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Hospital physicians' views on discharge and readmission processes: a qualitative study from Norway.

ABSTRACT: OBJECTIVES:To explore hospital physicians' views on readmission and discharge processes in the interface between hospitals and municipalities. DESIGN:Qualitative case study. SETTING:The Norwegian healthcare system. PARTICIPANTS:Fifteen hospital physicians (residents and consultants) from one hospital, involved in the treatment and discharge of patients. RESULTS:The results of this study showed that patients were being discharged earlier, with more complex medical conditions, than they had been previously, and that discharges sometimes were perceived as premature. Insufficient capacity at the hospital resulted in pressure to discharge patients, but the primary healthcare service of the area was not always able to assume care of these patients. Communication between levels of the healthcare service was limited. The hospital stay summary was the most important, and sometimes only, form of communication between levels. The discharge process was described as complicated and was affected by healthcare personnel, by patients themselves and by aspects of the primary healthcare service. Early hospital discharges, poor communication between healthcare services and inadequacies in the discharge process were perceived to affect hospital readmissions. CONCLUSION:The results of this study provide a better understanding of hospital physicians' views on the discharge and hospital readmission processes in the interface between the hospital and the primary healthcare service. The study also identifies discrepancies in governmental requirements, reform regulations and current practices in municipalities and hospitals.

SUBMITTER: Knutsen Glette M

PROVIDER: S-EPMC6720230 | biostudies-other | 2019 Aug

REPOSITORIES: biostudies-other

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Hospital physicians' views on discharge and readmission processes: a qualitative study from Norway.

Knutsen Glette Malin M Kringeland Tone T Røise Olav O Wiig Siri S

BMJ open 20190827 8

<h4>Objectives</h4>To explore hospital physicians' views on readmission and discharge processes in the interface between hospitals and municipalities.<h4>Design</h4>Qualitative case study.<h4>Setting</h4>The Norwegian healthcare system.<h4>Participants</h4>Fifteen hospital physicians (residents and consultants) from one hospital, involved in the treatment and discharge of patients.<h4>Results</h4>The results of this study showed that patients were being discharged earlier, with more complex medi ...[more]

PMID: 31462486

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Project description:BackgroundHospital readmissions is an increasingly serious international problem, associated with higher risks of adverse events, especially in elderly patients. There can be many causes and influential factors leading to hospital readmissions, but they are often closely related, making hospital readmissions an overall complex area. In addition, a comprehensive coordination reform was introduced into the Norwegian healthcare system in 2012. The reform changed the premises for readmissions with economic incentives enhancing early transfer from secondary to primary care, making research on readmissions in the municipalities more urgent than ever. General practitioners (GPs) and nursing home physicians, have traditionally held a gatekeepers function in hospital readmissions from the municipal healthcare service, as they are the main decision-makers in questions of hospital readmissions. Still, the GPs' gatekeeper function is an under-investigated area in hospital readmission research. The aim of the study was to increase knowledge about factors that lead to hospital readmissions among elderly in municipal healthcare, with special attention to GPs' and nursing home physicians' decision making.MethodThe study was conducted as a comparative case study. Two municipalities affiliated with the same hospital, but with different readmission rates were recruited. Twenty GPs and nursing home physicians from each municipality were recruited and interviewed. Forty hours of observation were conducted during the huddles in one long-term and one short-term nursing home in each municipality.ResultsSeven themes describing how different factors influence physicians' decision-making in the hospital readmission process in two municipalities were identified. Poor communication, continuity and information flow account for hospital readmissions in both municipalities. Several factors, including nurse staffing and competence, patients and their families, time constraints and experience affected physicians' decision-making.ConclusionCommunication, continuity and information flow contributed to hospital readmissions in both municipalities. The cross-case analysis revealed slight differences between municipalities. More research focusing on GPs' and nursing home physicians' decision-making, nursing home nurses and home care nurses' experience of hospital readmissions and discharges is needed.

Project description:Background Insufficient transfer of medicines information is a common challenge at discharge from hospital. Following discharge, home dwelling patients are expected to manage their medicines themselves and adequate counselling is an important prerequisite for patient empowerment and self-efficacy for medicines management. Objective The aim was to identify patients' needs for medicines information after discharge from hospital, including the patients' perception and appraisal of the information they received at discharge. Setting The study enrolled patients discharged from three medical wards at a secondary care hospital in Oslo, Norway. Method Patients were included at the hospital, at or close to the day of discharge and qualitative, semi-structured interviews were performed during the first 2 weeks after discharge. Eligible patients were receiving medicines treatment on admission and after discharge, were handling the medicines themselves, and discharged to their own home. Data were collected in 2017. Interviews were analysed with thematic analysis inspired by Systematic Text Condensation. Main outcome measure Patients' perceptions of medicines information. Results In total, 12 patients were interviewed. They were discharged in equal numbers from the three wards, representing both sexes and a broad age range. Patients perceive medicines information as a continuum and not limited to specific encounters, like the discharge conversation. They gain information in several ways; by receiving information from health care professionals, through observations, and by seeking it themselves. Some thought they could have been better informed about adverse reactions and how to manage life while being a medicines user. Others felt they did not want or need more information. Patients employ various strategies for coping with their use of medicines, influencing their self-efficacy towards medicine management. Conclusion Medicines information should focus on empowering the patients throughout the hospital stay and not solely at discharge, taking into account the individual patient's needs for information, preferences and prior knowledge.

Project description:OBJECTIVES:To understand from a patient and carer perspective: (1) what features of the discharge process could be improved to avoid early unplanned hospital readmission (within 72?hours of acute care discharge) and (2) what elements of discharge planning could have enhanced the discharge experience. DESIGN:A qualitative descriptive design was used. Study data were collected using semi-structured interviews that were transcribed verbatim and analysed using inductive thematic analysis. Data related to participant characteristic were collected by medical record audit and summarised using descriptive statistics. SETTING:Three acute care hospitals from one health service in Australia. PARTICIPANTS:Patients who had an early unplanned hospital readmission and/or their carers, if present during the interviews and willing to participate, with patient permission. FINDINGS:Thirty interviews were conducted (23 patients only; 6 patient and carer dyads; 1 carer only). Five themes were constructed: 'experiences of care', 'hearing and being heard', 'what's wrong with me', 'not just about me' and 'all about going home'. There was considerable variability in patients' and carers' experiences of hospital care, discharge processes and early unplanned hospital readmission. Features of the discharge process that could be improved to potentially avoid early unplanned hospital readmission were better communication, optimal clinical care including ensuring readiness for discharge and shared decision-making regarding discharge timing and goals on returning home. The discharge experience could have been enhanced by improved communication between patients (and carers) and the healthcare team, not rushing the discharge process and a more coordinated approach to patient transport home from hospital. CONCLUSIONS:The study findings highlight the complexities of the discharge process and the importance of effective communication, shared decision-making and carer engagement in optimising hospital discharge and reducing early unplanned hospital readmissions.

Project description:ImportanceThe Affordable Care Act has led to US national reductions in hospital 30-day readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Whether readmission reductions have had the unintended consequence of increasing mortality after hospitalization is unknown.ObjectiveTo examine the correlation of paired trends in hospital 30-day readmission rates and hospital 30-day mortality rates after discharge.Design, setting, and participantsRetrospective study of Medicare fee-for-service beneficiaries aged 65 years or older hospitalized with HF, AMI, or pneumonia from January 1, 2008, through December 31, 2014.ExposureThirty-day risk-adjusted readmission rate (RARR).Main outcomes and measuresThirty-day RARRs and 30-day risk-adjusted mortality rates (RAMRs) after discharge were calculated for each condition in each month at each hospital in 2008 through 2014. Monthly trends in each hospital's 30-day RARRs and 30-day RAMRs after discharge were examined for each condition. The weighted Pearson correlation coefficient was calculated for hospitals' paired monthly trends in 30-day RARRs and 30-day RAMRs after discharge for each condition.ResultsIn 2008 through 2014, 2 962 554 hospitalizations for HF, 1 229 939 for AMI, and 2 544 530 for pneumonia were identified at 5016, 4772, and 5057 hospitals, respectively. In January 2008, mean hospital 30-day RARRs and 30-day RAMRs after discharge were 24.6% and 8.4% for HF, 19.3% and 7.6% for AMI, and 18.3% and 8.5% for pneumonia. Hospital 30-day RARRs declined in the aggregate across hospitals from 2008 through 2014; monthly changes in RARRs were -0.053% (95% CI, -0.055% to -0.051%) for HF, -0.044% (95% CI, -0.047% to -0.041%) for AMI, and -0.033% (95% CI, -0.035% to -0.031%) for pneumonia. In contrast, monthly aggregate changes across hospitals in hospital 30-day RAMRs after discharge varied by condition: HF, 0.008% (95% CI, 0.007% to 0.010%); AMI, -0.003% (95% CI, -0.005% to -0.001%); and pneumonia, 0.001% (95% CI, -0.001% to 0.003%). However, correlation coefficients in hospitals' paired monthly changes in 30-day RARRs and 30-day RAMRs after discharge were weakly positive: HF, 0.066 (95% CI, 0.036 to 0.096); AMI, 0.067 (95% CI, 0.027 to 0.106); and pneumonia, 0.108 (95% CI, 0.079 to 0.137). Findings were similar in secondary analyses, including with alternate definitions of hospital mortality.Conclusions and relevanceAmong Medicare fee-for-service beneficiaries hospitalized for heart failure, acute myocardial infarction, or pneumonia, reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge. These findings do not support increasing postdischarge mortality related to reducing hospital readmissions.

Project description:BackgroundGenetic screening (GS), defined as the clinical testing of a population to identify asymptomatic individuals with the aim of providing those identified as high risk with prevention, early treatment, or reproductive options. Genetic screening (GS) improves patient outcomes and is accessible to the community. Family physicians (FPs) are ideally placed to offer GS. There is a need for FPs to adopt GS to address anticipated genetic specialist shortages.ObjectiveTo explore FP attitudes, perceived roles, motivators and barriers, towards GS; and explore similarities and differences between private and public sector FPs.MethodsWe developed a semi-structured interview guide using existing literature. We interviewed private and public sector FPs recruited by purposive, convenience and snowballing strategies, by telephone or video to theme saturation. All sessions were audio-recorded, transcribed and coded for themes by two independent researchers with an adjudicator.ResultsThirty FPs were interviewed (15 private, 15 public). Theme saturation was reached for each group. A total of 12 themes (6 common, 3 from private-practice participants, 3 public-employed participants) emerged. Six common major themes emerged: personal lack of training and experience, roles and relevance of GS to family medicine, reluctance and resistance to adding GS to practice, FP motivations for adoption, patient factors as barrier, and potential solutions. Three themes (all facilitators) were unique to the private group: strong rapport with patients, high practice autonomy, and high patient literacy. Three themes (all barriers) were unique to the public group: lack of control, patients' lower socioeconomic status, and rigid administrative infrastructure.ConclusionFPs are motivated to incorporate GS but need support for implementation. Policy-makers should consider the practice setting when introducing new screening functions. Strategies to change FP behaviours should be sensitive to their sense of autonomy, and the external factors (either as facilitators or as barriers) shaping FP practices in a given clinical setting.

Project description:BackgroundAs worldwide cancer prevalence continues to increase, the challenges facing cancer care are also increasing. Various topics related to deficiencies in cancer care have been discussed repeatedly in the literature. The most frequently stated topics are the unmet psychosocial support needs of cancer patients, difficulties in multidisciplinary teamwork, difficulties in communication between physicians and patients, and issues in palliative care settings. However, there is little research regarding the views of health care providers on these topics. With the aim of gaining abundant information regarding the care of German cancer patients, this study explores the stances of psycho-oncologists, physicians, and nurses regarding the quality of cancer care.Materials and methodsSemi-structured interviews were conducted at the University Medical Center Hamburg-Eppendorf (UKE) and in different oncological outpatient offices in Hamburg; twenty-five interviews in total were conducted with health care providers. Interviews were semi-structured to gain a broad range of information on cancer care. The data were analyzed using thematic analysis by Braun and Clarke with an inductive, constant comparison approach to identify themes and categorized codes.ResultsThe following five principle themes were identified in the interviews: "psycho-oncological care", "cooperation of health care providers", "palliative care", "health care provider-patient contact", and "coordination and organization of care". Participants seemed satisfied with the overall quality of cancer care in Germany. Nevertheless, the results showed deficiencies regarding communication among different health care providers and between health care providers and patients. Important findings in conjunction with these communication problems were a lack of psycho-oncological support, shortages in the oncology work force, language and cultural barriers, and deficient education in the communication of providers.ConclusionsThe statements of psycho-oncologists, physicians, and nurses on cancer care provide a suitable basis to conduct further focused research on the studied deficiencies in cancer care. In particular, communication in psycho-oncological care, communication within multidisciplinary teams, and health care provider-patient communication should be further explored with the aim of developing new ideas for improvements and thereby enhancing the quality of cancer care.

Dataset Information

Hospital physicians' views on discharge and readmission processes: a qualitative study from Norway.

Publications

Hospital physicians' views on discharge and readmission processes: a qualitative study from Norway.

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