Patient-Centered Care and Outcomes After Myocardial Infarction

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1 original Research Patient-Centered Care and Outcomes After Myocardial Infarction Benjamin C. Sun, MD, MPP, Phillip M. Pantoja, MA, Claude Setodji, PhD, and Allen M. Fremont, MD, PhD Abstract Objective: To examine the relationship between patient-reported experience of hospital care for acute myocardial infarction (AMI) and subsequent outcomes. Design: Prospective observational cohort study. Setting/participants: 2272 AMI patients discharged from 23 New Hampshire hospitals during 1996 and Measurements: Outcomes included cardiac rehospitalizations and/or cardiac mortality within the first year. We used patient responses to Picker survey items about their care to compute an overall problem score, classifying patients with top quartile scores as worse care and others as better care. Propensity score matching was used to adjust for baseline differences in selected demographic and clinical characteristics between the 2 groups. Results: Postdischarge surveys were completed by 1253 (55%) eligible patients. In unmatched analyses, better care patients had an equivalent annual rate of cardiac rehospitalization or cardiac death compared with worse care patients ( 0.09 [95% confidence interval {CI}, 0.19 to 0.01]; P = 0.11). Propensity score matching did not reveal a difference in annual cardiac event rates between worse and better care patients (0.05 [95% CI, 0.09 to 0.2]; P = 0.48). Conclusion: Patient-reported problems with AMI hospital care were not predictive of 1-year cardiac events among this cohort of New Hampshire patients. Larger cohort studies in other settings would help clarify whether associations differ in more diverse patient populations and detect any small, but clinically important, effects. Patient-centered care refers to health care processes that are highly responsive to patient needs and preferences [1]. It is a fundamental component of humane, highquality care [2,3] and is positively linked to patient satisfaction [4], treatment adherence, effective disease self-management, and low symptom burden [5,6]. In response to such findings as well as studies showing relatively low rates of adherence with patient-centered aspects of care, the Institute of Medicine [7] and the Department of Health and Human Services [8] have identified patient-centered care as a top priority for improving health care, and the use of surveys to measure patient experiences with hospitalization has proliferated. Despite increased focus on patient-centered care, the relationship between patient-centered aspects of care and subsequent clinical outcomes remains unclear, particularly among disease-specific cohorts, such as patients with acute myocardial infarction (AMI). One previous study showed that negative experiences with hospital care were associated with worse selfreported health status and self-reported chest pain in the year following the initial AMI hospitalization [9]. A second study showed a similar association between problems with care and self-reported health status 3 months postdischarge [10]. However, we are unaware of prior studies that have prospectively examined the link between measures of patient-centered care and more objective clinical events in AMI patients. In this report, we examine whether patients experiences with their AMI hospital care are associated with 1-year cardiac events, including cardiac rehospitalization and/or cardiac mortality. We hypothesized that better patient experience with hospital care would be associated with fewer 1-year cardiac events. Methods Participants Eligible patients included adults with a principal diagnosis of AMI who were discharged between 1 January 1996 and 31 December 1997 from 23 New Hampshire hospitals participating in the Foundation for Healthy Communities Patient-Centered Care Project. The goal of the project was to improve the quality of cardiac care based on patient reports about patient-centered processes of care during their initial AMI hospitalization. A total of 2272 (62%) eligible patients consented to participate and were enrolled in the study. Eligible patients were approached by a hospital staff member at each site who explained the study to them and obtained their consent to participate. Enrolled patients were From the Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA (Drs. Sun and Fremont); and RAND Health, Santa Monica, CA (Mr. Pantoja and Dr. Setodji). Vol. 15, No. 3 March 2008 JCOM 119

2 outcomes after MI younger (mean age, 62.4 vs years; P < 0.001) and less likely to be female (32.6% vs. 39.1%; P = 0.001) than patients who were not enrolled. However, the 2 groups did not differ significantly by race. Self-administered surveys asking about problems with hospital care were mailed to enrolled patients approximately 1 month after discharge with reminder postcards mailed 1 week later. Patients who had not responded 2 weeks after the reminder postcard were mailed a second questionnaire. Of the 2272 patients enrolled, 1253 (55%) returned the 1-month survey and had complete outcomes data. Compared with responders, nonrespondents were younger (mean age, 62 vs. 64 years; P < 0.001), had higher scores on a cardiac comorbidity severity index [10] (0.45 vs. 0.40; P = 0.008), were less often in a hospital with a high AMI volume (65% vs. 71%; P = 0.03), and were less likely to undergo coronary artery bypass graft (CABG) surgery (15% vs. 21%; P = 0.007), but were similar in other respects. Patient survey responses were linked to administrative discharge summary data from the index admission as well as to New Hampshire hospital discharge and New Hampshire State vital statistics data for the years 1996 to Outcomes The primary outcome was cardiac events in the year after index AMI. We defined cardiac events in 3 ways [11]: (1) counts of hospitalizations for cardiac arrest, myocardial infarction, angina, congestive heart failure, arrhythmia, or stroke; (2) occurrence of cardiac death; and (3) a combined measure of counts of cardiac hospitalizations and occurrence of cardiac death (eg, a patient who experienced 2 cardiac hospitalizations and then died of a cardiac cause within 1 year would be considered to have 3 events). We focused on cardiac events in the first year rather than for a longer period to be consistent with the time frame used in the previous study [9]. We identified cardiac hospitalizations using the first 3 ICD-9 discharge diagnoses codes in New Hampshire discharge abstracts (results were unchanged if only the first 2 or all ICD-9 codes were considered). Cardiac deaths were identified through New Hampshire vital statistics data. Cardiac mortality included deaths with an ICD-9 cause of death, including myocardial infarction, coronary artery disease, congestive heart failure, arrhythmia, and stroke. Explanatory Variable: Patient-Reported Problem Score Questions about patient experience with care were based on the widely used Picker survey [7,12]. In contrast to items in satisfaction surveys that ask patients to rate the quality of their care (eg, excellent, good, fair, poor), Picker questions typically ask patients to report whether or not specific processes of care had occurred. For example, a question relating to information and education was: When you had important questions to ask a doctor, did you get answers you could understand? An answer of no or yes, somewhat was scored as a problem for these items. Questions in the 1-month postdischarge survey focused on 7 dimensions of patient-centered care during hospitalization, including respect for patient preferences, coordination of care, information and education, physical comfort, emotional support, involvement of family and friends, and continuity and transition (Appendix). As in the previous study [9], we used patients survey responses to calculate an overall hospital problem score (0 100), with an increasing score indicating more problems. We first calculated the percent of items in each dimension (eg, continuity and transition) for which a response indicated a problem with care. For example, a score of 40 corresponds to a response indicating a problem on 2 out of 5 items in a given dimension. We then computed the mean problem score of the 7 individual dimensions. The distribution of the mean problem score was right skewed with only about one quarter of the patients reporting more than a few problems. Thus, we classified patients with problem scores in the worst (ie, top) quartile as having experienced worse care, while other patients were considered to have experienced better care. We assessed other parameterizations of the problem score, including continuous and logged values as well as analyzing patients by problem score quartile. However, we found similar associations between problems and outcomes regardless of which formulation of the overall problem score we used. Covariates We considered a number of potential confounding baseline variables including age, sex, race, education, insurance type, patient-reported hospitalizations in the 6 months before index AMI admission, treatment type (medical, percutaneous transluminal coronary angioplasty, or CABG), annual hospital AMI volume (< 200 per year or 200 per year), and interhospital transfers. Depression and poor mental health may contribute to reduced satisfaction and lead to increased reports of problems with care [13,14]. To adjust for patient differences in mental health, we included 4 mental health questions on the 1-month survey. These items were adapted from the Medical Outcomes Study questionnaire based on principal components analysis (Cronbach s α = 0.76) [15]. They included: 1. How much of the time during the past 4 weeks did you feel full of pep? 2. How much of the time during the past 4 weeks have you felt calm and peaceful? 3. How much of the time during the past 4 weeks have you felt downhearted and blue? 4. How much of the time during the past 4 weeks have you been a happy person? 120 JCOM March 2008 Vol. 15, No. 3

3 original Research Responses were on a 6-point scale that ranged from all the time to none of the time and were transformed to a 100-point scale with increasing score indicating better mental function. To further adjust for the effect of comorbid illnesses on subsequent health, we used a previously validated cardiac severity index that weights each comorbidity in terms of its impact on the likelihood of 2-year cardiovascular mortality [16]. This index captures the effects of preexisting comorbidities including but not limited to hypertension, diabetes, peripheral vascular disease, and old myocardial infarction. The index also captures diagnoses that may have resulted from the AMI, including but not limited to shock, congestive heart failure, arrhythmias, unstable angina, and cerebrovascular accidents. The index is calculated based on ICD-9 discharge diagnoses from the index AMI hospitalization, and a score is computed by summing logit weights for discharge diagnoses. A higher comorbidity score is associated with increased 2-year mortality. In separate validation studies with over 160,000 Medicare and 10,000 Veterans Affairs patients, this measure proved to be a strong predictor of mortality with areas of 73% and 72% under the receiver operating characteristics curves, respectively [16]. Data Analysis We compared sociodemographic and clinical characteristics of patients who experienced better care with those who experienced worse care using the Wilcoxon rank-sum test for continuous and ordinal variables and Fisher s exact test for categorical variables. Unadjusted differences in outcomes between the 2 groups were assessed using t test for independent samples with unequal variances. It is possible that various factors, such as age, mental health function, and disease severity, could influence patients tendency to report problems with care as well as subsequent cardiac events. We used propensity score analysis [17] to control for confounding. A propensity score models a patient s probability of reporting worse care based on a multivariate logistic regression model that included all covariates described in the previous section. We then used the propensity scores to match worse and better care patients in a 1:1 ratio. The propensity score approach reduces imbalances in measurable confounders between the worse and better care groups. We used paired t testing to identify differences in outcomes. Sensitivity analyses with different analytic approaches, including multivariate count and Cox models that included data from the entire study cohort, produced similar results to those generated through propensity matching. Data management, descriptive statistics, univariate analyses, and matching by propensity scores were performed with SAS 9.1 software (SAS Institute, Cary, NC). This study was approved by the institutional review boards of RAND and the State of New Hampshire. Table 1. Patient Characteristics Characteristic Better Care* (n = 943) Worse Care (n = 310) P Value Mean age, yr (SE) 63 (0.4) 62 (0.8) 0.09 Female 34% 37% 0.5 White 92% 92% 0.9 High-volume hospital (> 200 AMI) 75% 75% 0.8 Less than high school education 22% 17% 0.1 No insurance 04% 06% 0.3 Interhospital transfer during AMI care 53% 51% 0.7 Hospitalization in prior 6 mo 24% 32% Angioplasty at index admission 35% 33% 0.5 CABG at index admission 18% 20% 0.3 Mental health score (SE) 69 (0.6) 57 (1.1) < Cardiac comorbidity score (SE) 39 (1.7) 42 (3.1) 0.8 AMI = acute myocardial infarction; CABG = coronary artery bypass grafting; SE = standard error. *Patient hospital experience based on 1-month survey. Worse care group was defined as respondents with top quartile problem score (> 24); better care group included all other respondents. Results The baseline characteristics of patients reporting better and worse hospital care are presented in Table 1. Compared with patients reporting better hospital care, patients reporting worse care were more likely to report lower mental health function and have a hospitalization within 6 months prior to the index AMI admission. Most patients reported relatively few problems with their AMI hospital care, with a mean problem score of 7.8 in the better care group. In contrast, patients who experienced worse care had a mean overall problem score of 40 (Table 2). Compared with better care patients, those experiencing worse care reported higher average problem scores for all 7 dimensions of care (P < 0.001), with the highest average problem score (58) for items related to continuity and transition. After calculating propensity scores for reporting worse care, we were able to match 269 (87%) of the 310 patients in the worse care group with better care based on similar propensity scores (within 0.01 on a 0 1 scale). There were no statistical differences in the measured covariates between the 2 groups after matching (Table 3). Table 4 shows the 1-year cardiac event rates for worse versus better care patients before and after propensity score matching. Compared with better care patients, worse care patients had higher rates of cardiac rehospitalizations, mortality, and combined events, but these differences were not statistically significant (P values, ). After adjusting for covariates through propensity score matching, differences Vol. 15, No. 3 March 2008 JCOM 121

4 outcomes after MI Table 2. Overall and Subscale Hospital Problem Scores Problem Scores* in event rates between the 2 groups remained nonsignificant. Discussion Better Care (n = 943) Worse Care (n = 310) Mean overall score (SE) 7.8 (0.2) 40 (0.7) Mean subscale scores (SE) Continuity and transition 14 (0.7) 58 (1.8) Coordination 8.8 (0.5) 29 (1.3) Information and education 6.6 (0.4) 43 (1.3) Family involvement 7.4 (0.5) 49 (1.6) Physical comfort 1 (0.1) 11 (0.9) Patient preference 7.5 (0.4) 33 (1.3) SE = standard error. *P < for all comparisons. Table 3. Patient Characteristics After Propensity Score Matching Characteristic Better Care (n = 269) Worse Care (n = 269) P Value Mean age, yr (SE) 62 (0.7) 62 (0.8) 0.4 Female 36% 35% 1 White 89% 93% 0.2 High-volume hospital (> 200 AMI) 75% 77% 0.6 Less than high school education 21% 24% 0.4 No insurance 06% 05% 0.7 Interhospital transfer during AMI care 51% 51% 1 Hospitalization in prior 6 months 29% 29% 1 Angioplasty at index admission 39% 34% 0.2 CABG at index admission 19% 18% 0.8 Mental health score (SE) 60 (1.2) 59 (1.1) 0.7 Comorbidity score (SE) 44 (4)0. 41 (3) AMI = acute myocardial infarction; CABG = coronary artery bypass grafting; SE = standard error. A growing body of literature suggests that patient-centered care not only affects patient satisfaction [4] but also can directly or indirectly influence health behaviors that may be important to recovery from acute illness and management of chronic conditions [18 20]. Thus, we hypothesized that better patient experience with AMI hospital care would be associated with fewer subsequent cardiac events. However, in this multicenter, prospective study, we found that patientreported problems with hospital care were not predictive of 1-year cardiac events. These results differ from prior studies, including 1 analyzing the same cohort used by this investigation. As in the current study, Fremont and colleagues [9] examined differences in 1-year outcomes between New Hampshire AMI patients who experienced worse hospital care (top quartile problem score) versus other patients. Compared with others, worse care patients reported poorer overall and physical health and were more likely to report episodes of chest pain in the year after their index AMI. These differences persisted after accounting for the effects of potential confounders, including baseline self-reported health and symptoms. Although a negative hospital experience may adversely affect attitudes, behavior, and perceived health [9,10], the contrast in findings between the current and the prior studies suggests that the effects are not sufficient to significantly alter the disease course over a 1-year period. Although it is plausible that indirect effects of a negative hospital experience on disease progression, such as through less adherence to treatment, may take more than 1 year to manifest as clinical events, post hoc analyses we conducted extending up to 4 years post-ami produced the same results as in the 1-year analyses. It is also possible that potential consequences of a negative hospital experience are largely mitigated by subsequent encounters with providers in ambulatory settings. In the prior study [9], for example, patients who reported many problems with patient-centered aspects of their AMI hospital care but more positive experiences with providers during the first 3 months after discharge were no more likely than other patients to report chest pain or poor health at 1 year. Only those patients experiencing worse hospital and worse follow-up ambulatory care tended to report poor health and chest pain at 1 year. To assess whether ambulatory follow-up care could have mediating effect on subsequent cardiac events, we performed post hoc analyses comparing cardiac event rates for worse care patients as those who reported problem scores in the top quartile for both hospital and ambulatory care with other patients. As in the main analyses, we did not find a significant difference between the 2 groups. For example, the rate of combined cardiac events was 0.37 versus 0.27 (P = 0.33) for worse and better care subgroups, respectively (other results not shown). Another potential explanation is that our study was underpowered to detect a small but important relationship between 1-year cardiac events and patient-reported problems with care. The clinical endpoints used in this study occur infrequently, and very large cohort studies may be required to definitively demonstrate a clinically significant link between such outcomes and reported problems. For example, studies demonstrating mortality benefits of early administration of aspirin and b blockers in nonrandomized AMI patients required cohorts of 10,000 and 37,000 patients, respectively [21,22]. Although this is the largest study of 122 JCOM March 2008 Vol. 15, No. 3

5 original Research Table 4. One-Year Rate of Cardiac Events* Event Type Better Care (95% CI) Worse Care (95% CI) Difference (95% CI) P Value Unadjusted (n = 1253) Cardiac rehospitalization 0.34 ( ) 0.41 ( ) 0.08 ( 0.17 to 0.02) 0.16 Cardiac mortality ( ) 0.02 ( ) ( to 0) 0.12 Combined cardiac rehospitalization and mortality 0.35 ( ) 0.44 ( ) 0.09 ( 0.19 to 0.01) 0.11 Propensity matched (n = 582) Cardiac rehospitalization 0.42 ( ) 0.36 ( ) 0.07 ( 0.08 to 0.21) 0.36 Cardiac mortality (0 0.01) 0.02 ( ) 0.02 ( 0.03 to 0.003) 0.10 Combined cardiac rehospitalization and mortality 0.43 ( ) 0.38 ( ) 0.05 ( 0.09 to 0.2) 0.48 CI = confidence interval. *In unadjusted analysis, t test for independent samples with unequal variance was used; in propensity-matched analysis, paired t test was used. (Event rate for better care group) (event rate for worse care group). patient-centered care in AMI that we are aware of, we estimate in a post hoc analysis that our study had 80% power (2-sided alpha = 0.05) to identify a 10% increase in combined event rate in the worse versus better care group after propensity score matching. Thus, a small but clinically significant relationship may have been missed by our study. Our study has 2 other potential limitations worth noting. First, we had limited information on technical aspects of care, including administration of aspirin, b blockers, or angiotensin-converting enzyme inhibitors when indicated. Furthermore, our data are a decade old, and AMI care has evolved and improved significantly since data collection. However, data on technical care and temporal trends would likely to attenuate any unadjusted relationship between patient-reported problems with care and clinical event. Therefore, the lack of these data is unlikely to affect our negative findings. Second, the cohort of patients used in this study was from a single state with a predominantly white population. This is of concern since the potential impact of poor patient-centered care on subsequent intermediate outcomes, including medication adherence and patient enablement to self-manage illness, may be more pronounced in certain minority groups [23]. In conclusion, our analyses do not support the hypothesis that problems with AMI hospital care are predictive of subsequent cardiac events during the first post-ami year. Larger cohort studies in other settings would help clarify whether associations differ in more diverse patient populations and to identify small, but clinically important, effects that the current study was not powered to detect. Acknowledgments: We thank Rachel Rowe and Kathy Bizarro at the New Hampshire Hospital Association and staff members of the New Hampshire Department of Health and Human Services for their assistance obtaining additional data needed to conduct this follow-up study. Corresponding author: Allen Fremont, MD, PhD, RAND, 1776 Main St., Santa Monica, CA 90407, fremont@rand.org. Funding/support: This study was supported by the Agency for Health Research and Quality, (1R03HS A1). Dr. Sun was in part supported by the UCLA Robert Wood Johnson Clinical Scholars Program (050721), a UCLA National Institute of Aging K12 award (K12AG001004), and an American Geriatrics Society Dennis Jahnigen Career Development Award ( ). References 1. Gerteis M, Edgman-Levitan S, Daley J, et al, editors. Through the patient s eyes: understanding and promoting patientcentered care. San Francisco: Jossey-Bass; Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; Cleary PD, Edgman-Levitan S. Health care quality. Incorporating consumer perspectives. JAMA 1997;278: Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care. Inquiry 1988;25: Little P, Everitt H, Williamson I, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ 2001;323: Stewart M, Brown JB, Donner A, et al. The impact of patientcentered care on outcomes. J Fam Pract 2000;49: Cleary PD, Edgman-Levitan S, Roberts M, et al. Patients evaluate their hospital care: a national survey. Health Aff (Millwood) 1991;10: AHRQ Portfolios of Research. Rockville (MD): Agency for Health Care Research and Quality; Available at www. ahrq.gov/fund/portfolio.htm. Accessed 29 March Fremont AM, Cleary PD, Hargraves JL, et al. Patient-centered Vol. 15, No. 3 March 2008 JCOM 123

6 outcomes after MI processes of care and long-term outcomes of myocardial infarction. J Gen Intern Med 2001;16: Covinsky KE, Chren MM, Harper DL, et al. Differences in patient-reported processes and outcomes between men and women with myocardial infarction. J Gen Intern Med 2000; 15: Allison TG, Williams DE, Miller TD, et al. Medical and economic costs of psychologic distress in patients with coronary artery disease. Mayo Clin Proc 1995;70: Cleary PD, Edgman-Levitan S, Walker JD, et al. Using patient reports to improve medical care: a preliminary report from 10 hospitals. Qual Manag Health Care 1993;2: Stewart DE, Abbey SE, Shnek ZM, et al. Gender differences in health information needs and decisional preferences in patients recovering from an acute ischemic coronary event. Psychosom Med 2004;66: Spertus JA, McDonell M, Woodman CL, Fihn SD. Association between depression and worse disease-specific functional status in outpatients with coronary artery disease. Am Heart J 2000;140: Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30: Normand SL, Morris CN, Fung KS, et al. Development and validation of a claims based index for adjusting for risk of mortality: the case of acute myocardial infarction. J Clin Epidemiol 1995;48: D Agostino RB Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med 1998;17: Brody DS, Miller SM, Lerman CE, et al. Patient perception of involvement in medical care: relationship to illness attitudes and outcomes. J Gen Intern Med 1989;4: Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med 1985;102: Greenfield S, Kaplan SH, Ware JE Jr, et al. Patients participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3: Krumholz HM, Radford MJ, Wang Y, et al. National use and effectiveness of beta-blockers for the treatment of elderly patients after acute myocardial infarction: National Cooperative Cardiovascular Project. JAMA 1998;280: Krumholz HM, Radford MJ, Ellerbeck EF, et al. Aspirin in the treatment of acute myocardial infarction in elderly Medicare beneficiaries. Patterns of use and outcomes. Circulation 1995;92: The Commonwealth Fund. Quality of care for underserved populations. Available at list.htm?attrib_id=9133. Accessed 11 Feb Appendix. One-Month Hospital Patient-Centered Care Questions Dimension: Respect for patient preferences Did doctors talk in front of you as if you weren t there? Did nurses talk in front of you as if you weren t there? Did you have enough say about your treatment? Did you feel like you were treated with respect and dignity while you were in the hospital? Dimension: Coordination of care Do you feel you had to wait too long to go to your hospital room? Was there one particular doctor in charge of your care in the hospital? Sometimes in the hospital, one doctor or nurse will say one thing and another will say something quite different. Did this happen to you? Were your scheduled tests and procedures performed on time? Dimension: Information and education While you were in the emergency room, did you get enough information about your medical condition and treatment? If you had to wait to go to your room, did someone from the hospital explain the reason for the delay? When you had important questions to ask a doctor, did you get answers you could understand? When you had important questions to ask a nurse, did you get answers you could understand? Did a doctor or nurse explain the results of tests in a way you could understand? Dimension: Physical comfort When you needed help getting to the bathroom, did you get it in time? Do you think that the hospital staff did everything they could to help control your pain? Dimension: Emotional support If you had any anxieties or fears about your condition or treatment, did a doctor discuss them with you? Did you have confidence and trust in the doctors treating you? If you had any anxieties or fears about your condition or treatment, did a nurse discuss them with you? Did you have confidence and trust in the nurses treating you? Was it easy for you to find someone on the hospital staff to talk to about your concerns? Did you get as much help as you wanted from someone on the hospital staff in figuring out how to pay your hospital bill? Dimension: Involvement of Family and Friends Did your family or someone else close to you have enough opportunity to talk to your doctor? How much information about your condition or treatment was given to your family or someone close to you? Did the doctors and nurses give your family or someone close to you all the information they needed to help you recover? Dimension: Continuity and transition Did someone on the hospital staff explain the purpose of the medicines you were to take at home in a way you could understand? Did someone tell you about medication side effects to watch for when you went home? Did they tell you what danger signals about your illness or operation to watch for after you went home? Did they tell you when you could resume your usual activities, such as when to go back to work or drive a car? Copyright 2008 by Turner White Communications Inc., Wayne, PA. All rights reserved. 124 JCOM March 2008 Vol. 15, No. 3