From hospital to home: a critical transition

Two new studies from Yale School of Medicine reveal the myriad ways in which communication between doctors and patients fails when patients are released from the hospital, potentially contributing to serious setbacks or rehospitalization. The studies are published in the August 5 issue of the Journal of Hospital Medicine (JHM), and the August 19 issue of JAMA Internal Medicine (JAMA IM).

When hospitalized, patients are often cared for by physicians who do not continue to care for them once they are discharged. This creates a discontinuity of care, the authors write, that must be bridged through communication. Patients must understand their diagnosis, medications, follow-up plans and things to watch out for. Outpatient doctors must understand what happened in the hospital and what they need to do to follow up. Such communication between clinicians and patients, and between physicians inside and outside of the hospital, is critical to the patient’s continued wellbeing.

But this communication has long been problematic, and with a growing national focus on reducing hospital readmissions, the authors write, there is a need to comprehensively assess the quality of transitional care following hospitalization.

In both studies, researchers looked at 377 patients, aged 65 or older, who were admitted to the hospital for acute coronary syndrome, heart failure, or pneumonia.

The JAMA IM study looked at transitional care after hospitalization from the perspective of a patient. Among the researchers’ findings:

• 40% of patients could not understand or explain the reason they were in the hospital in the first place;
• A fourth of discharge instructions were written in medical jargon that a patient was not likely to understand;
• Only a third of patients were discharged with scheduled follow-up with a primary care physician or cardiology specialist; and
• Only 44% accurately recalled details of their appointments.

“Nearly one in five patients wind up back in the hospital after discharge,” said lead author on both studies Dr. Leora Horwitz, assistant professor of general internal medicine at Yale School of Medicine. “These findings may help us to understand why: We don’t yet do a great job of helping patients understand what is wrong with them, or what they need to do when they return home.”

In the JHM study, discharge summaries, the key method of communication between hospital and outpatient physicians, were evaluated for timeliness of dictation, transmission of the summary to the patients’ outside physicians, and the presence of key content. Among the findings:

• Not a single summary was completed on the day of discharge, transmitted to the appropriate outpatient physician and included all recommended key content;
• 25% of summaries were dictated more than a week after discharge;
• 38% of the discharge summaries were not sent to any outpatient physician; and
• Only 17% described the patient’s physical examination at the time of discharge

“The discharge summary is not yet serving as a useful tool for transitioning patients back to outpatient care,” Horwitz explained. “Since outpatient doctors rarely take care of their patients in the hospital any more, we have to do a better job as a healthcare system of bridging these gaps in care.”

Other authors of the JAMA IM study are Dr. John Moriarty, Dr. Christine Chen, Dr. Robert Fogerty, Dr. Ursula Brewster, Dr. Sandhya Kanada, Dr. Grace Jenq, and Dr. Harlan Krumholz of Yale and Yale-New Haven Hospital; and Dr. Boback Ziaeian of UCLA.

Additional authors on the JHM study are Peter Van Ness and Katy Araugo of Yale.

These studies were supported by the Yale Clinical and Translational Science Award grant from the National Center for Advancing Translational Sciences at the National Institutes of Health (NIH); NIH Grants UL1 RR024139 and KL2 RR024138; the NIH Roadmap for Medical Research; the John A. Hartford Foundation; the American Federation for Aging at the National Institute on Aging and The Paul B. Beeson Career Development Award Program (K08 AG038336); the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (P30AG021342 NIH/NIA); and grant U01HL105270-01 and -02 from the National Heart, Lung, and Blood Institute.