Test Results and Follow-Up Studies
Among the factors contributing to failures at discharge is disrupted continuity of responsibility for pending test results and radiologic studies. This discontinuity may be especially operational in teaching hospitals, where physicians-in-training may frequently change services or shifts, and yet they remain responsible for all or some of the discharge communication.10 To prevent this disruption and avoid confusion, the institution or team should clarify the person responsible for follow-up on tests or studies. And they must communicate this information to the primary care physician.
Roy and colleagues looked at the prevalence, characteristics, and physician awareness of potentially actionable test results returning after hospital discharge at two major tertiary care centers.10 Of the 2,644 patients discharged from the hospitalist services, 1,095 (41%) had a total of 2,033 test results pending on the day of discharge, and 877 of these results (43%) were abnormal. Of the final 671 results included, 191 (9.4%) from 177 patients were potentially clinically actionable. Surveyed physicians were unaware of almost two-thirds of these potentially actionable results; more than a third of these results would change the patient’s diagnostic or treatment plan, and 12.6% of cases required urgent action. Other data show the unreliability of providing test results at follow-up visits; discharge summaries were available at only 12% to 33% of visits studied in one series.10
When inpatient physicians were asked how they would like electronic results-management systems that could highlight important results, filter out normal results, and help hospitalists track results returning after discharge, they were eager to adopt such systems. A future article in The Hospitalist will cover the emergence of electronic systems to better manage discharge communications.
Follow-up Contact with Patients
Van Walraven and colleagues looked at whether early post-discharge outcomes changed when patients were seen after discharge by physicians who had treated them in the hospital.11 When 938,833 adults from Ontario, Canada, were followed over five years after discharge from a medical or surgical hospitalization, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% and 3% with each additional visit to a hospital physician—as opposed to a community physician or specialist, respectively. The effect of hospital physician visits was seen to have a dose-response effect, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had one, two, or three visits, respectively.
Hospital physician follow-up, say the authors of the Van Walraven, is a potentially modifiable factor that could decrease the risk of poor outcomes post discharge. Although not all providers embrace the concept, it does address the essential need of continuity of care through the potentially complicated transition from hospital to community. At the very least, the authors write, any physicians who sees the patient should have access to as much information as possible regarding the hospitalization and should be able to contact patients by phone post discharge.11-13
In a survey distributed by Steve Pantilat, MD, and colleagues, primary care physicians reported overwhelmingly that they preferred communicating with hospitalists by telephone at discharge (78%).14 While this may be unrealistic for all handoffs, says Dr. Merrens, hospitalists should make the effort for more complicated or serious cases.
Adverse Drug Events and Other Medication Issues
Although most adverse drug events (ADEs) are caused by the pharmacologic activity of the drug itself and can be predicted and mitigated, some one-third to one-half of ADEs are caused by human error or flawed systems.15
Coleman and colleagues looked at 375 patients, 65 and older, to analyze the medication problems they encountered.8 A significant percentage (14.1%) of older patients experienced one or more medication discrepancies after discharge; 50.8% were categorized as patient-associated; and 49.2% were seen as system-related. A total of 14.3% of the patients who experienced these discrepancies were rehospitalized at 30 days, compared with 6.1% of the patients who did not have any problems.