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ABSTRACT: Low health literacy negatively affects processes and outcomes of care. Physicians do not routinely use communication techniques recommended for use with low health literate patients. This study was conducted to compare the self-reported and actual use of clear verbal communication among medical residents and to identify characteristics associated with clear communication. Residents self-assessed their communication behaviors and then completed a low health literacy standardized patient encounter. Answers on the self-assessment were compared with behaviors observed in the standardized patient encounter. Residents (N = 82) reported frequent use of techniques recommended for clear verbal communication, including plain language (88%) and teach-back (48%). However, during the standardized patient encounter, they used an average of 2 jargon terms per minute, and only 22% used teach-back. No resident characteristics consistently predicted better communication. In conclusion, the study found that medical residents used clear communication techniques infrequently and tended to overestimate the clarity with which they communicate.
Journal of Health Communication 04/2013; · 1.61 Impact Factor
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ABSTRACT: OBJECTIVE: Because existing numeracy measures may not optimally assess 'health numeracy', we developed and validated the General Health Numeracy Test (GHNT). METHODS: An iterative pilot testing process produced 21 GHNT items that were administered to 205 patients along with validated measures of health literacy, objective numeracy, subjective numeracy, and medication understanding and medication adherence. We assessed the GHNT's internal consistency reliability, construct validity, and explored its predictive validity. RESULTS: On average, participants were 55.0±13.8 years old, 64.9% female, 29.8% non-White, and 51.7% had incomes ≤$39K with 14.4±2.9 years of education. Psychometric testing produced a 6-item version (GHNT-6). The GHNT-21 and GHNT-6 had acceptable-good internal consistency reliability (KR-20=0.87 vs. 0.77, respectively). Both versions were positively associated with income, education, health literacy, objective numeracy, and subjective numeracy (all p<.001). Furthermore, both versions were associated with participants' understanding of their medications and medication adherence in unadjusted analyses, but only the GHNT-21 was associated with medication understanding in adjusted analyses. CONCLUSIONS: The GHNT-21 and GHNT-6 are reliable and valid tools for assessing health numeracy. PRACTICE IMPLICATIONS: Brief, reliable, and valid assessments of health numeracy can assess a patient's numeracy status, and may ultimately help providers and educators tailor education to patients.
Patient Education and Counseling 02/2013; · 2.31 Impact Factor
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Annals of internal medicine 01/2013; 158(2):137-8. · 16.73 Impact Factor
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ABSTRACT: Hospital readmissions are common and costly; this has resulted in their emergence as a key quality indicator in the current era of renewed focus on cost containment. However, many concerns remain about the use of readmissions as a hospital quality measure and about how to reduce hospital readmissions. These concerns stem in part from deficiencies in the state of the science of transitional care. A conceptualization of the "ideal" discharge process could help address these deficiencies and move the state of the science forward. We describe an ideal transition in care, explicate the key components, discuss its implications in the context of recent efforts to reduce readmissions, and suggest next steps for policymakers, researchers, healthcare administrators, practitioners, and educators. Journal of Hospital Medicine 2012; © 2012 Society of Hospital Medicine.
Journal of Hospital Medicine 11/2012; · 1.40 Impact Factor
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ABSTRACT: Increasingly, hospitals are implementing multifaceted programs to improve medication reconciliation and transitions of care, often involving pharmacists.
To assess pharmacists' views on their roles in hospital-based medication reconciliation and discharge counseling and provide their recommendations for improving care transitions.
Eleven study pharmacists at 2 hospitals participated in the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study and completed semistructured one-on-one interviews, which were coded systematically in NVivo. Pharmacists provided their perspectives on admission and discharge medication reconciliation, in-hospital patient counseling, provision of simple medication adherence aids (eg, pill box, illustrated daily medication schedule), and telephone follow-up.
Pharmacists indicated that they considered medication reconciliation, although time consuming, to be their most important role in improving care transitions, particularly through detection of errors that required correction in the admission medication history. They also identified patients who required additional counseling because of poor understanding of their medications. Providing adherence aids was felt to be highly valuable for patients with low health literacy, although less useful for patients with adequate health literacy. Pharmacists noted that having trained administrative staff conduct initial postdischarge follow-up calls to screen for issues and triage which patients needed pharmacist follow-up was helpful and an efficient use of resources. Pharmacists' recommendations for improving care transitions included clear communication among team members, protected time for discharge counseling, patient and family engagement in discharge counseling, and provision of patient education materials.
Pharmacists are well positioned to participate in hospital-based medication reconciliation, identify patients with poor medication understanding or adherence, and provide tailored patient counseling to improve transitions of care. Additional studies are needed to confirm these findings in other settings and to determine the efficacy and cost-effectiveness of different models of pharmacist involvement.
Annals of Pharmacotherapy 08/2012; 46(9):1152-9. · 2.13 Impact Factor
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Amanda H Salanitro,
Chandra Y Osborn,
Jeffrey L Schnipper,
Christianne L Roumie,
Stephanie Labonville,
Daniel C Johnson,
Erin Neal,
Courtney Cawthon,
Alexandra Businger,
Anuj K Dalal, Sunil Kripalani
Journal of General Internal Medicine 07/2012; 27(10):1393. · 2.83 Impact Factor
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ABSTRACT: BACKGROUND: Up to 50 % of patients do not take medications as prescribed. Interventions to improve adherence are needed, with an understanding of which patients benefit most. OBJECTIVE: To test the effect of two low-literacy interventions on medication adherence. DESIGN: Randomized controlled trial, 2 × 2 factorial design. PARTICIPANTS: Adults with coronary heart disease in an inner-city primary care clinic. INTERVENTIONS: For 1 year, patients received usual care, refill reminder postcards, illustrated daily medication schedules, or both interventions. MAIN MEASURES: The primary outcome was cardiovascular medication refill adherence, assessed by the cumulative medication gap (CMG). Patients with CMG < 0.20 were considered adherent. We assessed the effect of the interventions overall and, post-hoc, in subgroups of interest. KEY RESULTS: Most of the 435 participants were elderly (mean age = 63.7 years), African-American (91 %), and read below the 9th-grade level (78 %). Among the 420 subjects (97 %) for whom CMG could be calculated, 138 (32.9 %) had CMG < 0.20 during follow-up and were considered adherent. Overall, adherence did not differ significantly across treatments: 31.2 % in usual care, 28.3 % with mailed refill reminders, 34.2 % with illustrated medication schedules, and 36.9 % with both interventions. In post-hoc analyses, illustrated medication schedules led to significantly greater odds of adherence among patients who at baseline had more than eight medications (OR = 2.2; 95 % CI, 1.21 to 4.04) or low self-efficacy for managing medications (OR = 2.15; 95 % CI, 1.11 to 4.16); a trend was present among patients who reported non-adherence at baseline (OR = 1.89; 95 % CI, 0.99 to 3.60). CONCLUSIONS: The interventions did not improve adherence overall. Illustrated medication schedules may improve adherence among patients with low self-efficacy, polypharmacy, or baseline non-adherence, though this requires confirmation.
Journal of General Internal Medicine 07/2012; · 2.83 Impact Factor
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Sunil Kripalani,
Christianne L Roumie,
Anuj K Dalal,
Courtney Cawthon,
Alexandra Businger,
Svetlana K Eden,
Ayumi Shintani,
Kelly Cunningham Sponsler,
L Jeff Harris,
Cecelia Theobald,
Robert L Huang,
Danielle Scheurer,
Susan Hunt,
Terry A Jacobson,
Kimberly J Rask,
Viola Vaccarino,
Tejal K Gandhi,
David W Bates,
Mark V Williams,
Jeffrey L Schnipper
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ABSTRACT: Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs).
To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge.
Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021)
Two tertiary care academic hospitals.
Adults hospitalized with acute coronary syndromes or acute decompensated heart failure.
Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge.
The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs.
Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39]). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]).
The characteristics of the study hospitals and participants may limit generalizability.
Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacist-delivered intervention.
National Heart, Lung, and Blood Institute.
Annals of internal medicine 07/2012; 157(1):1-10. · 16.73 Impact Factor
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ABSTRACT: Medication discrepancies at care transitions are common and lead to patient harm. Medication reconciliation is a strategy to reduce this risk.
To summarize available evidence on medication reconciliation interventions in the hospital setting and to identify the most effective practices.
MEDLINE (1966 through February 2012) and a manual search of article bibliographies.
Twenty-six controlled studies.
Data were extracted on study design, setting, participants, inclusion/exclusion criteria, intervention components, timing, comparison group, outcome measures, and results.
Studies were grouped by type of medication reconciliation intervention-pharmacist related, information technology (IT), or other-and were assigned quality ratings using US Preventive Services Task Force criteria.
Fifteen of 26 studies reported pharmacist-related interventions, 6 evaluated IT interventions, and 5 studied other interventions. Six studies were classified as good quality. The comparison group for all the studies was usual care; no studies compared different types of interventions. Studies consistently demonstrated a reduction in medication discrepancies (17 of 17 studies), potential adverse drug events (5 of 6 studies), and adverse drug events (2 of 2 studies) but showed an inconsistent reduction in postdischarge health care utilization (improvement in 2 of 8 studies). Key aspects of successful interventions included intensive pharmacy staff involvement and targeting the intervention to a high-risk patient population.
Rigorously designed studies comparing different inpatient medication reconciliation practices and their effects on clinical outcomes are scarce. Available evidence supports medication reconciliation interventions that heavily use pharmacy staff and focus on patients at high risk for adverse events. Higher-quality studies are needed to determine the most effective approaches to inpatient medication reconciliation.
Archives of internal medicine 06/2012; 172(14):1057-69. · 11.46 Impact Factor
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ABSTRACT: Optimizing postdischarge medication adherence is a target for avoiding adverse events. Nevertheless, few studies have focused on predictors of postdischarge medication adherence.
The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study used counseling and follow-up to improve postdischarge medication safety. In this secondary data analysis, we analyzed predictors of self-reported medication adherence after discharge. Based on an interview at 30-days postdischarge, an adherence score was calculated as the mean adherence in the previous week of all regularly scheduled medications. Multivariable linear regression was used to determine the independent predictors of postdischarge adherence.
The mean age of the 646 included patients was 61.2 years, and they were prescribed an average of 8 daily medications. The mean postdischarge adherence score was 95% (standard deviation [SD] = 10.2%). For every 10-year increase in age, there was a 1% absolute increase in postdischarge adherence (95% confidence interval [CI] 0.4% to 2.0%). Compared to patients with private insurance, patients with Medicaid were 4.5% less adherent (95% CI -7.6% to -1.4%). For every 1-point increase in baseline medication adherence score, as measured by the 4-item Morisky score, there was a 1.6% absolute increase in postdischarge medication adherence (95% CI 0.8% to 2.4%). Surprisingly, health literacy was not an independent predictor of postdischarge adherence.
In patients hospitalized for cardiovascular disease, predictors of lower medication adherence postdischarge included younger age, Medicaid insurance, and baseline nonadherence. These factors can help predict patients who may benefit from further interventions.
Journal of Hospital Medicine 04/2012; 7(6):470-5. · 1.40 Impact Factor
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Amanda H Salanitro,
Chandra Y Osborn,
Jeffrey L Schnipper,
Christianne L Roumie,
Stephanie Labonville,
Daniel C Johnson,
Erin Neal,
Courtney Cawthon,
Alexandra Businger,
Anuj K Dalal, Sunil Kripalani
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ABSTRACT: Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge.
To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list.
We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study.
Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors.
On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11).
Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.
Journal of General Internal Medicine 02/2012; 27(8):924-32. · 2.83 Impact Factor
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ABSTRACT: After hospital discharge, patients commonly suffer potentially avoidable adverse events and hospital readmissions. As hospitals implement interventions to improve discharge transitions, it is important to understand patients' perspectives on which intervention components are most beneficial. This study examined a sample of 125 patients randomized to the intervention arm of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease study who completed a telephone survey about the helpfulness of different components of the intervention, which included medication reconciliation, inpatient counseling, simple adherence aids, and telephone follow-up. The majority of patients indicated that it was "very helpful" to speak with a pharmacist about their medications before discharge (72.8%), particularly about how to take the medications and how to prevent and manage side effects. Receiving an illustrated medication list (69.6%) and a follow-up phone call after discharge (68.0%) were also considered very helpful. Patients with limited health literacy indicated the greatest benefit. Patients also reported feeling more comfortable speaking with their outpatient providers about their medications after receiving the intervention. In conclusion, patients-particularly those with limited health literacy-found a hospital pharmacist-based intervention to be very helpful and empowering.
Journal of Health Communication 01/2012; 17 Suppl 3:312-24. · 1.61 Impact Factor
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Journal of Hospital Medicine 11/2011; 6(9):487. · 1.40 Impact Factor
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ABSTRACT: Patients' ability to accurately report their preadmission medications is a vital aspect of medication reconciliation, and may affect subsequent medication adherence and safety. Little is known about predictors of preadmission medication understanding.
We conducted a cross-sectional evaluation of patients at 2 hospitals using a novel Medication Understanding Questionnaire (MUQ). MUQ scores range from 0 to 3 and test knowledge of the medication purpose, dose, and frequency. We used multivariable ordinal regression to determine predictors of higher MUQ scores.
Among the 790 eligible patients, the median age was 61 (interquartile range [IQR] 52, 71), 21% had marginal or inadequate health literacy, and the median number of medications was 8 (IQR 5, 11). Median MUQ score was 2.5 (IQR 2.2, 2.8). Patients with marginal or inadequate health literacy had a lower odds of understanding their medications (odds ratio [OR] = 0.53; 95% confidence interval [CI], 0.34 to 0.84; P = 0.0001; and OR = 0.49; 95% CI, 0.31 to 0.78; P = 0.0001; respectively), compared to patients with adequate health literacy. Higher number of prescription medications was associated with lower MUQ scores (OR = 0.52; 95% CI, 0.36 to 0.75; for those using 6 medications vs 1; P = 0.0019), as was impaired cognitive function (OR = 0.57; 95% CI, 0.38 to 0.86; P = 0.001).
Lower health literacy, lower cognitive function, and higher number of medications each were independently associated with less understanding of the preadmission medication regimen. Clinicians should be aware of these factors when considering the accuracy of patient-reported medication regimens, and counseling patients about safe and effective medication use.
Journal of Hospital Medicine 11/2011; 6(9):488-93. · 1.40 Impact Factor
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ABSTRACT: Although low health literacy and suboptimal medication adherence are more prevalent in racial/ethnic minority groups than Whites, little is known about the relationship between these factors in adults with diabetes, and whether health literacy or numeracy might explain racial/ethnic disparities in diabetes medication adherence. Previous work in HIV suggests health literacy mediates racial differences in adherence to antiretroviral treatment, but no study to date has explored numeracy as a mediator of the relationship between race/ethnicity and medication adherence. This study tested whether health literacy and/or numeracy were related to diabetes medication adherence, and whether either factor explained racial differences in adherence. Using path analytic models, we explored the predicted pathways between racial status, health literacy, diabetes-related numeracy, general numeracy, and adherence to diabetes medications. After adjustment for covariates, African American race was associated with poor medication adherence (r = -0.10, p < .05). Health literacy was associated with adherence (r = .12, p < .02), but diabetes-related numeracy and general numeracy were not related to adherence. Furthermore, health literacy reduced the effect of race on adherence to nonsignificance, such that African American race was no longer directly associated with lower medication adherence (r = -0.09, p = .14). Diabetes medication adherence promotion interventions should address patient health literacy limitations.
Journal of Health Communication 09/2011; 16 Suppl 3:268-78. · 1.61 Impact Factor
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Sunil Kripalani
Archives of internal medicine 09/2011; 171(16):1510-1. · 11.46 Impact Factor
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ABSTRACT: Abstract Background: Patient web portals (PWPs) offer patients remote access to their medical record and communication with providers. Adults with health literacy limitations are less likely to access and use health information technology (HIT), including PWPs. In diabetes, PWP use has been associated with patient satisfaction, patient-provider communication, and glycemic control. Methods: Using mixed methods, we explored the relationships between health literacy, numeracy, and computer literacy and the usage of a PWP and HIT. Participants (N=61 adults with type 2 diabetes) attended focus groups and completed surveys, including measures of health literacy, numeracy, and computer anxiety (an indicator of computer literacy) and frequency of PWP and HIT use. Results: Computer literacy was positively associated with health literacy (r=0.41, P<0.001) and numeracy (r=0.35, P<0.001), but health literacy was not associated with numeracy. Participants with limited health literacy (23%), numeracy (43%), or computer literacy (25%) were no less likely to access PWPs or HIT, but lower health literacy was associated with less frequent use of a computer to research diabetes medications or treatments. In focus groups, participants spontaneously commented on family support when accessing and using PWPs or HIT for diabetes management. Conclusions: Participants reported family members facilitated access and usage of HIT, taught them usage skills, and acted as online delegates. Participant statements suggest family members may bridge the HIT "digital divide" in diabetes by helping adults access a PWP or HIT for diabetes management.
Diabetes Technology & Therapeutics 06/2011; 13(10):1005-12. · 1.93 Impact Factor
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ABSTRACT: Although deficits in health literacy and numeracy have been described among Latinos, the impact of low numeracy on diabetes outcomes has not been studied. Study objectives were (1) to establish the reliability and validity of a 15-item Spanish, diabetes-specific numeracy measure (Diabetes Numeracy Test [DNT]-15 Latino) and (2) to examine the relationship between diabetes-specific numeracy and diabetes-related outcomes among a sample of Latino adults with diabetes.
Data collection included patient demographics, health literacy, general numeracy, diabetes-specific numeracy, acculturation, self-efficacy, self-care behaviors, and most recent glycosylated hemoglobin (HbA1c).
Participants (n=144) were on average 47.8 years old (SD=12.1). The majority were female (62%), uninsured (81%), and of Mexican nationality (78%) and reported low levels of acculturation (96%). The DNT-15 Latino had high internal reliability (Kruder-Richardson 20=0.78). The DNT-15 Latino demonstrated construct validity, correlating with measures of health literacy (ρ=0.291), general numeracy (ρ=0.500), education (ρ=0.361), and income (ρ=0.270) (P<0.001 for each). The DNT-15 Latino was significantly associated with acculturation but unrelated to self-efficacy, self-care behaviors, insulin use, and HbA1c.
The DNT-15 Latino is a reliable and valid measure of diabetes-specific numeracy for Latino patients with diabetes; however, additional studies are needed to further explore the association between diabetes-specific numeracy and acculturation and their impact on diabetes-related outcomes for Latinos.
Diabetes Technology & Therapeutics 06/2011; 13(9):893-8. · 1.93 Impact Factor
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Alessandro Morandi,
Eduard E Vasilevskis,
Pratik P Pandharipande,
Timothy D Girard,
Laurence M Solberg,
Erin B Neal,
Tyler Koestner,
Renee Torres,
Jennifer L Thompson,
Ayumi K Shintani,
Jin H Han,
John Schnelle,
Donna M Fick,
E Wesley Ely, Sunil Kripalani
Archives of internal medicine 06/2011; 171(11):1032-4. · 11.46 Impact Factor
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Archives of internal medicine 01/2011; 171(9):822-3. · 11.46 Impact Factor
