Karen Grimmer‐Somers, PhD

Item Development for the Physician‐PREPARED

Australian investigators designed the Physician‐PREPARED survey instrument to measure the quality of discharge planning activities and communication. The investigators developed the survey with the following process that was not published previously. First, a literature review identified survey content germane to outpatient practitioners.10 Investigators conducted interviews, focus groups, and pilot surveys to prioritize items for the survey instrument. The volunteer subjects for item development were general medical practitioners in Adelaide and Sydney, the capital cities of two states in Australia. The draft instrument was circulated to a small group of general medical practitioners for comment on layout, wording, and question intent. After feedback, minor modifications were made to item content and response categories. The result of development in Australia was a survey instrument with 15 items (see Appendix). The items reflected the following key areas of discharge quality: timeliness of communication, patient health status at discharge, adequacy of discharge support services, discharge medication information, and reasons for medication changes. These areas were congruent with the results of other investigators who assessed the quality of discharge planning and communication.14, 15

Validation of the Modified Physician‐PREPARED

The validation study for the Modified Physician‐PREPARED occurred in Illinois. The Peoria Institutional Review Board approved and monitored the human research. The patient sample for validation was a prospective cohort from a cluster randomized clinical trial. Willing patients or their proxies provided written consent for study participation. Patient enrollment occurred between December 2004 and August 2006. The subjects for scale analysis were the outpatient primary care physicians or practitioners designated by patients in the cohort. Outpatient physicians and practitioners gave implied consent when they completed and returned questionnaires. Follow‐up was 10 or more days after the patient's discharge from an acute care, 730‐bed, teaching hospital.

Patient Inclusion Criteria

Trained research coordinators identified all consecutive adult inpatients who were discharged to home by internal medicine hospitalist physicians. Patient inclusion in the cluster‐randomized trial required a probability of repeat admission (Pra) score greater than or equal to 0.40.16, 17 Consequently, the patients in the scale analysis cohort had the same high probability for repeat admission. The Pra score came from patient or proxy responses to questions about age, prior hospitalizations, prior doctor visits, self‐rated health status, and other health‐related questions.16, 17 In previous validation studies with elderly outpatients, a Pra score above 0.5 predicted that patients would have 1 hospital admission per person‐year of survival.16 In other validation studies with inpatients aged 18 to 101 years, the Pra items predicted nonroutine discharge planning needs.18

Exclusion Criteria

The exclusion criteria were designed to enroll a cohort with homogeneous risk for readmission. We excluded patients if their discharge destination was a nursing home, another acute care hospital, or an inpatient rehabilitation unit. Hospice patients were excluded if life expectancy was less than 6 months as estimated by the hospitalist. We also used exclusion criteria to avoid illogical enrollments. If the designated outpatient primary care physician or practitioner also managed the patient during the index hospitalization, then there was no perceived barrier to communication and the patient was excluded. Cognitive impairment was a conditional exclusion criterion. We defined cognitive impairment as a score less than 9 on the 10‐point clock test.19 A patient with cognitive impairment could participate with consent from a legally authorized representative. Before we enrolled a cognitively impaired patient, we required a proxy who spent a minimum of 3 hours daily with the patient and who agreed to answer interview questions.

Baseline Assessment

During the index hospitalization, trained data abstractors recorded baseline patient data to calculate the Pra: age, gender, diabetes mellitus, and ischemic heart disease. Patients or proxies provided the number of hospital admissions and doctor visits during the year before the index hospitalization. We recorded the availability of an informal caregiver in response to the question, Is there a friend, relative or neighbor who would take care of you for a few days, if necessary? Patients rated their health status on the following scale: poor, fair, good, very good, and excellent. In addition, we recorded heart failure and chronic obstructive pulmonary disease because of their possible association with readmission.20, 21 Information about outpatient physicians or practitioners came from the hospital's administrative database and was limited to specialty training.

Discharge Process

At the end of the index hospitalization, hospitalists and ward nurses used standardized forms for discharge diagnoses, prescriptions, instructions, and appointments. Discharge planning nurses or social workers consulted with hospitalists and ward nurses and then coordinated service providers including home health nurses, physical therapists, home health aides, homemaker service providers, durable medical equipment vendors, home oxygen vendors, home infusion pharmacists, social workers, rehabilitation service providers, legal aid providers, and others. Patients designated an outpatient primary care physician or nurse practitioner or physician assistant to receive discharge reports and results of diagnostic tests. Ten days after discharge, research personnel mailed the Physician‐PREPARED questionnaire to the designated outpatient primary care professional.

Item Reduction and Scoring

To develop a scale, we selected items from the Physician‐PREPARED survey instrument (see Appendix). Our goal was a parsimonious, comprehensive, and valid scale for use in clinical and research environments. We applied item reduction techniques according to the following steps that were defined a priori. First, we deleted items with nominal response categories that lacked graded or ordinal characteristics. This exclusion criterion caused us to delete the following items from the questionnaire in the appendix: (1a) Who made you aware of the admission, (2a) Who made you aware of the patient's discharge, and (5a) How did you receive this information? We deleted open‐ended questions, such as: (13) Have you any suggestions how the patient's discharge could have been improved? Next, we excluded items with a large proportion of missing responses because respondents checked Not applicable. Only item 12 from the Physician‐PREPARED fulfilled the latter criterion (see Appendix). Question 12 asked, Has the patient's caretaker voiced any concerns that they have not been coping since the patient was discharged? Among 403 respondents, 52% answered question 12 as Not applicable.

Measures of Construct Validity

We used 3 measures of construct validity in our assessment of the Modified Physician‐PREPARED scale. The first construct item asked the outpatient practitioner, Were you involved at all in planning the patient's discharge? The first construct was relevant because involvement by outpatient physicians improves the quality of hospital discharges.22 The second construct item asked, Are you aware of any community support services that are involved in providing assistance to the patient since discharge? For the third construct, we asked (Appendix item 11), Has the patient voiced any concerns that they have not been coping since discharge? We chose community support services and patient coping because these are clinically relevant and correlated with patients' perceptions of discharge preparedness.23 When we assessed construct validity, our hypotheses were significantly higher Modified Physician‐PREPARED scale values for respondents who answered yes to the construct questions about involvement and awareness and answered no to the question about patient‐voiced concerns.

Analysis

Analyses were performed with SPSS PC (version 14.0.2; SPSS Inc, Chicago, Illinois). We reported descriptive statistics as means, standard deviations (SDs), and range for interval variables; median and range for ordinal variables; and percentages for nominal variables. While developing the scale, the unit of analysis was the physician response to a unique patient. Specific descriptive analyses used the unique respondent as the unit of analysis. To determine the internal consistency of the scale, we calculated Cronbach's alpha with SPSS RELIABILITY. We assessed the distribution of the Modified Physician‐PREPARED scale with visual and statistical tests for skewness. While using the SPSS FACTOR program, we performed principal components extractions and then rotated components using the oblique promax technique. Component scores were saved using the regression score procedure. Component loadings above 0.30 were considered for interpretation.24 Statistical inference tests were the Mann‐Whitney U for median differences for 2 groups, the Kruskal‐Wallis for more than 2 groups, and Spearman correlation for associations. The accepted level of significance was P < 0.05.

Description of Validation Cohort for the Modified Physician‐PREPARED

We sent questionnaires to the primary care physician, nurse practitioner, or physician assistant designated by 549 patients. The survey response rate was 76% (417/549). If a respondent failed to check any response option for 2 or more scale items, then the questionnaire was excluded from analysis. We excluded 3% (14/549) of questionnaires for failure to respond to items. The responses from the remaining 403 questionnaires were analyzed. We did not exclude questionnaires from respondents who followed homebound patients or other patients who failed to come to the clinic for postdischarge visits. Our analysis included 90 questionnaires (22%) from respondents who had no contact with the patient after discharge.

The patient characteristics appear in Table 1. Most of the patients were less than 65 years old (77%, 310/403). Many patients had chronic diseases including diabetes mellitus, ischemic heart disease, heart failure, or chronic obstructive pulmonary disease. Most patients, 81% (327/403), rated their health as poor or fair and 55% (223/403) had 1 or more hospital admissions during the year before their index admission. The questionnaire respondents were primary care physicians who practiced internal medicine (41%, 167/403), medicine‐pediatrics (27%, 108/403), family practice (24%, 97/403), or other specialties (3%, 10/403). Nurse practitioners or physician assistants completed 5% (21/403) of questionnaires.

We conducted descriptive analyses that treated the respondent as the unit of analysis. There were 172 unique respondents. The number of questionnaires per respondent ranged from 1 to 20 with a median of 1 questionnaire. Respondents varied in the time to return a questionnaire. We measured response time as the difference between the date we received the questionnaire and the date of discharge. The response time ranged from 10 to 90 days with a median of 21 days after discharge.

Modified Physician‐PREPARED: Item Reduction, Internal Consistency, and Score Distributions

The questionnaire items appear in the Appendix. After item reduction, there were 8 items included in the Modified Physician‐PREPARED scale analysis (Table 2). None of the 8 items caused substantive reduction in Cronbach's alpha, so all were retained. The 8‐item scale had acceptable internal consistency (Cronbach's alpha = 0.86). For an individual questionnaire, the sum of the scores for eight items yielded the Modified Physician‐PREPARED scale value. High scale values reflected high perceptions of discharge quality. Each of the 8 items correlated significantly and positively with the scale value (P < 0.001, 2‐tailed).

Table 2 shows the distribution of responses to each item in the Modified Physician‐PREPARED questionnaire. There were substantial ceiling effects for 2 individual items. One of the 7 items with 3 response options had ceiling effects approaching 70% (item 1). One item had 2 response options and 73% responded yes (item 5). The distribution of Modified Physician‐PREPARED scale values for 403 questionnaires had mean 16.6 4.0 SD and skew 0.6 (standard error of skew = 0.1). When scale values of patients 64 years and younger were compared with those of 65 and older, there were no significant differences (P = 0.606). The scale values did not have noteworthy floor or ceiling effects. The distribution of scale values showed 1.2% (5/403) of respondents had the lowest score of 8 and 1.7% (7/403) had the highest score of 24.

Modified Physician‐PREPARED: Principal Component Analysis

The purpose of the principal component analysis was to evaluate the relationships between the items and domains. In the component analysis, we evaluated the correlation matrix of the 8 items in the Modified Physician‐PREPARED scale. The Kaiser‐Meyer‐Olkin statistic of 0.89 indicated sufficient sampling adequacy to extract components from the matrix. Principal components extracted 66% of the variance associated with the 8‐item scale. After inspection of scree plots, we determined that 2 components were extracted before the eigenvalue fell substantially below 1. The pattern matrix for the promax rotation was inspected and the factor loading for each item appears in Table 3. The item content identified 1 component as timeliness of communication. The other component was adequacy of discharge plan/transmission. Within the adequacy component, the item content addressed patient health status, medication information, and reasons for medication changes. All items loaded primarily on 1 of the components; except item 3, which loaded on both components.

Modified Physician‐PREPARED: Construct Validity

We compared Modified Physician‐PREPARED scale values between dichotomous groups defined by construct variables. When considering the discharge planning and communication for a specific patient, outpatient primary care practitioners reported higher scale values when they were involved in the discharge planning (median [25%, 75%] = 19 [19, 20.5]) than when they were not involved (17 [12.4, 19], P < 0.001). In addition, outpatient practitioners responded with higher scale values when they were aware of community support services (18 [16, 20]) than when they were unaware (17 [12, 19], P = 0.002). There was a nonsignificant trend to higher scale values if patients voiced no concern about coping after discharge (18 [15, 19]) versus concern (17 [12, 19], P = 0.059). For all 3 constructs, the analysis revealed higher Modified Physician‐PREPARED scale values that were in the same direction as hypothesized. We approximated the construct analysis with subscales defined by the principal components (data not shown). The subscale analysis confirmed the direction and significance of the analysis with the full, 8‐item, Modified Physician‐PREPARED scale.

Modified Physician‐PREPARED: Correlations with Baseline Characteristics

We evaluated the correlations between a patient's Modified Physician‐PREPARED scale value and baseline characteristics in Table 1. Patient characteristics were not associated with scale values. We also assessed the median differences between the scale values by practitioner specialty and found no significant differences.

Item Development for the Physician‐PREPARED

Australian investigators designed the Physician‐PREPARED survey instrument to measure the quality of discharge planning activities and communication. The investigators developed the survey with the following process that was not published previously. First, a literature review identified survey content germane to outpatient practitioners.10 Investigators conducted interviews, focus groups, and pilot surveys to prioritize items for the survey instrument. The volunteer subjects for item development were general medical practitioners in Adelaide and Sydney, the capital cities of two states in Australia. The draft instrument was circulated to a small group of general medical practitioners for comment on layout, wording, and question intent. After feedback, minor modifications were made to item content and response categories. The result of development in Australia was a survey instrument with 15 items (see Appendix). The items reflected the following key areas of discharge quality: timeliness of communication, patient health status at discharge, adequacy of discharge support services, discharge medication information, and reasons for medication changes. These areas were congruent with the results of other investigators who assessed the quality of discharge planning and communication.14, 15

Validation of the Modified Physician‐PREPARED

The validation study for the Modified Physician‐PREPARED occurred in Illinois. The Peoria Institutional Review Board approved and monitored the human research. The patient sample for validation was a prospective cohort from a cluster randomized clinical trial. Willing patients or their proxies provided written consent for study participation. Patient enrollment occurred between December 2004 and August 2006. The subjects for scale analysis were the outpatient primary care physicians or practitioners designated by patients in the cohort. Outpatient physicians and practitioners gave implied consent when they completed and returned questionnaires. Follow‐up was 10 or more days after the patient's discharge from an acute care, 730‐bed, teaching hospital.

Patient Inclusion Criteria

Trained research coordinators identified all consecutive adult inpatients who were discharged to home by internal medicine hospitalist physicians. Patient inclusion in the cluster‐randomized trial required a probability of repeat admission (Pra) score greater than or equal to 0.40.16, 17 Consequently, the patients in the scale analysis cohort had the same high probability for repeat admission. The Pra score came from patient or proxy responses to questions about age, prior hospitalizations, prior doctor visits, self‐rated health status, and other health‐related questions.16, 17 In previous validation studies with elderly outpatients, a Pra score above 0.5 predicted that patients would have 1 hospital admission per person‐year of survival.16 In other validation studies with inpatients aged 18 to 101 years, the Pra items predicted nonroutine discharge planning needs.18

Exclusion Criteria

The exclusion criteria were designed to enroll a cohort with homogeneous risk for readmission. We excluded patients if their discharge destination was a nursing home, another acute care hospital, or an inpatient rehabilitation unit. Hospice patients were excluded if life expectancy was less than 6 months as estimated by the hospitalist. We also used exclusion criteria to avoid illogical enrollments. If the designated outpatient primary care physician or practitioner also managed the patient during the index hospitalization, then there was no perceived barrier to communication and the patient was excluded. Cognitive impairment was a conditional exclusion criterion. We defined cognitive impairment as a score less than 9 on the 10‐point clock test.19 A patient with cognitive impairment could participate with consent from a legally authorized representative. Before we enrolled a cognitively impaired patient, we required a proxy who spent a minimum of 3 hours daily with the patient and who agreed to answer interview questions.

Baseline Assessment

During the index hospitalization, trained data abstractors recorded baseline patient data to calculate the Pra: age, gender, diabetes mellitus, and ischemic heart disease. Patients or proxies provided the number of hospital admissions and doctor visits during the year before the index hospitalization. We recorded the availability of an informal caregiver in response to the question, Is there a friend, relative or neighbor who would take care of you for a few days, if necessary? Patients rated their health status on the following scale: poor, fair, good, very good, and excellent. In addition, we recorded heart failure and chronic obstructive pulmonary disease because of their possible association with readmission.20, 21 Information about outpatient physicians or practitioners came from the hospital's administrative database and was limited to specialty training.

Discharge Process

At the end of the index hospitalization, hospitalists and ward nurses used standardized forms for discharge diagnoses, prescriptions, instructions, and appointments. Discharge planning nurses or social workers consulted with hospitalists and ward nurses and then coordinated service providers including home health nurses, physical therapists, home health aides, homemaker service providers, durable medical equipment vendors, home oxygen vendors, home infusion pharmacists, social workers, rehabilitation service providers, legal aid providers, and others. Patients designated an outpatient primary care physician or nurse practitioner or physician assistant to receive discharge reports and results of diagnostic tests. Ten days after discharge, research personnel mailed the Physician‐PREPARED questionnaire to the designated outpatient primary care professional.

Item Reduction and Scoring

To develop a scale, we selected items from the Physician‐PREPARED survey instrument (see Appendix). Our goal was a parsimonious, comprehensive, and valid scale for use in clinical and research environments. We applied item reduction techniques according to the following steps that were defined a priori. First, we deleted items with nominal response categories that lacked graded or ordinal characteristics. This exclusion criterion caused us to delete the following items from the questionnaire in the appendix: (1a) Who made you aware of the admission, (2a) Who made you aware of the patient's discharge, and (5a) How did you receive this information? We deleted open‐ended questions, such as: (13) Have you any suggestions how the patient's discharge could have been improved? Next, we excluded items with a large proportion of missing responses because respondents checked Not applicable. Only item 12 from the Physician‐PREPARED fulfilled the latter criterion (see Appendix). Question 12 asked, Has the patient's caretaker voiced any concerns that they have not been coping since the patient was discharged? Among 403 respondents, 52% answered question 12 as Not applicable.

Measures of Construct Validity

We used 3 measures of construct validity in our assessment of the Modified Physician‐PREPARED scale. The first construct item asked the outpatient practitioner, Were you involved at all in planning the patient's discharge? The first construct was relevant because involvement by outpatient physicians improves the quality of hospital discharges.22 The second construct item asked, Are you aware of any community support services that are involved in providing assistance to the patient since discharge? For the third construct, we asked (Appendix item 11), Has the patient voiced any concerns that they have not been coping since discharge? We chose community support services and patient coping because these are clinically relevant and correlated with patients' perceptions of discharge preparedness.23 When we assessed construct validity, our hypotheses were significantly higher Modified Physician‐PREPARED scale values for respondents who answered yes to the construct questions about involvement and awareness and answered no to the question about patient‐voiced concerns.

Analysis

Analyses were performed with SPSS PC (version 14.0.2; SPSS Inc, Chicago, Illinois). We reported descriptive statistics as means, standard deviations (SDs), and range for interval variables; median and range for ordinal variables; and percentages for nominal variables. While developing the scale, the unit of analysis was the physician response to a unique patient. Specific descriptive analyses used the unique respondent as the unit of analysis. To determine the internal consistency of the scale, we calculated Cronbach's alpha with SPSS RELIABILITY. We assessed the distribution of the Modified Physician‐PREPARED scale with visual and statistical tests for skewness. While using the SPSS FACTOR program, we performed principal components extractions and then rotated components using the oblique promax technique. Component scores were saved using the regression score procedure. Component loadings above 0.30 were considered for interpretation.24 Statistical inference tests were the Mann‐Whitney U for median differences for 2 groups, the Kruskal‐Wallis for more than 2 groups, and Spearman correlation for associations. The accepted level of significance was P < 0.05.

Description of Validation Cohort for the Modified Physician‐PREPARED

We sent questionnaires to the primary care physician, nurse practitioner, or physician assistant designated by 549 patients. The survey response rate was 76% (417/549). If a respondent failed to check any response option for 2 or more scale items, then the questionnaire was excluded from analysis. We excluded 3% (14/549) of questionnaires for failure to respond to items. The responses from the remaining 403 questionnaires were analyzed. We did not exclude questionnaires from respondents who followed homebound patients or other patients who failed to come to the clinic for postdischarge visits. Our analysis included 90 questionnaires (22%) from respondents who had no contact with the patient after discharge.

The patient characteristics appear in Table 1. Most of the patients were less than 65 years old (77%, 310/403). Many patients had chronic diseases including diabetes mellitus, ischemic heart disease, heart failure, or chronic obstructive pulmonary disease. Most patients, 81% (327/403), rated their health as poor or fair and 55% (223/403) had 1 or more hospital admissions during the year before their index admission. The questionnaire respondents were primary care physicians who practiced internal medicine (41%, 167/403), medicine‐pediatrics (27%, 108/403), family practice (24%, 97/403), or other specialties (3%, 10/403). Nurse practitioners or physician assistants completed 5% (21/403) of questionnaires.

We conducted descriptive analyses that treated the respondent as the unit of analysis. There were 172 unique respondents. The number of questionnaires per respondent ranged from 1 to 20 with a median of 1 questionnaire. Respondents varied in the time to return a questionnaire. We measured response time as the difference between the date we received the questionnaire and the date of discharge. The response time ranged from 10 to 90 days with a median of 21 days after discharge.

Modified Physician‐PREPARED: Item Reduction, Internal Consistency, and Score Distributions

The questionnaire items appear in the Appendix. After item reduction, there were 8 items included in the Modified Physician‐PREPARED scale analysis (Table 2). None of the 8 items caused substantive reduction in Cronbach's alpha, so all were retained. The 8‐item scale had acceptable internal consistency (Cronbach's alpha = 0.86). For an individual questionnaire, the sum of the scores for eight items yielded the Modified Physician‐PREPARED scale value. High scale values reflected high perceptions of discharge quality. Each of the 8 items correlated significantly and positively with the scale value (P < 0.001, 2‐tailed).

Table 2 shows the distribution of responses to each item in the Modified Physician‐PREPARED questionnaire. There were substantial ceiling effects for 2 individual items. One of the 7 items with 3 response options had ceiling effects approaching 70% (item 1). One item had 2 response options and 73% responded yes (item 5). The distribution of Modified Physician‐PREPARED scale values for 403 questionnaires had mean 16.6 4.0 SD and skew 0.6 (standard error of skew = 0.1). When scale values of patients 64 years and younger were compared with those of 65 and older, there were no significant differences (P = 0.606). The scale values did not have noteworthy floor or ceiling effects. The distribution of scale values showed 1.2% (5/403) of respondents had the lowest score of 8 and 1.7% (7/403) had the highest score of 24.

Modified Physician‐PREPARED: Principal Component Analysis

The purpose of the principal component analysis was to evaluate the relationships between the items and domains. In the component analysis, we evaluated the correlation matrix of the 8 items in the Modified Physician‐PREPARED scale. The Kaiser‐Meyer‐Olkin statistic of 0.89 indicated sufficient sampling adequacy to extract components from the matrix. Principal components extracted 66% of the variance associated with the 8‐item scale. After inspection of scree plots, we determined that 2 components were extracted before the eigenvalue fell substantially below 1. The pattern matrix for the promax rotation was inspected and the factor loading for each item appears in Table 3. The item content identified 1 component as timeliness of communication. The other component was adequacy of discharge plan/transmission. Within the adequacy component, the item content addressed patient health status, medication information, and reasons for medication changes. All items loaded primarily on 1 of the components; except item 3, which loaded on both components.

Modified Physician‐PREPARED: Construct Validity

We compared Modified Physician‐PREPARED scale values between dichotomous groups defined by construct variables. When considering the discharge planning and communication for a specific patient, outpatient primary care practitioners reported higher scale values when they were involved in the discharge planning (median [25%, 75%] = 19 [19, 20.5]) than when they were not involved (17 [12.4, 19], P < 0.001). In addition, outpatient practitioners responded with higher scale values when they were aware of community support services (18 [16, 20]) than when they were unaware (17 [12, 19], P = 0.002). There was a nonsignificant trend to higher scale values if patients voiced no concern about coping after discharge (18 [15, 19]) versus concern (17 [12, 19], P = 0.059). For all 3 constructs, the analysis revealed higher Modified Physician‐PREPARED scale values that were in the same direction as hypothesized. We approximated the construct analysis with subscales defined by the principal components (data not shown). The subscale analysis confirmed the direction and significance of the analysis with the full, 8‐item, Modified Physician‐PREPARED scale.

Modified Physician‐PREPARED: Correlations with Baseline Characteristics

We evaluated the correlations between a patient's Modified Physician‐PREPARED scale value and baseline characteristics in Table 1. Patient characteristics were not associated with scale values. We also assessed the median differences between the scale values by practitioner specialty and found no significant differences.

Item Development for the Physician‐PREPARED

Australian investigators designed the Physician‐PREPARED survey instrument to measure the quality of discharge planning activities and communication. The investigators developed the survey with the following process that was not published previously. First, a literature review identified survey content germane to outpatient practitioners.10 Investigators conducted interviews, focus groups, and pilot surveys to prioritize items for the survey instrument. The volunteer subjects for item development were general medical practitioners in Adelaide and Sydney, the capital cities of two states in Australia. The draft instrument was circulated to a small group of general medical practitioners for comment on layout, wording, and question intent. After feedback, minor modifications were made to item content and response categories. The result of development in Australia was a survey instrument with 15 items (see Appendix). The items reflected the following key areas of discharge quality: timeliness of communication, patient health status at discharge, adequacy of discharge support services, discharge medication information, and reasons for medication changes. These areas were congruent with the results of other investigators who assessed the quality of discharge planning and communication.14, 15

Validation of the Modified Physician‐PREPARED

The validation study for the Modified Physician‐PREPARED occurred in Illinois. The Peoria Institutional Review Board approved and monitored the human research. The patient sample for validation was a prospective cohort from a cluster randomized clinical trial. Willing patients or their proxies provided written consent for study participation. Patient enrollment occurred between December 2004 and August 2006. The subjects for scale analysis were the outpatient primary care physicians or practitioners designated by patients in the cohort. Outpatient physicians and practitioners gave implied consent when they completed and returned questionnaires. Follow‐up was 10 or more days after the patient's discharge from an acute care, 730‐bed, teaching hospital.

Patient Inclusion Criteria

Trained research coordinators identified all consecutive adult inpatients who were discharged to home by internal medicine hospitalist physicians. Patient inclusion in the cluster‐randomized trial required a probability of repeat admission (Pra) score greater than or equal to 0.40.16, 17 Consequently, the patients in the scale analysis cohort had the same high probability for repeat admission. The Pra score came from patient or proxy responses to questions about age, prior hospitalizations, prior doctor visits, self‐rated health status, and other health‐related questions.16, 17 In previous validation studies with elderly outpatients, a Pra score above 0.5 predicted that patients would have 1 hospital admission per person‐year of survival.16 In other validation studies with inpatients aged 18 to 101 years, the Pra items predicted nonroutine discharge planning needs.18

Exclusion Criteria

The exclusion criteria were designed to enroll a cohort with homogeneous risk for readmission. We excluded patients if their discharge destination was a nursing home, another acute care hospital, or an inpatient rehabilitation unit. Hospice patients were excluded if life expectancy was less than 6 months as estimated by the hospitalist. We also used exclusion criteria to avoid illogical enrollments. If the designated outpatient primary care physician or practitioner also managed the patient during the index hospitalization, then there was no perceived barrier to communication and the patient was excluded. Cognitive impairment was a conditional exclusion criterion. We defined cognitive impairment as a score less than 9 on the 10‐point clock test.19 A patient with cognitive impairment could participate with consent from a legally authorized representative. Before we enrolled a cognitively impaired patient, we required a proxy who spent a minimum of 3 hours daily with the patient and who agreed to answer interview questions.

Baseline Assessment

During the index hospitalization, trained data abstractors recorded baseline patient data to calculate the Pra: age, gender, diabetes mellitus, and ischemic heart disease. Patients or proxies provided the number of hospital admissions and doctor visits during the year before the index hospitalization. We recorded the availability of an informal caregiver in response to the question, Is there a friend, relative or neighbor who would take care of you for a few days, if necessary? Patients rated their health status on the following scale: poor, fair, good, very good, and excellent. In addition, we recorded heart failure and chronic obstructive pulmonary disease because of their possible association with readmission.20, 21 Information about outpatient physicians or practitioners came from the hospital's administrative database and was limited to specialty training.

Discharge Process

At the end of the index hospitalization, hospitalists and ward nurses used standardized forms for discharge diagnoses, prescriptions, instructions, and appointments. Discharge planning nurses or social workers consulted with hospitalists and ward nurses and then coordinated service providers including home health nurses, physical therapists, home health aides, homemaker service providers, durable medical equipment vendors, home oxygen vendors, home infusion pharmacists, social workers, rehabilitation service providers, legal aid providers, and others. Patients designated an outpatient primary care physician or nurse practitioner or physician assistant to receive discharge reports and results of diagnostic tests. Ten days after discharge, research personnel mailed the Physician‐PREPARED questionnaire to the designated outpatient primary care professional.

Item Reduction and Scoring

To develop a scale, we selected items from the Physician‐PREPARED survey instrument (see Appendix). Our goal was a parsimonious, comprehensive, and valid scale for use in clinical and research environments. We applied item reduction techniques according to the following steps that were defined a priori. First, we deleted items with nominal response categories that lacked graded or ordinal characteristics. This exclusion criterion caused us to delete the following items from the questionnaire in the appendix: (1a) Who made you aware of the admission, (2a) Who made you aware of the patient's discharge, and (5a) How did you receive this information? We deleted open‐ended questions, such as: (13) Have you any suggestions how the patient's discharge could have been improved? Next, we excluded items with a large proportion of missing responses because respondents checked Not applicable. Only item 12 from the Physician‐PREPARED fulfilled the latter criterion (see Appendix). Question 12 asked, Has the patient's caretaker voiced any concerns that they have not been coping since the patient was discharged? Among 403 respondents, 52% answered question 12 as Not applicable.

Measures of Construct Validity

We used 3 measures of construct validity in our assessment of the Modified Physician‐PREPARED scale. The first construct item asked the outpatient practitioner, Were you involved at all in planning the patient's discharge? The first construct was relevant because involvement by outpatient physicians improves the quality of hospital discharges.22 The second construct item asked, Are you aware of any community support services that are involved in providing assistance to the patient since discharge? For the third construct, we asked (Appendix item 11), Has the patient voiced any concerns that they have not been coping since discharge? We chose community support services and patient coping because these are clinically relevant and correlated with patients' perceptions of discharge preparedness.23 When we assessed construct validity, our hypotheses were significantly higher Modified Physician‐PREPARED scale values for respondents who answered yes to the construct questions about involvement and awareness and answered no to the question about patient‐voiced concerns.

Analysis

Analyses were performed with SPSS PC (version 14.0.2; SPSS Inc, Chicago, Illinois). We reported descriptive statistics as means, standard deviations (SDs), and range for interval variables; median and range for ordinal variables; and percentages for nominal variables. While developing the scale, the unit of analysis was the physician response to a unique patient. Specific descriptive analyses used the unique respondent as the unit of analysis. To determine the internal consistency of the scale, we calculated Cronbach's alpha with SPSS RELIABILITY. We assessed the distribution of the Modified Physician‐PREPARED scale with visual and statistical tests for skewness. While using the SPSS FACTOR program, we performed principal components extractions and then rotated components using the oblique promax technique. Component scores were saved using the regression score procedure. Component loadings above 0.30 were considered for interpretation.24 Statistical inference tests were the Mann‐Whitney U for median differences for 2 groups, the Kruskal‐Wallis for more than 2 groups, and Spearman correlation for associations. The accepted level of significance was P < 0.05.

Description of Validation Cohort for the Modified Physician‐PREPARED

We sent questionnaires to the primary care physician, nurse practitioner, or physician assistant designated by 549 patients. The survey response rate was 76% (417/549). If a respondent failed to check any response option for 2 or more scale items, then the questionnaire was excluded from analysis. We excluded 3% (14/549) of questionnaires for failure to respond to items. The responses from the remaining 403 questionnaires were analyzed. We did not exclude questionnaires from respondents who followed homebound patients or other patients who failed to come to the clinic for postdischarge visits. Our analysis included 90 questionnaires (22%) from respondents who had no contact with the patient after discharge.

The patient characteristics appear in Table 1. Most of the patients were less than 65 years old (77%, 310/403). Many patients had chronic diseases including diabetes mellitus, ischemic heart disease, heart failure, or chronic obstructive pulmonary disease. Most patients, 81% (327/403), rated their health as poor or fair and 55% (223/403) had 1 or more hospital admissions during the year before their index admission. The questionnaire respondents were primary care physicians who practiced internal medicine (41%, 167/403), medicine‐pediatrics (27%, 108/403), family practice (24%, 97/403), or other specialties (3%, 10/403). Nurse practitioners or physician assistants completed 5% (21/403) of questionnaires.

We conducted descriptive analyses that treated the respondent as the unit of analysis. There were 172 unique respondents. The number of questionnaires per respondent ranged from 1 to 20 with a median of 1 questionnaire. Respondents varied in the time to return a questionnaire. We measured response time as the difference between the date we received the questionnaire and the date of discharge. The response time ranged from 10 to 90 days with a median of 21 days after discharge.

Modified Physician‐PREPARED: Item Reduction, Internal Consistency, and Score Distributions

The questionnaire items appear in the Appendix. After item reduction, there were 8 items included in the Modified Physician‐PREPARED scale analysis (Table 2). None of the 8 items caused substantive reduction in Cronbach's alpha, so all were retained. The 8‐item scale had acceptable internal consistency (Cronbach's alpha = 0.86). For an individual questionnaire, the sum of the scores for eight items yielded the Modified Physician‐PREPARED scale value. High scale values reflected high perceptions of discharge quality. Each of the 8 items correlated significantly and positively with the scale value (P < 0.001, 2‐tailed).

Table 2 shows the distribution of responses to each item in the Modified Physician‐PREPARED questionnaire. There were substantial ceiling effects for 2 individual items. One of the 7 items with 3 response options had ceiling effects approaching 70% (item 1). One item had 2 response options and 73% responded yes (item 5). The distribution of Modified Physician‐PREPARED scale values for 403 questionnaires had mean 16.6 4.0 SD and skew 0.6 (standard error of skew = 0.1). When scale values of patients 64 years and younger were compared with those of 65 and older, there were no significant differences (P = 0.606). The scale values did not have noteworthy floor or ceiling effects. The distribution of scale values showed 1.2% (5/403) of respondents had the lowest score of 8 and 1.7% (7/403) had the highest score of 24.

Modified Physician‐PREPARED: Principal Component Analysis

The purpose of the principal component analysis was to evaluate the relationships between the items and domains. In the component analysis, we evaluated the correlation matrix of the 8 items in the Modified Physician‐PREPARED scale. The Kaiser‐Meyer‐Olkin statistic of 0.89 indicated sufficient sampling adequacy to extract components from the matrix. Principal components extracted 66% of the variance associated with the 8‐item scale. After inspection of scree plots, we determined that 2 components were extracted before the eigenvalue fell substantially below 1. The pattern matrix for the promax rotation was inspected and the factor loading for each item appears in Table 3. The item content identified 1 component as timeliness of communication. The other component was adequacy of discharge plan/transmission. Within the adequacy component, the item content addressed patient health status, medication information, and reasons for medication changes. All items loaded primarily on 1 of the components; except item 3, which loaded on both components.

Modified Physician‐PREPARED: Construct Validity

We compared Modified Physician‐PREPARED scale values between dichotomous groups defined by construct variables. When considering the discharge planning and communication for a specific patient, outpatient primary care practitioners reported higher scale values when they were involved in the discharge planning (median [25%, 75%] = 19 [19, 20.5]) than when they were not involved (17 [12.4, 19], P < 0.001). In addition, outpatient practitioners responded with higher scale values when they were aware of community support services (18 [16, 20]) than when they were unaware (17 [12, 19], P = 0.002). There was a nonsignificant trend to higher scale values if patients voiced no concern about coping after discharge (18 [15, 19]) versus concern (17 [12, 19], P = 0.059). For all 3 constructs, the analysis revealed higher Modified Physician‐PREPARED scale values that were in the same direction as hypothesized. We approximated the construct analysis with subscales defined by the principal components (data not shown). The subscale analysis confirmed the direction and significance of the analysis with the full, 8‐item, Modified Physician‐PREPARED scale.

Modified Physician‐PREPARED: Correlations with Baseline Characteristics

We evaluated the correlations between a patient's Modified Physician‐PREPARED scale value and baseline characteristics in Table 1. Patient characteristics were not associated with scale values. We also assessed the median differences between the scale values by practitioner specialty and found no significant differences.