Kangovi Shreya, Barg Frances K, Carter Tamala, Levy Kathryn, Sellman Jeffrey, Long Judith A, Grande David
Philadelphia Veterans Affairs Medical Center, , Philadelphia, PA, USA,
J Gen Intern Med. 2014 Feb;29(2):283-9. doi: 10.1007/s11606-013-2571-5. Epub 2013 Aug 6.
Patients with low socioeconomic status (low-SES) are at risk for poor outcomes during the post-hospital transition. Few prior studies explore perceived reasons for poor outcomes from the perspectives of these high-risk patients.
We explored low-SES patients' perceptions of hospitalization, discharge and post-hospital transition in order to generate hypotheses and identify common experiences during this transition.
We conducted a qualitative study using in-depth semi-structured interviewing.
We interviewed 65 patients who were: 1) uninsured, insured by Medicaid or dually eligible for Medicaid and Medicare; 2) residents of five low-income ZIP codes; 3) had capacity or a caregiver who could be interviewed as a proxy; and 4) hospitalized on the general medicine or cardiology services of two academically affiliated urban hospitals.
Our interview guide investigated patients' perceptions of hospitalization, discharge and the post-hospital transition, and their performance of recommended post-hospital health behaviors related to: 1) experience of hospitalization and discharge; 2) external constraints on patients' ability to execute discharge instructions; 3) salience of health behaviors; and 4) self-efficacy to execute discharge instructions. We used a modified grounded theory approach to analysis.
We identified six themes that low-SES patients shared in their narratives of hospitalization, discharge and post-hospital transition. These were: 1) powerlessness during hospitalization due to illness and socioeconomic factors; 2) misalignment of patient and care team goals; 3) lack of saliency of health behaviors due to competing issues; 4) socioeconomic constraints on patients' ability to perform recommended behaviors; 5) abandonment after discharge; and 6) loss of self-efficacy resulting from failure to perform recommended behaviors.
Low-SES patients describe discharge goals that are confusing, unrealistic in the face of significant socioeconomic constraints, and in conflict with their own immediate goals. We hypothesize that this goal misalignment leads to a cycle of low achievement and loss of self-efficacy that may underlie poor post-hospital outcomes among low-SES patients.
社会经济地位低（低SES）的患者在出院后的过渡阶段面临不良结局的风险。很少有先前的研究从这些高危患者的角度探讨不良结局的感知原因。
我们探讨了低SES患者对住院、出院和出院后过渡的看法，以便提出假设并确定这一过渡期间的常见经历。
我们采用深入的半结构化访谈进行了一项定性研究。
我们采访了65名患者，他们：1）未参保、由医疗补助计划承保或同时符合医疗补助计划和医疗保险资格；2）居住在五个低收入邮政编码地区；3）有能力或有可作为代理人接受访谈的护理人员；4）在两家学术附属城市医院的普通内科或心脏科住院。
我们的访谈指南调查了患者对住院、出院和出院后过渡的看法，以及他们在出院后与以下方面相关的推荐健康行为的表现：1）住院和出院经历；2）患者执行出院指示能力的外部限制；3）健康行为的显著性；4）执行出院指示的自我效能感。我们采用改良的扎根理论方法进行分析。
我们确定了低SES患者在其住院、出院和出院后过渡的叙述中共同的六个主题。这些主题是：1）由于疾病和社会经济因素，住院期间感到无力；2）患者与护理团队目标不一致；3）由于存在相互竞争的问题，健康行为缺乏显著性；4）社会经济因素限制患者执行推荐行为的能力；5）出院后被遗弃；6）因未能执行推荐行为而导致自我效能感丧失。
低SES患者描述的出院目标令人困惑，面对重大社会经济限制时不切实际，且与他们自己的近期目标相冲突。我们假设这种目标不一致会导致低成就和自我效能感丧失的循环，这可能是低SES患者出院后不良结局的潜在原因。
