OBJECTIVES:

Children with medical complexity (CMC) have an increased risk of adverse events after hospital discharge. Authors of previous studies have evaluated discharge communication practices with primary care providers (PCPs) in adults and general pediatric patients. There is a lack of evidence surrounding hospitalist communication practices at discharge for CMC. In this study, we explore hospitalist-to-PCP communication for CMC at hospital discharge.

METHODS:

A retrospective chart review was performed at a single tertiary care children’s hospital. The population included patients with ≥1 complex chronic condition who were discharged from the pediatric hospitalist team. The presence, type, and quality of discharge communication were collected. A descriptive analysis in which we used χ2, t test, Wilcoxon rank testing, and odds ratios was conducted to identify differences in communication practices in CMC.

RESULTS:

We identified 368 eligible patients and reviewed their electronic medical records. Discharge communication was documented for 59% of patient encounters. Communication was less likely to occur for patients with technology dependence (P = .01), older patients (P = .02), and those who were admitted to a teaching service (P = .04). The quality of discharge summaries did not change for patients with technology dependence compared with patients without technology dependence.

CONCLUSIONS:

Communication with the PCP at discharge was less likely to be documented in children with technology dependence. Hospitalists may encounter barriers in completion of appropriate and timely discharge communication with PCPs for CMC. Consistent handoff processes could be used to improve care for our patients with enhanced coordination needs.

Children with medical complexity (CMC) represent ∼6% of all children covered by Medicaid but account for 33% of total health care spending for children and 71% of pediatric readmissions.1  CMC have increased care coordination needs especially during the time of hospital discharge to safely transition home. CMC also have an increased risk for adverse events during care transitions. Improvements in care coordination between the inpatient and outpatient settings may reduce negative postdischarge events.2  Care coordination for CMC requires more planning at the time of discharge because of their complex diagnoses, multiple medications, many subspecialty physicians, and possible technology dependence.35  CMC are making up a larger percentage of the patients cared for by pediatric hospitalists.2,6  Medical care for these patients is already fragmented with the need for multiple subspecialists.7  As the field of pediatric hospital medicine expands, CMC may experience more fragmented care because their inpatient physician is unlikely to be their primary care provider (PCP).

PCPs and hospitalists both believe that CMC deserve more comprehensive discharge communication surrounding follow-up testing, home health care orders, new medications, and ongoing medical problems.8  Although previous studies have revealed no difference in outcomes in the general pediatric and adult populations when hospitalist-to-PCP communication is documented, communication may be more important for CMC.9,10  The discharge process for CMC, especially with technology dependence, is complicated and often requires significant effort by the discharging hospitalist. The discharging hospitalist must secure accurate home supplies and medications for the patient, as well as instruct their appropriate caregivers. Hospitalists may prioritize these tasks to ensure a safe discharge over communication with the patient’s PCP. Although it seems that communication with the PCP for CMC would ensure a safe discharge process, there is a paucity of literature in which authors describe current practices for communication with PCPs for this group of patients.

Our goal with this study was to understand the current communication practices with the patient’s PCP at the time of discharge for CMC discharged from a hospitalist team. In secondary analysis, we evaluated the effect of hospitalist communication with the PCP on 30-day unplanned readmissions. We aimed to analyze the presence, type, and quality of the discharge communication summary to describe factors that may influence hospitalist communication practices. Our goal was to identify gaps in current communication practices to provide avenues for future improvements in hospitalist-to-PCP communication.

We conducted a retrospective cohort study through rigorous chart review of the electronic medical record (EMR). We evaluated the presence and content of documented hospitalist-to-PCP communication at the time of discharge in CMC who were discharged from the hospitalist service at 1 large, urban tertiary care hospital. We also analyzed the correlation between 30-day unplanned readmission and communication practices.

Our population consisted of pediatric patients with medical complexity discharged from a pediatric hospitalist service at a large tertiary care children’s hospital over a 5-month period from September 1, 2016, through January 1, 2017. We limited the population to those patients discharged only from the hospitalist service because we postulated that these patients were most likely to rely on a PCP, rather than a subspecialty provider, for care coordination. Our system does have a complex care consult team to provide continuity during recurrent admissions; however, the primary hospitalist is still responsible for communication at the time of discharge. The involvement of the consultant team was not included as a factor that might impact communication practices.

We defined CMC as any patient whose medical record reflected 1 or more complex chronic condition (CCC) on the basis of International Classification of Diseases, 10th Revision coding.11  We identified our population by first using the Pediatric Health Information System database to query patients who were discharged from our general pediatric services that had ≥1 CCC.12  This system was chosen both for ease of patient identification because CCC fields were already in place in the original data set and so that patients could be further classified by type of CCC to clarify functional limitations. This system encompasses the 4 domains of CMC, including chronic conditions, functional limitations (eg, technology dependence), health care needs, and health care use.13  Patients who had a scheduled readmission within 30 days, who were discharged from a subspecialty service, or who died while hospitalized were excluded from this study.

Once our cohort of patients was identified, we conducted an institutional chart review for each encounter. Demographic data were collected for each patient that could impact either the likelihood of hospitalist communication at the time of discharge or propensity for readmission. Demographics included number and type of CCC, discharging service (attending-only team versus teaching service), insurance type (public, private, or no insurance listed), length of hospital stay in days, sex, patient age, if the patient had >5 prescription medications at the time of discharge, and if the patient spent time in the ICU while hospitalized.14 

The presence or absence of documented physician to physician communication at time of discharge was recorded. Communication was defined as 1 or more of the following: (1) a faxed discharge notification form completed by the attending physician on the day of discharge, which usually included a short description of the hospital course and pertinent information for follow-up care, (2) a note in the chart indicating a phone call or e-mail was made to the PCP by the attending or hospitalist fellow on the day of discharge, or (3) a notation in the attending addendum to the discharge summary stating that the patient’s case was discussed with the PCP. We also collected information indicating that a completed resident-authored discharge summary was faxed to the PCP through an automated system and the components present in each discharge summary as a proxy of communication quality.15  These quality metrics were based on a previously studied hospital-to-home transition bundle, which highlighted factors needed for completion of handoff to a patient’s PCP and included a complete medication list, physical examination with vitals, follow-up appointments needed, the status of any pending laboratory studies, vaccines given during hospitalization, discharge diagnosis, hospital course, and admission and discharge dates.15  Communication practices were analyzed for patients with technology dependence and >2 CCCs to describe communication for the most complex patients.

Unplanned readmission within 30-days of discharge to any service in our hospital was also collected to assess if there was a difference in readmission in patients with PCP communication at discharge compared with patients without PCP communication. Study data were collected and managed by using Research Electronic Data Capture tools hosted at our children’s hospital.16  This study was approved by the Children’s National Hospital Institutional Review Board.

Patient characteristics and communication practices were analyzed by using χ2 testing, t testing, Wilcoxon rank testing, and odds ratios (ORs). Normality was evaluated by using Shapiro-Wilk testing and quantile-quantile plots. χ2 and Fisher’s exact tests were used to identify statistical differences in communication practices and discharge summary quality. P values were considered significant at <.05. We conducted power analysis to identify the ability to detect differences in readmissions between patients with PCP communication and those without using Power Analysis and Sample Size version 15.0.17  The sample size provided the power to identify a 9% change in readmission rate. OR and logistic regression modeling was used to analyze correlations between communication practices and readmissions. Statistical analysis was completed in R version 3.4.3.18 

There were 377 patient encounters reviewed who were discharged from the hospitalist team from September 1, 2016, to January 1, 2017, in which the patient had 1 or more CCC. Nine of these patients were excluded from our analysis: 6 patients had a planned readmission such as a scheduled surgery, 2 were transferred to and eventually discharged from a subspecialty service, and 1 patient died while hospitalized. This resulted in 368 eligible patient encounters. Of these 368 eligible patients, 217 patients (59%) had at least 1 type of communication with their PCP documented on the day of discharge (Fig 1).

FIGURE 1

Flow sheet indicating the number of charts reviewed. Nine charts met exclusion criteria, leaving a total of 368 eligible encounters. PCP communication occurred in 59.0% of patient encounters.

FIGURE 1

Flow sheet indicating the number of charts reviewed. Nine charts met exclusion criteria, leaving a total of 368 eligible encounters. PCP communication occurred in 59.0% of patient encounters.

Bivariate analysis revealed patients who had documented physician communication at the time of discharge were less likely to be technology dependent (OR 0.5; confidence interval [CI] 0.33 to 0.84; P value .01), more likely to be younger (mean difference in age of −0.8 years; CI −2.0 to 0.001; P = .02), and more likely to be discharged from the attending-only service than a teaching service (OR 2.55; CI 1.03 to 7; P = .04) (Table 1). Other demographic factors that indicated illness severity, including length of stay and a PICU stay at any point during their admission, did not impact the likelihood of hospitalist-to-PCP communication at discharge.

TABLE 1

Demographics: Differences Between Patients Who Had Communication With the PCP Documented at the Time of Discharge and Those Who Did Not Have Documented Discharge Communication

PCP Communication (n = 217)No PCP Communication (n = 151)P
Average No. CCCs 1.9 (σ = 1.3) 2.2 (σ = 1.2) .22 
Technology dependence, n (%)   .01a 
 Technology dependent (n = 120) 58 (27) 62 (41)  
 Not technology dependent (n = 248) 159 (73) 89 (59)  
No. medications at discharge, n (%)   .46 
 >5 (n = 114) 64 (29) 50 (33)  
 ≤5 (n = 254) 153 (71) 101 (67)  
ICU stay, n (%)   .99 
 ICU stay (n = 117) 69 (32) 48 (32)  
 No ICU stay (n = 251) 148 (68) 103 (68)  
Average length of stay, d 8.2 (σ = 17.3) 7.5 (σ = 10.6) .58 
Admission service, n (%)   .04a 
 Attending only (n = 31) 24 (11) 7 (5)  
 Teaching (n = 337) 193 (89) 144 (95)  
Insurance type, n (%)   .98 
 Medicaid (n = 242) 143 (66) 99 (66)  
 Private (n = 108) 63 (29) 45 (30)  
 No insurance (n = 18) 11 (5) 7 (4)  
Sex, n (%)   .062 
 Male (n = 193) 105 (48) 88 (58)  
 Female (n = 175) 112 (52) 63 (42)  
Average age, y 4.8 (σ = 5.8) 5.6 (σ = 5.5) .02a 
PCP Communication (n = 217)No PCP Communication (n = 151)P
Average No. CCCs 1.9 (σ = 1.3) 2.2 (σ = 1.2) .22 
Technology dependence, n (%)   .01a 
 Technology dependent (n = 120) 58 (27) 62 (41)  
 Not technology dependent (n = 248) 159 (73) 89 (59)  
No. medications at discharge, n (%)   .46 
 >5 (n = 114) 64 (29) 50 (33)  
 ≤5 (n = 254) 153 (71) 101 (67)  
ICU stay, n (%)   .99 
 ICU stay (n = 117) 69 (32) 48 (32)  
 No ICU stay (n = 251) 148 (68) 103 (68)  
Average length of stay, d 8.2 (σ = 17.3) 7.5 (σ = 10.6) .58 
Admission service, n (%)   .04a 
 Attending only (n = 31) 24 (11) 7 (5)  
 Teaching (n = 337) 193 (89) 144 (95)  
Insurance type, n (%)   .98 
 Medicaid (n = 242) 143 (66) 99 (66)  
 Private (n = 108) 63 (29) 45 (30)  
 No insurance (n = 18) 11 (5) 7 (4)  
Sex, n (%)   .062 
 Male (n = 193) 105 (48) 88 (58)  
 Female (n = 175) 112 (52) 63 (42)  
Average age, y 4.8 (σ = 5.8) 5.6 (σ = 5.5) .02a 

Patients who were not technology dependent, younger, and those admitted to a nonteaching service were more likely to have documented discharge communication. σ, SD for continuous variables.

a

Indicates statistical significance at a P value of <.05 determined by using Wilcoxon rank testing for nonnormally distributed variables and χ2 testing.

Subgroup analysis was done to explore types of communication documented for patients with increasing numbers of CCCs and technology dependence, as a proxy for increasing medical complexity. Patients with >2 CCCs were less likely to have a faxed discharge notification sent to their PCPs office (OR 0.6; CI 0.4 to 1; P = .04). Of note, there was no difference in the rate of trainee-authored discharge summaries as complexity increased. Children who were technology dependent were less likely to have an attending-authored fax (OR 0.6; CI 0.4 to 0.9; P = .02) or a notation in the discharge summary that the attending spoke with their PCP (OR 0.3; CI 0.1 to 0.9 P = .04) (Table 2). Bidirectional communication including an e-mail or phone call was uncommon in all groups and did not differ in patients with technology dependence or >2 CCCs (Table 2).

TABLE 2

Types of Discharge Communication for Patients With Higher Medical Complexity

Type of Communication, n>2 CCC, OR (P)Technology Dependent, OR (P)
Discharge notification by attending, 182 0.6 (.04)a 0.6 (.02)a 
Documented phone call or e-mail, 18 0.9 (1) 0.3 (.07) 
Attending attestation in the discharge summary, 24 0.4 (.12) 0.3 (.04)a 
Automatic faxed trainee-completed discharge summary, 138 1.5 (.08) 1.3 (.25) 
Any 1 or more of the above groups, 275 0.8 (.53) 0.7 (.15) 
Type of Communication, n>2 CCC, OR (P)Technology Dependent, OR (P)
Discharge notification by attending, 182 0.6 (.04)a 0.6 (.02)a 
Documented phone call or e-mail, 18 0.9 (1) 0.3 (.07) 
Attending attestation in the discharge summary, 24 0.4 (.12) 0.3 (.04)a 
Automatic faxed trainee-completed discharge summary, 138 1.5 (.08) 1.3 (.25) 
Any 1 or more of the above groups, 275 0.8 (.53) 0.7 (.15) 

Attending-initiated notification was less common for patients with >2 CCCs and technology dependent. Attending attestation in the discharge summary was also less likely for technology-dependent patients.

a

Indicates statistically significant difference between subgroups of patients when compared with all patients (P < .05) by using χ2 testing and Fischer’s exact testing when appropriate.

Discharge summary quality was assessed by identifying the presence or absence of components found in a high-quality discharge summary.15  There was no significant difference in the quality of discharge summaries between patients who were technology dependent and those who were not (Fig 2). Patients who were technology dependent had the same likelihood of having a discharge summary include all quality metrics as children without technology dependence (OR 0.57; CI 0.31 to 1.01).

FIGURE 2

Quality of discharge summary for technology-dependent children. There was no difference in the quality of discharge summaries in patients who were technology dependent compared with those who were not on the basis of χ2 and Fischer’s exact testing. There remained no difference between the groups if all quality factors were documented in the same discharge summary (OR of all components completed for children with technology dependence 0.57 [CI 0.3 to 1.01]).

FIGURE 2

Quality of discharge summary for technology-dependent children. There was no difference in the quality of discharge summaries in patients who were technology dependent compared with those who were not on the basis of χ2 and Fischer’s exact testing. There remained no difference between the groups if all quality factors were documented in the same discharge summary (OR of all components completed for children with technology dependence 0.57 [CI 0.3 to 1.01]).

Our cohort had a 30-day readmission rate of 19.6%. There was no difference in the OR of 30-day readmission between patients with discharge communication documented and those without (19.8% vs 19.2%; OR 1.04 [95% CI: 0.62 to 1.77]). Subgroup analysis of technology-dependent patients did not show any impact of documented PCP communication at discharge on readmission, with an OR of 1.29 (CI 0.57 to 2.99).

This study revealed that at a single urban tertiary care pediatric hospital, CMC had variability in documented communication with their PCP at the time of discharge. Children with increased complexity, measured by increasing numbers of CCCs and analysis of technology-dependent patients alone, were less likely to have attending-authored communication with their PCP at discharge.

There are several possible explanations for this finding. First, CMC with increasing complexity are generally admitted to the teaching service because the attending-only service is usually reserved for patients with a single, clear admitting diagnosis. Our study is consistent with previously published literature in that teaching services are less likely to complete PCP communication. This could be due to unclear roles and expectations with multiple learners per team.8  It is possible that the most medically complex, technology-dependent patients are not using their PCP as their main locus of care. A subspecialty doctor may be assuming care coordination for the children with more medical complexity. Additionally, some patients with multiple CCCs at the hospital are managed by a complex care coordination team, which liaises between the inpatient and outpatient settings. If patients are managed by this team, conversations about care coordination are continuous and, generally, face to face, and it is possible that these communications are not documented in the medical record. Finally, because of the complex nature of discharges for CMC, hospitalists may simply not prioritize PCP communication.

The majority of communication in this study took the form of a faxed discharge notification letter. Previous literature has not revealed consensus of PCP preferences regarding modality of communication, although there is agreement that discharge communication should be structured, timely, and direct.4,19,20  Bidirectional communication such as telephone calls or e-mails were uncommon. Interestingly, attending-generated communication was less likely to occur with increasing patient complexity, but trainee-generated discharge summaries were of similar quality and faxed at similar frequency. This possibly reflects the increased workload on the attending physician in case management tasks at the time of discharge or increased reliance on consulting services to complete inpatient-to-outpatient handoff.

Discharge summary quality was the same when comparing technology-dependent children with those who were not technology dependent. This is possibly due to the templated nature of the discharge summary that prompts the author to enter many components of a high-quality summary. This template is the same for every patient being discharged leading to highly equitable discharge summaries.

We had hoped to link discharge communication with health care use in the form of 30-day unplanned readmissions. We were unable to demonstrate any impact of the presence of discharge communication on readmission. Our conclusions are limited by a sample size that provided a power to detect only a 9% difference in readmissions.

There are multiple limitations in this study. Communication was quantified in a retrospective way on the basis of documentation in the patient’s EMR. Communication may have occurred without documentation. Most communication consisted of a faxed letter summarizing the hospital stay written by the attending hospitalist. The timing and physical receipt of this fax was not confirmed or quantified. We did not collect information about what was contained in these faxed letters. The names and offices of PCPs are obtained and documented in our electronic health record through verification with a family member during the admission process. If the documented PCP is incorrect, the discharge notification letter could be sent to the wrong office.

The analysis was conducted at a single study center in a large tertiary care urban medical center, which limits generalizability. PCPs affiliated within the health system may have access to the inpatient medical record, whereas other community pediatricians may not. We did not delineate groups on the basis of PCP association with the medical system. As described above, the system uses a consultative service for the most medically complex patients. The consulting team coordinates with an outpatient clinic and provides care continuity. It is possible that communication was occurring through this consultative team without being documented in the EMR.

In this study, we highlight the need for improved and standardized communication for CMCs who are being discharged from the hospital. Varied care models for CMCs including multiple physicians and complicated home care needs may create barriers to timely and effective discharge communication between hospitalists and PCPs. Further study used to identify reasons for the communication gap identified in the most complex patients could include a survey of hospitalists, families, and PCPs used to identify communication barriers. Multicenter prospective studies would be useful to characterize communication practices across multiple care models. Finally, researchers of a prospective randomized controlled trial of discharge communication could further evaluate the relationship between communication and health care use in this population.

Communication with a PCP at the time of discharge was less likely to occur for patients with technology dependence at a tertiary care medical center. Attending-authored documentation was less likely to occur for patients with increasing numbers of CCCs. Discharge summary completion and quality were similar among all patients with CCCs. Fragmented medical care systems put pediatric patients with multiple medical conditions at risk for overuse because of poor care transitions. Standardization in discharge communication practices for CMC may increase the frequency of PCP communication, which could lead to improved care coordination. Improvement in care coordination and communication during discharge from the hospital for CMC would improve quality of care. Identifying reasons for the gap in discharge communication for CMCs could increase patient and provider satisfaction by improving overall communication and workflow.

We acknowledge Dr Padma Pavuluri, DO, Dr Karen Fratantoni, MD, MPH, and Dr Catherine Forster, MD, PhD, for their contributions to this article.

Dr Rush conceptualized and designed the study and drafted the initial manuscript; Ms Herrera conducted data analysis and reviewed and revised the manuscript; Dr Melwani aided in conceptualization and study design and critically reviewed the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.