Friday, August 7, 2015

A Focus on Health Literacy: Teaching Pediatric Residents How To Write Discharge Instructions That Optimize Readability and Understandability

Ndidi Unaka, MD, MEd
Cincinnati Children's Hospital Medical Center

Background: Health literacy is defined as the “degree to which individuals can obtain, process and understand the basic health information and services they need to make appropriate health decisions”. Approximately 1 in 3 adults in the U.S. with limited health literacy and 1 in 10 adults unable to complete “below basic” health literacy-based tasks. Those with low health literacy are at risk for poorer clinical outcomes, high utilization of ED services and poor adherence to preventive care recommendations. Hospitalized children have acute illnesses and many discharged home with new or changed medications, follow up instructions with multiple providers and information on home care and reasons to return to the hospital. Children rely on adult caregivers to carry out discharge instructions and consequently are dependent on the health literacy of their parents or caregivers. Additionally, most physicians lack training on how to provide written materials at an appropriate literacy level and pediatric providers shown to overestimate parental health literacy levels. Commonly used written medical information for patients and families are frequently written between 10th and 12th grade reading levels.

Objectives: The objectives of the study were to determine 1) the current readability levels and understandability scores of instructions written by CCHMC pediatric residents and given to patients and their caregivers at the time of hospital discharge and 2 )the impact of an educational intervention for pediatric residents on the readability level of written discharge instructions.

Methods: Charts were randomly selected from all discharges from two distinct periods: January 2014-March 2014 and January 2015- March 2015. Discharge instructions and clinical information were abstracted from the EMR and anonymized for measurement and analysis. Each set of discharge instructions were scored for readability and understandability and assessed for inclusion of specific content: statement and description of diagnosis, “red flags”, who to call if worried, and provider contact information. The educational intervention was an online module shared with residents at the beginning of their rotation during the 3 months in 2015. Discharge instructions were compared between the two years to assess the impact of the intervention. Residents also completed a short survey at the end of the month.

Results: A significant difference between mean Fry readability scores of the discharge instructions was noted, with the higher mean in the post intervention instructions; mean Fry readability score of the 2014 and 2015 discharge instructions were 9.54 and 10.26 respectively (p <0.05). A statistically significant difference in mean PEMAT scores between the 2014 and 2015 discharge instructions was also noted (71% versus 75% respectively; p 0.01). 2015 instructions were more likely to explicitly state the discharge diagnosis (17% vs. 37%) and who to call if symptoms persisted (59% vs. 66%). Instructions from both years consistently included “red flags” (82% in pre and post intervention instructions) but rarely included the contact information for various providers (10% vs. 13% of pre and post intervention instructions). 31/51 residents completed the survey; only 17 of the 31 respondents reviewed the health literacy module. 15 out of 17 found the module helpful.

Conclusion: Readability levels in the pre and post intervention groups were above the 9th grade. Impact of the educational intervention was low despite statistically significant differences between the PEMAT scores pre and post intervention.