Impact of providing patients with copies of their medical correspondence: a randomised controlled study

Treat to target in Crohn's disease: A practical guide for clinicians

A treat-to-target (T2T) approach applies the principles of early intervention and tight disease control to optimise long-term outcomes in Crohn's disease. The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE)-II guidelines specify short, intermediate, and long-term treatment goals, documenting specific treatment targets to be achieved at each of these timepoints. Scheduled appraisal of Crohn's disease activity against pre-defined treatment targets at these timepoints remains central to determining whether current therapy should be continued or modified. Consensus treatment targets in Crohn's disease comprise combination clinical and patient-reported outcome remission, in conjunction with biomarker normalisation and endoscopic healing. Although the STRIDE-II guidelines endorse the pursuit of endoscopic healing, clinicians must consider that this may not always be appropriate, acceptable, or achievable in all patients. This underscores the need to engage patients at the outset in an effort to personalise care and individualise treatment targets. The use of non-invasive biomarkers such as faecal calprotectin in conjunction with cross-sectional imaging techniques, particularly intestinal ultrasound, holds great promise; as do emerging treatment targets such as transmural healing. Two randomised clinical trials, namely, CALM and STARDUST, have evaluated the efficacy of a T2T approach in achieving endoscopic endpoints in patients with Crohn's disease. Findings from these studies reflect that patient subgroups and Crohn's disease characteristics likely to benefit most from a T2T approach, remain to be clarified. Moreover, outside of clinical trials, data pertaining to the real-world effectiveness of a T2T approach remains scare, highlighting the need for pragmatic real-world studies. Despite the obvious promise of a T2T approach, a lack of guidance to support its integration into real-world clinical practice has the potential to limit its uptake. This highlights the need to describe strategies, processes, and models of care capable of supporting the integration and execution of a T2T approach in real-world clinical practice. Hence, this review seeks to examine the current and emerging literature to provide clinicians with practical guidance on how to incorporate the principles of T2T into routine clinical practice for the management of Crohn's disease.

Discharge communication study: a realist evaluation of discharge communication experiences of patients, general practitioners and hospital practitioners, alongside a corresponding discharge letter sample

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.

Adult patient perspectives on receiving hospital discharge letters: a corpus analysis of patient interviews

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.

Patient Experiences with Colonoscopy: A Qualitative Study

Background

Patient perspectives have important roles in improving the quality of colonoscopy services. The purpose of this qualitative study was to obtain the perspectives of patients who recently had undergone colonoscopy procedures, about their experiences with bowel preparation, the procedure itself, and communication of follow-up results and recommendations.

Methods

We recruited adults who had undergone a colonoscopy, to participate in semistructured interviews. Interviews were audiotaped, transcribed and analyzed using inductive qualitative methods.

Results

Twenty-four adults (58% female) with an average age of 53.8 years participated. Results were categorized within the themes of bowel preparation, the colonoscopy procedure and communication of the results. Participants appreciated having clear consistent plain language messages about bowel preparation. Some participants experienced additional challenges to understanding, and navigating, colonoscopy procedures. At the time of the procedure, positive and reassuring interactions with, and between, members of the health care team, in addition to management of physical pain and discomfort, were important. Participants wanted clear and timely information about the results of their test.

Conclusions

Understanding patients' needs for information and support can promote higher quality colonoscopy services. Our findings suggest that quality indicators should include: patients' perspectives of the clarity of bowel instructions; the need for supports that are not routinely provided; the extent to which concerns about the procedure are addressed; interactions with the endoscopy team; the endoscopy team's interactions with each other; comfort during the procedure, and the timeliness and clarity of results and follow-up instructions. These indicators should be included in annual patient surveys.

Improving best practice for patients receiving hospital discharge letters: a realist review

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.

Should patients still be copied into their letters? A rapid review

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.