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Original Investigation |

Quality of Discharge Practices and Patient Understanding at an Academic Medical Center

Leora I. Horwitz, MD, MHS1,2; John P. Moriarty, MD1; Christine Chen, MD3; Robert L. Fogerty, MD, MPH1; Ursula C. Brewster, MD4; Sandhya Kanade, MD3; Boback Ziaeian, MD5; Grace Y. Jenq, MD6; Harlan M. Krumholz, MD, SM2,7,8,9
[+] Author Affiliations
1Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
2Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
3Hospitalist Service, Yale–New Haven Hospital, New Haven, Connecticut
4Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
5Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles
6Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
7Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
8Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
9Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
JAMA Intern Med. 2013;173(18):1715-1722. doi:10.1001/jamainternmed.2013.9318.
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Importance  With growing national focus on reducing readmissions, there is a need to comprehensively assess the quality of transitional care, including discharge practices, patient perspectives, and patient understanding.

Objective  To conduct a multifaceted evaluation of transitional care from a patient-centered perspective.

Design  Prospective observational cohort study, May 2009 through April 2010.

Setting  Urban, academic medical center.

Participants  Patients 65 years and older discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia.

Main Outcomes and Measures  Discharge practices, including presence of follow-up appointment and patient-friendly discharge instructions; patient understanding of diagnosis and follow-up appointment; and patient perceptions of and satisfaction with discharge care.

Results  The 395 enrolled patients (66.7% of those eligible) had a mean age of 77.2 years. Although 349 patients (95.6%) reported understanding the reason they had been in the hospital, only 218 patients (59.6%) were able to accurately describe their diagnosis in postdischarge interviews. Discharge instructions routinely included symptoms to watch out for (98.4%), activity instructions (97.3%), and diet advice (89.7%) in lay language; however, 99 written reasons for hospitalization (26.3%) did not use language likely to be intelligible to patients. Of the 123 patients (32.6%) discharged with a scheduled primary care or cardiology appointment, 54 (43.9%) accurately recalled details of either appointment. During postdischarge interviews, 118 patients (30.0%) reported receiving less than 1 day’s advance notice of discharge, and 246 (66.1%) reported that staff asked whether they would have the support they needed at home before discharge.

Conclusions and Relevance  Patient perceptions of discharge care quality and self-rated understanding were high, and written discharge instructions were generally comprehensive although not consistently clear. However, follow-up appointments and advance discharge planning were deficient, and patient understanding of key aspects of postdischarge care was poor. Patient perceptions and written documentation do not adequately reflect patient understanding of discharge care.

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Figure 1.
Flow Diagram of Enrolled Participants
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Figure 2.
Word Clouds of Common Phrases Describing Reason for Hospitalization

A, Thirty most common phrases describing reason for hospitalization in written discharge instructions to patients. B, One hundred most common phrases describing reason for hospitalization used by patients.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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