The Ideal Hospital Discharge Summary: A Survey of U.S. Physicians.

BACKGROUND: Hospital discharge summaries enable communication between inpatient and outpatient physicians. Despite existing guidelines for discharge summaries, they are frequently suboptimal. OBJECTIVE: The aim of this study was to assess physicians' perspectives about discharge summaries and the differences between summaries' authors (hospitalists) and readers (primary care physicians [PCPs]). METHODS: A national survey of 1600 U.S. physicians was undertaken. Primary measures included physicians' preferences in discharge summary standardization, content, format, and audience. RESULTS: A total of 815 physicians responded (response rate = 51%). Eighty-nine percent agreed that discharge summaries "should have a standardized format." Most agreed that summaries should "document everything that was done, found, and recommended in the hospital" (64%) yet "only include details that are highly pertinent to the hospitalization" (66%). Although 74% perceived patients as an important audience of discharge summaries, only 43% agreed that summaries "should be written in language that patients…can easily understand," and 68% agreed that it "should be written solely for provider-to-provider communication." Compared with hospitalists, PCPs preferred comprehensive summaries (68% versus 59%, P = 0.002). More PCPs agreed that separate summaries should be created for patients and for provider-to-provider communication than hospitalists (60% versus 47%, P < 0.001). Compared with PCPs, more hospitalists believe that "hospitalists are too busy to prepare a high-quality discharge summary" (44% versus 23%, P < 0.001) and "PCPs have insufficient time to read an entire discharge summary" (60% versus 38%, P < 0.001). CONCLUSIONS: Physicians believe that discharge summaries should have a standardized format but do not agree on how comprehensive or in what format they should be. Efforts are necessary to build consensus toward the ideal discharge summary.

Information Transfer and the Hospital Discharge Summary: National Primary Care Provider Perspectives of Challenges and Opportunities.

PURPOSE: The hospital discharge summary (HDS) serves as a critical method of patient information transfer between hospitalist and primary care provider (PCP). This study was designed to increase our understanding of PCP preferences for, and perceived deficiencies in, the discharge summary. METHODS: We designed a mail survey that was sent to a random sample of 800 American Academy of Family Physicians members nationally. The survey response rate was 59%. We analyzed the availability of summaries at hospital followup, whether all desired information was contained in the summary and whether certain specific items were completed. Provider subgroup analysis was performed. RESULTS: The strongest predictor of discharge summary availability at posthospital followup is direct access to inpatient data. Respondents (27.5%) had a summary available 0% to 40% of the time, 41.4% noted availability 41% to 80% of the time and 31.1% >80% of the time; if a provider had access to inpatient data they tended to have a discharge summary available to them (P < .0001). Providers also described significant content deficits: 26.5% of providers noted the summary contained all information needed 0% to 40% of the time, 48.5% of providers noted this 41% to 80% of the time and only 25% >80% of the time. Specific summary items considered "very important" by providers included medication list (94% of respondents), diagnosis list (89%), and treatment provided (87%). CONCLUSIONS: Opportunities remain in timely delivery of a complete HDS to the PCP. Further multifaceted practice redesign should be directed at optimizing this critical information transfer tool, potentially encompassing electronic medical record utilization and specific training for clinicians preparing summaries. Initial efforts should focus on ensuring availability of a complete summary (containing items deemed important by PCPs including medication list, diagnosis list, and treatment provided) at the posthospital follow-up visit.

Comparing performance of 30-day readmission risk classifiers among hospitalized primary care patients.

RATIONALE, AIMS AND OBJECTIVES: Hospital readmission within 30 days of discharge occurs in almost 20% of US Medicare patients and may be a marker of poor quality inpatient care, ineffective hospital to home transitions, or disease severity. Within a patient centered medical home, care transition interventions may only be practical from cost and staffing perspectives if targeted at patients with the greatest risk of readmission. Various scoring algorithms attempt to predict patients at risk for 30-day readmission, but head-to-head comparison of performance is lacking. Compare published scoring algorithms which use generally available electronic medical record data on the same set of hospitalized primary care patients. METHODS: The LACE index, the LACE+ index, the HOSPITAL score, and the readmission risk score were computed on a consecutive cohort of 26,278 hospital admissions. Classifier performance was assessed by plotting receiver operating characteristic curves comparing the computed score with the actual outcome of death or readmission within 30 days. Statistical significance of differences in performance was assessed using bootstrapping techniques. RESULTS: Correct readmission classification on this cohort was moderate with the following c-statistics: Readmission risk score 0.666; LACE 0.680; LACE+ 0.662; and HOSPITAL 0.675. There was no statistically significant difference in performance between classifiers. CONCLUSIONS: Logistic regression based classifiers yield only moderate performance when utilized to predict 30-day readmissions. The task is difficult due to the variety of underlying causes for readmission, nonlinearity, and the arbitrary time period of concern. More sophisticated classification techniques may be necessary to increase performance and allow patient centered medical homes to effectively focus efforts to reduce readmissions.

Impact of an Emergency Department Observation Unit Management Algorithm for Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a common, growing, and costly medical condition. We aimed to evaluate the impact of a management algorithm for symptomatic AF that used an emergency department observation unit on hospital admission rates and patient outcomes. METHODS AND RESULTS: This retrospective cohort study compared 563 patients who presented consecutively in the year after implementation of the algorithm, from July 2013 through June 2014 (intervention group), with 627 patients in a historical cohort (preintervention group) who presented consecutively from July 2011 through June 2012. All patients who consented to have their records used for chart review were included if they had a primary final emergency department diagnosis of AF. We observed no significant differences in age, sex, vital signs, body mass index, or CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke or transient ischemic attack) score between the preintervention and intervention groups. The rate of inpatient admission was significantly lower in the intervention group (from 45% to 36%; P<0.001). The groups were not significantly different with regard to rates of return emergency department visits (19% versus 17%; P=0.48), hospitalization (18% versus 16%; P=0.22), or adverse events (2% versus 2%; P=0.95) within 30 days. Emergency department observation unit admissions were 40% (P<0.001) less costly than inpatient hospital admissions of ≤1 day's duration. CONCLUSIONS: Implementation of an emergency department observation unit AF algorithm was associated with significantly decreased hospital admissions without increasing the rates of return emergency department visits, hospitalization, or adverse events within 30 days.