What we have here is a failure to communicate! Improving communication between tertiary to primary care for chronic heart failure patients

How can communication to GPs at hospital discharge be improved? A systems approach

Background

Poor communication to GPs at hospital discharge threatens patient safety and continuity of care, with reliance on discharge summaries that are commonly written by the most junior doctors. Previous quality improvement efforts have largely focused on adherence to standardised templates, with limited success. A lack of understanding has been identified as a cause of the issue’s resistance to decades of improvement work.

Aim

To understand the system of communication to GPs at hospital discharge, with a view to identifying potential routes to improvement.

Design & setting

A qualitative exploration of the secondary-to-primary care communication system surrounding a large UK hospital.

Method

A systems approach, recently defined for the healthcare domain, was used to structure and thematically analyse interviews (n = 18) of clinical and administrative staff from both sides of the primary–secondary care interface, and a subsequent focus group.

Results

The largely one-way communication system structure and the low level of hospital stakeholder insight into recipient GP needs emerged as consistent hindrances to system performance. More open lines of communication and shared records might enable greater collaboration to share feedback and resolve informational deficits. Teaching sessions and assessments for medical students and junior doctors led by GPs could help to instil the importance of detail and nuance when using standardised communication templates.

Conclusion

Facilitating the sharing of performance insights between stakeholder groups emerged as the key theme of how communication might be improved. The empirical measures proposed have the potential to mitigate the safety risks of key barriers to performance such as patient complexity.

Evaluating a cardiovascular disease risk management care continuum within a learning healthcare system: a prospective cohort study

BACKGROUND

Many patients now present with multimorbidity and chronicity of disease. This means that multidisciplinary management in a care continuum, integrating primary care and hospital care services, is needed to ensure high quality care.

AIM

To evaluate cardiovascular risk management (CVRM) via linkage of health data sources, as an example of a multidisciplinary continuum within a learning healthcare system (LHS).

DESIGN & SETTING

In this prospective cohort study, data were linked from the Utrecht Cardiovascular Cohort (UCC) to the Julius General Practitioners' Network (JGPN) database. UCC offers structured CVRM at referral to the University Medical Centre (UMC) Utrecht. JGPN consists of electronic health record (EHR) data from referring GPs.

METHOD

The cardiovascular risk factors were extracted for each patient 13 months before referral (JGPN), at UCC inclusion, and during 12 months follow-up (JGPN). The following areas were assessed: registration of risk factors; detection of risk factor(s) requiring treatment at UCC; communication of risk factors and actionable suggestions from the specialist to the GP; and change of management during follow-up.

RESULTS

In 52% of patients, ≥1 risk factors were registered (that is, extractable from structured fields within routine care health records) before UCC. In 12%-72% of patients, risk factor(s) existed that required (change or start of) treatment at UCC inclusion. Specialist communication included the complete risk profile in 67% of letters, but lacked actionable suggestions in 86%. In 29% of patients, at least one risk factor was registered after UCC. Change in management in GP records was seen in 21%-58% of them.

CONCLUSION

Evaluation of a multidisciplinary LHS is possible via linkage of health data sources. Efforts have to be made to improve registration in primary care, as well as communication on findings and actionable suggestions for follow-up to bridge the gap in the CVRM continuum.

Pharmacist-Physician Collaboration to Improve the Accuracy of Medication Information in Electronic Medical Discharge Summaries: Effectiveness and Sustainability

Inaccurate or missing medication information in medical discharge summaries is a widespread and intractable problem. This study evaluated the effectiveness and sustainability of an intervention in which ward-based hospital pharmacists reviewed, contributed and verified medication information in electronic discharge summaries (EDSs) in collaboration with physicians. Retrospective audits of randomly selected EDSs were conducted on seven wards at a major public hospital before and after implementation of the intervention and repeated two years later on four wards where the intervention was incorporated into usual pharmacist care. EDSs for 265 patients (prescribed a median of nine discharge medications) were assessed across the three time points. Pharmacists verified the EDSs for 47% patients in the first post-intervention audit and 68% patients in the second post-intervention audit. Following the intervention, the proportion of patients with one or more clinically significant discharge medication list discrepancy fell from 40/93 (43%) to 14/92 (15%), p < 0.001. The proportion of clinically significant medication changes stated in the EDSs increased from 222/417 (53%) to 296/366 (81%), p < 0.001, and the proportion both stated and explained increased from 206/417 (49%) to 245/366 (67%), p < 0.001. Significant improvements were still evident after two years. Pharmacists spent a median of 5 (range 2-16) minutes per patient contributing to EDSs. Logistics, timing and pharmacist workload were barriers to delivering the intervention. Additional staff resources is needed to enable pharmacists to consistently deliver this effective intervention.

An audit of the accuracy of medication information in electronic medical discharge summaries linked to an electronic prescribing system

BACKGROUND

Poor communication of medication information to general practitioners when patients are discharged from hospital is a widely recognised problem. There has been little research exploring the accuracy of medication information in electronic discharge summaries (EDS) linked to hospital e-prescribing systems.

OBJECTIVE

To evaluate the accuracy of medication lists and medication change information in EDS produced using an integrated e-prescribing and EDS system (where EDS discharge medication lists were imported from discharge e-prescription records, medication change information was manually entered, and medications were dispensed from paper copies of the patients' e-prescriptions).

METHOD

Retrospective audit of EDSs for a random sample, representative of adult patients ( n = 87) discharged from a major teaching hospital. EDS medication lists were compared to pharmacist-verified paper discharge prescriptions (considered to be the most accurate discharge medication list) to identify discrepancies. EDS medication change information was compared to medication changes identified by comparing pharmacist-verified "Medication History on Admission" forms with pharmacist-verified paper discharge prescriptions.

RESULTS

There were 85/87 (98%) EDSs that included a discharge medication list. Of these, 50/85 (59%) contained one or more medication list discrepancies (median 1, range 0-15). The most common discrepancy was omission of medication (58%); 84/131 (64%) discrepancies were considered clinically significant (risk of adverse outcome); 162/351 (46%) clinically significant medication changes were stated in the EDS; and 153/351 (44%) changes were both stated and included a reason.

CONCLUSION

EDS discrepancies were common despite integration with e-prescribing. Eliminating paper prescriptions, enhancing e-prescribing/EDS functionality and involving pharmacists in EDS preparation may reduce discrepancies.

Improving communication of medication changes using a pharmacist-prepared discharge medication management summary

Background Discontinuity of care between hospital and primary care is often due to poor information transfer. Medication information in medical discharge summaries (DS) is often incomplete or incorrect. The effectiveness and feasibility of hospital pharmacists communicating medication information, including changes made in the hospital, is not clearly defined. Objective To explore the impact of a pharmacist-prepared Discharge Medication Management Summary (DMMS) on the accuracy of information about medication changes provided to patients' general practitioners (GPs). Setting Two medical wards at a major metropolitan hospital in Australia. Method An intervention was developed in which ward pharmacists communicated medication change information to GPs using the DMMS. Retrospective audits were conducted at baseline and after implementation of the DMMS to compare the accuracy of information provided by doctors and pharmacists. GPs' satisfaction with the DMMS was assessed through a faxed survey. Main outcome measure Accuracy of medication change information communicated to GPs; GP satisfaction and feasibility of a pharmacist-prepared DMMS. Results At baseline, 263/573 (45.9%) medication changes were documented by doctors in the DS. In the post-intervention audit, more medication changes were documented in the pharmacist-prepared DMMS compared to the doctor-prepared DS (72.8% vs. 31.5%; p < 0.001). Most GPs (73.3%) were satisfied with the information provided and wanted to receive the DMMS in the future. Completing the DMMS took pharmacists an average of 11.7 minutes. Conclusion The accuracy of medication information transferred upon discharge can be improved by expanding the role of hospital pharmacists to include documenting medication changes.

Prescribing and up-titration in recently hospitalized heart failure patients attending a disease management program

BACKGROUND

Heart failure (HF) medications improve clinical outcomes, with optimal doses defined in clinical trials. Patient, provider and system barriers may limit achievement of optimal doses in real life settings, although disease management programs (HF-DMPs) can facilitate up-titration.

METHODS AND RESULTS

Secondary analysis of a prospective cohort of 216 participants recently hospitalized with systolic HF, attending 5 HF-DMPs in Queensland, Australia. Medication history at baseline (6weeks after discharge) and 6months provided data to describe prescription rates, dosage and optimal titration of HF medications, and associations with patient and system factors were explored. At baseline, 94% were on an angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB), 94% on a beta-blocker (BB) and 42% on a mineralocorticoid receptor antagonist (MRA). The proportion of participants on optimal doses of ACEI/ARB increased from 38% (baseline) to 52% (6months, p=0.001) and on optimal BB dose from 23% to 49% (p<0.001). Significant barriers to ACEI/ARB up-titration were body mass index (BMI)<25, female gender, polypharmacy, previously diagnosed HF, and tertiary hospital. Significant barriers for BB up-titration were BMI<25, previously diagnosed HF and non-cardiologist care.

CONCLUSIONS

Effective up-titration in HF DMPs is influenced by patient, disease and service factors. Better understanding of barriers to effective up-titration in women, normal weight, and established HF patients may help provide targeted strategies for improving outcomes in these groups.

Implementation of an electronic surgical referral service. Collaboration, consensus and cost of the surgeon - general practitioner Delphi approach

Background

Poor coordination between levels of care plays a central role in determining the quality and cost of health care. To improve patient coordination, systematic structures, guidelines, and processes for creating, transferring, and recognizing information are needed to facilitate referral routines.

Methods

Prospective observational survey of implementation of electronic medical record (EMR)-supported guidelines for surgical treatment.

Results

One university clinic, two local hospitals, 31 municipalities, and three EMR vendors participated in the implementation project. Surgical referral guidelines were developed using the Delphi method; 22 surgeons and seven general practitioners (GPs) needed 109 hours to reach consensus. Based on consensus guidelines, an electronic referral service supported by a clinical decision support system, fully integrated into the GPs’ EMR, was developed. Fifty-five information technology personnel and 563 hours were needed (total cost 67,000 £) to implement a guideline supported system in the EMR for 139 GPs. Economical analyses from a hospital and societal perspective, showed that 504 (range 401–670) and 37 (range 29–49) referred patients, respectively, were needed to provide a cost-effective service.

Conclusion

A considerable amount of resources were needed to reach consensus on the surgical referral guidelines. A structured approach by the Delphi method and close collaboration between IT personnel, surgeons and primary care physicians were needed to reach consensus.

A qualitative study of a primary-care based intervention to improve the management of patients with heart failure: the dynamic relationship between facilitation and context

Background

There is currently a growing emphasis in primary care on upscaling the provision of evidence-based services for specific conditions, such as heart failure (HF), which have traditionally been seen as part of a specialist’s domain. While contextual challenges associated with improvement in primary care have been documented previously, we still know relatively little about how the intentional, theory-informed facilitation of evidence-based change is shaped by contextual factors within this healthcare setting. Hence, a qualitative study was conducted to address the question: How is the process of facilitating evidence-based practice affected by the context of primary care?

Methods

Data collection took place across general practices in northwest England as part of a process evaluation of the Greater Manchester HF Investigation Tool (GM-HFIT) - a programme of work aiming to improve the management of HF in primary care. Semi-structured interviews, with purposefully selected GM-HFIT team members (n = 9) and primary care practitioners (n = 7), were supplemented by observational data and a three-month diary reflecting on facilitation activities. Framework analysis was used to manage and interpret data.

Results

We describe a complex and dynamic interplay between facilitation and context, focusing on three major themes: (1) Addressing macro and micro agendas; (2) Forming a facilitative unit; (3) Maintaining momentum. We show that HF specialist nurses (HFSNs) have a high level of professional credibility, which allows them to play a key role in making recommendations to practices for improving patient care. At the same time, we argue that contextual factors, such as top-level endorsement, the necessity to comply with a performance measurement system, and the varying involvement of practice nurses produce tensions that can have both an enabling and constraining effect on the process of facilitation.

Conclusions

When facilitating the transfer of evidence, context is an important aspect to consider at a macro and micro level; a complex interplay can exist between these levels, which may constrain or enable efforts to amend practice. Those involved in facilitating change within primary care have to manage tensions arising from the interplay of these different contextual forces to minimise their impact on efforts to alter practice based on best evidence.

National survey of hospital strategies to reduce heart failure readmissions: findings from the Get With the Guidelines-Heart Failure registry

BACKGROUND

Reducing 30-day heart failure readmission rates is a national priority. Yet, little is known about how hospitals address the problem and whether hospital-based processes of care are associated with reductions in readmission rates.

METHODS AND RESULTS

We surveyed 100 randomly selected hospitals participating in the Get With the Guidelines-Heart Failure quality improvement program regarding common processes of care aimed at reducing readmissions. We grouped processes into 3 domains (ie, inpatient care, discharge and transitional care, and general quality improvement) and scored hospitals on the basis of survey responses using processes selected a priori. We used linear regression to examine associations between these domain scores and 30-day risk-standardized readmission rates. Of the 100 participating sites, 28% were academic centers and 64% were community hospitals. The median readmission rate among participating sites (24.0%; 95% CI, 22.6%-25.7%) was comparable with the national average (24.6%; 23.5-25.9). Sites varied substantially in care processes used for inpatient care, education, discharge process, care transitions, and quality improvement. Overall, neither inpatient care nor general quality improvement domains were associated with 30-day readmission rates. Hospitals in the lowest readmission rate quartile had modestly higher discharge and transitional care domain scores (P=0.03).

CONCLUSIONS

A variety of strategies are used by hospitals in an attempt to improve 30-day readmission rates for patients hospitalized with heart failure. Although more complete discharge and transitional care processes may be modestly associated with lower 30-day readmission rates, most current strategies are not associated with lower readmission rates.

Application of a prescribing indicators tool to assist in identifying drug-related problems in a cohort of older Australians

Objective

Drug-related problems (DRPs) are common in older people, resulting in a disproportionate number of serious medication adverse events. Pharmacist-led interventions have been shown to be effective in identifying and reducing DRPs such as medication interactions, omission of recommended medications and use of ineffective medications. In 2008 we proposed a prescribing indicators tool to assist in identifying DRPs as part of the Australian medication review process. The objective was to apply the proposed prescribing indicators tool to a cohort of older Australians, to assess its use in detecting potential DRPs.

Methods

The prescribing indicators tool was applied in a cross-sectional observational study to 126 older (aged ≥65 years) English-speaking Australians taking five or more medications, as they were being discharged from a small private hospital into the community. Indicators were unmet when prescribing did not adhere to indicator tool guidelines.

Key findings

We found a high incidence of under-treatment, and use of inappropriate medications. There were on average 18 applicable indicators per patient, with each patient having on average seven unmet indicators.

Conclusion

The use of a prescribing indicators tool for commonly used medications and common medical conditions in older Australians may contribute to the efficient identification of DRPs.