Reducing the Hospital Readmission Rates in Hong Kong

Introduction

Discharge education is an important component of patient’s quality of care. It is to ensure the patients’ needs are met and they can function at an optimal level after they return back to home, especially for the patients who have just done the surgery since their physical abilities are not yet optimized. Through the discharge education, patients can understand their current health condition and provide methods to prevent post-surgical complications (Coleman, Parry, Chalmers, & Min, 2006). Inadequacies in discharge education may lead to higher hospital readmission rates (Horwitz et al., 2013). It was found that 31% of 600 hospital readmissions in Hong Kong under the surgical department within 30 days which could be avoidable, of which 14.6% readmitted mainly due to inadequate discharge education such as no teaching in symptoms monitoring (Yam et al., 2010). To optimize patient’s transitional care from hospital to home and reduce preventable hospital readmissions, it is necessary to think about the components of a comprehensive discharge education program. Previous studies mostly focused on how a discharge education improves the health conditions of patients with chronic diseases (Meng et. al., 2016). There is not much insights to investigate the effects of a discharge teaching into the post-operative patients. There are findings suggested that elderly who at risk of poor health outcomes could benefit from home follow-up interventions (Naylor et al., 1994). However, there is no study to assess the effects of the combination of discharge teaching with post-discharge home visit services. Most of the researches on evaluating of the effectiveness of the discharge education program normally held at overseas. As the health policies between overseas and Hong Kong are different, the aims of the research is to conduct a study to investigate the effectiveness of a comprehensive discharge education program with home follow-up in improving the self-caring abilities of patients and reduction in hospital readmission rates in Hong Kong.

Hypothesis

The experimental group that received a specific and comprehensive discharge education program about post-operative care given by the nurse at the time of discharge and received home follow-up will enhance the patient’s self-caring ability and reduce the patient’s hospital readmission rates than the control group who received the usual discharge education.

Methods

Study Design

A randomized controlled trial (RCT) will be conducted for this study, with one experimental group and one control group. The reasons for using RCT is that it can provide empirical evidence on treatment’s efficacy (Stewart & Tierney, 2002). Each patient within the experimental group will receive a specified discharge education program at the point of discharge by a APN and receive home followup at 7th, 30th, 60th and 90th days of post-discharge. The patients of the control group will receive the standard usual discharge instructions.

The independent variables in this research are the specific and comprehensive discharge education program and the post-discharge home follow-up. The dependent variables are the patients’ self- caring ability and their hospital readmission’s frequency.

Subjects and Sampling

The target subject of this study is the elderly who has an inadequate self-caring ability and has the history of repeated hospital readmission within 30 days from last discharge. Patient who fulfill the following inclusion criteria will be recruited for the study. The followings are the inclusion and exclusion criteria.

Inclusion criteria:

1. Patients should be 65 years or older;
2. Patients are diagnosed of one of the following cancers: colorectal, lung, breast, prostate, liver, stomach (these are the most common cancers that leading to complications and death worldwide in 2018 (World Health Organization, 2018, “Cancer”, para. 2));
3. Patients should be clinically admitted;
4. Patients/ care-givers should be alert (since they need to understand the content of the discharge instructions);
5. Patients should also fulfill one of the following criteria : inadequate social and financial support e,g, receiving Comprehensive Social Security Allowance (CSSA) Scheme; chronic health diseases; complications during hospitalization; history of multiple hospitalizations or history of poor adherence to the therapeutic treatment (Since they are the group that has a higher chance resulting in poor discharge outcomes e. g. surgical wound infection(Naylor et al., 1994))

Exclusion criteria:

1. Patients who are DNACPR
2. Patients/care-givers who do not know Cantonese

Since there is no similar RCT to be held in Hong Kong before, the sample size will be estimated according to the previous RCT on the discharge education program held in the overseas countries. One of the RCT on the warfarin education showed that the self-monitoring and insights rate of the patients was 0.19 for the control group and 0.33 for the experimental group (95% CI, 0.16-0.49), with type I error 0.01. Total 475 patients with 227 and 248 patients in the control and intervention group respectively (Meng, et. al., 2016). One of the RCT on the discharge education improves health outcomes for the patients with chronic heart failure showed the time to readmit within 180 days was 64% for the control group and 47% for the intervention group (95% CI, 0.45-0.93). With type 1 error 0.05, power 80%. Total 223 participants enrolled with 116 in the control group and 107 in the interventional group (Koelling, Johnson, Cody, & Aaronson, 2005). Therefore, total 250-300 patients will be recruited for the study, which is considered to be practical within the proposed period of time by the clinical collaborators. A data and safely monitoring board (DSMB) will be formed to monitor the participants’ safety as well as to advise to recruit the participants or not.

Recruitment

The recruitment procedure will start from March to September 2019. The research assistants will screen the patients based on the inclusion criteria within 24 hours once the patients admit. The research assistants will be blinded to both the study groups and the hypothesis. After the eligible subjects are screened, the research assistants will then approach and ask them the permissions to undertake the study. After screening the patients for eligibility and gaining the informed consent, the research assistants will then inform the research manager. The research manager will then allocate the subjects into the study groups by using a computer generated algorithm. The project manager will then contact the APNs if patients are allocated to the experimental group.

Setting

This study will be conducted at the surgical departments of the Queen Elizabeth Hospital (QEH) since it is the biggest acute hospital at the east of Kowloon. Its location is much near the people who are living underprivileged. Permission will be obtained from the director of the hospital to conduct the study and ethical approval will also be gained from the Institute of the Research Board of the QEH. The findings of this study will be circulated within the surgical department first and then to other departments gradually to formulate better practice in the discharge education process.

Randomization and Intervention

A stratified randomization will be adopted for this study. At first, all the eligible participants will be stratified by sex. Then, each of the strata will be stratified by age group: age 65-80 and above 80. Finally, each of the sub-group will be randomly assigned into the experimental group and the control group by using a list generated in a computer. This kind of randomization can ensure every members can have the equal probability to be selected and a stratified sample can provide greater precision than a simple randomization. The findings of the study can be much more representative (Suresh, 2011).

Control group: The patients will receive standard discharge information by the ward nurse at the time of discharge. It includes the discharge summary which records what treatment the patient received during the hospitalization, current medications, the followup appointments and the education on the wound or drain care.

Experimental group: A comprehensive discharge education program is a one to one teaching program taught by a surgical APN with at least 8 years of clinical experience. Each session lasts for 60 minute. The APN will visit the patient at least 2 times during the hospitalization. One is within 48 hours after the operation and the another one is at the time of discharge so that the patients or care-providers can keep the fresh memory of education back to home. Additional times of APN visits depends on the necessary of the patients. During the visit, the APN will assess the condition of the patient and identify the education needs. According to a survey done among the nurses, patients and other health professionals based on the content of the discharge education, apart from covering the standard discharge information, the program also covers the education on the signs and symptoms of the wound infection, the dangerous signs of the post-operation complications, management on the occurrence or worsening of the symptoms, specific dietary instructions after the operation, the purpose, the side effects and the precautions of the new medication added such as the antibiotics (Anderson, Deepak, Amoateng‐Adjepong, & Zarich, 2005). The telephone number of the APN and the ward will also be provided to the patients when they have questions at home. Besides, the discharge education program reinforces the importance of doing daily exercise, avoiding smoking and alcohol intake. At the end of the education, a booklet which covered the information taught in the session will be given to the patient. The APN will also conduct home visits at the 7th, 30th, 60th, 90th days of post-discharge to evaluate the self-caring abilities of the patients or caregivers. Besides, the APN will initiate weekly telephone contact with the patients or caregivers. Through home visits and telephone follow-up, the APN can identify concerns from patients or caregivers and make referrals afterwards.

Data Collection Procedure

The baseline data such as age, gender, past health history, surgical diagnosis, the operation will be received, social and financial support will be collected by a structured questionnaire before randomization by the research assistants. The self-caring abilities for both groups will also be collected via survey before the education and at the 30th, 90th days of post-discharge. The outcome measure for self-caring will be scored by the Therapeutic Self-Care (TSC) measure. The result will be collected and input by the researchers. The researchers will also trace any patient (both control and experimental group) admitted to the hospital by using a patient readmission system everyday from first day till 90th days of post-discharge. Data on the number, timing and the reasons of hospital readmissions will be abstracted and recorded on the standardized data collection forms.

Measurement

The patients’ self-caring will be measured by the Therapeutic Self-Care (TSC) measure. It consists of 13 items which was derived from extensive literature review on the concepts of self-care and the items mainly measure the patient’s ability in self-care, monitoring and managing the symptoms. (Sidani, & Doran, 2014). Findings suggest that the items of this measure are internally consistent and the scores correlate positively with other self-care measuring scale (Scherbaum, Cohen-Charash, & Kern, 2016) .

Outcomes and Data Analysis

The primary outcome is to enhance the self-caring abilities of the patients after discharge. The secondary outcome is to reduce the hospital readmission rates.

Statistical Package for Social Science (SPSS) will be used for data analysis, a software package used for researchers for complex statistical analysis 21.0 (SPSS Inc, 1994). The ANOVA will be used to test the primary outcome. The significance is set at 0.05. The reason for using ANOVA is that it is useful in analysis of multi-item scales (Wilcox, 2002). For the secondary outcomes, it will be used the independent t-test to compare the means of hospital readmissions between two groups at the specified interval of time as described before. It is used because it is widely to use in the medical industry when studying the impact of an intervention or program (Calhoun, Adali, Pearlson, & Pekar, 2001)

Ethical and Safety Consideration

Ethical approval for the study will be gained from the Institutional Review Board of the QEH. Before the start of the study, the research purpose, the procedure as well as the rights to quit from the research will be clearly explained in details. Written consent will then be obtained from the participants. Participants will also be reminded that they should seek medical advise immediately once the health condition cannot be managed. All the findings obtained will be kept confidential and anonymous.

References

1. Anderson, C., Deepak, B. V., Amoateng‐Adjepong, Y., & Zarich, S. (2005). Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure. Congestive Heart Failure, 11(6), 315-321.
2. Calhoun, V. D., Adali, T., Pearlson, G. D., & Pekar, J. J. (2001). A method for making group inferences from functional MRI data using independent component analysis. Human brain mapping, 14(3), 140-151.
3. Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The care transitions intervention: results of a randomized controlled trial. Archives of internal medicine, 166(17), 1822-1828.
4. Horwitz, L. I., Moriarty, J. P., Chen, C., Fogerty, R. L., Brewster, U. C., Kanade, S., … & Krumholz, H. M. (2013). Quality of discharge practices and patient understanding at an academic medical center. JAMA internal medicine, 173(18), 1715-1722.
5. Koelling, T. M., Johnson, M. L., Cody, R. J., & Aaronson, K. D. (2005). Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation, 111(2), 179-185.
6. Meng, K., Musekamp, G., Schuler, M., Seekatz, B., Glatz, J., Karger, G., … & Faller, H. (2016). The impact of a self-management patient education program for patients with chronic heart failure undergoing inpatient cardiac rehabilitation. Patient education and counseling, 99(7), 1190-1197.
7. Naylor, M., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M., & Pauly, M. (1994). Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial. Annals of internal Medicine, 120(12), 999-1006.
8. Scherbaum, C. A., Cohen-Charash, Y., & Kern, M. J. (2016). Measuring general self-efficacy: A comparison of three measures using item response theory. Educational and Psychological Measurement, 66(6), 1047-1063.
9. Sidani, S., & Doran, D. I. (2014). Development and validation of a self-care ability measure. CJNR (Canadian Journal of Nursing Research), 46(1), 11-25.
10. Stewart, L. A., & Tierney, J. F. (2002). To IPD or not to IPD? Advantages and disadvantages of systematic reviews using individual patient data. Evaluation & the health professions, 25(1), 76-97.
11. SPSS Inc. (1994). SPSS 21.0 for Windows student version. Prentice Hall.
12. Suresh, K. P. (2011). An overview of randomization techniques: an unbiased assessment of outcome in clinical research. Journal of human reproductive sciences, 4(1), 8.
13. Wilcox, R. R. (2002). Understanding the practical advantages of modern ANOVA methods. Journal of Clinical Child and Adolescent Psychology, 31(3), 399-412.
14. World Health Organization (2018). Fact-sheets. Retrieved September 12, 2018, from https://www.who.int/news-room/fact-sheets/detail/cancer
15. Yam, C. H., Wong, E. L., Chan, F. W., Leung, M. C., Wong, F. Y., Cheung, A. W., & Yeoh, E. K. (2010). Avoidable readmission in Hong Kong-system, clinician, patient or social factor?. BMC health services research, 10(1), 311.