Use of Patient After-Visit Instructions in the Rheumatology Clinic

Patient health literacy, including understanding of diagnoses and plan of care, often plays a critical role in clinical outcomes. Organizational health literacy is a newer framework within health literacy, acknowledging a role for organizations to ensure individuals can find, understand, and use information and services to inform health-related decisions. Estimates suggest up to one-third of adults in the United States have basic or below basic health literacy, which has been replicated in rheumatology cohorts. Various efforts have been implemented to improve patient understanding of their medical condition and disease management, including the use of after-visit summaries to help enhance information retention and support patient engagement. There is also the “teach-back” (TB) method, where patients repeat instructions from the provider in their own words to help bridge gaps in health literacy.

Joseph et al sought to optimize health outcomes through efforts focusing on organizational health literacy in a 2-part study: (1) they conducted a needs assessment evaluating the use and appropriateness of standardized after-visit instructions (AVIs), and (2) they looked at the effectiveness of 2 AVI interventions aimed at improving comprehension and retention of management plans by rheumatology patients.¹

In phase 1, a retrospective study evaluated the use of AVIs at Rush University rheumatology clinics. The primary outcome was frequency of providing AVIs at discharge among all patients. Secondary outcomes included readability of AVIs and concordance between AVIs and provider documentation of management plans. Researchers evaluated readability of AVIs using Flesch-Kincaid scores.

In phase 2, a prospective, randomized, proof-of-concept study aimed to optimize AVI delivery by implementing patient standardized AVIs (sAVIs) and the TB method. Researchers excluded telemedicine visits and those where English was not the primary language spoken, given the inability to provide custom translated AVIs. The study had 3 arms: a control group, a group receiving sAVIs only, and a group receiving sAVIs and TB. The primary outcome was patient retention and comprehension of discharge information; the secondary outcome was patient satisfaction.

In the first phase, 316 patients were enrolled, and approximately 26% (n=82) received an AVI during routine visits. Of the 210 patients who had change in management, only 36% received an AVI. A total of 74% of instructions in those AVIs were concordant with changes in the note. The AVIs were written at a median 6.8-grade level. There was higher frequency of AVI use noted in patients with change in management, new patient visits, or if patients were seen in a medical trainee clinic.

In phase 2, 510 patients were contacted, of whom 120 were randomized into the prospective arm from December 2022 to April 2023. A total of 75 patients completed the study. The cohort was 76% female and 45% Black. Around 17% of those who completed the study had health literacy under a ninth-grade level (as measured by A-REALM). There were no statistically significant differences in number of patients achieving high comprehension/retention scores in the 3 groups receiving AVIs. The discharge instruction mean Flesch-Kincaid readability grade levels were 7.6, 9.2, and 8.8 in the control, sAVI only, and sAVI and TB groups, respectively. Of the 41 patients who endorsed receiving AVIs, 29 (approximately 71%) stated they read the AVIs.

This novel pilot study evaluated the use of AVIs as one strategy to improve organizational health literacy. Researchers acknowledged the study had some limitations, including the exclusion of non-English-speaking patients and generalizability. They noted there was a gap in the delivery of AVIs, with only around a quarter of patients in their clinic receiving them. Although implementing sAVIs and TB did not appear to improve patient retention or comprehension of discharge health information, patient subsets in the group that received AVIs and TB had higher concordance in medication changes than controls or those who received sAVIs only. Further work is needed to better understand the most efficient patient education strategies to optimize clinical and health outcomes.

Reference

[1] Joseph D, Hu R, Min R, Jolly M, Hassan S. Use and utility of patient after-visit instructions at a university rheumatology outpatient clinic: status and randomized prospective pilot intervention study. ACR Open Rheumatol. 2024. doi:10.1002/acr2.11659