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OBJECTIVE: To determine if the delivery of hospital discharge summaries to follow-up physicians decreases the risk of hospital readmission.
SUBJECTS: Eight hundred eighty-eight patients discharged from a single hospital following treatment for an acute medical illness.
SETTING: Teaching hospital in a universal health-care system.
DESIGN: We determined the date that each patient's discharge summary was printed and the physicians to whom it was sent. Summary receipt was confirmed by survey and phoning each physician's office. Each patient's hospital chart was reviewed to determine their acute and chronic medical conditions as well as their course in hospital. Using population-based administrative databases, all post-hospitalization visits were identified. For each of these visits, we determined whether the summary was available.
MAIN OUTCOME MEASURES: Time to nonelective hospital readmission during 3 months following discharge.
RESULTS: The discharge summary was available for only 568 of 4,639 outpatient visits (12.2%). Overall, 240 (27.0%) of patients were urgently readmitted to hospital. After adjusting for significant patient and hospitalization factors, we found a trend toward a decreased risk of readmission for patients who were seen in follow-up by a physician who had received a summary (relative risk 0.74, 95% confidence interval 0.50 to 1.11).
CONCLUSIONS: The risk of rehospitalization may decrease when patients are assessed following discharge by physicians who have received the discharge summary. Further research is required to determine if better continuity of patient information improves patient outcomes.
Communication is central to the practice of medicine. Physicians must regularly communicate effectively with both patients and other health professionals for optimal care. Increased patient-physician communication is associated with improved outcomes 1 but interphysician communication has been less studied. Individual accounts have documented poor communication in health care, 2,3 medico-legal case reports have associated poor interphysician communication with serious adverse outcomes, 4 and communication among health professionals has been labeled “a mess.”2 The effect of interphysician communication upon patient outcomes requires further analysis. 2,5,6
Despite its importance, the effect of interphysician communication on patient outcomes has been infrequently studied. Direct contact between radiologists and family physicians may increase the likelihood of further testing for patients with mammographic abnormalities. 7 Improved communication between diabetologists and family physicians was associated with a marginal improvement in glycemic control. 8 Tierney and colleagues 9 found that providing physicians with previous laboratory results decreased the number of tests that physicians ordered. Communication between family physicians and emergentologists decreased laboratory utilization. 10 However, increased interphysician communication does not always improve patient care. 11,12
Patients who are discharged from the care of a hospitalist represent an ideal setting for studying the effect of interphysician communication upon health outcomes. Hospitalists are physicians who spend much of their time caring for inpatients who are commonly unknown to them prior to the admission. These patients are often returned to the care of their regular physician following discharge from hospital. Hospitalists are common in both Canada and Europe, and their prevalence is increasing in the United States. 13 However, concern has been raised over the effect that such “discontinuity of care,” combined with poor communication, might have upon the quality of care. 13–16 Several authorities have called for research into the effects that such discontinuity has upon health care. 17,18 However, to our knowledge, no such research has ever been conducted.
This study determines if communication between hospitalists and patients' regular physicians by the discharge summary affects patient outcomes. The discharge summary is one of the most common methods used by hospital physicians to communicate with family doctors. 19 Although many studies have assessed discharge summary content, 20–22 accuracy, 23 and timeliness, 21,22,24 no study has measured their effects upon health outcomes. In this study, we anonymously linked information about patients who participated in a previous trial 25 with administrative databases to determine if delivery of the discharge summary to posthospitalization physicians changed the risk of rehospitalization.
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Continuity of care can improve patient outcomes. 28,29 To our knowledge, this is the only study to explore whether the dissemination of patient-specific information alters the risk of hospital readmission. After controlling for important factors, we found a trend toward a lower likelihood of readmission for patients who were seen in follow-up by a physician who had received the discharge summary. Our data suggest that discharge summary dissemination could be more successful at decreasing hospital readmission than case managers. 30,31 Further study is required to determine whether ‘continuity of information,’ in addition to continuity of care, can improve patient outcomes.
We were surprised by two of our findings. First, only a small number of follow-up physicians had received the discharge summary at the time of the patient visit. Although this may have occurred because patients consulted new physicians after discharge from hospital, we believe that it more likely results from hospital physicians failing to systematically identify all physicians involved in a patient's care and ensuring that summaries were sent to each. Since discharge summaries can only help patient care if they are received by their physicians, we must pursue methods to improve the timely dissemination of discharge summaries.
We also found that patients who had a regular family physician had a significantly higher risk of readmission. This is probably because patients with a family physician were sicker. Such patients were significantly older (66.6 vs 55.5 years; P < .001) and were more likely to have coronary artery disease (20.2% vs 8.3%; P = .01), chronic renal failure (9.3% vs 1.4%; P = .02), diabetes (20.7% vs 9.7%; P = .03), or any significant chronic medical condition (91.8% vs 77.8%; P < .001). Therefore, we believe that having a regular family physician is a marker of underlying chronic illness and comorbidity that increases the risk of readmission and was not controlled for in our model.
If the association between the receipt of discharge summaries and decreased readmission is true, this would be one of the most dramatic effects of interphysician communication yet documented. Previous studies have found that improved interphysician communication decreased waiting time in the emergency room, 10 repetition of laboratory tests, 10 and glycosylated hemoglobin levels, 8 and increased cancer screening rates. 7,32 One other study, by Williams and Fitton, 33 found that communication between the hospital and the primary care physician was significantly less likely to occur in elderly patients who were readmitted to hospital. However, this study was susceptible to recall bias, given its case-control design, and did not use a multivariate analysis to determine the independent association of communication with readmission.
This study has a number of strengths including a large and well-defined sample of patients. We combined primary data with population-based administrative databases to collect enough information on each patient that we could adjust for factors that have been associated with readmission to hospital. These include demographic factors (such as age, 34–38 gender, 34–36,39–41 nursing home status, 37,42 and socioeconomic status 43,44), prehospitalization health service utilization (including emergency department use, 45 hospitalizations, 34,35,37,44,46–50 and physician visits 35), baseline medical conditions (such as diabetes, 35,51 coronary artery disease, 35 congestive heart failure, 47,52,53 and chronic renal failure 41,52) and hospital factors (including length of stay 34,37). Follow-up was sufficiently long and was, given the population-based status of the administrative databases used to follow patients, complete. Our outcome, emergent readmission to hospital, was objective and was measured without some of the common pitfalls often encountered when measuring hospital readmissions. 54 This is because we were able to document readmissions to all Ontario hospitals (not just the original hospital, as is sometimes used in studies) and we censored people who died during the observation period. We also completely determined whether follow-up physicians received the discharge summary, using both mail and phone surveys.
However, this study had some weaknesses that need to be addressed in future research to truly determine the effect that continuity of information has upon patient outcomes. While the discharge summary is the most common media of communication following discharge from hospital, 19 we did not document information flow using other methods such as interim discharge reports, faxes, phone calls, and patient knowledge about their hospitalization. We could not determine whether the summary was actually read by the receiving physician. Although hospital readmission is a very important outcome, many readmissions are due to progression of disease rather than medical errors. Therefore, future studies should explore the effect of postdischarge communication on outcomes such as avoidable adverse events and avoidable readmissions. We did not control for whether physicians seeing patients after discharge had also seen them prior to the hospitalization. Physician continuity could importantly influence patient outcomes. Although we studied 888 patients, they were all from 1 service in a single teaching hospital. Furthermore, we had notably poor dissemination of our discharge summaries to follow-up physicians. More studies are needed to determine if our observations are reproduced in a variety of hospital care systems.
The final 3 weaknesses of this study could be addressed simultaneously by a trial in which patients are randomized to routine care versus exemplary dissemination of patient information to follow-up physicians. Although we controlled for many important factors, our observational study could not control for all potential confounders. For example, patients whose follow-up physicians received a discharge summary may be systematically different from other patients. Also, readmission to hospital might be associated with poor care during the initial hospitalization, 55–58 which itself could be associated with poor dissemination of discharge summaries. These and other unmeasured confounding factors, such as quality of care by the primary care physician, would be controlled in a properly conducted randomized clinical trial. Finally, our study was unable to determine how the dissemination of discharge summaries to follow-up physicians might avoid readmission to hospital. Ideally, one would want to document how information in the summary affected the decision making that influenced outcomes.
Our finding that dissemination of patient-specific hospital information to follow-up physicians may influence important outcomes is important for both physicians and health policy makers. Recent advances have resulted in a rapid proliferation of information and communication technologies that could extensively integrate health information as never before. However, the costs of adopting these technologies into exisiting health systems will be considerable. We believe that further research to determine the effects that continuity of patient information have upon important health outcomes is essential for appropriate decision making regarding these technologies.