Discharge Instruction Comprehension and Adherence Errors: Interrelationship Between Plan Complexity and Parent Health Literacy

Abstract

Objective: To examine associations between parent health literacy, discharge plan complexity, and parent comprehension of and adherence to inpatient discharge instructions.

Study design: This was a prospective cohort study of English/Spanish-speaking parents (n = 165) of children ≤12 years discharged on ≥1 daily medication from an urban, public hospital. Outcome variables were parent comprehension (survey) of and adherence (survey, in-person dosing assessment, chart review) to discharge instructions. Predictor variables included low parent health literacy (Newest Vital Sign score 0-3) and plan complexity. Generalized estimating equations were used to account for the assessment of multiple types of comprehension and adherence errors for each subject, adjusting for ethnicity, language, child age, length of stay, and chronic disease status. Similar analyses were performed to assess for mediation and moderation.

Results: Error rates were highest for comprehension of medication side effects (50%), adherence to medication dose (34%), and return precaution (78%) instructions. Comprehension errors were associated with adherence errors (aOR, 8.7; 95% CI, 5.9-12.9). Discharge plan complexity was associated with comprehension (aOR, 7.0; 95% CI, 5.4-9.1) and adherence (aOR, 5.5; 95% CI, 4.0-7.6) errors. Low health literacy was indirectly associated with adherence errors through comprehension errors. The association between plan complexity and comprehension errors was greater in parents with low (aOR, 8.3; 95% CI, 6.2-11.2) compared with adequate (aOR, 3.8; 95% CI, 2.2-6.5) health literacy (interaction term P = .004).

Conclusions: Parent health literacy and discharge plan complexity play key roles in comprehension and adherence errors. Future work will focus on the development of health literacy-informed interventions to promote discharge plan comprehension.

Keywords: communication; hospital medicine; inpatient setting; medication errors; pediatrics.

Figure 1.

Conceptual model depicting associations between discharge plan complexity, parent health literacy, and parent comprehension of and adherence to discharge instructions.

Figure 2.

Summary of types and timing of study assessments. Some participants required an additional phone call between T3 and T4 if their T3 assessment occurred before the completion of all instruction (eg, completion of medication course).

Figure 3.

Study flow diagram.

Figure 4.

Path analysis assessing comprehension errors as a possible mediator in the association between A, discharge plan complexity and B, parent health literacy (predictors) and adherence errors (outcomes) (n = 165). Values are OR [95% CI] and P values from logistic regressions using generalized estimation equations to account for multiple possible error types for each parent (adjusting for parent race/ethnicity, language, child age, length of stay, chronic disease status, health literacy [A only], and plan complexity [B only]). Note that, unlike separate analyses in which comprehension errors were the sole outcome, these analyses only include subdomains examined for both comprehension and adherence errors (medication dose and adherence, appointment attendance, return precautions, and restrictions). *Not adjusting for comprehension errors. †Adjusting for comprehension errors.