Assessment of readability, understandability, and completeness of pediatric hospital medicine discharge instructions
The average American adult reads at an 8th-grade level. Discharge instructions written above this level might increase the risk of adverse outcomes for children as they transition from hospital to home. We conducted a cross-sectional study at a large urban academic children’s hospital to describe readability levels, understandability scores, and completeness of written instructions given to families at hospital discharge. Two hundred charts for patients discharged from the hospital medicine service were randomly selected for review. Written discharge instructions were extracted and scored for readability (Fry Readability Scale [FRS]), understandability (Patient Education Materials Assessment Tool [PEMAT]), and completeness (5 criteria determined by consensus). Descriptive statistics enumerated the distribution of readability, understandability, and completeness of written discharge instructions. Of the patients included in the study, 51% were publicly insured. Median age was 3.1 years, and median length of stay was 2.0 days. The median readability score corresponded to a 10th-grade reading level (interquartile range, 8-12; range, 1-13). Median PEMAT score was 73% (interquartile range, 64%-82%; range, 45%-100%); 36% of instructions scored below 70%, correlating with suboptimal understandability. The diagnosis was described in only 33% of the instructions. Although explicit warning signs were listed in most instructions, 38% of the instructions did not include information on the person to contact if warning signs developed. Overall, the readability, understandability, and completeness of discharge instructions were subpar. Efforts to improve the content of discharge instructions may promote safe and effective transitions home. Journal of Hospital Medicine 2017;12:98-101. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
The average American adult reads at an 8th-grade level.1 Limited general literacy can affect health literacy, which is defined as the “degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”2,3 Adults with limited health literacy are at risk for poorer outcomes, including overuse of the emergency department and lower adherence to preventive care recommendations.4
Children transitioning from hospital to home depend on their adult caregivers (and their caregivers’ health literacy) to carry out discharge instructions. During the immediate postdischarge period, complex care needs can involve new or changed medications, follow-up instructions, home care instructions, and suggestions regarding when and why to seek additional care.
The discharge education provided to patients in the hospital is often subpar because of lack of standardization and divided responsibility among providers.5 Communication of vital information to patients with low health literacy has been noted to be particularly poor,6 as many patient education materials are written at 10th-, 11th-, and 12th-grade reading levels.4 Evidence supports providing materials written at 6th-grade level or lower to increase comprehension.7 Several studies have evaluated the quality and readability of discharge instructions for hospitalized adults,8,9 and one study found a link between poorly written instructions for adult patients and readmission risk.10 Less is known about readability in pediatrics, in which education may be more important for families of children most commonly hospitalized for acute illness.
We conducted a study to describe readability levels, understandability scores, and completeness of written instructions given to families at hospital discharge.
METHODS
Study Design and Setting
In this study, we performed a cross-sectional review of discharge instructions within electronic health records at Cincinnati Children’s Hospital Medical Center (CCHMC). The study was reviewed and approved by CCHMC’s Institutional Review Board. Charts were randomly selected from all hospital medicine service discharges during two 3-month periods of high patient volume: January-March 2014 and January-March 2015.
CCHMC is a large urban academic referral center that is the sole provider of general, subspecialty, and critical pediatric inpatient care for a large geographical area. CCHMC, which has 600 beds, provides cares for many children who live in impoverished settings. Its hospital medicine service consists of 4 teams that care for approximately 7000 children hospitalized with general pediatric illnesses each year. Each team consists of 5 or 6 pediatric residents supervised by a hospital medicine attending.
Providers, most commonly pediatric interns, generate discharge instructions in electronic health records. In this nonautomated process, they use free-text or nonstandardized templates to create content. At discharge, instructions are printed as part of the postvisit summary, which includes updates on medications and scheduled follow-up appointments. Bedside nurses verbally review the instructions with families and provide printed copies for home use.
