Emergency Room Confusion - The Study And The Findings
Today’s New York Times includes E.R. Patients Often Left Confused After Visits, an article by Laurie Tarkan that focuses on a study published in the Annals of Emergency Medicine, Patient Comprehension of Emergency Department Care and Instructions: Are Patients Aware of When They Do Not Understand?.
Excerpts from the abstract of that study follow:
We conducted structured interviews of 140 adult English-speaking patients or their primary caregivers after ED discharge in 2 health systems. Participants rated their subjective understanding of 4 domains: (1) diagnosis and cause; (2) ED care; (3) post-ED care, and (4) return instructions. We assessed patient comprehension as the degree of agreement (concordance) between patients’ recall of each of these domains and information obtained from chart review. Two authors scored each case independently and discussed discrepancies before providing a final concordance rating (no concordance, minimal concordance, partial concordance, near concordance, complete concordance).
Seventy-eight percent of patients demonstrated deficient comprehension (less than complete concordance) in at least 1 domain; 51% of patients, in 2 or more domains. Greater than a third of these deficiencies (34%) involved patients’ understanding of post-ED care, whereas only 15% were for diagnosis and cause. The majority of patients with comprehension deficits failed to perceive them. Patients perceived difficulty with comprehension only 20% of the time when they demonstrated deficient comprehension.
Many patients do not understand their ED care or their discharge instructions. Moreover, most patients appear to be unaware of their lack of understanding and report inappropriate confidence in their comprehension and recall.
The Times article elaborates:
78% Of ER Patients Misunderstand Or Lack Discharge Instructions
Based purely on subjective recall of my own limited experience working in Emergency Departments and my treatment of patients who had been referred by Emergency Rooms, I would have guessed at least 60-70% of these clients would demonstrate serious misunderstandings of their discharge instructions. I suspect other clinicians would report similar speculations with some variance based on the presence or absence of a patient population whose native language is different than that used by local clinicians.
Consequently, the finding that 78% of patients in the study left the ER with at least one significant misunderstanding re their discharge instructions falls into that category, familiar to ongoing readers of these posts, of Old News, relegating the chief value of the study to confirmation rather than revelation, the enthusiasm of the New York Times notwithstanding.
On the other hand, this article does raise an important question pertinent to patient compliance:
Is The Problem Noncompliance Or Health Illiteracy Or Both?
And Why Should Anyone Care?
Dr. Eric Coleman, Director of the Care Transitions Program at the University of Colorado (not involved in the study), contributes this observation to the Times article:
In fact, the classic definition of medication noncompliance by Sackett and Haynes is “failure or refusal to comply with treatment recommendations.”2 Extrapolating from medication noncompliance to patient noncompliance in general, it would seem that failure to follow ER discharge instructions, whatever the reason, qualifies as noncompliance.
with the concept of patient noncompliance.
The following may well be a recycled rant for return readers - steel yourselves.
The concept of patient compliance, as used today is not clinically relevant as a management tool because the multitude of factors that have an impact on adherence transcends complexity, commingling disparate categories, primary causes and collateral effects, and generally making a hash of it.
At best, noncompliance is a statistical phenomenon, a nonspecific symptom. If a patient’s body temperature exceeds a given point, that patient has a fever. If another patient demonstrates less behavioral inhibition than a certain percentile of the population, that patient is clinically impulsive. A patient does not take a specified amount (often a seemingly arbitrary percentage) of the total medications prescribed; that patient is noncompliant. Now, symptoms are obviously useful in some ways. They may warn the physician, for example, of an impending catastrophe. Patients spiking a fever of 108, patients so impulsive that they attack bystanders for trivial slights, and patients who take far too many or far too few pills are potential disasters. Bu the fundamental benefit of symptoms is their role in the service of diagnosis and determining etiology of health problems. In this aspect, noncompliance is a no-show. The difference between fever and impulsiveness on one hand and noncompliance on the other as symptoms is that few clinicians would be content to end a workup of a patient once “fever” or “impulsiveness” are identified.
At worst, noncompliance is a truism: patients are noncompliant because they don’t adhere to treatment recommendations; those patients don’t adhere to treatment recommendations because they are noncompliant.
The real clinker, of course, is that exploring a clinically irrelevant concept by pursuing ever more well-designed, ever larger studies and expending more intellectual effort developing models of that concept’s operations will result - if all goes well - in more elaborate and precise explanations that are also clinically irrelevant.
Who knows? Maybe that is part of the reason there have been no significant strides forward in the field of compliance in the past 100 years despite the thousands of articles, books, and reports dedicated to the theme.
Footnotes
__________- Oversimplification in the service of stukffing material into the column inches allotted it has resulted, I believe, in a false dichotomy, i.e., that patients suffer from either noncompliance or health illiteracy. Aside from health illiteracy being commonly considered a cause of noncompliance, I would wager that even if all of these patients had been educated to the point of expertise, a large percentage would nonetheless succumb to one or another of the other 42,823 varieties of noncompliance.↩
- Haynes RB, Taylor DW, Sackett DL: Compliance in health care. Baltimore: Johns Hopkins University Press; 1979↩