Inpatient Care Provider Communication with Outpatient Care Provider

There is a growing model of inpatient care that includes the use of hospitalists, which may be one of the factors exacerbating the already poor level of communication between inpatient and outpatient healthcare providers. The discontinuity of care between the inpatient and outpatient settings has been shown to contribute to adverse events and medical errors that often occur following hospital discharge.

The 2 primary methods of communication between inpatient and outpatient physicians are (1) discharge summaries and (2) direct conversations. Written summaries are often not available at a patient’s first follow-up appointment, however, and studies have demonstrated the lack of a written summary limits the ability of the primary care physician to provide adequate care in nearly 25% of postdischarge follow-up appointments.

Studies of the importance of written summaries have yielded conflicting results, according to researchers. The value of direct communication has not been frequently studied, leading researchers to conduct a single-center prospective study to examine the frequency with which inpatient providers report communicating directly with outpatient providers. The study also sought to determine whether direct communication was associated with 30-day readmissions. Study results were reported in JAMA Internal Medicine [2013;173(8):624-629].

The study, conducted at The Johns Hopkins Hospital in Baltimore, Maryland, utilized self-reported communication patterns by discharging healthcare providers on inpatient medical services from September 2010 to December 2011. During the study period, there were 13,954 hospitalizations; of those, 9719 were for initial visits. After applying exclusion criteria, the final study cohort included 6635 hospitalizations.

Successful communication was reported in 36.7% (n=2438) of the cases, attempted, but unsuccessful, communication was reported in 8.8% (n=585) of the cases, and no attempts were reported in 54.4% (n=3612) of the cases.

In 1459 of the cases where no direct communication attempt was made, the healthcare provider felt that the discharge summary was adequate. Other reasons for lack of direct communication included uncertainty if communication had taken place, communication was attempted, but unsuccessful, and the patient or a family member planned to update the primary care provider personally.

Over the duration of the study, there was a modest, but significant trend, toward higher rates of direct communication. Treating time as a continuous variable, the odds ratio (OR) for successful handoff on the last day of the study was 1.22 (95% confidence interval [CI], 1/03-1/44) relative to the first day of the study. This OR translated to a fitted direct communication rate of 34.7% during the first month of the study and 39.1% during the last month.

Adjusted predictors of direct communication included patients cared for by hospitalists without in-house staff, high expected 30-day readmission rate, and health insurance from Medicare or commercial insurance company (compared with Medicaid).

In an adjusted analysis, there was no association between direct communication with the outpatient healthcare provider and readmissions.

In conclusion, the researchers said, “Self-reported direct communication between inpatient and outpatient providers occurred at a low rate, but was not associated with readmissions. This suggests that enhancing interprovider communication at hospital discharge may not, in isolation, prevent readmissions.”