In this study of general medicine services at two major academic medical centers, we found that physician teams were often unaware when patients they discharged within the past 14 days were readmitted and that communication between the discharging and readmitting teams occurred for less than half of all readmitted patients. Physician-rated medical complexity was associated with physician communication, but patient demographics, time to readmission, and psychosocial complexity were not. When communication did occur, potentially valuable clinical information was exchanged, such as information about the discharging teams overall impression, psychosocial issues, discharge medications, and pending tests. When communication did not occur, most physicians responded that they would have welcomed the opportunity to exchange information. Interestingly, when communication did not occur and physicians of both teams responded, there were often discordant responses regarding desire for communication, with readmitting team physicians often indicating that communication was not needed and discharging team physicians responding that it was.
Several of our findings deserve further comment. Discharging physicians who were unaware overwhelmingly desired notification of readmissions, and many were simply curious about the outcome. In academic centers, discontinuity of care is the rule rather than the exception, and so perhaps it is unsurprising that physicians in this setting desire this feedback. In fact, less than a third of the patients readmitted during our study period were assigned to a team that included a physician who was on the original discharging team. Several factors that are commonplace in academic medical centers contribute to this discontinuity, including changing admitting and rotation schedules among house staff and faculty, increased “hand-offs” of patients because of restrictions on house staff duty hours,12
and the widespread use of hospitalists and subspecialty services for inpatient care. This discontinuity occurred despite the presence in both hospitals of “bounce back” rules, common among house staff programs, which provide guidelines that facilitate repatriation of readmitted patients to their prior team. Another finding worth comment is that psychosocial complexity did not predict communication, but paradoxically, when communication did occur, psychosocial factors were often discussed. It may be that this information is left out of discharge summaries for privacy concerns, and hence only available through direct communication.
These gaps in awareness and communication may be explained by several factors. First, physicians in our study reported several barriers, including (1) having no system in place to notify discharging team physicians about readmissions, (2) not having enough time to communicate, and (3) not knowing whom to contact. Second, readmitting physicians frequently thought communication was unnecessary, which may have been true for some patients, but for others it may have been a case of physicians “not knowing what they didn’t know,” supported by frequently discordant responses among discharging and readmitting physicians regarding desire for communication. This may also explain the frequency with which psychosocial matters were discussed when communication did occur, despite the failure of psychosocial complexity to drive communication.
Similar to our study, Swan and colleagues found low surgeon awareness of 27 postoperative readmissions for venous thromboembolic disease, with only 44% of charts containing evidence that the surgeon from the prior admission was aware of the readmission.6
The authors hypothesized that the surgeon’s lack of awareness of this complication might lead to the mistaken belief that this complication is rarer than it is, and might lead to less aggressive prophylaxis. They concluded that better physician communication might improve patient care. Our findings suggest a lack of awareness of readmissions and a failure to communicate about them are widespread and not limited to this specific clinical scenario. If physicians do not communicate directly when a patient is readmitted, it can be assumed that most information about the prior admission is obtained from the discharge summary. However, several authors have found discharge summaries are often missing important information, including discharge diagnosis, pending tests, follow-up plans, and discharge medications.13–16
In our study, physicians frequently communicated to clarify similar clinical data, further supporting prior evidence that the discharge summary is frequently inadequate.
Our study has several important limitations. First, it was conducted at two tertiary academic medical centers in Boston, and so our findings may not be generalizable to other settings with different cultures and systems in place. However, the previously mentioned surgical study by Swan and colleagues found a similar prevalence of awareness of readmissions for venous thromboembolic disease in an Australian medical center. Second, our study was observational, and the primary outcome was physician communication. As such, we are unable to determine whether more physician communication about readmissions would translate into better patient care, but one might argue that physician communication is so fundamental to patient care that it is an important outcome itself. Third, it is possible that our results are biased by differences in awareness and communication practices among survey responders and non-responders, or by limitations in the scope of our study to readmissions within the same hospital. We would expect the general direction of this bias would lead us to have underestimated the problem, since (1) it seems likely that physicians would be more reluctant to respond to the survey if they were unaware or had not communicated, (2) non-responders were more likely to be interns and residents who, because of competing demands on their time, and because attendings are more likely to be identified as having cared for the patient, are less likely to be aware or communicate, and (3) we would be expect that physician awareness and communication would be even lower for patients readmitted to other hospitals, given the relative ease of e-mail communication within our own hospitals and the difficulty of communication with physicians in other institutions.
Improving physician communication about readmissions has implications for quality of care: (1) by directly improving the immediate care of the patient who was readmitted (for example, by informing the readmitting team of a discrepancy in medications, pending results, or important psychosocial factors) and (2) by educating discharging physicians about what happened to the patient, the care of those physician’s future patients may be improved (for example, informing the discharging physicians of an important drug dosing error or missed diagnosis may potentially prevent this error being committed in the future). Because clinical diagnosis is mostly an “open loop” system, where the individual physician only receives minimal, ad-hoc feedback about diagnostic errors and a patient’s lack of response to treatment (as well as about correct diagnoses and successful responses to treatment), systematic approaches to providing “upstream” feedback and follow-up may result in substantial improvements in quality of care.17,18
Our findings also have important implications for medical education and residency training programs. In this era of high patient turnover, shorter length of stay, and reduced resident work hours, the care of inpatients by residents is often fragmented and episodic, and as a result residents often miss the opportunity to learn what happens to patients as their course evolves. As such, residents may derive valuable and otherwise unlearned lessons from more emphasis on follow-up of patients who are readmitted.
In summary, we found gaps in physician awareness of and communication about readmissions that may be detrimental to quality of care and physician education. Future research should focus on determining the impact of interventions aimed at increasing physician awareness of and communication about readmissions. Discontinuity of care is the root of the problem, so institutions might work to minimize this by lengthening rotations and extending “bounce back” rules. Information systems may be useful to notify physicians of readmissions, while dedicating time during rounds or morning report to readmitted patients may allow residents and faculty the opportunity to discuss these patients in real time. More broadly, future work should focus on improving physician communication in general and on providing systematic feedback to physicians about patient outcomes.