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Harvey Newnham, 1 Department of Medicine , Monash University , Level 5, 99 Commercial Road, Melbourne, Victoria 3004, Australia 2 General Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004 , Australia Search for other works by this author on: Anna Barker,3 School of Public Health and Preventive Medicine , Monash University , Level 4, 553 St. Kilda Road, Melbourne, Victoria 3004, Australia Search for other works by this author on: Edward Ritchie,2 General Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004 , Australia Search for other works by this author on: Karen Hitchcock,2 General Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004 , Australia Search for other works by this author on: Harry Gibbs,1 Department of Medicine , Monash University , Level 5, 99 Commercial Road, Melbourne, Victoria 3004, Australia 2 General Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004 , Australia Search for other works by this author on: Sara Holton3 School of Public Health and Preventive Medicine , Monash University , Level 4, 553 St. Kilda Road, Melbourne, Victoria 3004, Australia 1Address reprint requests to: Sara Holton, School of Public Health and Preventive Medicine, Monash University, Level 4, 553 St. Kilda Road, Melbourne, Victoria 3004, Australia. Tel: +61-3-9903-0294; Email: Search for other works by this author on: Received: 20 December 2016 Revision received: 13 August 2017 Published: 07 September 2017
Close Navbar Search Filter Microsite Search Term Search AbstractPurpose To systematically review the available evidence about hospital discharge communication practices and identify which practices were preferred by patients and healthcare providers, improved patient and provider satisfaction, and increased patients’ understanding of their medical condition. Data sources OVID Medline, Web of Science, ProQuest, PubMed and CINAHL plus. Study selection Databases were searched for peer-reviewed, English-language papers, published to August 2016, of empirical research using quantitative or qualitative methods. Reference lists in the papers meeting inclusion criteria were searched to identify further papers. Data extraction Of the 3489 articles identified, 30 met inclusion criteria and were reviewed. Results of data synthesis Much research to date has focused on the use of printed material and person-based discharge communication methods including verbal instructions (either in person or via telephone calls). Several studies have examined the use of information technology (IT) such as computer-generated and video-based discharge communication practices. Utilizing technology to deliver discharge information is preferred by healthcare providers and patients, and improves patients’ understanding of their medical condition and discharge instructions. Conclusion Well-designed IT solutions may improve communication, coordination and retention of information, and lead to improved outcomes for patients, their families, caregivers and primary healthcare providers as well as expediting the task for hospital staff. IntroductionTimely and accurate discharge communication is important in continuing patient care between hospitals and primary care physicians (PCP) [1]. The discharge summary is the most common method for documenting and communicating a patient's diagnostic findings, hospital management and planned follow-up to the post-hospital care team [2]. It is a vital communication and information tool which can enhance the quality and continuity of patient care [3, 4]. Effective discharge summaries reduce adverse drug events, unplanned hospital readmission, post-discharge complications and mortality, and increase patient and carer satisfaction [2, 3, 5–11]. Delivery of discharge instructions is often rushed and patients frequently do not understand aspects of their discharge, particularly medication management [12, 13]. Patients who have poor comprehension of discharge instructions may have higher rates of emergency department (ED) visits, hospital readmissions [14] and medication errors [15]. They also lack knowledge about their diagnosis, follow-up care and treatment [16, 17]. Improving patients’ understanding is likely to improve health outcomes and avoid unnecessary healthcare utilization and costs [18, 19]. Despite their importance, discharge summaries are often poorly constructed, incomplete, delayed, misdirected or unhelpful for the healthcare providers in the community [5, 6, 8, 20, 21]. Although they are one of the most commonly produced hospital documents, there is not a standardized process for providing discharge information [22], and little is known about healthcare providers’ and patients’ needs, preferences and satisfaction with processes. The aim of this review was to identify evidence for the provision of information on transfer of a patient's care from hospital to the community. We sought to review methods used to provide appropriate, contextually sensitive and comprehensible information to a patient, their family, carer and healthcare providers; and to understand which discharge communication practices were: preferred by patients and healthcare providers, improved satisfaction and increased patients’ understanding of their medical condition and treatment. MethodWe followed the PRISMA ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ procedure [23] of identification, screening, eligibility and material included in the review. Search strategySearches were performed for papers published to August 2016 in relevant social science and medical science databases (OVID Medline, Web of Science, ProQuest, PubMed and CINAHL plus). Reference lists in the papers meeting inclusion criteria were also searched to identify further papers. Inclusion criteriaPapers were included if they described empirical research and were written in English. Papers were excluded if they were conducted in ‘low’ or ‘lower middle’ income countries given the differences in availability, affordability, and accessibility of health services between ‘higher’ and ‘lower’ income countries [24]. Search termsThe search strategy included the medical subject heading terms and multiple synonyms and related keywords listed in Table 1.
Combined terms: 1 AND 2 AND 3 AND 4 AND 5 AND 6 AND 7 AND 8 AND 9.
Combined terms: 1 AND 2 AND 3 AND 4 AND 5 AND 6 AND 7 AND 8 AND 9. SH conducted the initial search; all authors together made final decisions about inclusion. Selection of articlesThe selection process is outlined in Fig. 1. Figure 1  PRISMA flow diagram of review process. Quality assessmentThe methodological quality of each study was assessed by two authors (H.N. and S.H.) independently using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields (QualSyst tool) [25]. This tool was used as it is designed to appraise both qualitative and quantitative papers, using two scoring systems. The quantitative checklist included 14 criteria and qualitative checklist 10. Each criterion is scored as ‘yes’ (2), ‘partial’ (1) or ‘no’ (0). A summary score was calculated for each paper to produce an overall quality rating. For the quantitative studies, there is also the possibility to score ‘not applicable’, such items were excluded from the calculation of the summary score. The maximum total score for the quantitative studies is 28 and 20 for the qualitative studies (Table 1). Studies were excluded based on a minimum threshold of a summary score of 0.55 [25]. Data analysisThe review included papers reporting studies using qualitative or quantitative methods. We therefore undertook an aggregative synthesis in which the data were summarized with a narrative review of the evidence [26]. Quantitative synthesis (meta-analysis) was deemed not appropriate due to the variability in research design, populations, types of interventions, and outcomes of the studies identified. The full text of included papers was reviewed by two authors (H.N. and S.H.) for: (i) all discharge communication practices used to provide information to a patient, their family and carer and their healthcare providers; and (ii) measures of patient and healthcare provider satisfaction and preferences, and patient comprehension. Reported practices were categorized into groups according to their format. All authors discussed and agreed on the final categories. For each paper, we identified and tabulated the year published, research aims, sample characteristics, methods, outcomes/measures and relevant findings. We compared the effectiveness of the identified methods in terms of healthcare provider and patient preferences and satisfaction; and patient comprehension and knowledge. ResultsWe included in the review 30 papers reporting 30 studies which described practices for transferring information about a patient's care from hospital to the community. Studies were conducted in 10 countries: and used quantitative (23 papers—13 randomized control studies, 7 surveys, 2 pre–post design, 1 record audit) or qualitative methods (2 papers: 1 in-depth interviews, 1 focus group). Five studies employed mixed-methods. Analysis of the 30 papers revealed 3 methods used to provide discharge information: 1. Information technology (IT)-based methods (15 papers); 2. Person-based methods (13 papers); and 3. Written methods (11 papers). Multiple methods were identified in 9 papers [4, 10, 28, 29, 33, 38, 39, 47, 48]. These practices were evaluated in terms of the identified measures: healthcare provider and patient preferences (5 papers) and satisfaction (23 papers); and patient comprehension and knowledge (13 papers). Overall the studies were of good quality with a summary score of 0.83 or higher indicating appropriate study design and research questions, definition of outcomes and exposures, reporting of bias and confounding, and sufficient reporting of results and limitations (Table 2a, 2b). No studies were excluded based on quality scores. Table 2a Assessment of Study Quality using the QualSyst tool [25]—Quantitative Studies
2 = yes; 1 = partial; 0 = no; N/A = not applicable. Table 2a Assessment of Study Quality using the QualSyst tool [25]—Quantitative Studies
2 = yes; 1 = partial; 0 = no; N/A = not applicable. Table 2b Assessment of Study Quality using the QualSyst tool [25]—Qualitative Studies
2 = yes; 1 = partial; 0 = no. Table 2b Assessment of Study Quality using the QualSyst tool [25]—Qualitative Studies
2 = yes; 1 = partial; 0 = no. The study design and methods, sample characteristics and relevant categories of each reviewed paper are presented in Table 3. A summary of the studies and the discharge communication method(s) used and measures evaluated is given in Table 4. Table 3. Study characteristics and discharge practices and outcomes identified in papers included in the review
Discharge practice: 1 = written; 2 = person-based; 3 = IT based. Table 3. Study characteristics and discharge practices and outcomes identified in papers included in the review
Discharge practice: 1 = written; 2 = person-based; 3 = IT based. Table 4 Summary of discharge communication methods and outcome measures by study
Table 4 Summary of discharge communication methods and outcome measures by study
Discharge communication practicesThe most common practice for communicating discharge information was IT based methods which included both discharge information such as diagnosis, treatment and medication regimes generated by computer [4, 27–29, 33, 38, 39, 46, 51], and the use of a website [30], audio-visual recording of discharge information [17, 35, 37, 50] or video conferencing between hospital and primary care providers [40] in the discharge process. Person-based methods were the second most common way of communicating discharge information to a patient, their family or healthcare provider. Discharge information was delivered verbally by a nurse [4, 10, 31, 32, 34, 43], pharmacist [36], ED staff [47], the attending physician [28, 41, 45, 48] and unspecified healthcare providers [42]. Written methods included printed or handwritten summaries [7, 10, 18, 29, 33, 38, 39, 44, 47–49] which were mailed, transferred electronically or hand delivered to the patient or primary healthcare provider. Effectiveness of the identified discharge communication methodsIt is difficult to synthesize the effectiveness of each discharge method in terms of the outcomes assessed given the variability in research design, populations, interventions and time-points of the studies reviewed. Instead we compared the effectiveness of the identified methods in response to our three identified measures: healthcare provider and patient preferences and satisfaction, and patient comprehension. We have framed this evaluation in terms of three questions we identified as practically important to healthcare providers.
DiscussionEffective communication between hospitals and primary healthcare providers that also meets the needs of their patients is important for providing continuity of care [5, 38]. This systematic review found variability in the way information is transferred to patients and primary care providers at hospital discharge. Three main methods were identified: 1. IT based; 2. Person-based and 3. Written. In the reviewed studies, IT-based methods were the most commonly used and included computer-generated information, website or video-based summaries, followed by person-based methods with the discharge information delivered by a healthcare provider. Written methods were the least used. The patient and healthcare provider preferences and satisfaction results for each method were consistent across all study designs evaluated. Both patients and providers preferred discharge practices that provided relevant, concise, and personalized information, and were easily accessible and efficient. In particular, computer-generated summaries were preferred by physicians and patients due their structured format and time efficiency, and resulted higher levels of satisfaction for both healthcare providers and patients. Video-based discharge summaries and instructions were also beneficial in improving patients and caregiver comprehension of patient's diagnosis and discharge instructions. These findings suggest that utilizing technology to deliver information improves patient understanding of their condition and discharge instructions. The primary limitations of this review relate to the variability in research design, populations, types of interventions and time-points of the studies reviewed. This impeded the synthesis of their findings. Further, many of the outcome measures were only assessed by a few studies. The studies reviewed were conducted in 10 countries with different national health systems which may also make comparisons difficult. These limitations restrict the generalizations that can be made from the findings. Directions for future researchThe findings of this review indicate the need for further research to inform the development of innovative tools to provide information at hospital discharge. The use of IT has been proposed as a way of enhancing the quality and transmission of discharge summaries [2]. Yet only a few studies have assessed the effectiveness of IT solutions such as video-based discharge summaries despite evidence that the provision of information with video is helpful in patient comprehension and decision-making [52–56]. The personalized interdisciplinary audio-visual record (CareTV) designed to facilitate effective communication with patients, family, carers and other care team at hospital discharge also improved patient knowledge and satisfaction [35]. Redesigning discharge practices in combination with IT solutions has the potential to improve communication; make discharge summaries more accessible and transparent for patients, their families, carers and healthcare providers; and achieve higher quality of care and outcomes for patients [40, 57]. This study suggests that a single format of discharge summary is unlikely to fulfil all expectations and needs of patients and healthcare providers. A combination of discharge communication tools may be required and further research should seek the most effective combinations of tools for particular categories of patients. Conclusion and implications for clinical practiceImprovements are needed in the processes used for transferring information to patients and their primary healthcare providers at hospital discharge. Well-designed IT solutions may improve communication, coordination and retention of information, and lead to improved outcomes for patients, their families, caregivers and primary healthcare providers as well as expediting the task for hospital staff. Further research is required to inform the development of processes for provision of information at the time of transfer of care that meet the needs of both patients and their healthcare providers. FundingThis work was supported by a grant from the Victorian Department of Health and Human Services. The Victorian Department of Health and Human Services had no role in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. A.B.'s salary was funded by a Career Development Fellowship from the National Health and Medical Research Council (NHMRC) (APP1067236). References1 Chen Y ,Brennan N ,Magrabi F .Is email an effective method for hospital discharge communication? A randomized controlled trial to examine delivery of computer-generated discharge summaries by email, fax, post and patient hand delivery . Int J Med Inform 2010 ; 79 : 167 – 72 . 2
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