examine the effect of health literacy on the perceived quality and clarity of communication.
METHODS
Setting/Subjects:
Grady Memorial Hospital (Atlanta, GA)
Patients admitted with Acute Coronary Syndromes (ACS) between 8/05 and 4/06
Procedures:
Inpatient interview: demographics, cognition, health literacy
Follow-up interview via phone 2 weeks after discharge: communication ratings
Measures:
Cognition: Mini-Mental State Examination (MMSE)
Impaired: MMSE < 24
Health literacy: Rapid Estimate of Adult Literacy in Medicine (REALM)
Inadequate: ≤ 6th grade (score 0-44)
Marginal/Adequate: > 6th grade (score 45-66)
Communication: Interpersonal Processes of Care in Diverse Populations (IPC)
Validated 27-item measure
Responses on 5-point Likert scale
8 domains: General clarity, Responsiveness to patient concerns, Explanations of condition and prognosis, Explanations of processes of care, Explanations of self-care after discharge, Empowerment, Decision making, and Consideration of compliance
Analysis:
Bivariate analyses: Each of the 27 IPC items and 8 IPC domains by level of health literacy and other relevant patient characteristics
RESULTS
Patients enrolled and interviewed in hospital: N=100
Response rate for follow-up phone interview: 84%
DISCUSSION
Overall, patients gave the lowest ratings on domains of communication that related to post-discharge care.
Consideration of compliance
Explanations of self-care after discharge
Decision-making
Patients with inadequate health literacy experienced lower quality and clarity of in-hospital communication on multiple domains.
General clarity
Responsiveness to patient concerns
Explanations of processes of care
Other patient characteristics were not as consistently related to communication ratings (results not shown).
Limitations:
Participants were from a single teaching hospital where low health literacy is prevalent.
88% African-American, other racial/ethnic groups not well represented.
Communication ratings were self-reported ~2 wks after discharge, subject to recall bias.
Relatively small sample size limits ability to perform multivariable analyses.
Future directions:
Larger, multi-center studies to confirm factors related to quality of in-hospital communication.
Interventions to improve in-hospital communication and care transitions.
Given the association of poor in-hospital communication with post-discharge adverse events and readmission, more attention to effective health communication in the hospital setting is warranted.
ACKNOWLEDGEMENTS
The project described was supported by award number K23HL from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health.
Table 1. Patient characteristics (N=84)
Characteristic
N (%)
Age < 55 years
45 (54)
Female gender
35 (42)
Black race
74 (88)
Education: high school graduate or more
52 (62)
Employed full-time or part-time
18 (21)
Cognition impaired (MMSE < 24)
42 (50)
Health literacy:
Inadequate
Marginal or adequate
37 (44)
47 (56)
Table 2. Interpersonal Processes of Care (IPC) overall and by level of health literacy
IPC Domain
Total
(N=84)
Health Literacy
P-value
Inadequate (N=37)
Marginal or adequate (N=47)
General clarity*
3.66 (1.00)
3.36 (1.14)
3.89 (0.74)
0.02
Responsiveness to patient concerns
1.68 (0.68)
1.86 (0.76)
1.53 (0.58)
0.03
Explanations of condition & prognosis
1.75 (0.87)
1.93 (0.99)
1.61 (0.74)
0.09
Explanations of processes of care
2.01 (0.86)
2.22 (0.96)
1.84 (0.74)
0.04
Explanations of self-care after d/c
2.37 (1.04)
2.42 (1.20)
2.33 (0.90)
0.71
Empowerment
1.76 (1.03)
1.85 (1.27)
1.69 (0.81)
0.51
Decision-making
2.34 (0.78)
2.34 (0.80)
2.34 (0.77)
1.00
Consideration of compliance
3.15 (1.19)
3.24 (1.16)
3.07 (1.23)
0.54
* Values are presented as mean (SD). Range for all scores is 1 to 5. On the domain of General clarity, higher scores indicate more favorable responses. On other domains, lower scores indicate more favorable responses.