Hospital-based physicians are doing a poor job of communicating with their primary-care providers (PCPs) when patients are discharged, according to a recent meta-analysis.
The two types of doctors had no direct contact in at least four out of five cases studied, and discharge summaries were often incomplete —if they were available at all— when patients had their first follow-up visit with the primary-care physician.
These shortcomings in-crease the chance of a gap in care, errors, and other adverse events in as many as 25% of hospitalizations, the researchers conclud-ed in the Journal of the American Medical Association (2007;297:831-841).
“Historically, the same physician often provided inpatient and outpatient care,” wrote Sunil Kri-palani, MD, MSc, of the Emory University School of Medicine in Atlanta. “As the specialty of hospital medicine expands, the transfer of responsibility for patient care between hospital-based physicians (hospitalists) and primary-care physicians becomes increasingly common. In this new model, the discharge summary becomes a vital tool for communication and information transfer.”
Dr. Kripalani’s team reviewed 73 studies published between 1970 and 2005. Most were observational analyses. They found that few primary-care physicians (12%-34%) had a discharge summary at the first follow-up visit.
Part of the reason was that the visits were scheduled much sooner than the 30 days the Joint Commission on Accreditation of Healthcare Organiza-tions (JCAHO) requires for the summaries to be completed. Still, after four weeks, availability “remained poor,” with only 51%-77% of the outpatient doctors ever having summaries in hand.
Even when the summaries were available, vital information was often missing from the file. Among the omissions:
- Name of the responsible hos-pital physician (25%)
- A summary of diagnostic test results (33%-63%)
- Treatment or hospital course (7%-22%)
- Test results pending at discharge (65%)
- A list of discharge medications (2%-40%)
- Follow-up plans (2%-43%)
Several studies cited in the meta-analysis found an association be-tween poor communication and hospital readmissions.
A study showed that 40% of patients have laboratory tests pending at discharge. “Physicians are commonly unaware of the results, even though about 10% of the results require some action,” Dr. Kripalani’s team wrote.
The researchers recommended sending at least an interim report to primary-care physicians on the day of discharge. It should list diagnoses, procedure results, discharge medications, follow-up items, and pending test results. Patients should get a copy to present at their first post-discharge visit as a backup.
Having electronic medical records would also help, the re-searchers said. Besides allowing quick retrieval of data and flagging pending tests for follow-up, these systems can fax or e-mail reports to primary-care physicians promptly and allow them to access the reports directly.