DiscussionIn the EDUCAP randomized

Discussion

In the EDUCAP randomized trial, we assessed an individualized educational program for hospitalized patients with CAP that focused on improving patient fluid intake, adherence to drug therapy and preventive vaccines, knowledge and management of the disease, progressive adaptive physical activity, and counseling for alcohol and smoking cessation. Importantly, we found that this educational program decreased the frequency of healthcare visits and rehospitalizations within 30 days of discharge.

Some studies have concluded that strategies to reduce the length of hospitalization, as well as the trend toward community-based treatment, of patients with CAP should be accompanied by an increased emphasis on the information and support required by patients when returning home [14,15,17]. In addition, it has been documented that hospitalization for CAP is associated with more healthcare interactions after hospital discharge and higher long-term mortality compared with other major medical conditions [6,7,25–28]. Therefore, some investigators have recommended that new educational interventions are needed to improved patient understanding of their post-discharge care. These interventions could have important economic benefits by encouraging cost-effective health service use. Discharge planning has been associated with improved referral to and utilization of post-discharge services, and also with fewer readmissions. Furthermore, such planning appears to prepare patients and caregivers for post-discharge care [13].

Few studies have evaluated the efficacy of educational interventions in patients with CAP. In the studies undertaken to date, the results are mixed. Some studies support the usefulness of such programs in improving patient understanding of post-discharge care [14,15], but others do not [16]. For example, investigators designed interventions to improve patient knowledge that aimed to reduce the time from clinical stability to the switch to oral antibiotics. Patient education included explaining that it takes time to recover from pneumonia, recommending that medications be taken as prescribed, that patient eat healthy foods, and that they monitor for warning signs. Patients were satisfied that they received the information which needed to recover, and most reported that they were of the danger signs of relapse [14]. In the present study, the individualized educational program results in a significant decrease in additional healthcare visits and rehospitalizations within 30-days of hospital discharge.

The group that received the individualized educational program achieved more of the educational objectives. Patient fluid intake, knowledge and management of the disease, progressive adaptive physical activity, and smoking cessation were higher, although no differences were found in adherence to drug therapy, influenza and pneumococcal vaccination uptake, and alcohol cessation. Our findings are consistent with the findings of previous reports that educational interventions improved patient experiences, increased their understanding of post-discharge care, and increases the level of patient satisfaction [14,15]. Moreover, our results may help to developed a new model of in-hospital smoking cessation intervention as suggested in a recent review [29].

The strengths of this study are that it is the first randomized, controlled clinical trial with an intervention arm that received individualized patient education according to the Precede–Proceed model [18]. In addition, a large number of patients were included and just one patient who died was lost of 30-day follow-up visit. Nevertheless, there were no missing data on primary and secondary outcomes. However, some limitations should be acknowledged. First, patients receiving conventional information tended to be older and with low educational level; however, when we restricted the analysis to patients aged 70-years or older and none or primary-education we obtained similar results. In patients aged 70-years or older, the individualized educational program results only have a significant decrease in emergency department visits within 30 days of hospital discharge. Our finding concurs with previous reports that patient education could optimize the use of post-discharge services in patients with CAP [6,15]. Second, information about additional healthcare visits and rehospitalizations within 30 days of discharge were obtained by reviewing the Catalan Health Services database and checked by asking patients or family members at the final outpatient visit or by telephone. Therefore, patients or relatives might not have remembered some visits to private primary care centre or hospitals. Third, we did not evaluate the long-term mortality after hospital discharge in our study. Future studies, may need to assess the effect of individualized educational program on long-term mortality. Finally, it should be emphasized that the EDUCAP trial was not blinded.

In summary, th