1. Low Health Literacy Is a Barrier to Inpatient Medication Reconciliation
Sunil Kripalani, MD, MSc;1 Christianne L. Roumie, MD, MPH;1 Ankita Munjal;1 Courtney Cawthon, MPH;1 Edith Swain;2 Kurt J. Niesner;1 Alexandra Businger;2 Jeffrey L. Schnipper, MD, MPH2
1Vanderbilt University, Nashville, TN; 2Brigham and Women’s Hospital, Boston, MA
INTRODUCTION
Patients with low health literacy often have a poor understanding of their medication regimen.
They may be unable to accurately communicate a medication history.
When performing medication reconciliation at hospital admission, physicians often rely on patients’ medication histories, but also have other sources of information available: inpatient and outpatient electronic records, pharmacy records, family members, etc.
It is not known what effect patient health literacy may have on the accuracy of the physician’s pre-admission medication lists.
OBJECTIVES
To determine the effect of health literacy on the number of errors present in the physician’s pre-admission medication list (PAML) at two large teaching hospitals
METHODS
Setting/Subjects:
Site 1: Vanderbilt University Medical Center, Nashville, TN
Site 2: Brigham and Women’s Hospital, Boston, MA
Both have robust electronic health records, access to outpatient medication lists (within system), and medication reconciliation protocols
Patients randomized to the treatment arm of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study
RCT to reduce serious medication errors after discharge
Patients admitted with acute coronary syndromes or acute decompensated heart failure
May 2008 – September 2009
Procedures:
Subjects typically enrolled within 24 hrs of admission
Health literacy assessed during enrollment interview
Short Test of Functional Health Literacy in Adults (s-TOFHLA)
Adequate (23-36), Marginal (17-22), or Inadequate (0-16)
PAML documented by treating physicians according to convention at each site
Study pharmacists:
Obtained “gold standard” medication history per best practices
Reviewed physician’s PAML
Tabulated total errors and clinically relevant errors
Design/Analysis:
Cross-sectional analysis
Poisson regression: association of patients’ health literacy with
Number of PAML errors
Number of clinically relevant errors
Adjusted for number of pre-admission medications
RESULTS
Patients in PILL-CVD: N=862; Randomized to treatment arm: N=430
Patients with ≥1 pre-admission medication included here: N=374 (87%)
Results of Poisson regression, adjusted for number of medications:
PAMLs of patients with inadequate or marginal health literacy had significantly more:
Overall errors (IRR = 1.29; 95% CI 1.04 to 1.60)
Median number of errors = 2 (IQR 1-4)
Clinically relevant errors (IRR = 1.36; 95% CI 1.10 to 1.68)
Median number of errors = 2 (IQR 1-3)
DISCUSSION
Low health literacy is associated with errors in the physician’s admission medication history, even at academic hospitals with well-developed electronic health records and medication reconciliation protocols.
Errors in admission medication reconciliation are a patient safety concern
Contribute to post-discharge errors and adverse drug events
Clinicians should exercise more caution among patients with low health literacy
Confirm medication history with other sources
Limitations:
Performed at 2 academic hospitals, so results may not be generalizable
Potentially worse at hospitals without electronic health records or good procedures for medication reconciliation
Did not examine specific type of error – drug omission/comission, dose, frequency, route
Did not account for potential differences by physician in the process of obtaining PAML
Future directions:
Does medication understanding mediate the observed relationship between health literacy and PAML errors?
Is a similar relationship present between health literacy and errors in medication reconciliation at discharge?
How does the presence of medication reconciliation errors affect the incidence of serious medication errors after hospital discharge?
Develop interventions to reduce medication discrepancies by creating, maintaining, and communicating an accurate medication list.
CONCLUSIONS
Given that patients with inadequate or marginal health literacy were more likely to have errors in their pre-admission medication list, physicians should be aware that low health literacy poses a barrier to inpatient medication reconciliation.
ACKNOWLEDGEMENTS
Supported by award numbers R01 HL (Kripalani), K23 HL (Kripalani), and K08 HL (Schnipper) from the National Heart, Lung, and Blood Institute; and VA Career Development Award (Roumie). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health.
Patient Characteristics
N (%)
Age, mean (SD)
61.4 (14.0)
Female
149 (39.8%)
Race: White
281 (75.1%)
Black
67 (17.9%)
Other
26 (7.0%)
Health Literacy: Adequate
293 (78.4%)
Marginal
33 (8.8%)
Inadequate
48 (12.8%)
Number of pre-admission meds, median (IQR)
8 (4-11)
Figure. Frequency Distribution of Total Errors and Clinically Relevant Errors in PAML