Discharge communication study: a realist evaluation of discharge communication experiences of patients, general practitioners and hospital practitioners, alongside a corresponding discharge letter sample

Abstract

ObjectivesTo develop a programme theory for the intervention of patients receiving discharge letters.DesignWe used a realist evaluation approach and captured multiple perspectives of hospital discharge to refine our previously developed programme theory. General practitioner (GP), patient and hospital clinician views of a single discharge event in which they were all involved were collected using semi-structured interviews and surveys. These were then triangulated to match the corresponding discharge letter. Data were qualitatively synthesised and compared in meta-matrices before interrogation with realist logic of analysis to develop the programme theory that maps out how patients receiving discharge letters works in specific contexts.Setting14 GP practices and four hospital trusts in West Midlands, UK.Participants10 complete matched cases (GP, patient and hospital practitioner), and a further 26 cases in which a letter was matched with two out of the three participants.ResultsWe identified seven context mechanism outcome configurations not found through literature searching. These related to the broad concepts of: patient preference for receiving letters, patient comprehension of letters, patient-directed letters, patient harm and clinician views on patients receiving letters. ‘Patient choice’ was important to the success (or not) of the intervention. Other important contexts for positive effects included: letters written in plain English, lay explanations for jargon, verbal information also provided, no new information in letter and patient choice acknowledged. Three key findings were: patient understanding is perhaps greater than clinicians perceive, clinician attitudes are a barrier to patients receiving letters and that, negative outcomes more commonly manifested when patients had not received letters, rather than when they had.ConclusionsWe suggest how patients receiving discharge letters could be improved to enhance patient outcomes. Our programme theory has potential for use in different healthcare contexts and as a framework for policy development relating to patient discharge.

Communication of palliative care needs in discharge letters from hospice providers to primary care: a multisite sequential explanatory mixed methods study

“…As a result of this inconsistency, patients may lack awareness of the information that has been communicated to their general practice team and of any care advice that has been given. Our previous realist review [ 33 ] and realist evaluation [ 34 ] on hospital discharge letters found that patient preference for receiving their discharge letters is generally high and that there are many benefits of this practice, including increased patient satisfaction and sense of involvement [ 72 , 74 ]. Future research needs to consider whether these findings occur within hospice discharge contexts, particularly accounting for experiences of general practitioners, patients, and carers.…”

“…In the United Kingdom, national guidance [29][30][31] suggests that discharge from a specialist service should include written communication that is sent to the clinician who will continue patient care; this is typically the general practitioner who acts as the family/primary care physician. Discharge communication is a complex practice in that the content, structure, and style may differ depending on local processes and the letter author [32][33][34]. Broadly, discharge letters should summarise "what has happened" (medication changes, treatment, tests and results …) and "what should happen next" (actions and plan for future care…) [30,35].…”

The person-based development and realist evaluation of a summary report for GP consultations

“…There is little literature on producing a summary report for patients in UK primary care. A 2020 realist evaluation of discharge letters in a secondary care setting showed that, if patients understand their letters this can lead to patient empowerment and improved patient knowledge and recall 30 . However, hospital discharge letters are primarily for the GP, although the patient may be sent a copy.…”

“…They therefore contain medical jargon and acronyms. Some patients and GPs agreed that the patient would have benefitted from use of lay terms in the letter 30 .…”

Improving patients’, carers’ and primary care healthcare professionals’ experiences of discharge communication from specialist palliative care to community settings: a protocol for a qualitative interview study

“…Miscommunications and unclear information can result in a lack of patient-centred care [ 7 ] and continuity of care [ 8 ], confusion and anxiety [ 9 ], and avoidable crises such as readmission as an emergency [ 10 ]; such readmissions may be unnecessary and/or preventable as they could be avoided or at least reduced with better co-ordinated care transitions [ 11 ] and improved communication and information continuity/sharing [ 12 ]. However, if communication is effective and involves patients in a way that respects their choices and needs, this can lead to benefits such as improved well-being [ 9 ], increased satisfaction [ 13 ], and better understanding of how to manage their symptoms [ 14 , 15 ]. Indeed, it has been good practice for over 20 years in the UK for patients to receive copies of written communications sent between their physicians [ 16 – 19 ].…”