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Weetman K, Dale J, Scott E, Schnurr S. Discharge communication study: a realist evaluation of discharge communication experiences of patients, general practitioners and hospital practitioners, alongside a corresponding discharge letter sample. BMJ Open 2021; 11:e045465. [PMID: 34290064 PMCID: PMC8296817 DOI: 10.1136/bmjopen-2020-045465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To develop a programme theory for the intervention of patients receiving discharge letters. DESIGN We used a realist evaluation approach and captured multiple perspectives of hospital discharge to refine our previously developed programme theory. General practitioner (GP), patient and hospital clinician views of a single discharge event in which they were all involved were collected using semi-structured interviews and surveys. These were then triangulated to match the corresponding discharge letter. Data were qualitatively synthesised and compared in meta-matrices before interrogation with realist logic of analysis to develop the programme theory that maps out how patients receiving discharge letters works in specific contexts. SETTING 14 GP practices and four hospital trusts in West Midlands, UK. PARTICIPANTS 10 complete matched cases (GP, patient and hospital practitioner), and a further 26 cases in which a letter was matched with two out of the three participants. RESULTS We identified seven context mechanism outcome configurations not found through literature searching. These related to the broad concepts of: patient preference for receiving letters, patient comprehension of letters, patient-directed letters, patient harm and clinician views on patients receiving letters. 'Patient choice' was important to the success (or not) of the intervention. Other important contexts for positive effects included: letters written in plain English, lay explanations for jargon, verbal information also provided, no new information in letter and patient choice acknowledged. Three key findings were: patient understanding is perhaps greater than clinicians perceive, clinician attitudes are a barrier to patients receiving letters and that, negative outcomes more commonly manifested when patients had not received letters, rather than when they had. CONCLUSIONS We suggest how patients receiving discharge letters could be improved to enhance patient outcomes. Our programme theory has potential for use in different healthcare contexts and as a framework for policy development relating to patient discharge.
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Affiliation(s)
- Katharine Weetman
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Emma Scott
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
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Weetman K, Dale J, Spencer R, Scott E, Schnurr S. GP perspectives on hospital discharge letters: an interview and focus group study. BJGP Open 2020; 4:bjgpopen20X101031. [PMID: 32398346 PMCID: PMC7330207 DOI: 10.3399/bjgpopen20x101031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Written discharge communication following inpatient or outpatient clinic discharge is essential for communicating information to the GP, but GPs' opinions on discharge communication are seldom sought. Patients are sometimes copied into this communication, but the reasons for this variation, and the resultant effects, remain unclear. AIM To explore GP perspectives on how discharge letters can be improved in order to enhance patient outcomes. DESIGN & SETTING The study used narrative interviews with 26 GPs from 13 GP practices within the West Midlands, England. METHOD Interviews were transcribed and data were analysed using corpus linguistics (CL) techniques. RESULTS Elements pivotal to a successful letter were: diagnosis, appropriate follow-up plan, medication changes and reasons, clinical summary, investigations and/or procedures and outcomes, and what information has been given to the patient. GPs supported patients receiving discharge letters and expounded a number of benefits of this practice; for example, increased patient autonomy. Nevertheless, GPs felt that if patients are to receive direct discharge letter copies, modifications such as use of lay language and avoidance of acronyms may be required to increase patient understanding. CONCLUSION GPs reported that discharge letters frequently lacked content items they assessed to be important; GPs highlighted that this can have subsequent ramifications on resources and patient experiences. Templates should be devised that put discharge letter elements assessed to be important by GPs to the forefront. Future research needs to consider other perspectives on letter content, particularly those of patients.
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Affiliation(s)
- Katharine Weetman
- Unit of Academic Primary Care, University of Warwick, Warwick Medical School, Coventry, UK
| | - Jeremy Dale
- Unit of Academic Primary Care, University of Warwick, Warwick Medical School, Coventry, UK
| | - Rachel Spencer
- Unit of Academic Primary Care, University of Warwick, Warwick Medical School, Coventry, UK
| | - Emma Scott
- Unit of Academic Primary Care, University of Warwick, Warwick Medical School, Coventry, UK
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Weetman K, Dale J, Scott E, Schnurr S. Adult patient perspectives on receiving hospital discharge letters: a corpus analysis of patient interviews. BMC Health Serv Res 2020; 20:537. [PMID: 32539716 PMCID: PMC7294646 DOI: 10.1186/s12913-020-05250-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND UK government guidelines and initiatives emphasise equity in delivery of care, shared decision-making, and patient-centred care. This includes sharing information with patients as partners in health decisions and empowering them to manage their health effectively. In the UK, general practitioners (GPs) routinely receive hospital discharge letters; while patients receiving copies of such letters is seen as "good practice" and recommended, it is not standardised. The effects and consequences of whether or not this happens remains unclear. The aim of this study (one of three forming the Discharge Communication Study) was to explore patient perspectives on receiving discharge letters and their views on how this could be improved in order to optimise patient experience and outcomes. METHODS Semi-structured interviews were conducted with a diverse sample of 50 patients recruited from 17 GP surgeries within the West Midlands, UK. All participants were adults with a recent episode of general hospital inpatient or outpatient care. Data were audio recorded, transcribed and analysed using mixed methods corpus linguistics techniques. RESULTS Participants reported inconsistent access to discharge letters. Most wanted to receive a copy of their discharge letter although some expressed reservations. Perceived benefits included: increased understanding of their condition and treatment, reduced anxiety, and increased satisfaction. Consequences where participants had not received letters included: letter inaccuracies being overlooked, missed follow up actions, failure to fully remember diagnosis, treatment, or self-management or recommendations, and confusion and anxiety at what occurred and what will happen next. Participants felt the usefulness of receiving copies of letters could be increased by: including a patient information section, avoidance of acronyms, and jargon or technical terms explained with lay language. CONCLUSIONS Most patients value receiving copies of hospital discharge letters, and should be consistently offered them. Patients' preferences for letter receipt could be logged in their health records. To enable positive outcomes letters should have a clear and accessible format that reflects the priorities and information needs of patients. Patients appear not to be receiving or being offered copies of letters consistently despite UK policies and guidelines supporting this practice; this suggests a need for greater standardisation of practice.
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Affiliation(s)
- Katharine Weetman
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Jeremy Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Emma Scott
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
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Weetman K, Wong G, Scott E, MacKenzie E, Schnurr S, Dale J. Improving best practice for patients receiving hospital discharge letters: a realist review. BMJ Open 2019; 9:e027588. [PMID: 31182447 PMCID: PMC6561435 DOI: 10.1136/bmjopen-2018-027588] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/25/2019] [Accepted: 05/15/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To understand how different outcomes are achieved from adult patients receiving hospital discharge letters from inpatient and outpatient settings. DESIGN Realist review conducted in six main steps: (1) development of initial theory, (2) searching, (3) screening and selection, (4) data extraction and analysis, (5) data synthesis and (6) programme theory (PT) refinement. ELIGIBILITY CRITERIA Documents reporting evidence that met criteria for relevance to the PT. Documents relating solely to mental health or children aged <18 years were excluded. ANALYSIS Data were extracted and analysed using a realist logic of analysis. Texts were coded for concepts relating to context, mechanism, outcome configurations (CMOCs) for the intervention of patients receiving discharge letters. All outcomes were considered. Based on evidence and our judgement, CMOCs were labelled 'positive' or 'negative' in order to clearly distinguish between contexts where the intervention does and does not work. RESULTS 3113 documents were screened and 103 were included. Stakeholders contributed to refining the PT in step 6. The final PT included 48 CMOCs for how outcomes are affected by patients receiving discharge letters. 'Patient choice' emerged as a key influencer to the success (or not) of the intervention. Important contexts were identified for both 'positive' CMOCs (eg, no new information in letter) and 'negative' CMOCs (eg, letter sent without verifying patient contact details). Two key findings were that patient understanding is possibly greater than clinicians perceive, and that patients tend to express strong preference for receiving letters. Clinician concerns emerged as a barrier to wider sharing of discharge letters with patients, which may need to be addressed through organisational policies and direction. CONCLUSIONS This review forms a starting point for explaining outcomes associated with whether or not patients receive discharge letters. It suggests several ways in which current processes might be modified to support improved practice and patient experience.
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Affiliation(s)
- Katharine Weetman
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Emma Scott
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Jeremy Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
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Harris E, Rob P, Underwood J, Knapp P, Astin F. Should patients still be copied into their letters? A rapid review. PATIENT EDUCATION AND COUNSELING 2018; 101:2065-2082. [PMID: 30420045 DOI: 10.1016/j.pec.2018.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/20/2018] [Accepted: 06/24/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To systematically identify, synthesise and evaluate the strength of the international evidence on copy letter practice. METHODS A systematic search identified original research studies on copy letters. Searches were limited by date and language as permitted in rapid review methods guidance. Article screening, data extraction and strength of evidence assessment were completed independently by multiple authors. RESULTS Thirty-seven studies were included. There was a lack of information about copy letter content. Many patients report being satisfied with copy letters, understand them and find them useful. However, there is a lack of objective, high quality evidence to suggest that copy letters increased patient understanding or improved physical or psychological health outcomes. Many letters were written at a level which would make them inaccessible to patients with low health literacy. The strength of evidence was either "emerging" or "acceptable" practice for most studies (n = 30). CONCLUSION There is a lack of objective, high quality evidence to demonstrate the benefits of copy letters as described in health policy. PRACTICE IMPLICATIONS Personalising letters and using lay rather than medical terms appears to be useful for improving copy letter readability. Further research is required to explore this, especially in people with low health literacy levels.
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Affiliation(s)
- Emma Harris
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK.
| | - Priyanka Rob
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Janet Underwood
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Peter Knapp
- Department of Health Sciences and the Hull York Medical School, University of York, York, UK
| | - Felicity Astin
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
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From the laboratory to the clinic: sharing BRCA VUS reclassification tools with practicing genetics professionals. J Community Genet 2017; 9:209-215. [PMID: 29124491 DOI: 10.1007/s12687-017-0343-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 10/19/2017] [Indexed: 10/18/2022] Open
Abstract
Despite ongoing research efforts to reclassify BRCA variant of uncertain significance (VUS), results for strategies to disseminate findings to genetic counselors are lacking. We disseminated results from a study on reclassification of BRCA VUS using a mailed reclassification packet including a reclassification guide, patient education aid, and patient letter template for patients/families with BRCA VUS. This study reports on genetic counselors' responses to the dissemination materials. Eligible participants (n = 1015) were identified using mailing lists from professional genetics organizations. Participants were mailed a BRCA VUS reclassification packet and a return postcard to assess responses to the materials. Closed-ended responses were analyzed using descriptive statistics, and thematic analysis was conducted on open-ended responses. In response to the mailing, 128 (13.0%) genetic counselors completed and returned postcards. The majority of respondents (n = 117; 91.4%) requested the patient letter template and patient education guides as PDFs (n = 122; 95.3%). The majority (n = 123; 96.9%) wanted an updated reclassification guide upon availability. Open-ended responses demonstrate the material was well-received; some specified they would tailor the patient letter to fit their practice and patients' needs. Participants requested additional patient and provider educational materials for use in practice. Materials communicating BRCA VUS reclassification updates were liked and were likely to be used in practice. To achieve the benefits of VUS reclassification in clinical practice, ongoing efforts are needed to continuously and effectively disseminate findings to providers and patients.
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Assessment of the Readability of Genetic Counseling Patient Letters. J Genet Couns 2015; 25:454-60. [DOI: 10.1007/s10897-015-9890-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 09/16/2015] [Indexed: 10/23/2022]
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Cachat F, Marques-Vidal P, Girardin E, Chehade H, Piot-Ziegler C. Parents and primary care physicians have different views about copying medical letters to parents after paediatric outpatient visits. Acta Paediatr 2014; 103:e459-64. [PMID: 24953484 DOI: 10.1111/apa.12725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 04/11/2014] [Accepted: 06/17/2014] [Indexed: 11/30/2022]
Abstract
AIM We assessed how satisfied parents were when they received a copy of the letter sent to their primary care physician after their child attended a hospital outpatient clinic and compared their views with those of the primary care physician. METHODS Anonymised questionnaires were sent to parents, and their primary care physician, after their child had visited a paediatric nephrology unit. RESULTS We received responses from 112 parents (46%) and 69 primary care physicians (93%). Most parents (97%) were satisfied with the process, 94% thought that the letter was a true reflection of the outpatient consultation and easy to understand, and 55% read it to their child. However, 21% would have preferred a simpler letter. More than a third (37%) of the primary care physicians did not approve of the parents being sent the letter, and 30% felt that the letter was difficult for the parents to understand and should be replaced with a simpler letter. CONCLUSION Most parents (97%) appreciated receiving a copy of the letter following their child's outpatient clinic visit, and 95% understood its contents. More than half (55%) read the letter to their child. However, 37% of primary care physicians did not approve of the practice.
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Affiliation(s)
- Francois Cachat
- Division of Paediatric Nephrology; Department of Paediatrics; University Hospital; Lausanne Switzerland
| | - Pedro Marques-Vidal
- Division of Biostatistics; Institute of Social and Preventive Medicine; University Hospital of Lausanne; Lausanne Switzerland
| | - Eric Girardin
- Division of Paediatric Nephrology; Department of Paediatrics; University Hospital; Geneva Switzerland
| | - Hassib Chehade
- Division of Paediatric Nephrology; Department of Paediatrics; University Hospital; Lausanne Switzerland
| | - Chantal Piot-Ziegler
- Department of Psychology, Health Psychology; University of Lausanne; Lausanne Switzerland
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Developing patient-friendly genetic and genomic test reports: formats to promote patient engagement and understanding. Genome Med 2014; 6:58. [PMID: 25473429 PMCID: PMC4254435 DOI: 10.1186/s13073-014-0058-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 07/23/2014] [Indexed: 11/10/2022] Open
Abstract
With the emergence of electronic medical records and patient portals, patients are increasingly able to access their health records, including laboratory reports. However, laboratory reports are usually written for clinicians rather than patients, who may not understand much of the information in the report. While several professional guidelines define the content of test reports, there are no guidelines to inform the development of a patient-friendly laboratory report. In this Opinion, we consider patient barriers to comprehension of lab results and suggest several options to reformat the lab report to promote understanding of test results and their significance to patient care, and to reduce patient anxiety and confusion. In particular, patients’ health literacy, genetic literacy, e-health literacy and risk perception may influence their overall understanding of lab results and affect patient care. We propose four options to reformat lab reports: 1) inclusion of an interpretive summary section, 2) a summary letter to accompany the lab report, 3) development of a patient user guide to be provided with the report, and 4) a completely revised patient-friendly report. The complexity of genetic and genomic test reports poses a major challenge to patient understanding that warrants the development of a report more appropriate for patients.
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