Telephone follow-up improves patients satisfaction following hospital discharge

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1 European Journal of Internal Medicine 20 (2009) Original article Telephone follow-up improves patients satisfaction following hospital discharge Eyal Braun a,c, Amjad Baidusi c, Gideon Alroy b,c,1, Zaher S. Azzam a,b,d, a Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel b Ombudsman, Rambam Health Care Campus, Haifa, Israel c Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel d Rappaport Family Institute for Research in the Medical Sciences, Technion Israel Institute of Technology, Haifa, Israel Received 26 April 2008; received in revised form 1 July 2008; accepted 7 July 2008 Available online 28 August 2008 Abstract Background: Many patients encounter problems in the first weeks after discharge from hospital. Telephone follow-up (TFU) is reputed to be a good tool for providing medical advice, managing symptoms, identifying complications and giving reassurance after discharge. Therefore, we aimed to study whether tight TFU would increase patient satisfaction, improve compliance and reduce re-hospitalization rate. Methods: The study population included 400 patients, hospitalized in an Internal Medicine Department, randomly divided into two groups; TFU and control. TFU took place one week and one month after discharge. Three months later, members of both groups were contacted by telephone. Results: Satisfaction was increased in the TFU group compared with control group by 6 12% in most fields. Notably, 87% of patients in the TFU group indicated that earlier telephone contact increased their satisfaction. In addition, 78.2% of the patients in the control group reported that they performed the tests that were recommended at discharge and 86.5% reported that they received explanations regarding their medications. In the TFU group, this percentage was increased significantly to 86.9% (P = 0.02) and 96.7% (P b ), respectively. As to treatment results, 93% of the patients in the TFU group as compared to 84% in the control group reported improvement in their symptoms. A non-significant trend towards fewer readmission was observed in the TFU group (26% vs. 35% P=0.062). Conclusions: TFU can improve medical treatment by increasing satisfaction and compliance. A trend towards decreased readmission rates was observed, which may lead to a reduction in the burden on the medical system European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Keywords: Telephone follow-up; Adherence; Compliance; Readmission; Internal medicine 1. Introduction A large proportion of patients encounter a variety of problems during the first weeks after discharge from hospital [1]. While patients usually rely on their family physician, during their hospitalization they encounter physicians who are strangers to them and who, in many cases, do not have the time or the means Corresponding author. Department of Internal Medicine B, Rambam Health Care Campus, P.O. Box 9602, Haifa Israel. Tel.: ; fax: addresses: z_azzam@rambam.health.gov.il, azzam@tx.technion.ac.il (Z.S. Azzam). 1 Deceased. to develop appropriate patient doctor relations [2,3]. The relatively short and eventful period of hospitalization, in addition to the limited availability of readily accessible physicians, often limits the patient's ability to appropriately understand the scope of the disease and to properly grasp changes in various aspects of their therapy and lifestyle which are required after discharge. Moreover, discharge from hospital is in many ways a crossroad: in many cases, a patient may return to old habits or resume his regular medications [4]. Once back at home, the patient often has to tackle various obstacles, such as a lack of appropriate medical information and a lack of help from medical staff and family members. Patients often feel anxious and uncertain [5 7]. Bull found that patients discharged after hospitalization usually had little information on their medical status and medications and, /$ - see front matter 2008 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi: /j.ejim

2 222 E. Braun et al. / European Journal of Internal Medicine 20 (2009) Table 1 Baseline characteristics of the study populations. Control TFU P value N Age (average±sd) years 62.0± ±15.7 NS Gender female, % NS Length of stay (average±sd) days 8.5± ± Primary diagnosis N (%) Pulmonary edema/decompensated NS heart failure Cardiac arrhythmia 7 9 NS Chronic lung disease 10 7 NS Pneumonia NS Urinary tract infection 9 13 NS Cellulitis 3 4 NS Other infectious diseases 7 4 NS Anemia 7 7 NS Coagulation disorders 7 4 NS Venous thromboembolism 7 3 NS Neurologic disorders NS Malignancy 10 5 NS Gastrointestinal disorders 8 12 NS Liver disease 5 6 NS Chronic kidney disease 4 5 NS Complications of diabetes mellitus 2 3 NS Other NS therefore, they had many questions regarding their nutritional and lifestyle habits [8]. These problems are usually more prominent during the first six weeks after discharge [9], even more so during the first week after the hospitalization [10]. Modern technology, such as the internet, and mobile telephones, may help medical authorities to track problems after discharge. Since many older patients have no access to web services, telephone follow-up, initiated by professionals in the hospital, remains the easiest tool for exchanging information, providing medical advice, identifying complications, and giving reassurance to patients [11]. A recent Cochrane review described 33 studies involving 5110 patients showed equivalent results between TFU and control groups. However, the authors themselves describe the included studies as predominantly of low methodological quality, as many of them were quasirandomized studies [12]. Therefore, we aimed to study whether patients under tight telephone follow-up (TFU) would benefit from this intervention in terms of compliance, outcome, and reduction of number of readmissions. 2. Materials and methods Between May 2005 and February 2006, a total of 1878 patients were admitted to the department of medicine. Patients who did not speak at least one of Hebrew, Arabic, Russian or English, or showed signs of dementia were excluded, as were patients who did not have telephone access or did not respond to telephone calls. In addition, patients that were discharged within 2 days were not included since the investigators did not have enough time to enroll them to the cohort. Four hundred patients were found eligible and were prospectively randomized to TFU and control groups; 200 patients in each group. Patients who had odd numbers on the patients list were included in the TFU group; while those who had even numbers were included in the control group. Each patient was interviewed by one of the investigators before discharge (AB, who was not connected to the patient's in-patient care) and assisted by a Russian speaking nurse; during which, the patient was given explanations on the purposes of the study and was asked to give informed consent. The hospital Institutional Review Board approved the study and informed consent was obtained from all participants. For each patient, we noted age, gender, cause of hospitalization, major diagnosis, duration of hospitalization, and number of medications at admission and discharge. Every patient that is discharged from our hospital is provided with Discharge Report that includes patient's history, physical examination, laboratory and other accessory examinations, discussion and recommendations that include medications. In addition, each patient that is discharged from our department gets a detailed explanation from the medical staff and advised to handle the discharge report to her/his primary care provider. Following hospitalization, patients in the TFU group received telephone calls one week and one month after discharge. Telephone access was either ground or mobile. They were asked about various aspects of the recommendations at discharge, how they followed the recommendations and their compliance with the subscribed medications. Both the control and TFU groups were called three months following discharge and were asked Table 2 Contact findings in the TFU group one week and one month after discharge. No. Question One week after discharge (%) One month after discharge (%) Yes Partial No Yes Partial No 1. Do you feel better since discharge? Do you have questions about medications during your hospitalization? Did you understand the recommendations at discharge? Do you follow the recommendations at discharge? Do you have questions regarding the recommendations at discharge? Did you visit your primary care provider Did you obtain your recommended medications? Do you have questions regarding your medications? Do you have adverse events from the recommended medications? Did you get sufficient information about lifestyle recommendations?

3 E. Braun et al. / European Journal of Internal Medicine 20 (2009) Table 3 Patient satisfaction three months after discharge from hospital. Question % of patients who answered yes P value Control group (%) TFU group (%) Are you satisfied with the information about how to take the medication? b Are you satisfied with the medical treatment given in the hospital? b0.001 Are you satisfied with the nursing treatment given in the hospital? NS If you were treated by physicians other than your family doctor, are you satisfied with their treatment? b0.001 Are you satisfied with the information you received on discharge? NS about their satisfaction with the treatment, results and compliance with treatment, and whether they had been readmitted during the period. All telephone calls in both groups were made by one of the investigators. The endpoints of the study were readmission rates within three months of discharge, satisfaction with the medical treatment and treatment outcome, as well as compliance with treatment and other medical recommendations suggested at discharge. 3. Statistical analysis All data were entered and analyzed using SPSS software, version 11 (Statistics Products Solution Services Inc., Chicago, Illinois). Group averages were expressed as mean value ± SD. A comparison between the two study groups was performed using the chi-square test. A two-sided P value of b0.05 was considered to be statistically significant [13]. 4. Results Four hundred patients were included in the study and randomly divided to TFU and control groups. Age, gender, duration of stay and primary diagnosis on discharge occurred at similar rates in both groups (Table 1). Average age was 62.0 and 63.9 years in the control and TFU groups, respectively. Acute coronary syndrome was the most common cause of hospitalization. Full contact was available with 153 (76.5%) and 156 (78%) patients in the TFU and control groups, respectively. The other patients failed to answer at least one of the follow-up telephones and were excluded from the study. The responses of the remaining patients in the TFU group one week and one month after discharge are shown in Table Patient satisfaction We examined five different aspects of patient satisfaction; information about the medications, quality of in-hospital treatment, quality of nursing treatment, quality of treatment by primary care providers after discharge, and quality of medical data at discharge. In three of these parameters, a statistically significant improvement in satisfaction was found (Table 3). Overall, 87% of the patients in the TFU group noted an increase in satisfaction rate as a result of the telephone calls; 24% noted that the calls were very helpful, 43% thought the calls were helpful, and 20% thought the calls were somewhat helpful. Only 13% of the followup patients considered the calls to be non-helpful Compliance with therapy We found that 78.2% of the control group as compared to 86.9 (P=0.04) in the TFU group reported that they complied with the recommendations in the discharge letter. A total of 86.5% and 96.7% (Pb0.0001) in the control and TFU groups, respectively, said that they were instructed to take the recommended medications; while 87.2% and 94.1% (P = 0.02) of the patients in the control and TFU groups, respectively, said that they take the recommended medications (Table 4). Overall compliance increased from 82% in the control group to 90.7% in the TFU group (P=0.04). Some 54% of the patients in the TFU group said that the telephone calls contributed to increasing their compliance, 23% described the contribution of the telephone call as very helpful, and 31% as helpful Outcome of treatment As shown in Table 5, patients in the TFU group had an impression of improvement in their health as compared with the control group (93% vs. 84%; P=0.03). Patients in the TFU group reported that they had less questions or concerns regarding their treatment as compared with the control group (13% vs. 23%; P = 0.04). No significant differences were found in numbers of patients who had side effects as a result of the treatment, 12% vs. 14% in the TFU and control groups, respectively Readmissions The readmission rate was 12 of the 156 (7.7%) patients and 11 of the 153 (7.2%) within the first month in the control and Table 4 Patient compliance three months after discharge from hospital. Question % of patients who answered yes P value Control group (%) TFU group (%) Did you perform all the recommended instructions in the discharge letter? Did you obtain all the medications recommended in the discharge letter? Were you instructed how to take your medications on discharge? b0.0001

4 224 E. Braun et al. / European Journal of Internal Medicine 20 (2009) Table 5 Subjective outcome of treatment three months after hospital discharge. Question Control group (%) TFU group (%) P Very much Little Not at all Very much Little Not at all value Do you feel an improvement in your state of health as a result of treatment? Do you have questions concerning your treatment? TFU groups respectively; this difference was not statistically different. There was a trend toward decreased numbers of readmissions in the TFU group; 55 (35.3%) patients in the control group were readmitted during the three months following discharge, as compared to 39 (25.5%) patients in the TFU group. The difference was not found to be statistically significant (P = 0.062). 5. Discussion In the era of modern medicine, there is near total disconnection between hospital-based and family physicians [2,12]. After discharge from hospital, the patient is usually totally dependent upon the family physician, and it is nearly always the primary care provider's sole responsibility to implement the recommendations of the hospital physician and to provide comfort to the patient [14]. In this study, we tried to examine whether telephone follow-up could solve, at least partially, this lack of communication. There is some evidence that telephone follow-up can be a relatively simple and accessible tool to achieve better communication between the hospital and the patient after discharge, thereby increasing the probability of the hospital recommendations being implemented [15]. In addition, the hospital can get information regarding adherence to recommended medications, progress in the process of recovery, and readmissions. Physicians tend to overestimate the ability of their patients to grasp information provided by health-care providers [14]. For this reason, during the early telephone calls (provided only to the TFU group) one week and one month after discharge, we examined the extent of patient's insight into the treatment plan, both during and after hospitalization, and to provide answers to questions. We tried to give comfort to their concerns, assuming that such measures would improve compliance and satisfaction, and eventually improve treatment outcome and reduce the number of readmissions. In our study we found that telephone calls from the hospital one week and one month after discharge helped to identify a substantial number of patients who needed assistance in understanding the recommendations and provided the means to answer questions regarding the medications and their side effects. Although the rate of satisfaction from the medical treatment was relatively high in both groups, the rate was higher in the TFU group. It is noteworthy that, during the early calls, the majority of these patients reported that they had only partial, if any, information regarding how to take their medical treatment at home. Moreover, 25% of the patients reported a total lack of understanding of their treatment strategy especially the medication intervention. An increase in the rate of compliance and understanding of the medical treatment was noted in the second interview performed one month after discharge. This can probably be attributed, at least partially, to the telephone call one week after discharge. This finding probably led to the higher rate of satisfaction of the patients in the TFU group as compared with the control group three months after discharge. In the current study we found a significant increase in-patient compliance with the recommendations of the physicians after the intervention of the telephone follow-up. This increase was noted in general compliance, implementation of required examinations at discharge, and proper use of recommended medications. This trend can be ascribed to the frequent telephone calls. As compared to the results of the interview one week after discharge, there was a substantial rise in the number of patients who fully implemented the recommendations one month after discharge [16 20]. Our data are inconsistent with a recent review by Mistiaen et al. that examined 33 studies that involved 5110 patients. Overall, there was inconclusive evidence about the effects of TFU since the reviewed studies were considered of low methodological quality with large variety in the ways the TFU performed and the effects were not constant across studies nor within patient groups [12]. In terms of the outcome of treatment, the number of patients who reported partial or complete disappearance of symptoms was higher in the TFU group by 7%. After three months, more patients in the control group had questions or concerns regarding their medications, and 39% of the patients in the TFU group claimed that the early phone calls contributed to their process of recovery. We found a trend toward a decrease in the number of readmissions during the first three months after discharge, not statistically significant. Similar results were found in recently published meta-analyses [12]. The readmission rate in the control group was 7.6% and 35.3% within one and three months respectively; Stein et al. found that the readmission rate was 7.4% within 1 week and 16.3% within 1 month [21]; whereas, Zamir et al. reported that the readmission rates were 4.98% within one month [22]; however, both studies did not provide data concerning readmissions within 3 months. Therefore, studies which include greater numbers of patients will be needed to try to reach statistically significant results regarding this issue. There were some limitations in our study. Overall only 21% of the patients admitted to the ward were included in the cohort. We noted that there was some pre-selection of specific study groups; several patients that were discharged within 2 days were not included since the investigators did not have enough time to enroll them to the cohort. In addition, patients who did not speak Hebrew, Arabic, Russian or English were also excluded, an important limitation in Israel, a country with a significant

5 E. Braun et al. / European Journal of Internal Medicine 20 (2009) diversity of ethnic groups. In addition patients who could not or refused to give informed consent were excluded; finally patients with imprecise communication data were also excluded. Another limitation was the application of this tool only in medical wards. However, despite these limitations that might weaken the power of the study, it is still demonstrative to reflect differences between TFU and control groups. In summary, telephone follow-up after discharge can improve medical treatment by increasing satisfaction and compliance. In addition, the trend toward fewer readmissions that was observed may eventually lead to a reduction in the burden on the medical system. 6. Learning points Telephone follow-up is a relatively simple and accessible tool to achieve better communication between the hospital and the patient after discharge. Telephone follow-up increased the rate of compliance and understanding of the medical treatment recommended at discharge. Telephone follow-up may decrease the readmission rate and reduce the burden on the medical system References [1] Wachter RM, Goldman L. The emerging role of hospitalists in the American health care system. N Engl J Med 1996;335(7): [2] Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1988;26(7): [3] Alpers A. Key legal principles for hospitalists. Am J Med 2001;111(9B): 5S 9S. [4] Dudas V, Bookwalter T, Kerr KM, Pantilat SZ. The impact of follow-up telephone calls to patients after hospitalization. Am J Med 2001;111(9B): 26S 30S. [5] Stewart MA. Effective physician patient communication and health outcomes: a review. Cmaj 1995;152(9): [6] Hyde CJ, Robert IE, Sinclair AJ. The effects of supporting discharge from hospital to home in older people. Age Ageing 2000;29(3): [7] Cole MG. The impact of geriatric post-discharge services on mental state. Age Ageing 2001;30(5): [8] Bull MJ. Discharge planning for older people: a review of current research. Br J Community Nurs 2000;5(2):70 4. [9] Naylor MD. Transitional care of older adults. Annu Rev Nurs Res 2002;20: [10] Mistiaen P, Duijnhouwer E, Prins-Hoekstra A, Ros W, Blaylock A. Predictive validity of the BRASS index in screening patients with postdischarge problems. Blaylock Risk Assessment Screening Score. J Adv Nurs 1999;30(5): [11] Nelson JR. The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches. Am J Med 2001;111(9B):43S 4S. [12] Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev 2006;4:CD [13] Hirsch RP, Riegelman RK. Statistical First Aid Interpretation of Health Research Data, vol. 1. Boston: Blackwell Scientific Publications; [14] Calkins DR, Davis RB, Reiley P, Phillips RS, Pineo KL, Delbanco TL, et al. Patient physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med 1997;157(9): [15] Sehgal NL, Wachter RM. The expanding role of hospitalists in the United States. Swiss Med Wkly 2006;136(37 38): [16] Chande VT, Exum V. Follow-up phone calls after an emergency department visit. Pediatrics 1994;93(3): [17] Jones J, Clark W, Bradford J, Dougherty J. Efficacy of a telephone followup system in the emergency department. J Emerg Med 1988;6(3): [18] Shesser R, Smith M, Adams S, Walls R, Paxton M. The effectiveness of an organized emergency department follow-up system. Ann Emerg Med 1986;15(8): [19] Keeling AW, Dennison PD. Nurse-initiated telephone follow-up after acute myocardial infarction: a pilot study. Heart Lung 1995;24(1):45 9. [20] Miller L, Caton S, Lynch D. Telephone clinic improves quality of followup care for chronic bowel disease. Nurs Times 2002;98(31):36 8. [21] Stein GY, Zeidman A. Trends in admissions to internal medicine wards in a community hospital in Israel. Eur J Intern Med 2006;17(4): [22] Zamir D, Zamir M, Reitblat T, Zeev W, Polishchuk I. Readmissions to hospital within 30 days of discharge from the internal medicine wards in southern Israel. Eur J Intern Med 2006;17(1):20 3.

6 ID Title Pages Telephone follow-up improves patients satisfaction following hospital discharge 5