Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care

Quality of care for decompensated heart failure: comparable performance between academic hospitalists and non-hospitalists

BACKGROUND

Hospitalists improve efficiency, but little information exists regarding whether they impact quality of care.

OBJECTIVE

To determine hospitalists' effect on the quality of acute congestive heart failure care.

DESIGN AND PARTICIPANTS

Using data from the Multicenter Hospitalist Study, we retrospectively evaluated quality of care in patients admitted with congestive heart failure who were assigned to hospitalists (n = 120) or non-hospitalists (n = 252) among six academic hospitals.

MEASUREMENTS

Quality measures included the percentage of patients who had ejection fraction (EF) measurement, received appropriate medications [i.e., angiotensin-converting enzyme inhibitor (ACE-I) or beta-blockers] at discharge, measures of care coordination (e.g., follow-up within 30 days), testing for cardiac ischemia (e.g., cardiac catheterization), as well as hospital length of stay, cost, and combined 30-day readmissions and mortality.

RESULTS

Compared to non-hospitalist physicians, hospitalists' patients had similar rates of EF measurement (85.3% vs. 87.5%; P = 0.57), ACE-I (91.5% vs. 88.0%; P = 0.52), or beta-blocker (46.9% vs. 42.1%; P = 0.57) prescriptions. Multivariable adjustment did not change these findings. Hospitalists' patients had higher odds of 30-day follow-up (adjusted OR = 1.83, 95% CI, 1.44 - 2.93). There were no significant differences between the groups' frequency of cardiac testing, length of stay, costs, or risk for readmission or death by 30-days.

CONCLUSION

Academic hospitalists and non-hospitalists provide similar quality of care for heart failure patients, although hospitalists are paying more attention to longitudinal care. Future efforts to improve quality of care in decompensated heart failure may require attention towards system-level factors.

Evaluating the accuracy of existing EMR data as predictors of follow-up providers

In order to evaluate the accuracy of existing EMR data in predicting follow-up providers, a retrospective analysis was performed on six months of data for inpatient and ED encounters occurring at two hospitals, and on related outpatient data. Sensitivity and Positive Predictive Value (PPV) were calculated for each of eight predictors, to determine their effectiveness in predicting follow-up providers. Our findings indicate that access to longitudinal patient care records can improve prediction of which providers a patient is likely to see post-discharge compared to simply using Primary Care Provider data from admissions records. Of the predictors evaluated, a patient's past appointment history was the best predictor of which providers they would see in the future (PPV = 48% following inpatient visits, 35% following emergency department visits). However, even the best performing predictors failed to predict more than half of the follow-up providers and might generate many "false" alerts.

Patients' understanding of the reasons for starting and discontinuing inhaled corticosteroids

AIM

Although early discontinuation of treatment in new users of inhaled corticosteroids (ICS) has been widely discussed, the reasons for stopping have not been investigated in depth. We aimed to describe reasons for discontinuation from a patient's perspective in relation to their experience of symptoms at the time of the investigation.

METHODS

A cross-sectional study among new users that discontinued ICS use in the Netherlands was performed. Patients were interviewed by telephone, aiming to identify the symptoms for which they were prescribed ICS, the reasons for discontinuing treatment and the respiratory symptoms patients still experienced at the time of the survey. In addition, automated dispensing records of all patients were retrieved.

RESULTS

From 287 eligible patients, 230 (80.1%) were interviewed. Only 22 patients (9.6%) mentioned asthma as the reason for a first ICS prescription. A decrease in symptoms was the main reason for discontinuation (45%). Thirty patients (13%) reported clinically significant residual symptoms. These patients reported more seasonal variation of symptoms and were more often prescribed short-acting beta(2)-agonists.

CONCLUSIONS

The majority of patients mentioned a wide range of symptoms and conditions, other than asthma or chronic obstructive pulmonary disease, as the reason for the start of ICS therapy. Most of these conditions may be expected to be of short duration. Not surprisingly a decrease in symptoms was the main, and justifiable, reason for discontinuing ICS. However, a non-negligible proportion of patients reported residual symptoms that suggest the need of continued ICS use. Physicians and pharmacists could cooperate in identifying those patients for which ICS are really indicated and motivate them to continue the use of ICS.

Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study

BACKGROUND

Patients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists and primary care providers can further compromise post-discharge care. Redesigning the discharge process may improve the continuity and the quality of patient care.

OBJECTIVES

To evaluate a low-cost intervention designed to promptly reconnect patients to their "medical home" after hospital discharge.

DESIGN

Randomized controlled study. Intervention patients received a "user-friendly" Patient Discharge Form, and upon arrival at home, a telephone outreach from a nurse at their primary care site.

PARTICIPANTS

A culturally and linguistically diverse group of patients admitted to a small community teaching hospital.

MEASUREMENTS

Four undesirable outcomes were measured after hospital discharge: (1) no outpatient follow-up within 21 days; (2) readmission within 31 days; (3) emergency department visit within 31 days; and (4) failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors. Outcomes of the intervention group were compared to concurrent and historical controls.

RESULTS

Only 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent and 55.0% of the historical controls. Notably, only 14.9% of the intervention patients failed to follow-up within 21 days compared to 40.8% of the concurrent and 35.0% of the historical controls. Only 11.5% of recommended outpatient workups in the intervention group were incomplete versus 31.3% in the concurrent and 31.0% in the historical controls.

CONCLUSIONS

A low-cost discharge-transfer intervention may improve the rates of outpatient follow-up and of completed workups after hospital discharge.

Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient

The case of an elderly patient with mild dementia and severe depression is reviewed including analysis of the barriers to successful transition that led to readmission. Situations likely to result in failed transitions include poor social support, discharge during times when ancillary services are unavailable, uncertain medication reconciliation, depression, and patients' cognitive limitations. Evidence suggests deficits in communication by hospital physicians to primary care providers occur commonly but this is only one of many systems barriers to successful discharge. Review of the literature reveals interventions such as involvement of advance practice nurses or family members in the transition may overcome some of the difficulties inherent in discharge of the vulnerable geriatric patient. Weekend discharges present unique challenges and potential solutions are explored. This case offers the opportunity to review the elements necessary for success and insight into the systems limitations which underlie failed transitions.

Do hospitalists or physicians with greater inpatient HIV experience improve HIV care in the era of highly active antiretroviral therapy? Results from a multicenter trial of academic hospitalists

BACKGROUND

Little is known about the effect of provider type and experience on outcomes, resource use, and processes of care of hospitalized patients with human immunodeficiency virus (HIV) infection. Hospitalists are caring for this population with increasing frequency.

METHODS

Data from a natural experiment in which patients were assigned to physicians on the basis of call cycle was used to study the effects of provider type-that is, hospitalist versus nonhospitalist-and HIV-specific inpatient experience on resource use, outcomes, and selected measures of processes of care at 6 academic institutions. Administrative data, inpatient interviews, 30-day follow-up interviews, and the National Death Index were used to measure outcomes.

RESULTS

A total of 1207 patients were included in the analysis. There were few differences in resource use, outcomes, and processes of care by provider type and experience with HIV-infected inpatients. Patients who received hospitalist care demonstrated a trend toward increased length of hospital stay compared with patients who did not receive hospitalist care (6.0 days vs. 5.2 days; P = .13). Inpatient providers with moderate experience with HIV-infected patients were more likely to coordinate care with outpatient providers (odds ratio, 2.40; P = .05) than were those with the least experience with HIV-infected patients, but this pattern did not extend to providers with the highest level of experience.

CONCLUSION

Provider type and attending physician experience with HIV-infected inpatients had minimal effect on the quality of care of HIV-infected inpatients. Approaches other than provider experience, such as the use of multidisciplinary inpatient teams, may be better targets for future studies of the outcomes, processes of care, and resource use of HIV-infected inpatients.

Underutilized time for health education of hospitalized patients

BACKGROUND

Our anecdotal observations suggested that hospitalized patients had considerable time during the day when they were not occupied with diagnostic testing or other activities. Accordingly, we sought to quantify the fraction of free time that hospitalized patients had available to participate in health educational activities and if and when during their hospitalization they were interested in participating in these activities and felt capable of doing so.

METHODS

From June 25 through August 15, 2005, randomly selected consenting patients admitted to the Internal Medicine service of an academic safety-net hospital became subjects of a time-motion study that was conducted from admission to discharge or to hospital Day 6. Another randomly selected group received daily surveys, and patients in a third group were interviewed on Day 2 or 3 of their hospitalization.

RESULTS

Time-motion data, surveys, and interviews were obtained from 13, 138, and 15 patients, respectively. Of the 316 patient-hours observed, 71% were classified as downtime. More than 80% of patients either "strongly agreed" or "agreed" that they were interested in and capable of being educated on all days of their hospitalization. The themes generated from the interviews included the desire to know more about self-management, prevention of disease recurrence or progression, and their primary illness.

CONCLUSIONS

Adult medical inpatients have considerable time and strong motivation to participate in health educational activities throughout their hospitalization. The current structure for educating hospitalized patients should be supplemented to take these findings into account.

The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs

OBJECTIVES

To examine 1-year mortality and healthcare payments of stroke patients experiencing zero, one and two or more bounce-backs within 30 days of discharge.

DESIGN

Retrospective analysis of administrative data.

SETTING

Four hundred twenty-two hospitals in the southern and eastern United States.

PARTICIPANTS

Eleven thousand seven hundred twenty-nine Medicare beneficiaries aged 65 and older surviving at least 30 days with acute ischemic stroke in 2000.

MEASUREMENTS

One-year mortality and predicted total healthcare payments were calculated using log-normal parametric survival analysis and quantile regression, respectively. Models included sociodemographics, prior medical history, stroke severity, length of stay, and discharge site.

RESULTS

Crude survival at 1 year for the zero, one and two or more bounce-back groups was 83%, 67%, and 55%, respectively. The one bounce-back group had 49% shorter (time ratio (TR)=0.51, 95% confidence interval (CI)=0.46-0.56) and the two or more bounce-backs group had 68% shorter (TR=0.32, 95% CI=0.27-0.38) adjusted 1-year survival time than the zero bounce-back group. For high- and low-cost patients, adjusted predicted payments were greater with each additional bounce-back experienced.

CONCLUSION

Acute stroke patients experiencing bounce-backs within 30 days have strikingly poorer survival and higher healthcare payments over the subsequent year than their counterparts with no bounce-backs. Bounce-backs may serve as a simple predictor for identifying stroke patients at extremely high risk for poor outcomes.

Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care

BACKGROUND

Medication discrepancies at the time of hospital discharge are common and can result in error, patient/carer inconvenience or patient harm. Providing accurate medication information to the next care provider is necessary to prevent adverse events.

AIMS

To investigate the quality and consistency of medication details generated for such transfer from an Irish teaching hospital.

METHODS

This was an observational study of 139 cardiology patients admitted over a 3 month period during which a pharmacist prospectively recorded details of medication inconsistencies.

RESULTS

A discrepancy in medication documentation at discharge occurred in 10.8% of medication orders, affecting 65.5% of patients. While patient harm was assessed, it was only felt necessary to contact three (2%) patients. The most common inconsistency was drug omission (20.9%).

CONCLUSIONS

Inaccuracy of medication information at hospital discharge is common and compromises quality of care.

Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients

BACKGROUND

There is growing interest in the use of interactive telephone technology to support chronic disease management. We used the implementation of an automated telephone self-management support program for diabetes patients as an opportunity to monitor patient safety.

METHODS

We identified adverse and potential adverse events among a diverse group of diabetes patients who participated in an automated telephone health-IT self-management program via weekly interactions augmented by targeted nurse follow-up. We defined an adverse event (AE) as an injury that results from either medical management or patient self-management, and a potential adverse event (PotAE) as an unsafe state likely to lead to an event if it persists without intervention. We distinguished between incident, or new, and prevalent, or ongoing, events. We conducted a medical record review and present summary results for event characteristics including detection trigger, preventability, potential for amelioration, and primary care provider awareness.

RESULTS

Among the 111 patients, we identified 111 AEs and 153 PotAEs. Eleven percent of completed calls detected an event. Events were most frequently detected through health IT-facilitated triggers (158, 59%), followed by nurse elicitation (80, 30%), and patient callback requests (28, 11%). We detected more prevalent (68%) than incident (32%) events. The majority of events (93%) were categorized as preventable or ameliorable. Primary care providers were aware of only 13% of incident and 60% of prevalent events.

CONCLUSIONS

Surveillance via a telephone-based, health IT-facilitated self-management support program can detect AEs and PotAEs. Events detected were frequently unknown to primary providers, and the majority were preventable or ameliorable, suggesting that this between-visit surveillance, with appropriate system-level intervention, can improve patient safety for chronic disease patients.

Implementing patient safety interventions in your hospital: what to try and what to avoid

Hospitalists play an important role in improving patient safety through clinical expertise and leadership in hospital quality improvement activities. The evidence base in patient safety remains incomplete, despite an increasing body of published research in recent years. Thus, physicians must consider other factors in addition to the strength of evidence supporting a practice when deciding which patient safety interventions to implement. These factors include the prevalence of the safety problem targeted, the potential for unintended consequences of the intervention, the costs and complexity of implementing the intervention, and the potential of the intervention to generate momentum for further safety initiatives. In this article, the authors define a framework for evaluating patient safety interventions and discuss specific interventions hospitalists should consider.

Care transitions for hospitalized patients

Ensuring safe care transitions is a core part of hospital medicine. These transitions include inpatient-outpatient transitions and in-hospital transitions. To ensure safe care during these transitions, clinicians should be aware of the types of transitions and the way in which these transitions can impede safe patient care. With this knowledge, strategies to ensure patient safety during care transitions can be adopted and training directed at teaching physicians safe hands-off practices could be developed and supported.

Medication Use in the Transition from Hospital to Home

After hospital discharge, correct understanding and use of medications are key components of patient safety. The current discharge process does not provide adequate fail-safes to ensure quality post-discharge care. This often leads to preventable medication errors as well as non-adherence. Several barriers to successful discharge counselling, including use of medical jargon, lack of educational and administrative resources, time constraints, and low health literacy, contribute to ineffective communication between hospital physicians and patients. Other obstacles include inaccurate or incomplete documentation of the medication history, lack of social support, financial constraints, and poor transfer of information to outpatient physicians. Solutions to improve medication use in the transition period after hospital discharge require effective communication with patients through the use of easily understood language, highlighting key information, and ensuring patient comprehension through the “teach back” technique. More timely communication with outpatient physicians in addition to a more comprehensive transfer of information further facilitates the transition home. Finally, a systematic process of medication reconciliation also aids in decreasing the incidence of medication errors. Hospital-based physicians who attend to key details in the process of discharging patients can have a profound impact on improving medication adherence, avoiding medication errors, and decreasing adverse outcomes in the post-discharge period. Key words: Communication, Hospital medicine, Medication adherence, Medication reconcilia-tion, Patient education

Clopidogrel-taking behavior by drug-eluting stent patients: Discontinuers versus continuers

BACKGROUND

Each day, patients make choices whether or not to take their prescribed medications. Previous research has shown that 1 in 7 myocardial infarction (MI) patients discontinued thienopyridines within 1 month of receiving a drug-eluting stent (DES) with serious consequences. This qualitative research study explored in depth the clopidogrel-taking behavior among DES-treated patients who quit taking clopidogrel 1 month after treatment and those who continued therapy.

METHODS

Sequential patients from a prospective MI registry who reported discontinuing clopidogrel within 30 days of DES treatment (N = 11) were matched with continuers (N = 11). Both groups underwent detailed qualitative phone interviews. Coding and thematic representation using directed qualitative content analysis by 3 PhD researchers was done.

RESULTS

Patients were 41-77 years old and the majority was Caucasian and male. Multiple barriers were described by discontinuers that were not reported by continuers. The most frequently cited barrier was misunderstanding the intended duration of treatment. Discontinuers also described system weaknesses that contributed to early discontinuance such as gaps in the transition to primary care.

CONCLUSIONS

While premature discontinuation of a prescribed therapy is viewed by clinicians as a willful disregard for medical advice, early stopping of clopidogrel is influenced greatly by processes of care and system issues.

Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists

The period following discharge from the hospital is a vulnerable time for patients. About half of adults experience a medical error after hospital discharge, and 19%-23% suffer an adverse event, most commonly an adverse drug event. This article reviews several important challenges to providing high-quality care as patients leave the hospital. These include the discontinuity between hospitalists and primary care physicians, changes to the medication regimen, new self-care responsibilities that may stress available resources, and complex discharge instructions. We also discuss approaches to promoting more effective transitions of care, including improvements in communication between inpatient and outpatient physicians, effective reconciliation of prescribed medication regimens, adequate education of patients about medication use, closer medical follow-up, engagement with social support systems, and greater clarity in physician-patient communication. By understanding the key challenges and adopting strategies to improve patient care in the transition from hospital to home, hospitalists could significantly reduce medical errors in the postdischarge period.

Management of breakthrough seizures in the emergency department: continuity of patient care

BACKGROUND

Epilepsy is a chronic disorder requiring long-term management. Communication between emergency physicians, neurologists, and primary care physicians (PCPs) is especially critical for the continuity of care for patients who present in an emergency department (ED) with a breakthrough seizure. Therefore, maximizing communication between the emergency physician and the PCP is of the utmost importance. The emergency physician, who is on the front line, must gather the information necessary to identify the underlying cause of the seizure and decide whether the pharmaceutical management must be changed.

SCOPE

This paper provides a clinical commentary on issues to consider when managing breakthrough seizures in the ED, to inform and facilitate communication between emergency physicians, consulting neurologists, and PCPs.

CONCLUSIONS

Clinical management decisions, especially when considering adjustment in an antiepileptic drug (AED) regimen, are often best made in coordination with a consulting neurologist. Increasing emergency physicians' comfort level regarding the use of newer-generation AEDs can improve the dialogue between the emergency physician and neurologist and the dialogue with the patient. Understanding the risks and benefits of the newer AEDs will assist the emergency physician in clinical decision making and, it is hoped, improve clinical outcomes. To preserve continuity of patient care, a patient's treating physician should be notified of all the particulars of the ED visit, and an appointment should be scheduled at the time of discharge for follow-up evaluation.