In a multicenter study of hospitalists and non-hospitalists in six US academic medical centers, few primary care providers (PCPs) had direct communication with the inpatient medical team during their patients’ hospitalizations, more than half reported not receiving a discharge summary within 2 weeks, and almost one quarter did not have any knowledge that their patients had been admitted at all. However, these lapses in communication were not associated with adjusted 30-day risk for death, hospital readmission, or emergency department visits.
Much has been discussed about the importance of discharge communication for hospitalized patients, but little work has evaluated “hard” outcomes.9
Most previous studies of inter-physician communication have focused on process measures or surrogate markers, such as decreased laboratory test repetition, reduced emergency department waits, improved glycosylated hemoglobin levels, and higher cancer screening rates.15–18
However, not all work has demonstrated improved patient care.19,20
Perhaps the largest study that evaluated communication between hospital-based and ambulatory-care physicians with respect to patient outcomes assessed almost 900 patients and found that discharge summaries were available to treating physicians in less than 25% of follow-up visits.21
However, adjusted analyses of 90-day risk of hospital readmission related to discharge summary availability were not significant (odds ratio 0.74; 95% CI 0.05 to 1.10). This study involved only a single center and only measured hospital readmission at 90 days as compared to a composite outcome of 30-day death, hospital readmission, or ED visit that is now the standard for many studies of quality.
Although our observed rate of PCP-hospital-based physician communication showed that almost one-quarter of PCPs were unaware that their patient was hospitalized, it is far lower than the average described in a recent systematic review.9
Previous studies have documented that formal direct communication between hospital and primary care physicians within 2 weeks occurs less than two-thirds of the time (range 29–80%) depending on the study and communication type.9
Our findings may be due to the expectation that residents contact PCPs at many of the sites. Further, rates observed in earlier work could be due to publication bias underscoring poor performance and may have preceded the recent and widespread adoption of the hospitalist movement, which emphasizes timely communication.1,2,4,5,11
The lack of a significant relationship between these aspects of communication and patient outcomes after discharge may be explained by several factors. First, the study may have been underpowered to detect such a relationship. The effects of direct communication and receipt of a discharge summary were associated with non-significant reductions in the composite outcome. That knowledge of the admission did not show even a non-significant trend towards improved outcomes may have been due to chance or to the fact that simple knowledge of admission may not be sufficient to improve outcomes. Also, PCPs may have other means of discovering that their patient was admitted to hospital and may take appropriate steps for follow-up.11
Second, the presence of any communication is not the same as receipt of high-quality communication, and only the latter may be capable of improving outcomes. Third, there are many other factors that can lead to ED visits, hospital readmission, or death besides presence and quality of communication, thus limiting our ability to find an effect. Fourth, patients may have misreported ED visits and hospital readmissions, leading to measurement bias towards the null. Fifth, there may be confounding by indication: inpatient physicians may be more likely to communicate with PCPs regarding patients who are particularly at high risk for adverse outcomes after discharge. We did not assess for this aspect – particularly because many of our patients were younger and had fewer comorbidities. Finally, there may be other patient confounders of the outcome that could not be adjusted for in our analyses.
Interestingly, we observed little difference in PCP responses or adjusted patient outcomes between patients cared for by hospitalists compared to other attending physicians. There may be several explanations for this finding. First, hospitalist physicians may not have that large of an effect on the patient outcomes measured in this study even though there may be other benefits. Second, the major role that residents have in patient care in academic centers may mitigate some of the effect of the attending physician. Also, many of the hospitalists in our study were relatively inexperienced, and it may take a while to hone communication skills and develop relationships with community PCPs.12
Finally, there may be systemic barriers to communication (e.g., incorrect PCP contact information) that apply equally to all attending physicians. Further research in this area is warranted.
Our study has limitations that merit mention. First, our study was not designed to determine how improved communication and information transfer might avoid adverse outcomes. Second, no sites involved in the study employed standardized templates for discharge summaries during the study, even though it is a recommended practice.9,22
Third, the surveys measured PCP knowledge of patient hospitalization at 2 weeks. This should have allowed enough time for any informal communication or the delivery of formal discharge summaries. However, PCPs may still have received information after the survey was completed but prior to their patient’s follow-up visit. Fourth, our study only involved academic centers and medical teams involving medical housestaff. Although many community hospitals may have closer relationships with PCPs, an increasing number of community hospitals also rely on hospitalist models of care, and the findings may therefore apply.1,2,4
Finally, our composite outcome of 30-day death, hospital or ED admission is not the only relevant metric. We did not present any information on other important patient outcomes like adverse drug events, missed follow-up, quality of life, and patient satisfaction.10,23,24
Our findings are strengthened by several aspects of this study. We studied diverse patient groups from disparate geographic areas throughout the US. Moreover, we accounted for possible differences between these six sites in our analyses. Further, we included data on the availability of the discharge summary as well as other communication strategies that may be preferred by PCPs, such as telephone or e-mail.11
Our use of a composite outcome allowed us to increase the statistical power of our study while still incorporating relevant quality of care measures. Finally, we had a high response rate of 70%, limiting the potential impact of respondent bias.
Patients are being discharged from hospitals quicker and sicker
than in previous years.10,25–27
Consequently, adequate follow-up and care continuity increases in importance. Though our results provide no direct link between physician communication and important patient outcomes, they demonstrate that communication between hospital physicians and PCPs can be substantially improved.