Factors influencing patient adherence to hospital discharge instructions

Twenty years ago I had an indirect inguinal hernia repaired under general anesthesia in a surgical outpatient setting. Two hours after I woke up in the recovery room the surgeon came to my bedside and explained that I could go home, but that I should be prepared for some discomfort moving around and should expect 10% improvement as each day went by. The surgeon’s prediction proved to be true—I got better and better—but a couple of weeks later I still had quite an indurated inguinal area, which worried me a bit. I checked with my family doctor, who called the surgeon, who then asked me to come in to see him. After the visit and brief examination he reassured me that I was healing well, adding that he would have been worried had that induration not been there. I remember wishing that I had been forewarned about this natural part of healing when I was discharged from the hospital.

That experience came to mind when I read a recent qualitative study published in the CMAJ Open.[1] The article was about patients’ and caregivers’ perspectives on factors influencing understanding and adherence to hospital discharge instructions. The study included 16 patients discharged from three different hospitals in Ontario with a diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or pneumonia. Each of these ongoing conditions require considerable home care to prevent emergency room visits or readmissions to the hospital. Eleven family member–caregivers were also part of the study.

Separate, standardized, semistructured open-ended interview guides were used in approaching the patients and their at-home caregivers. Admission diagnosis, age, gender, language barrier, limited health literacy, and degree of reliance on caregivers for care were some of the baseline questions. Initial interviews were followed up with phone calls. Transcripts of interviews were analyzed by the research team members to identify key elements in the responses.

Five themes appeared to influence the study subjects’ understanding of and adherence to discharge instructions:
1.    Confusion about the perceived role of the caregivers.
2.    The patients’ relationship with inpatient and outpatient caregivers.
3.    Previous hospital experience.
4.    Barriers to accessing postdischarge care.
5.    Factors related to the delivery of discharge instructions.

On an individual level most of the patients felt more engaged and connected to hospital staff when they involved family members in the review of discharge instructions. Several patients were confused by the hospital physician’s role, if any, in the postdischarge care. Some patients commented on experiencing a feeling of disjointed care due to having multiple physicians involved. Physical limitations interfered with follow-up care in a few instances. The need for interpreters at the time of discharge was mentioned. At the organization level, patients mentioned being rushed at discharge, not getting written instructions, and not having an opportunity to clarify some instructions. 

Reading the patient concerns that surfaced in this study I can clearly see opportunities to improve discharge procedures through patient and family-caregiver centred communication and outpatient follow up. More confident home care, and fewer emergency visits and readmissions to hospital care should follow. 
—George Szasz CM, MD

1.    Okrainec K, Hahn-Goldberg S, Abrams H, et al. Patients’ and caregivers’ perspectives on factors that influence understanding of and adherence to hospital discharge instructions: A qualitative study. CMAJ Open 2019;7:E478-E483.

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