Patient concerns at hospital admission

TO THE EDITOR

Patient-centered care, communication, and patient satisfaction are increasingly important metrics of hospital care.¹ A key aspect of patient-centered communication is eliciting and addressing patients’ concerns.² Outpatient research indicates that when concerns are addressed, patients report higher satisfaction.³ Hospitalized patients’ concerns have not been studied.

METHODS

We surveyed patients before and after the attending physician hospital admission encounter to describe the number and topics of concerns and the degree to which physicians addressed them. The study was conducted between August 2008 and March 2009 on the general medical services at two hospitals within a university system where attendings care for patients with and without trainees. Participants were attending hospitalist physicians and patients admitted under their care who were able to give informed consent and communicate verbally in English. Eligible patients were approached before meeting the physician, and, if they agreed to participate, asked to list “all of the problems and concerns you want to talk with the doctor about today.”⁴ During the encounter, the study coordinator waited outside the patient’s room to measure encounter length. After the encounter, patients rated how well each of their pre-encounter concerns was addressed: “Not at all”, “Somewhat”, “Mostly”, or “Completely”.

In quantitative content analysis,⁵ we iteratively developed a codebook to describe themes within the topics of patients’ concerns. The final codebook included 11 conceptual categories. Two-coder agreement on a 20% sample of concerns was 92% on at least one category and 79% on all categories. We assessed associations between whether concerns were addressed, number of pre-encounter concerns, and encounter length using logistic regression (Stata 11, StataCorp LP, College Station, Texas). The Institutional Review Board at the University of California, San Francisco approved the study; participants gave written informed consent.

RESULTS

We enrolled 109 patients (consent rate 65%; mean [SD], age 54 [19] years; 44% male, 6% Hispanic; 8% Asian; 8% African American) of 30 physicians (consent rate 91%; mean [SD] age, 35 [5] years; 43% male; 3% Hispanic; 30% Asian).

Patients listed a median of 2 pre-encounter concerns (range, 0–10). Ninety-five (87%) patients listed at least one concern. While 77 (71%) reported multiple concerns, only 30 (28%) reported more than 3. Concerns related to patients’ hospital care and the ongoing care of hospital admission diagnoses (Table). Most frequently concerns regarded treatments, including medications, procedures, therapies, and side effects; diagnoses, including known diagnoses and desire to obtain a diagnosis or cause of illness; and logistics, including facilities, communication, and coordination of care.

Table.

Topics of patient concerns at admission

Topic Category	Concerns n=299* (%)	Examples
Treatments Including medications, procedures, therapies, side effects, and patient preferences	101 (34%)	“Course of treatment – what are we doing and why?” “Am I starting a new set of medications?” “Concerned about hip surgery, hoping everything will work out.”
Diagnoses Including known diagnosis, or to obtain a diagnosis or cause of illness	83 (28%)	“Pneumonia.” “What is wrong with my colon?” “Why am I sick?” “I'd like a definite diagnosis of why the breathless problems.”
Logistics Including facilities, communication, and coordination of care	57 (19%)	“When will I get moved from ER to bed upstairs?!” “Who is coordinating different care teams?” “Who do I call if I have a problem?”
Prognosis Expected course or outcome of disease, severity of illness, and likelihood of recovery	40 (13%)	“How could this possibly affect my future health?” “Current condition's level of seriousness.” “How long will I be incapacitated?”
Pain or other symptoms Any concern about a physical or emotional symptom, including cause of and management	38 (13%)	“Pain in legs, especially in right leg.” “Cough -- dry, dry throat.” “Relief of current symptoms.”
Patient behavior How patient should manage their medical condition, including lifestyle choices and diet	24 (8%)	“What am I allowed/not allowed to do during and after my radioactive iodine treatment?” “Discuss with doctor my lifestyle health-wise.”
Tests and test results Including blood work, imaging, and biopsies, and results of these	23 (8%)	“Chest x-ray.” “More answers/info about the MRI and CAT scan.” “First, I'd like to hear about the test results.”
Hospital discharge Including length of hospitalization, discharge planning, follow-up care	19 (6%)	“How long will I have to be in the hospital?” “Who is in charge of my discharge?” “What kind of follow-up care should I have to ensure complete healing?”
Prevention Actions patient or providers should take to prevent recurrence, or further illness	16 (5%)	“How to stop UTIs from happening?” “What I could have done to prevent current condition.”
Advanced care planning Including code status and advance directives	1 (<1%)	“I want a notation/correction on my records that I do have a DNR.”
Other Concerns that could not be clearly categorized into above categories	22 (7%)	“My health.” “Heart.” “Long time (since spring) of one medical thing after another.”

^*Based on quantitative content analysis of n=109 patients’ pre-encounter concerns. Topic categories are not mutually exclusive as some concerns included elements of multiple categories. Thus counts sum to >299 and percentages to >100%.

Eighty-five patients completed the post-encounter survey, of which 76 listed at least one pre-encounter concern. Thirty-eight (50%) reported at least one “Somewhat” or “Not at all” addressed concern. Only 27 (36%) patients reported all concerns “Completely” addressed. Many patients with few pre-encounter concerns reported a “Somewhat” or “Not at all” addressed concern: 27% of patients with 1 concern, 49% of patients with 2–3, and 68% of patients with >3. In an unadjusted model, patients with >3 pre-encounter concerns were more likely to report a “Somewhat” or “Not at all” addressed concern, OR 5.9 (95% CI, 1.1–32.6) compared to patients with 1; an adjusted model revealed similar results. Mean encounter length was 21 minutes (range, 3–68). Reporting a “Somewhat” or “Not at all” addressed concern was not associated with encounter length in unadjusted or adjusted analyses.

COMMENT

As when presenting to outpatient visits, patients being admitted to the hospital have pre-formed concerns that they hope physicians will address. Exploring concerns is an opportunity for physicians to ensure understanding of and adherence to the care plan. Unaddressed concerns may lead to lower satisfaction as well as lower quality medical care, because clinically relevant symptoms, questions, or treatment barriers are not disclosed.^3,4

Yet, similar to outpatient studies,⁴ many patients’ few, relevant concerns were incompletely addressed. That encounters were not longer for patients who reported their concerns addressed suggests that how physicians and patients communicate influences addressing of concerns. In outpatient studies physicians infrequently elicit all of patients’ concerns, and interrupt patients before they finish describing them.^4,6,7 Methods of addressing concerns include prompting patients to identify concerns before an encounter,⁸ and physicians eliciting all concerns and agenda setting at the beginning of encounters.^2,6

Limitations include that we did not account for the effect of other providers on patients’ responses, studied only one encounter, and studied a small number of patients at two hospitals within the same academic system. Sources of bias include: 1) increased concern disclosure because of pre-encounter listing, 2) physicians exhibiting best communication behaviors secondary to study involvement, and 3) administering fewer post-encounter surveys on physicians’ busiest days as a result of relying on physicians to notify us of encounters’ occurrence. We would expect these factors to bias toward overestimating the frequency of concerns being addressed.

In conclusion, research, education, and quality improvement efforts should focus on eliciting and addressing hospitalized patients’ concerns.