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Research Letter |

Patients’ Understanding of Their Hospitalizations and Association With Satisfaction FREE

Sosena Kebede, MD, MPH1,2; Hasan M. Shihab, MBChB, MPH3; Zackary D. Berger, MD, PhD1,4; Nina G. Shah, MS1; Hsin-Chieh Yeh, PhD1,5; Daniel J. Brotman, MD1
[+] Author Affiliations
1Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
2Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
3Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
4Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland
5Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Intern Med. 2014;174(10):1698-1700. doi:10.1001/jamainternmed.2014.3765.
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Published online

Effective communication is a health care quality indicator. Patients with a good understanding of their health are likely to be more satisfied with it and more adherent to their treatment plans.1,2 We sought to examine shared understanding between patients and clinicians in the hospital and how it might affect patient satisfaction.

The John Hopkins institutional review board approved this study. All participants provided written informed consent.

A total of 177 eligible internal medicine patients who had 2 or more medical conditions, 2 or more medical procedures, and 2 or more days of hospital stay between June 2012 and February 2013 were interviewed on the day of discharge. Patients were asked to rate their satisfaction with their hospitalization and their overall understanding of aspects of their hospitalization. They were then asked to (1) list all their medical diagnoses, (2) identify the indications for their medications from the discharge instruction sheet, and (3) identify the tests and/or procedures they underwent from a list of common tests and procedures provided. Patients’ answers were compared with physician documentations, and the degree of concordance (shared understanding) was calculated for the 3 knowledge domains.

The mean patient age was 57.4 years; 45% had “college and above” level of education. The estimated median household income was $36 360, and the mean length of stay was 7.7 days. Mean shared understanding scores for the entire cohort were 48.9%, 56.2%, and 59.4% for diagnoses, medication indications, and tests and/or procedures, respectively. The mean perceived understanding of overall hospitalization was 4.0 (very good), and the mean satisfaction score was 4.0 (very satisfied). Eighty-eight percent of patients indicated that their physicians communicated to them in a “courteous” manner; 78% reported being “listened [to] carefully”; and 72% reported that things were “explained [to them] in a way [they] could understand” “almost always” or “always.”

Each decade of increasing age was associated with poorer shared understanding for medical diagnoses (odds ratio [OR], 0.81 (95% CI, 0.21-0.70) and medication indications (OR, 0.78 [95% CI, 0.64-0.95]). Lower educational attainment was associated with poorer shared understanding in all the 3 domains, whereas higher household income predicted better shared understanding (Table). In multivariable analysis, black race, length of stay 8 days or longer, and increased number of procedures were associated with poorer shared understanding for tests and/or procedures. Both black and nonblack patients had a better perceived understanding of aspects of their hospital care than their measured understanding suggested. Each unit of increased patient-perceived understanding (but not measured shared understanding) was associated with an increasing level of satisfaction (Table) (Figure).

Table Graphic Jump LocationTable.  Association of Patient Characteristics With Domains of Shared Understanding and Patient Satisfactiona
Place holder to copy figure label and caption
Figure.
Association of Patients’ Perception of Shared Understanding With Percentage of Patients Extremely Satisfied With Their Care

P < .001 for the trend. A score of 1 indicates a patient perception of poor shared understanding; 2, fair understanding; 3, good understanding; and 4 or 5, excellent understanding.

Graphic Jump Location

Patients’ shared understanding with their physicians in the domains of diagnosis, medication indications, and tests and/or procedures was suboptimal, yet patients’ perceived understanding and their satisfaction with the quality of communication they received was fairly high. This may suggest that patients’ expectations for health communication is limited or selective. Additionally, it makes the relationship between quality of care (as measured by effective communication) and patient satisfaction unclear. However, the positive and linear relationship between perceived understanding and satisfaction (Figure) argues that patients value this aspect of quality care.

The racial disparity in shared understanding among black patients (who were less educated and had lower median income) in the domain of test and/or procedure knowledge may be a reflection of the fact that early socioeconomic disadvantages have been shown to have a lifetime effect on adult health behaviors, including learning.3,4 Additionally, patients from lower socioeconomic strata may not feel empowered to ask for detailed explanation, or their physicians may not offer detailed explanations owing to their own implicit biases toward these patients.5,6

Patient satisfaction can be better aligned with quality improvement efforts if patients’ expectations and preferences for their care are elucidated early on in the care. Future studies should investigate if higher shared understanding may have impact on patient (and physician) behaviors in the hospital.

Corresponding Author: Sosena Kebede, MD, MPH, Johns Hopkins University School of Medicine, Department of Medicine, 600 N Wolfe St, Nelson 215, Baltimore, MD 21287 (skebede3@jhmi.edu).

Published Online: August 18, 2014. doi:10.1001/jamainternmed.2014.3765.

Author Contributions: Author Brotman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kebede, Shihab, Berger, Brotman.

Acquisition, analysis, or interpretation of data: Kebede, Shihab, Shah, Yeh, Brotman.

Drafting of the manuscript: Kebede, Shihab, Brotman.

Critical revision of the manuscript for important intellectual content: Kebede, Shihab, Berger, Shah, Yeh, Brotman.

Statistical analysis: Shihab, Shah, Yeh, Brotman.

Obtained funding: Brotman.

Administrative, technical, or material support: Kebede, Berger.

Study supervision: Kebede, Brotman.

Conflict of Interest Disclosures: None reported.

Manning  DM, O’Meara  JG, Williams  AR,  et al.  3D: a tool for medication discharge education. Qual Saf Health Care. 2007;16(1):71-76.
PubMed   |  Link to Article
Williams  AM, Irurita  VF.  Therapeutic and non-therapeutic interpersonal interactions: the patient’s perspective. J Clin Nurs. 2004;13(7):806-815.
PubMed   |  Link to Article
Centers for Disease Control and Prevention. Injury Prevention & Control: Adverse Childhood Experiences (ACE) Study.http://www.cdc.gov/violenceprevention/acestudy/. Accessed June 26, 2014.
Bateson  P, Barker  D, Clutton-Brock  T,  et al.  Developmental plasticity and human health. Nature. 2004;430(6998):419-421.
PubMed   |  Link to Article
Johnson  RL, Roter  D, Powe  NR, Cooper  LA.  Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94(12):2084-2090.
PubMed   |  Link to Article
Levine  CS, Ambady  N.  The role of non-verbal behaviour in racial disparities in health care: implications and solutions. Med Educ. 2013;47(9):867-876.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Association of Patients’ Perception of Shared Understanding With Percentage of Patients Extremely Satisfied With Their Care

P < .001 for the trend. A score of 1 indicates a patient perception of poor shared understanding; 2, fair understanding; 3, good understanding; and 4 or 5, excellent understanding.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Association of Patient Characteristics With Domains of Shared Understanding and Patient Satisfactiona

References

Manning  DM, O’Meara  JG, Williams  AR,  et al.  3D: a tool for medication discharge education. Qual Saf Health Care. 2007;16(1):71-76.
PubMed   |  Link to Article
Williams  AM, Irurita  VF.  Therapeutic and non-therapeutic interpersonal interactions: the patient’s perspective. J Clin Nurs. 2004;13(7):806-815.
PubMed   |  Link to Article
Centers for Disease Control and Prevention. Injury Prevention & Control: Adverse Childhood Experiences (ACE) Study.http://www.cdc.gov/violenceprevention/acestudy/. Accessed June 26, 2014.
Bateson  P, Barker  D, Clutton-Brock  T,  et al.  Developmental plasticity and human health. Nature. 2004;430(6998):419-421.
PubMed   |  Link to Article
Johnson  RL, Roter  D, Powe  NR, Cooper  LA.  Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94(12):2084-2090.
PubMed   |  Link to Article
Levine  CS, Ambady  N.  The role of non-verbal behaviour in racial disparities in health care: implications and solutions. Med Educ. 2013;47(9):867-876.
PubMed   |  Link to Article

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