Poor Patient Activation Leads to Claim of Inadequate Discharge Instructions

The ability of patients to comply with discharge instructions is related to their activation level. Research indicates that identifying and intervening on behalf of patients with low activation levels could reduce their risk of an unplanned rehospitalization.¹

Allegation

Inadequate education about medication adherence during discharge resulted in the patient requiring a permanent colostomy.

Case File

A patient was admitted to the hospital for suspected food poisoning. During her admission, however, she was diagnosed with Clostridium difficile (C. diff) and a foot infection. At discharge, her attending physician prescribed various medications, including oral vancomycin for the C. diff and dicloxacillin for the foot infection. When she went to pick up her medications, however, she discovered that the vancomycin cost $650. Because she couldn’t afford it, she filled her other prescriptions, hoping the dicloxacillin would be sufficient to also treat the C. diff. Because dicloxacillin is not effective for the treatment of C. diff, her gastrointestinal symptoms worsened and within three weeks she was back in the hospital.

After a lengthy hospitalization and removal of the majority of her colon, she was discharged with a permanent colostomy. She sued the attending physician and the hospital for failing to adequately educate her about the importance of taking the vancomycin and for prescribing a medication that was prohibitively expensive.

Discussion

Defense experts who reviewed this case believed the attending physician was not negligent. They also acknowledged the patient’s responsibility in taking medications as prescribed. However, one expert commented that the attending should have anticipated that this patient would have difficulty affording oral vancomycin, since she was underinsured and vancomycin is very expensive. Although this case was dismissed, the dismissal came after a prolonged period of litigation, during which numerous members of the healthcare team underwent depositions, medical record review, and meetings with defense attorneys. The patient injury, utilization of clinician time, and defense costs could arguably have been avoided had the attending physician discovered whether the patient had the means to comply with his treatment recommendations and, if not, provided guidance on treatment alternatives or medication assistance strategies. Although time constraints can make delving into prescription costs difficult, it can be worth the effort.

Medical Liability Risk Management Recommendations

Patient Activation at Hospital Discharge

The patient’s activation level can help tailor patient support before, during, and after discharge. Consider the following patient activation recommendations for hospital discharge:^1,2,3

• Start educating the patient about post-discharge treatment and self-care before the day of discharge.
• Encourage patients to write down questions during admission and to have unanswered questions addressed prior to discharge.
• Consider providing patients with educational materials during admission via video, illustrations, animation, computer programs, etc.
  • For example, the MyChart Bedside app, which works with Epic EHR software, connects patients to test results, provides a notepad for questions, lists scheduled procedures, and provides access to patient education materials.
• For scheduled procedures, provide the patient with educational materials related to after-care prior to the patient’s scheduled procedure.
• Use the show-me method when prescribing new medicines, new medication doses, or self-care routines the patient is expected to follow after discharge. For example, you could say, “I’ve noticed that many people have trouble remembering how to use their inhaler. Can you show me how you use it?”
• Ask the patient to repeat back instructions.
• Ensure that discharge instructions use simple concepts and are written at about a sixth-grade level.

Patient Activation When Medications Are Too Expensive

It’s difficult for patients to be engaged in their healthcare when they cannot afford medications. Almost 8% of patients do not take their medications as prescribed because they cannot afford them.⁴ It’s important to find a way to discuss drug cost when prescribing medication. Consider the following strategies:^5,6,7,8,9

• Be aware of the potential for noncompliance when ordering high-cost medications.
• Learn how to recognize patients at risk. Patients who are low income, uninsured, historically noncompliant with medications, have no insurance or high co-pays, complain about the cost of medication, or take multiple medications for chronic diseases are more likely to have difficulty affording medications.
• Find nonjudgmental and empathetic ways to ask if the cost of the medication will keep the patient from taking it as prescribed. (Of patients who are noncompliant because of medication cost, 75% never mention it because they weren’t asked.¹⁰)
• If you suspect or are informed that a medication will be financially prohibitive, help the patient obtain the medication at a lower cost.
  • If the patient has a prescription drug plan, consider prescribing drugs that are “preferred.”
  • Consider prescribing a generic version of a medication.
  • If no generic is available, consider whether a less-expensive brand name drug in the same medication family would be equally effective.
  • Encourage the patient to comparison shop. Prices can vary significantly between pharmacies.
    • Various websites provide medication price comparisons, for example, GoodRx and FamilyWize show the price of medication at various pharmacies within a designated zip code.
  • Be familiar with medication assistance resources, for example:
    • Co-pay assistance programs and advocacy foundations such as Patient Access Network Foundation
    • Patient assistance programs (PAPs) such as RxAssist, which provide free medications to low-income adults
      • RxAssist also provides a list of other PAPs with its resource, “Lowering Medication Costs.”
    • Disease-specific medication assistance programs, such as AIDS drug assistance programs
    • Drug discount cards, which are offered by various pharmacies
  • While the time commitment can be considerable, be prepared to offer assistance to patients if their insurance plan denies coverage of the medication.
    • Document your offer of assistance in the medical record.
  • When discussing nonadherence with medications, confirm patient understanding of the risks, benefits, and alternatives and document that understanding.
  • Explain the outcome of discontinuing a medication.
  • Make sure the patient understands why the medication you have prescribed needs to be taken and the consequences of nonadherence.
  • Follow-up with the patient to determine whether they’re responding to prescribed medications or whether the medications are being taken as prescribed.
  • Document your efforts to improve patient medication adherence.

References

1. Mitchell SE, Gardiner PM, Sadikova E, et al. “Patient Activation and 30-Day Post-Discharge Hospital Utilization.” J Gen Intern Med. 2014;29(2):349-355. (accessed 9/18/2018)

2. Hibbard J, Gilburt H. “Supporting People to Manage their Health: An Introduction to Patient Activation.” The King’s Fund. May 2014. (accessed 9/18/2018)

3. Agency for Healthcare Research and Quality (AHRQ). “The SHARE Approach—Essential Steps of Shared Decision Making: Expanded Reference Guide with Sample Conversation Starters.” July 2014. (accessed 9/18/2018)

4. Cohen RA, Villarroel, MA. “Strategies Used by Adults to Reduce Their Prescription Drug Costs: United States, 2013.” NCHS Data Brief No. 184. January 2015. (accessed 9/18/2018)

5. Rx Partnership. “How to Recognize and Help Patients Who Are Uninsured or Underinsured Access Medication.” June 2010. (accessed 9/18/2018)

6. Heisler M, Wagner TH, Peitte JD. “Clinician Identification of Chronically Ill Patients Who Have Problems Paying for Prescription Medications.” Am J Med. 2004;116(11):753-8. (accessed 9/18/2018)

7. Hams M, Wilkinson W. “Evaluation of a Model Comparative Drug Price Resource in Fostering Prescriber-Patient Engagement, Lowering Consumer Costs and Improving Adherence.” Innovations in pharmacy. 2014, 5(3)article 174. (accessed 9/18/2018)

8. Newman KL, Varkey J, Rykowski J, Mohan AV. “Yelp for Prescribers: A Quasi-Experimental Study of Providing Antibiotic Cost Data and Prescription of High-Cost Antibiotics in an Academic and Tertiary Care Hospital.” J Gen Intern Med. 2015 Aug;30(8):1140-6. (resource not available online)

9. LeWine, H. “Millions of Adults Skip Medications Due to Their High Cost.” Harvard Health Blog. January 30, 2015. (accessed 9/18/2018)

10. Piette JD, Heisler M, Wagner TH. Cost-Related Medication Underuse: Do Patients with Chronic Illnesses Tell Their Doctors?” Arch Intern Med. 2004;164(16):1749-55. (resource not available online)