Participants and setting
The participants were recruited in a university hospital’s three orthopedic wards (treatment focus on endoprosthetics, reconstructive joint interventions, and general traumatology) and one rheumatological ward (treatment focus on rheumatic diseases). Older patients admitted to one of these wards were invited to participate during their hospital stay. Inclusion criteria were age at least 70 years old (to enrol older patients), living independently, taking at least 5 drugs (to enrol patients with polymedication to treat multimorbidity), sufficient cognition assessed by the hospital physician, and written informed consent. Additionally, the patients needed to be able to talk on the telephone (adequate hearing and language skills).
Development of the semi-structured interview
We used a quantitative explorative semi-structured telephone interview to assess the extent and variety of symptoms including those that might not have been communicated before. This design should facilitate the participation of older multimorbid patients in a telephone survey.
Two pharmacists with experience in palliative and geriatric pharmacy developed a semi-structured interview based on Somers et al. [22
], the Memorial Symptom Assessment Scale [17
] and the Common Terminology for Adverse Events [15
]. Physicians with experience in geriatrics were involved for consultation.
To ensure comprehensibility and feasibility, the interview guide was cognitively pretested (by paraphrasing and comprehension probing) stepwise with nine professionals (pharmacists not included in the study design) and with three laypersons (older patients within the inclusion criteria). The participants in the pretest were not involved in developing the study protocol or the main study. The results of the pretests were not included in the final data assessment. The pretest with the professionals resulted in improved comprehensibility and notes to adjust the interview duration. The lay pretest resulted in the following modifications: inclusion of the symptom “hearing impaired”, shortening the interview guide (not asking which activities of daily living were impaired by the symptom, asking about treatment for only the 5 most severe or impairing symptoms), simplifying the wording in questions to increase lay understanding, including the response categories “ward physician” and “nobody” for the question about who recommended treatment.
The final interview (Supplement 1) consisted of four parts: (i) symptom characteristics (occurrence, intensity, impairment, timing, and cause), (ii) symptom communication, (iii) symptom treatment, and (iv) further support.
(i) Symptom characteristics
The interviewer discussed 24 predefined geriatric symptoms one after the other and asked for each whether the patient currently experienced the symptom (occurrence), how severe the symptom was (intensity: severe, moderate, weak, fully treated, not specified), how much it impaired them in their everyday life (impairment: severe, moderate, weak, none, not specified) and when the symptom first occurred (timing: before hospitalization, during hospitalization or after discharge). The patients were further asked what they considered the main causes of their symptoms. Age, disease and drug treatment were predefined categorized answers. Other named causes were also documented.
(ii) Symptom communication
The patients were asked with whom they had discussed the symptom before (physician, pharmacist, others, or nobody). In cases where the patients explained this in more detail, causes for the lack of communication were documented.
(iii) Symptom treatment
We asked the patients what measures they already took to improve the symptoms (drug and non-drug measures, asked for the five most severe or impairing symptoms), how effective these measures were (good, fair, poor) and who recommended the treatment (GP, specialist, ward physician, pharmacy, nursing service, family, friends, nobody, or others). The patients were further asked which of the symptoms they wished to be improved and what they thought could help them to improve their symptoms (open questions).
(iv) Further support
The patients were asked how easy or difficult it was to obtain support from GP, specialist, pharmacy, nursing service, family, friends or others. If the answer was “difficult”, the patients were asked to describe why it was difficult (open question). They were further asked whether they actively requested support (yes/no) and wished for more support (yes/no).
Demographic data were collected at the end of the survey.
Data collection and analysis
During the first week after discharge, the interviewer (pharmacists) contacted the patients by telephone to make an appointment for the telephone interview. The interviewer wrote patients’ answers on a documentation sheet and documented the interview’s duration. For quality assurance, the interview was audio-recorded. Complete data were digitalized within 24 h of the interview. To ensure complete, accurate and comprehensible data, a second study person randomly checked every sixth data set for transcription errors and inconsistency. No irregularities were found. Data were analyzed descriptively. Open answers were categorized post hoc.