This stakeholder audit confirms that GPs consider some clinical information essential to optimally care for their patients following hospitalisation for EJR surgery, consistent with earlier findings.
15,
16 While we have not completed a typical clinical audit cycle by implementing changes and evaluating their effects, the results of this audit will be important for informing these later stages, particularly implementing and evaluating strategies to improve communication between hospital-based orthopaedic surgery teams and GPs. The data will be particularly relevant to medical interns, who are generally responsible for developing discharge summaries, and database architects, who are responsible for developing and implementing information fields in hospital software used to build automated discharge summaries. Moreover, as Australia implements a national e-health system and hospitals adopt paperless modes of communication and the creation of standardised discharge summaries, such data will be important in planning how discharge summaries are developed and how junior medical staff populate information fields within discharge summary templates. The Australian National E-Health Transition Authority (NEHTA) suggests that the discharge summary should include
any information considered important for safe and effective continual management and the data collected in this audit align with the fields suggested as essential information by the NEHTA.
17 The importance of such information for quality and safety of patient care is highlighted by earlier studies. For example, an Australian study identified serious problems with discharge summaries produced in a public hospital in New South Wales, most notably in terms of accuracy and the low rate of receipt,
18 while a recent Scandinavian study identified that inadequate communication between hospitals and GPs significantly increased the likelihood of GPs referring their patients to non-local sites for joint replacement surgery.
19GPs considered discharge information related to early post-operative requirements (such as removal of staples or stitches), the surgical procedure and any postoperative complications, medications, allergies, and mobility and physical activity restrictions and plans to be most important for continuity of care, with more than three out four GPs identifying these as essential and almost all identifying these as useful. This is consistent with earlier literature
16,
19 and NETHA recommendations.
17 These findings are unsurprising as GPs need to address immediate post-surgical priorities after discharge, particularly as the length of hospital stays are decreasing for these procedures. The data also reflect a recognition by GPs of information required for high quality care and mirror three of five Australian Commission of Safety and Quality in Health Care identified key safety issues which contribute to patient risk in primary care: diagnosis, prescribing and communication.
20 Notably, an earlier study identified that GPs preferred longer and more comprehensive discharge summaries for patients undergoing orthopaedic surgery.
15Although clinical guidelines for infection control, wound care and venous thromboembolism (VTE) were largely considered ‘useful’ (47.5-56.7% of respondents), a proportion of GPs (25.0-30.5%) reported such information to be ‘essential’ for patient care. This data may suggest some uncertainty among GPs in appropriate and evidence-based management of these clinical issues and highlight a potentially important area of future research and targeted education. For example, recent data from the Australian CareTrack study identified that a sizable proportion of patients were not receiving care which aligned with clinical practice guidelines for VTE prophylaxis and surgical site infections.
21 Our data may also highlight the difficulties associated with locating and interpreting full clinical practice guidelines and the desire to receive brief and clear guidance on best-practice management for specific clinical issues, for example brief ‘care standards’, as recommended by CareTrack.
22 For example, in the context of managing osteoporosis, simple GP-focussed management algorithms have improved patient care in WA in the context of osteoporosis.
23Allied health information, such as physiotherapy and occupational therapy information and arrangements (other than mobility and physical activity restrictions), were largely considered useful by respondents. Discharge summaries are routinely developed by junior medical officers, on behalf of the consultant surgeons. Consequently, the nature of the information is often medically-based and may inadequately capture other potentially important clinical and social information relevant to the GP,
24 such as information from the allied health team. Notably, a recent study identified that GPs desired information from all health professionals in a hospital-based lung cancer care team and suggested the development of multidisciplinary discharge summaries.
25 This may be an important consideration for informing the development of discharge summaries for patients undergoing EJR surgery. While information related to the brand and type of prosthesis used was viewed relatively as the least important discharge information (29.5%), 70% of respondents still identified this information as useful or essential to ongoing care. This finding may relate to recent reports concerning systemic toxicity related to hip prostheses
26 and/or an increased awareness of the Australian National Joint Replacement Register which prospectively monitors prosthesis performance.
6The results reported in this audit should be considered in the context of some limitations, particularly the limited sample size and low response rate, and the absence of psychometric testing of the audit instrument. Given the total number of GPs in the Medicare Local's catchment area (N=484); representing 20% GPs in WA,
27 our sample size of n=62 represents 2.2% of the state's GPs and, arguably reflects a low sample size and possibly a responder bias. Therefore, it will be important to replicate our findings in a larger sample of GPs in diverse geographic areas. Although earlier studies in this clinical area using surveys with GPs reported higher response rates of 48-66%, the sample sizes have varied from a size comparable to this study to much larger samples (n=50-266).
15,
16,
28,
29 While the future of epidemiologic investigations may lie with web-based collection modalities,
30 such approaches may not be the most effective methods to engage with busy clinicians. For example, a recent study requiring responses from primary care practitioners to online survey reported a comparable response rate of 10.8%.
31 Further, other authors have acknowledged the difficulty in recruitment using web-based methods
32 and with GPs in busy practices.
33 The findings from this audit should now be used to assess the adequacy of discharge summaries sent to GPs, which is anecdotally reported to be highly variable, and examine whether modifications to system processes are acceptable to GPs, as reported by Castleden et al (1992),
29 and whether they positively influence patient outcomes. Importantly, implementation of changes to processes used to create discharge summaries will require active engagement and collaboration between clinical staff, hospital administrators and information technology staff, supported in parallel by education provided to junior medical staff. The WA Musculoskeletal Health Network may be one vehicle to facilitate this process.
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