Association between cultural factors and readmissions: the mediating effect of the quality of transitional care

Abstract

Introduction: Care transitions from hospital to outpatient care are a particularly vulnerable period in the care trajectory especially among minority patients, due to cultural and linguistic barriers that affect the comprehension of medical instructions and the ability to navigate among the various settings. Objectives: The study examines whether quality of the discharge process and transitional-care preparedness mediate the relationship between the cultural factors of patients and readmissions. Methods: A prospective cohort study of 599 internal medicine patients, Hebrew (general population) and Russian, or Arabic native speakers (minority groups), at a tertiary medical center in central Israel (2013 to 2014). The in-hospital baseline questionnaire included sociodemographic, cultural and linguistic characteristics (Internal Health Locus Control [IHLC], Powerful others Health Locus of Control [PHLC], Chance Health Locus of Control [CHLC], family collectivism and health literacy) and physical, mental, and functional health status (control variables). A follow-up telephone survey assessed the quality of the discharge process (parallel mediators): use of the teach-back method, providers' cultural competence, language concordance and caregiver presence, and the Care Transition Measure [CTM] (serial mediator). Information on chronic conditions, length of stay, prior hospitalization, and 30-day readmissions was retrieved from the healthcare organization's data warehouse. Testing multiple mediation models was conducted using Hayes PROCESS procedure, model 80. Results: A total of 101 patients (17%) were readmitted within 30 days. Multiple logistic regressions indicated that all cultural factors (IHLC, PHLC, CHLC, Family collectivism, Health literacy), except for minority status, were associated with 30-day readmission when no mediators were included (p<0.05). Path analysis indicated significant indirect effects of the cultural factors on readmission through the quality of the discharge process (parallel mediators) and CTM (serial mediator). Finally, when the mediators were included, strong direct and indirect effects between minority status and readmission were found (B coefficient=-0.949; p=0.021). Discussion: The results show that the association between patients' cultural factors and 30-day readmission is mediated by the quality of the discharge process and care transitions. Conclusions (comprising key findings): Providing high-quality discharge planning tailored to patients' cultural characteristics is related to better care-transition preparedness, which is related to reduced 30-day readmissions. Lessons learned: An understanding of the entire range of factors and their effects on the quality of care transitions may guide policy and practice in improving the quality of care by tailoring the discharge process to patients' personal and cultural needs. Limitations: Generalizability may be limited due to characteristics of the Israeli society. Nonetheless, transitions of minority patients are challenging in various healthcare systems worldwide. Suggestions for future research: future studies should test interventions aimed at improving transitions of minority patients through tailored discharge planning processes and examining the impact on the care transition experience and on readmissions.