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A randomised trial deploying a simulation to investigate the impact of hospital discharge letters on patient care in general practice.

ABSTRACT: OBJECTIVE:To determine how the timing and length of hospital discharge letters impact on the number of ongoing patient problems identified by general practitioners (GPs). TRIAL DESIGN:GPs were randomised into four groups. Each viewed a video monologue of an actor-patient as he might present to his GP following a hospital admission with 10 problems. GPs were provided with a medical record as well as a long or short discharge letter, which was available when the video was viewed or 1?week later. GPs indicated if they would prescribe, refer or order tests for the patient's problems. METHODS:Setting Primary care. Participants Practising Australian GPs. Intervention A short or long hospital discharge letter enumerating patient problems. Outcome measure Number of ongoing patient problems out of 10 identified for management by the GPs. Randomisation 1:1 randomisation. Blinding (masking) Single-blind. RESULTS:Numbers randomised 59 GPs. Recruitment GPs were recruited from a network of 102 GPs across Australia. Numbers analysed 59 GPs. Outcome GPs who received the long letter immediately were more satisfied with this information (p<0.001). Those who received the letter immediately identified significantly more health problems (p=0.001). GPs who received a short, delayed discharge letter were less satisfied than those who received a longer delayed letter (p=0.03); however, both groups who received the delayed letter identified a similar number of health problems. GPs who were older, who practised in an inner regional area or who offered more patient sessions per week identified fewer health problems (p values <0.01, <0.05 and <0.05, respectively). Harms Nil. CONCLUSIONS:Receiving information during patient consultation, as well as GP characteristics, influences the number of patient problems addressed. TRIAL REGISTRATION NUMBER:ACTRN12614000403639.

SUBMITTER: Jiwa M

PROVIDER: S-EPMC4091507 | biostudies-literature | 2014 Jul

REPOSITORIES: biostudies-literature

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A randomised trial deploying a simulation to investigate the impact of hospital discharge letters on patient care in general practice.

Jiwa Moyez M Meng Xingqiong X O'Shea Carolyn C Magin Parker P Dadich Ann A Pillai Vinita V

BMJ open 20140708 7

<h4>Objective</h4>To determine how the timing and length of hospital discharge letters impact on the number of ongoing patient problems identified by general practitioners (GPs).<h4>Trial design</h4>GPs were randomised into four groups. Each viewed a video monologue of an actor-patient as he might present to his GP following a hospital admission with 10 problems. GPs were provided with a medical record as well as a long or short discharge letter, which was available when the video was viewed or ...[more]

PMID: 25005597

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Project description:670 patients attend Wansbeck General Hospital each year for elective and emergency permanent pacemaker insertion or modification. Elective patients for new devices attend the cardiology department on the day of procedure and are clerked onto the cardiology ward after insertion. Patients are discharged home the following day with a letter typed by a junior doctor. Prior to October 2011, junior doctors were unaware of any guidelines regarding content of discharge letters due to poor accessibility. Vital information such as pacemaker model and indication for implantation were frequently absent from the typed summaries. In October 2011, the cardiology department reviewed the guidelines establishing the information required in all discharge summaries for pacemaker implantation and these guidelines were published on the ward in an easy to follow proforma for any junior doctor typing letters. Eight essential criteria should be included in each letter; date and indication for insertion, pacemaker type, make and model, access route, complications, chest x-ray and device check results, and follow-up details. Finally, a copy of the letter was to be sent to the cardiology department for clinic follow-up. Ten letters were audited prior to the proforma being issued. 0 letters contained 100% of the required information. Main criteria missing in most letters included indication for insertion (50%), make of device (0%), the route of access (10%) and cc to cardiology department (0%). 70 letters were audited in October 2012, one year following introduction of the discharge proforma.100% of letters contained all of the eight essential criteria required by the departmental guidelines. 53% of the letters were also received by the cardiology department. In conclusion, a set of easy to follow guidelines in the form of a published document on the cardiology ward has produced dramatic improvement in the quality of e-discharge letters for patients undergoing permanent pacemaker implantation.

Project description:ObjectiveTo understand how different outcomes are achieved from adult patients receiving hospital discharge letters from inpatient and outpatient settings.DesignRealist 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 criteriaDocuments reporting evidence that met criteria for relevance to the PT. Documents relating solely to mental health or children aged <18?years were excluded.AnalysisData 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.Results3113 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.ConclusionsThis 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.

Project description:BackgroundUK 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.MethodsSemi-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.ResultsParticipants 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.ConclusionsMost 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.

Project description:BackgroundSharing information about hospital care with primary care in the form of a discharge summary is essential to patient safety. In the United Kingdom, although discharge summary targets on timeliness have been achieved, the quality of discharge summaries' content remains variable.MethodsMixed methods study in West Midlands, England with three parts: 1. General Practitioners (GPs) sampling discharge summaries they assessed to be "successful" or "unsuccessful" exemplars, 2. GPs commenting on the reasons for their letter assessment, and 3. surveying the hospital clinicians who wrote the sampled letters for their views. Letters were examined using content analysis; we coded 15 features (e.g. "diagnosis", "GP plan") based on relevant guidelines and standards. Free text comments were analysed using corpus linguistics, and survey data were analysed using descriptive statistics.ResultsFifty-three GPs participated in selecting discharge letters; 46 clinicians responded to the hospital survey. There were statistically significant differences between "successful" and "unsuccessful" inpatient letters (n = 375) in relation to inclusion of the following elements: reason for admission (99.1% vs 86.5%); diagnosis (97.4% vs 74.5%), medication changes (61.5% vs 48.9%); reasons for medication changes (32.1% vs 18.4%); hospital plan/actions (70.5% vs 50.4%); GP plan (69.7% vs 53.2%); information to patient (38.5% vs 24.8%); tests/procedures performed (97.0% vs 74.5%), and test/examination results (96.2% vs 77.3%). Unexplained acronyms and jargon were identified in the majority of the sample (≥70% of letters). Analysis of GP comments highlighted that the overall clarity of discharge letters is important for effective and safe care transitions and that they should be relevant, concise, and comprehensible. Hospital clinicians identified several barriers to producing "successful" letters, including: juniors writing letters, time limitations, writing letters retrospectively from patient notes, and template restrictions.ConclusionsThe failure to uniformly implement national discharge letter guidance into practice is continuing to contribute to unsuccessful communication between hospital and general practice. While the study highlighted barriers to producing high quality discharge summaries which may be addressed through training and organisational initiatives, it also indicates a need for ongoing audit to ensure the quality of letters and so reduce patient risk at the point of hospital discharge.

Project description:IntroductionDischarge documents are important for transferring information from hospitals to the referring clinician; in the UK and many countries, this is often the patient's general practitioner or family physician. However, patients may or may not receive their discharge letters, and whether patients should routinely receive discharge letters remains unclear.Methods and analysisThe review will consolidate evidence on patients receiving discharge letters through the theory-driven approach of a realist review.The review will be conducted systematically and seek to explain how, why, for whom and in what contexts does this practice 'work'. The review will specifically explore whether there are benefits of this practice and if so what are the important contexts for triggering the mechanisms associated with these outcome benefits. Negative effects will also be considered.Several steps will occur: devising initial rough programme theory, searching the evidence, selecting relevant documents, extracting data, synthesising and finally programme theory refinement. As the process is viewed as iterative, this cycle of steps may be repeated as many times as is necessary to reach theoretical saturation and may not be linear.The initial programme theory will be tested and refined throughout the review process and by stakeholder involvement of National Health Service (NHS) policy makers, practitioners and service users.Ethics and disseminationFormal ethical review is not required. The resulting programme theory is anticipated to explain how the intervention of patients receiving written discharge communication may work in practice, for whom and in what contexts; this will inform best practice of patients receiving discharge communication. The review findings will be disseminated in a peer-reviewed journal and presentations and discussions with relevant organisations and stakeholders. While the review will be from the perspective of the UK NHS, its findings should be relevant to other healthcare systems.Prospero registration numberCRD42017069863.

Project description:BackgroundAlthough absolute risk of death associated with raised blood pressure increases with age, the benefits of treatment are greater in older patients. However, fewer patients in this group are identified, treated, and controlled.AimTo evaluate the impact of the provision of different levels of feedback on identification, treatment, and control of older patients with hypertension.Design of studyRandomised controlled trial.SettingFifty-two Scottish general practices.MethodPractices were randomly allocated to either control (n = 19), audit only feedback (n = 16), or audit plus risk feedback, prioritising patients by absolute risk (n = 17). Electronic data were extracted from practice computer systems annually from 1999 to 2001 and used to develop feedback. Data were collected for 30 345 patients aged 65-79 years.ResultsThe majority of known patients with hypertension in each group had an initial blood pressure recorded (control = 89.6%; audit = 80.4%; risk = 96.1%) and this increased over the study period (control = 92.3%; audit = 86.0%; risk = 96.6%). Initially, more than 80% of patients in each group were treated but many were uncontrolled (blood pressure >/=160/ >/=90 mmHg) (control = 41.5%; audit = 41.3%; risk = 36.1%). The numbers of untreated and uncontrolled patients in each group reduced (control = 32.3%; audit = 38.3%; risk = 32.6%). There was some evidence of a significant difference in mean systolic pressure between the audit plus risk and audit only groups: (149.6 versus 152.7 mmHg; P = 0.019) and of significantly greater control in the audit plus risk group compared with the other groups 49.4% (versus audit only = 35.4%; versus control = 46.5%; odds ratio = 1.72 [95% confidence interval = 1.09 to 2.70]; P = 0.019).ConclusionsLevels of identification, treatment, and control improved in each group. Although there were still significant numbers of patients with uncontrolled hypertension, there is some evidence to suggest that providing patient-specific feedback may have a positive impact on identification and management of hypertension in older people and produce an increase in control.

Project description:ImportancePatient education at time of hospital discharge is critical for smooth transitions of care; however, empirical data regarding discharge communication are limited.ObjectiveTo describe whether key communication domains (medication changes, follow-up appointments, disease self-management, red flags, question solicitation, and teach-back) were addressed at the bedside on the day of hospital discharge, by whom, and for how long.Design, setting, and participantsThis quality improvement study was conducted from September 2018 through October 2019 at inpatient medicine floors in 2 urban, tertiary-care teaching hospitals and purposefully sampled patients designated as "discharge before noon." Data analysis was performed from September 2018 to May 2020.ExposuresA trained bedside observer documented all content and duration of staff communication with a single enrolled patient from 7 am until discharge.Main outcomes and measuresPresence of the key communication domains, role of team members, and amount of time spent at the bedside.ResultsDischarge days for 33 patients were observed. Patients had a mean (SD) age of 63 (18) years; 14 (42%) identified as White, 15 (45%) were female, and 6 (18%) had a preferred language of Spanish. Thirty patients were discharged with at least 1 medication change. Of these patients, 8 (27%) received no verbal instruction on the change, while 16 of 30 (53%) were informed but not told the purpose of the changes. About half of the patients (15 of 31, 48%) were not told the reason for follow-up appointments, and 18 of 33 (55%) were not given instructions on posthospital disease self-management. Most patients (27 of 33, 81%) did not receive guidance on red-flag signs. While over half of the patients (19 of 33, 58%) were asked if they had any questions, only 1 patient was asked to teach back his understanding of the discharge plan. Median (IQR) total time spent with patients on the day of discharge by interns, senior residents, attending physicians, and nurses was 4.0 (0.75-6.0), 1.0 (0-2.0), 3.0 (0.5-7.0), and 22.5 (15.5-30.0) minutes, respectively. Most of the time was spent discussing logistics rather than discharge education.Conclusions and relevanceIn this quality improvement study, patients infrequently received discharge education in key communication domains, potentially leaving gaps in patient knowledge. Interventions to improve the hospital discharge process should address the content, method of delivery, and transparency among team members regarding patient education.

Project description:BACKGROUND: Self-administered questionnaires are becoming increasingly common in general practice. Much research has explored methods to increase response rates but comparatively few studies have explored the effect of questionnaire administration on reported answers. METHODS: The aim of this study was to determine the effect on responses of returning patient questionnaires to the respondents' medical practice or an independent researcher to questions relating to adherence and satisfaction with a GP consultation. One medical practice in Waveney primary care trust, Suffolk, England participated in this randomised trial. Patients over 18 years initiated on a new long-term medication during a consultation with a GP were randomly allocated to return a survey from their medical practice to either their medical practice or an independent researcher. The main outcome measures were self reported adherence, satisfaction with information about the newly prescribed medicine, the consultation and involvement in discussions. RESULTS: 274 (47%) patients responded to the questionnaire (45% medical practice, 48% independent researcher (95% CI -5 to 11%, p = 0.46)) and the groups appeared demographically comparable, although the high level of non-response limits the ability to assess this. There were no significant differences between the groups with respect to total adherence or any of the satisfaction scales. Five (4%) patients reported altering doses of medication in the medical practice group compared with 18 (13%) in the researcher group (P = 0.009, Fisher's exact test). More patients in the medical practice group reported difficulties using their medication compared to the researcher group (46 (35%) v 30 (21%); p = 0.015, Fisher's exact test). CONCLUSION: Postal satisfaction questionnaires do not appear to be affected by whether they are returned to the patient's own medical practice or an independent researcher. However, returning postal questionnaires relating to detailed patient behaviours may be subject to response biases and further work is needed to explore this phenomena.

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A randomised trial deploying a simulation to investigate the impact of hospital discharge letters on patient care in general practice.

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A randomised trial deploying a simulation to investigate the impact of hospital discharge letters on patient care in general practice.

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