CHICAGO – Roughly a fourth of ED patients are ready to hit the delete button on standard written discharge instructions.
When asked 30 days post discharge how they preferred to receive their antibiotic discharge instructions, 26% of patients said they prefer text messages or voice mail to written instructions alone.
Dr. Travis Olives
"It’s an interesting finding, and it’s not really been discussed in the literature that I could find," lead author Dr. Travis Olives said at the annual meeting of the Society for Academic Emergency Medicine.
He pointed out that ED discharge information is commonly written at 8th- to 13th-grade reading levels and that as many as 45% of ED patients are unable to comprehend this level of written complexity yet are unaware of their low level of comprehension.
"I can’t understand them myself when I read them, frankly," he quipped.
It was in this context that the investigators sought to determine whether patient preference for discharge instruction modality varies by health literacy levels.
The secondary analysis included 660 patients enrolled in a prospective randomized trial who were discharged with outpatient antibiotics from an urban county ED with an annual census of 100,000. Patients were randomly assigned to typed and verbal medication and case-specific instructions (standard of care) or standard of care plus text messages sent to the patient’s cell phone or standard of care plus voice-mailed instructions sent to the patient’s cell phone.
Health literacy assessment using the Newest Vital Sign test classified 23% as likely having limited literacy (NVS score 0-1), 31% as possibly having limited literacy (score 2-3), and 46% as having adequate literacy (score 4-6). Their median age was 30 years, and 55% were female.
Among the 51% of participants reached by telephone at 30 days, more than 50% across all health literacy levels preferred either a modality other than written or a combination of modalities, said Dr. Olives, a resident with the Hennepin County Medical Center in Minneapolis.
Text messages were preferred by 18.75% of participants with limited health literacy, 10.4% with possibly limited literacy, and 12.5% with adequate literacy. Voice-mailed instructions were preferred by 7.5%, 3.25%, and 6%, respectively.
To protect the privacy of participants, all text messages and voice mails were sent without identifiers or a diagnosis. For example, the script for a text simply said: "Take doxycycline 100 mg two times a day for 7 days."
Standard typewritten instructions were preferred by 40% of patients with limited literacy, 32% with possibly limited literacy, and 44% with adequate literacy, he said during the poster presentation.
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26% of emergency patients said they would prefer their discharge instructions to be delivered via text messages or a voice mail.
The proportion of patients who preferred discharge instructions in written form plus another modality varied significantly across health literacy levels (13.75% NVS score 0-1, 42% NVS score 2-3, and 20% NVS score 4-6; P = .017). With the exception of "written plus another modality," patient preference was similar across all NVS score groups.
Dr. Olives said the study is ongoing and that the goal is to access hard outcomes such as antibiotic compliance among 3,000 ED patients. So far 1,800 patients have been enrolled. The data show, not surprisingly, that 72-hour prescription pickup varies by health literacy level, with compliance increasing with increasing health literacy, he said.
An audience member asked whether the investigators had a hard time tracking patients down by telephone, remarking that when ED physicians ask a patient for a contact number, the number they’re given is usually different from the number the patient gave at registration.
Dr. Olives said they verified the phone number directly with the patient and then cross-referenced it with what was in the electronic medical record. If any discrepancy was found, health coordinators corrected the phone numbers in the record.
He said fewer than a dozen patients gave a bad cell phone number and pointed out that a recent unpublished study reported patient cell phone penetration of more than 99%.
"I know that’s not the case for all populations, but it’s a lot higher than I anticipated going in to this study," Dr. Olives added. "We did not have a lot of trouble with patients without a cell phone."
Dr. Olives reported no relevant conflicts of interest.