Hospital and Primary-Care Physicians Aren't on Same Page

ATLANTA, March 12 -- Faulty communication between hospital-based and primary-care physicians may disrupt proper care of a quarter of patients when they are discharged, according to a review of the literature.

The primary tool for communicating details of a patient's hospital stay and required follow up treatment, the discharge summary, is not available to as many as nearly half of primary care physicians within the required 30 days, said Sunil Kripalani, M.D., M.Sc, of Emory University here.

In fact, the discharge summary fails to materialize at all in about 25% of cases, Dr. Kripalani and colleagues determined from a meta analysis.

Even when the summary does show up, it often lacks important information, such as diagnostic test results, discharge medications, or a follow-up plan, the investigators said in the Feb. 28 issue of the Journal of the American Medical Association.

Although the analysis did not examine the reasons why discharge summaries are often late or incomplete, one reason may be the complexity of the process and the time needed for it, Dr. Kripalani said in an interview. Hospital physicians must gather patient records, dictate the summary (often with help of a template to provide structure), then wait for the summary to be transcribed so they can review it before it is mailed to the primary care physician, he said.

In some cases, not having contact information for a patient's primary care doctor may cause delay, Dr. Kripalani said. A hospital physician's heavy workload or simple lack of diligence may sometimes be a factor, but rarely, as hospitals require medical records, including discharge summaries, to be complete, he added.

Dr. Kripalani and colleagues reviewed 55 observational studies of communication and information transfer at hospital discharge published between 1970 and 2005. They went back more than three decades in order to provide a more complete picture, he said. Key findings of the review included:

• Hospital and primary care physicians rarely communicated directly (an average of 3% to 20% of cases, depending on the study).
• The discharge summary was not usually available at the first post-discharge visit (12% to 34% of visits).
• Availability of the summary was still "poor" at four weeks (51% to 71% of cases). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that discharge summaries be completed within 30 days, but discharged patients commonly meet with their primary-care doctor much sooner, the investigators said.

In addition, discharge summaries tended to lack important information, such as:

• Diagnostic test results (missing from 33% to 63% of summaries)
• Treatment or hospital course (7% to 22%)
• Discharge medications (2% to 40%)
• Test results pending at discharge (65%)
• Patient or family counseling (90% to 92%)
• Follow-up plans (2% to 43%)

In one study reviewed, outpatient physicians estimated that their follow-up care was negatively impacted by delayed or incomplete discharge communications in about 24% of cases. Another study showed that patients without discharge summaries had a greater tendency to have to return to the hospital (data not given), although the trend was not significant.

"Deficits in communication and information transfer between hospital-based physicians and primary care physicians are substantial and ubiquitous," the investigators said. "The traditional methods of completing and delivering discharge summaries are suboptimal for communicating timely, accurate, and medically important patient data to the physician who will be responsible for follow-up care."

"Urgent improvements are needed in the processes and formats used for transferring information to primary care physicians at hospital discharge," they concluded.

One such promising improvement may be computer generated discharge summaries generated automatically for hospital-physician review by the hospital's electronic records system, the investigators suggested. After review and correction, these summaries could even be-mailed or faxed to primary-care doctors, they added.

The investigators also reviewed 18 studies examining interventions to improve information transfer. Basing clear conclusions on a review of these studies was not possible because they varied widely in their patient populations, outcome measures, and interventions tested, the investigators said.

However, one study comparing computer-generated summaries to traditional dictated summaries produced particularly promising data, the investigators noted. It found that 80% of computer-generated summaries reached primary care physicians by four weeks, compared with only 57% of traditional summaries (P<.001).

In addition, computer generated summaries were more likely to include important items such as main discharge diagnosis (P=.001), radiology test results (P=.08), laboratory test results (P=.01), discharge medications (P=.006), and pending test results (P=.001), according to this study, which was published in the Canadian Medical Association Journal in 1999.

Primary-care physicians should strive to be more proactive in obtaining discharge information on hospitalized patients, Dr. Kripalani said. A call to the hospital physician before discharge to get important information and coordinate the transfer process should improve patient care, he said.

Patients can also play a role in improving communication, Dr. Kripalani said. Patients should be advised to make sure the hospital doctor has the correct contact information for their primary care physician. On the day of discharge, patients should also be advised to request a discharge letter or discharge note-something handwritten by the hospital doctor containing the important medical information that they can bring to their first primary-care follow-up visit, he said.